Surgical Interventions for COPD

Max Huang, MD, FRCPC, Respirology Fellow, Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON.
Lianne G. Singer, MD, FRCPC, Medical Director, Toronto Lung Transplant Program, University Health Network; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Chronic obstructive pulmonary disease (COPD) often has a profound effect upon the quality of life and mortality of the older adult. Despite numerous medical treatments, surgery may be considered for the symptomatic patient with medically-optimized, end-stage COPD. Bullectomy, lung volume reduction surgery (LVRS), and lung transplantation have all proven to be important surgical therapies. This article reviews the current state of these interventions, and the criteria when deciding on the best surgical option for a given patient.

Key words: emphysema, COPD, lung transplant, lung volume reduction surgery, bullectomy.

Bronchiectasis in Older Adults

Nasreen Khalil, MD, FRCPC, FCCP, Associate Professor of Medicine, The University of British Columbia, Jack Bell Research Centre, Vancouver, BC.

Bronchiectasis is an anatomic abnormality of the airway characterized by irreversible dilatation and thickening of the airway wall. The most common etiology in older patients appears to be a previous pulmonary infection. Prior to the antibiotic era the age group most frequently affected by bronchiectasis was young children. Currently, bronchiectasis is seen primarily in individuals between the ages of 60 and 80. Pseudomonas aeruginosa and Hemophilus influenza are the most commonly isolated pathogens in the sputum of bronchiectatic patients. Treatment consists of ruling out reversible or correctible causes, commencing antibiotic therapy, and improving bronchial hygiene.

Key words: bronchiectasis, chronic cough, chronic sputum, mucociliary, immunodeficiency.

Hemoptysis in Older Adults: Etiology, Diagnosis, and Management

Samir Gupta, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Robert Hyland, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.

Hemoptysis is an important clinical problem that is especially ominous when seen in older patients. The main causes of hemoptysis in first world nations are bronchogenic carcinoma, bronchitis, and bronchiectasis. In older patients cancer remains the main concern, especially if there is a smoking history. The diagnostic approach to nonmassive hemoptysis starts with a chest x-ray, followed by a CT scan and then fibre optic bronchoscopy, which is well tolerated by older adults. In massive hemoptysis, chest x-ray is usually followed immediately by fibre optic or rigid bronchoscopy. Older patients require closer monitoring due to poor cardiopulmonary reserve; management options include endoscopic interventions, bronchial artery embolization,
surgery, and radiation.

Key words: hemoptysis, etiology, management, older adults, bronchiectasis.

Lung Disease and the Aging Adult

For my sins, I am currently acting as the interim division director for general internal medicine and geriatrics at my hospital. A quick tour around the general medical units revealed the following information. Most of the inpatients are older and shortness of breath is the most common symptom they arrive with. The likeliest reasons for the shortness of breath are congestive heart failure (CHF), an exacerbation of chronic lung disease, and pneumonia. Many of those with CHF or pneumonia also have underlying chronic lung disease as a predisposing factor. There are many reasons for the high prevalence of chronic lung disease in older adults, but I believe that the major reason is the one most obvious: they have been smokers for many, many years. I do not believe that it is ever too late to stop smoking, and when we see older patients in our offices or on the wards, it behooves us to determine in each case if there is a smoking history and prudently offer to provide the tools to help them stop if they are presently smokers.

This issue focuses on lung diseases in older adults and covers a variety of topics. Dr. Jean Bourbeau tackles a large topic in his article “Diagnosis and Management of Chronic Obstructive Pulmonary Disease in Older Adults.” Drs. Ashraf Alzaabi and Theodore Marras review the “Management of Community-Acquired Pneumonia in Older Adults,” while Drs. Samir Gupta and Robert Hyland have contributed the article “Hemoptysis in Older Adults: Etiology, Diagnosis, and Management.” Next, Dr. Nasreen Khalil reviews “Bronchiectasis in Older Adults.” My experience has been that as CT scans of the chest are performed more routinely, we are making the diagnosis more frequently.
As well, we have our usual collection of interesting topics in other areas. Dr. Diego Delgado has written about the “Diagnosis and Management of Diastolic Heart Failure,” while Rory Fisher and Eoin Connolly review the issue of “Artificial Nutrition and Hydration in the Management of End-Stage Dementias.” In the last few years, real information is being presented on this topic, rather than the opinions and ivory tower philosophical discussions that were published in years past. Dr. Fisher is one of those who have contributed to that scientific base on the topic. Drs. Dror Marchaim, Victor Dishy, and Ahuva Golik present a timely reminder, “Concepts in Geriatric Clinical Pharmacology” for our Drugs & Aging column. Finally, Drs. Loren Mell and Arno Mundt review the topic of “Radiation Therapy in Older Adults”.

