Module 1: Chronic care model
6 Elements-
1. Community
• Partnership with community programs to support needs of patients
o Fitness centers, smoking cessation programs, support groups
2. Health systems
• Creation of a culture, organization, & mechanisms that promote safe, high-quality care
o Patient safety
3. Self-management support
• Recognize central role of patient in managing their own care
4. Delivery system design
• Focus on teamwork, proactive (not reactive) management, f/u after office visit, case
management for complex patients, recognizing cultural values (cultural competencies)
5. Decision support
• Using EBP, continuing education of healthcare team
6. Clinical information systems
• Make data available to monitor progress of individual patient level and service level
o Care coordination, track outcome data
Module 2: Respiratory
Integrate knowledge of the epidemiology and pathophysiology of the respiratory system in order to
determine the primary differential diagnosis in a patient presenting with a complex pulmonary problem.
Lung Cancer
• Affects lung or bronchi, classified by cell type & microscopic appearance (NSCLC, SCLC)
• Risk factors:
• Tobacco use (80-90% of lung cancer), environmental/occupational exposure, radon,
radiation, genetic predisposition, racial minority, low socioeconomic class,
decreased physical activity
• NSCLC: 80%, 3 sub-types (adenocarcinoma, squamous SCC, large cell) grouped b/c potential
for cure by surgery (resection) when tumor is localized
• SCLC: Classified as limited stage (confined to 1 hemithorax) or extensive (widely disseminated)
o Limited tx- chemo/radiation. Extensive tx- palliative chemo
o From endocrine glands of bronchial mucosa, rapid growth, most present with mets
▪ Hormonal involvement – breast involvement
• Presentation:
o Cough
o Dyspnea, hoarseness, hemoptysis, chest pain, wheezing, stridor, dysphasia, SVC
syndrome, pleural effusion (d/t obstruction)
o Paraneoplastic syndrome
o Systemic (weight loss, anorexia), Neuro/endocrine (SIADH, neuropathy),
Heme (hypercoagulable, anemia, leukocytosis)
• W/U:
o H&P- ID risk factors, smoking/environmental Hx, ROS (fatigue, weight loss)
o PE- Head/neck, chest, extremities (clubbing), lymph nodes
o Labs- CBC/d, CMP, LFT, LDH (lactate dehydrogenase); CXR (possible visible lesion),
CT (diagnostic), PET (for staging). Biopsy for staging
• Mgmt:
, o NSCLC- Surgery to resect in early stages (I&II). Radiation even in non-operable, palliative.
Chemo
• Lung Carcinoid Tumor
• Rare, good survival, average 60y. Known to recur
• Pathophys- Mutated neuroendocrine cells in large airways, cause obstruction. Slow
growing, can produce peptides & hormones
• Mgmt: Chemo, surgery (partial lobe to lung), radiation
Pulmonary HTN
• Pulmonary pressure inappropriately high for blood to flow through lungs. Remodeling of small
pulm arteries, increased PVR & RV failure. Characterized by progressive dyspnea & associated
functional limitations
• Causes: Idiopathic, familial, diseases, drugs/toxins, connective tissue d/o, HIV, valvular
d/o, hypoxia most common (obstructive sleep apnea OSA, COPD)
• Presentation:
• Usually asymptomatic until severe, normal exam in early stages
• Fatigue, angina, syncope, cough, hemoptysis, Reynaud’s phenomenon, edema,
decreased exercise tolerance
• Loud 2nd heart sound, high pitched holosystolic murmur, jugular V wave, left
parasternal heave
• Advanced symptoms r/t RH failure (hepatomegaly, ascites, JVD, peripheral edema)
• W/U:
• Find causative factor
• ECG (changes show RVH), CXR (large pulm arteries), V/Q (r/o embolus), echo, cardiac
MRI, cardiac cath (get exact pressures)
• Labs- CBC, LFT, TSH, BNP
• Mgmt:
• Referral to Pulmonary/Cardiology
• Improve symptoms (dyspnea), enhance functional capacity & exercise endurance
• 02 therapy, correct acid/base balance, diuretics, treat OSA, anticoagulation,
meds, Low-Na diet, lung transplant
• Directed by causative factor
COPD
• Characterized by persistent airflow limitation that's usually progressive and associated with
an enhanced abnormal inflammatory response in lungs
• Exacerbations and comorbidities contribute to the overall severity in individual patients.
• COPD is a leading cause of mortality worldwide and projected to increase in the next
several decades.
, •
• Chronic Bronchitis:
• Pathophys: Airway edema, airway wall thickening, excess mucous production, loss of
ciliary function. Airflow obstructed inspiration & expiration
• Chronic hypoxia & hypercapnia increase pulmonary artery resistance, cause
pulmonary HTN, cause cor pulmonale
• Blue bloaters
• Emphysema:
• Pathophys: Enlarged air spaces from alveolar wall destruction by elastace
• Pink puffers
• Risk factors: Cigarettes, occupational dust/chemicals, second hand smoke, indoor/outdoor
air pollution, poor nutrition, infections, low socioeconomic status, old, genetics
• Presentation:
• Dyspnea: Progressive, persistent and characteristically worse with exercise. Air hunger
• Chronic cough: May be intermittent and may be unproductive.
• Chronic sputum production: COPD patients commonly cough up sputum.
• W/U:
• Clinical diagnosis should be considered in any patient who has dyspnea, chronic cough,
or sputum production, and a history of exposure to risk factors for the disease.
• Spirometry: Required to make diagnosis; post-bronchodilator FEV1/FVC < 0.7 OR FVC <
80% expected
• Goals: Determine the severity of the disease (including the severity of
airflow limitation), impact on the patient's health status, and risk of future
events.
• Chest X-ray: Not diagnostic, can detect complications or comorbidities
• PNA, pulmonary HTN, pneumothorax. HF
• Lung volumes and diffusing capacity: Help to characterize severity but not essential
to patient management.
• EKG: Assess severity of lung disease & RH involvement
• Oximetry and ABG: Pulse oximetry to evaluate 02 saturation and need for supplemental
02 therapy.
• Labs: Alpha-1 antitrypsin deficiency screening (develops in Caucasian <45 years or
with strong family history of COPD), CBC/d (Hg/Hct elevated in severe hypoxemia)
Assess symptoms using:
• COPD Assessment Test (CAT)
• Clinical COPD Questionnaire (CCQ)
• mMRC Breathlessness scale
Classification of Severity of Airflow Limitation in COPD
, In patients with FEV1/FVC
GOLD 1 Mild FEV1 ≥80%
predicted GOLD 2 Moderate 50% ≤FEV1
GOLD 3 Severe 30% ≤FEV1
GOLD 4 Very Severe Below 30% FEV1
Assess Risk of Exacerbations
Use history of exacerbations and spirometry:
• Two or more exacerbations within the last year or an FEV1, less than 50%
• One or more hospitalizations for COPD exacerbation should be considered high risk.
Assess COPD Comorbidities
COPD patients are at increased risk for:
• CV diseases, Osteoporosis (chronic steroid use), Respiratory infections, Anxiety and
depression, DM, Lung cancer, Bronchiectasis
• Mgmt:
• Some interventions improve survival, some improve symptoms
• Smoking cessation #1 intervention to reduce decline of lung function. Encourage all
patients who smoke to quit at all encounters
• Pharmacotherapy and nicotine replacement reliably increase long-term
smoking abstinence rates.
• All benefit from regular physical activity and should repeatedly be encouraged to
remain active.
• Medications:
• Can improve exercise tolerance, reduce # and severity of exacerbations, & improve
lung function
• Beta2 agonists (Bronchodilator)- Short & Long-acting
• Anticholinergics (Bronchodilator)- Short & Long-acting. – preferred
• Long-acting formulations are preferred over short-acting formulations.
• Combo short-acting beta2 agonists + anticholinergic in one OR Combo long-acting
beta2 agonists + anticholinergic in one
• Inhaled corticosteroid with a long-acting beta2 agonist is more effective than the
individual components in improving lung function and health status and reducing
exacerbations in moderate to very severe COPD.
• Methylxanthines (Bronchodilator)- Less popular
• Inhaled corticosteroids
• Reduce exacerbations in FEV1 <60%
• Associated with increased risk of pneumonia
• Long-term treatment with inhaled corticosteroids added to long-acting
bronchodilators is recommended for patients with high risk of
exacerbations.
• Combination long-acting beta2 agonists + corticosteroids in one inhaler
• Systemic corticosteroids
• Chronic treatment with systemic corticosteroids should be avoided because of
an unfavorable benefit-to-risk ratio.
• Phosphodiesterase-4 inhibitors
6 Elements-
1. Community
• Partnership with community programs to support needs of patients
o Fitness centers, smoking cessation programs, support groups
2. Health systems
• Creation of a culture, organization, & mechanisms that promote safe, high-quality care
o Patient safety
3. Self-management support
• Recognize central role of patient in managing their own care
4. Delivery system design
• Focus on teamwork, proactive (not reactive) management, f/u after office visit, case
management for complex patients, recognizing cultural values (cultural competencies)
5. Decision support
• Using EBP, continuing education of healthcare team
6. Clinical information systems
• Make data available to monitor progress of individual patient level and service level
o Care coordination, track outcome data
Module 2: Respiratory
Integrate knowledge of the epidemiology and pathophysiology of the respiratory system in order to
determine the primary differential diagnosis in a patient presenting with a complex pulmonary problem.
Lung Cancer
• Affects lung or bronchi, classified by cell type & microscopic appearance (NSCLC, SCLC)
• Risk factors:
• Tobacco use (80-90% of lung cancer), environmental/occupational exposure, radon,
radiation, genetic predisposition, racial minority, low socioeconomic class,
decreased physical activity
• NSCLC: 80%, 3 sub-types (adenocarcinoma, squamous SCC, large cell) grouped b/c potential
for cure by surgery (resection) when tumor is localized
• SCLC: Classified as limited stage (confined to 1 hemithorax) or extensive (widely disseminated)
o Limited tx- chemo/radiation. Extensive tx- palliative chemo
o From endocrine glands of bronchial mucosa, rapid growth, most present with mets
▪ Hormonal involvement – breast involvement
• Presentation:
o Cough
o Dyspnea, hoarseness, hemoptysis, chest pain, wheezing, stridor, dysphasia, SVC
syndrome, pleural effusion (d/t obstruction)
o Paraneoplastic syndrome
o Systemic (weight loss, anorexia), Neuro/endocrine (SIADH, neuropathy),
Heme (hypercoagulable, anemia, leukocytosis)
• W/U:
o H&P- ID risk factors, smoking/environmental Hx, ROS (fatigue, weight loss)
o PE- Head/neck, chest, extremities (clubbing), lymph nodes
o Labs- CBC/d, CMP, LFT, LDH (lactate dehydrogenase); CXR (possible visible lesion),
CT (diagnostic), PET (for staging). Biopsy for staging
• Mgmt:
, o NSCLC- Surgery to resect in early stages (I&II). Radiation even in non-operable, palliative.
Chemo
• Lung Carcinoid Tumor
• Rare, good survival, average 60y. Known to recur
• Pathophys- Mutated neuroendocrine cells in large airways, cause obstruction. Slow
growing, can produce peptides & hormones
• Mgmt: Chemo, surgery (partial lobe to lung), radiation
Pulmonary HTN
• Pulmonary pressure inappropriately high for blood to flow through lungs. Remodeling of small
pulm arteries, increased PVR & RV failure. Characterized by progressive dyspnea & associated
functional limitations
• Causes: Idiopathic, familial, diseases, drugs/toxins, connective tissue d/o, HIV, valvular
d/o, hypoxia most common (obstructive sleep apnea OSA, COPD)
• Presentation:
• Usually asymptomatic until severe, normal exam in early stages
• Fatigue, angina, syncope, cough, hemoptysis, Reynaud’s phenomenon, edema,
decreased exercise tolerance
• Loud 2nd heart sound, high pitched holosystolic murmur, jugular V wave, left
parasternal heave
• Advanced symptoms r/t RH failure (hepatomegaly, ascites, JVD, peripheral edema)
• W/U:
• Find causative factor
• ECG (changes show RVH), CXR (large pulm arteries), V/Q (r/o embolus), echo, cardiac
MRI, cardiac cath (get exact pressures)
• Labs- CBC, LFT, TSH, BNP
• Mgmt:
• Referral to Pulmonary/Cardiology
• Improve symptoms (dyspnea), enhance functional capacity & exercise endurance
• 02 therapy, correct acid/base balance, diuretics, treat OSA, anticoagulation,
meds, Low-Na diet, lung transplant
• Directed by causative factor
COPD
• Characterized by persistent airflow limitation that's usually progressive and associated with
an enhanced abnormal inflammatory response in lungs
• Exacerbations and comorbidities contribute to the overall severity in individual patients.
• COPD is a leading cause of mortality worldwide and projected to increase in the next
several decades.
, •
• Chronic Bronchitis:
• Pathophys: Airway edema, airway wall thickening, excess mucous production, loss of
ciliary function. Airflow obstructed inspiration & expiration
• Chronic hypoxia & hypercapnia increase pulmonary artery resistance, cause
pulmonary HTN, cause cor pulmonale
• Blue bloaters
• Emphysema:
• Pathophys: Enlarged air spaces from alveolar wall destruction by elastace
• Pink puffers
• Risk factors: Cigarettes, occupational dust/chemicals, second hand smoke, indoor/outdoor
air pollution, poor nutrition, infections, low socioeconomic status, old, genetics
• Presentation:
• Dyspnea: Progressive, persistent and characteristically worse with exercise. Air hunger
• Chronic cough: May be intermittent and may be unproductive.
• Chronic sputum production: COPD patients commonly cough up sputum.
• W/U:
• Clinical diagnosis should be considered in any patient who has dyspnea, chronic cough,
or sputum production, and a history of exposure to risk factors for the disease.
• Spirometry: Required to make diagnosis; post-bronchodilator FEV1/FVC < 0.7 OR FVC <
80% expected
• Goals: Determine the severity of the disease (including the severity of
airflow limitation), impact on the patient's health status, and risk of future
events.
• Chest X-ray: Not diagnostic, can detect complications or comorbidities
• PNA, pulmonary HTN, pneumothorax. HF
• Lung volumes and diffusing capacity: Help to characterize severity but not essential
to patient management.
• EKG: Assess severity of lung disease & RH involvement
• Oximetry and ABG: Pulse oximetry to evaluate 02 saturation and need for supplemental
02 therapy.
• Labs: Alpha-1 antitrypsin deficiency screening (develops in Caucasian <45 years or
with strong family history of COPD), CBC/d (Hg/Hct elevated in severe hypoxemia)
Assess symptoms using:
• COPD Assessment Test (CAT)
• Clinical COPD Questionnaire (CCQ)
• mMRC Breathlessness scale
Classification of Severity of Airflow Limitation in COPD
, In patients with FEV1/FVC
GOLD 1 Mild FEV1 ≥80%
predicted GOLD 2 Moderate 50% ≤FEV1
GOLD 3 Severe 30% ≤FEV1
GOLD 4 Very Severe Below 30% FEV1
Assess Risk of Exacerbations
Use history of exacerbations and spirometry:
• Two or more exacerbations within the last year or an FEV1, less than 50%
• One or more hospitalizations for COPD exacerbation should be considered high risk.
Assess COPD Comorbidities
COPD patients are at increased risk for:
• CV diseases, Osteoporosis (chronic steroid use), Respiratory infections, Anxiety and
depression, DM, Lung cancer, Bronchiectasis
• Mgmt:
• Some interventions improve survival, some improve symptoms
• Smoking cessation #1 intervention to reduce decline of lung function. Encourage all
patients who smoke to quit at all encounters
• Pharmacotherapy and nicotine replacement reliably increase long-term
smoking abstinence rates.
• All benefit from regular physical activity and should repeatedly be encouraged to
remain active.
• Medications:
• Can improve exercise tolerance, reduce # and severity of exacerbations, & improve
lung function
• Beta2 agonists (Bronchodilator)- Short & Long-acting
• Anticholinergics (Bronchodilator)- Short & Long-acting. – preferred
• Long-acting formulations are preferred over short-acting formulations.
• Combo short-acting beta2 agonists + anticholinergic in one OR Combo long-acting
beta2 agonists + anticholinergic in one
• Inhaled corticosteroid with a long-acting beta2 agonist is more effective than the
individual components in improving lung function and health status and reducing
exacerbations in moderate to very severe COPD.
• Methylxanthines (Bronchodilator)- Less popular
• Inhaled corticosteroids
• Reduce exacerbations in FEV1 <60%
• Associated with increased risk of pneumonia
• Long-term treatment with inhaled corticosteroids added to long-acting
bronchodilators is recommended for patients with high risk of
exacerbations.
• Combination long-acting beta2 agonists + corticosteroids in one inhaler
• Systemic corticosteroids
• Chronic treatment with systemic corticosteroids should be avoided because of
an unfavorable benefit-to-risk ratio.
• Phosphodiesterase-4 inhibitors