I hope you all survived the recent holiday season with your waistlines intact.

Enjoy this issue,

Barry Goldlist

Management of Community-Acquired Pneumonia in Older Adults

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words: pneumonia, management, older adults, guidelines, resistance.

CME: Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Jean Bourbeau MD, MSc, FRCPC, Montreal Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology and Biostatistics, McGill University, Montreal, QC.

With the population progressively aging, the geriatric aspects of COPD deserve special consideration. Older adults with respiratory symptoms and a current or previous history of smoking should be considered for a diagnosis of COPD. Objective demonstration of airflow obstruction is mandatory for the diagnosis of COPD. The majority of older people can adequately perform spirometry for an objective demonstration of airflow obstruction. Nonpharmacological treatment includes smoking cessation, vaccination, self-management education and communication with a case manager, and pulmonary rehabilitation. Bronchodilators are the most important agents in the pharmacotherapy of COPD. Inhaled corticosteroids are indicated for patients with recurrent exacerbations who are already on optimal bronchodilator therapy.

Key words: chronic obstructive pulmonary disease, older adults, diagnosis, spirometry, management.

Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

George P. Chandy, MD, MSc, Department of Medicine, University of Ottawa, Ottawa, ON.
Shawn D. Aaron, MD, MSc, Department of Medicine and the Ottawa Health ResearchInstitute, University of Ottawa, Ottawa, ON.

Chronic Obstructive Pulmonary Disease (COPD) has been increasing in prevalence over the past several decades. The impact of COPD on the health status of Canadians will continue to be a major issue, despite declining rates of smoking, as physiologic manifestations of COPD may only be evident decades after the initiation of smoking. Given the delay between the initiation of smoking and the development of significant disease, COPD is primarily a disease of the older population. While a cure for COPD is not available, a number of medications have been noted to have a significant impact on symptoms, exercise tolerance, and quality of life.

Key words: COPD, treatment, management, older adults.

The BreathWorks Program

The Lung Association Helps Patients Learn to Manage COPD

Susan Lightstone, co-author of Every Breath I Take: A Guide to Living with COPD, and former Senior Advisor for the National Judicial Institute, Ottawa, ON.

Looking hopeful and gazing skyward, Lorraine LeBlanc is pictured on the front cover of The BreathWorks Plan, a 41-page educational guide about living with Chronic Obstructive Pulmonary Disease (COPD) written for those, like Ms. LeBlanc, who know they have the disease or those who suspect they might have it. The guide is plainly written and full of practical advice for COPD patients on how to work together with their doctors to manage their disease, and is also intended for use by the family, friends and caregivers of those with COPD.

The BreathWorks Plan is distributed free of charge and forms an integral part of The Lung Association's recently announced BreathWorks Program.

The Aging Lung: Implications for Diagnosis and Treatment of Respiratory Illnesses in the Elderly

Benjamin Chiam, MD, Department of Medicine, Pulmonary Division, University of Alberta, Edmonton, AB.
Don D. Sin, MD, FRCP(C), Department of Medicine, Pulmonary Division, University of Alberta, and The Institute of Health Economics, Edmonton, AB.

Introduction
Respiratory conditions are among the leading causes of morbidity and mortality worldwide. Although they are currently listed as the fifth leading cause of death in Canada, respiratory diseases are predicted to be the third leading cause of mortality by the year 2020, following ischemic heart disease and stroke.¹ Furthermore, since the prevalence of these conditions increases with age, the adverse impact of respiratory illnesses on the Canadian health care system will grow enormously over the next few decades as the overall population ages² and treatments for other common conditions, such as ischemic heart disease, stroke and diabetes, improve. A good understanding of the aging process of the respiratory system is clearly needed to formulate better strategies to prevent, diagnose and manage respiratory conditions in Canada.

Why are Respiratory Diseases so Prevalent in the Elderly?
The lungs of elderly persons are subject to a lifetime of exposure to known and unknown harmful agents. Decades may pass before the physical manifestations of cigarette smoke, pollution and other noxious environmental agents become clinically apparent.

Pulmonary Arterial Hypertension: An Update

John Granton, MD, Assistant Professor of Medicine, University of Toronto; Pulmonary Arterial Hypertension Programme, University Health Network, Toronto, ON.
Moiz Zafar, MD, Resident, Respiratory Medicine, McMaster University, Hamilton, ON; Pulmonary Arterial Hypertension Programme, University Health Network, Toronto, ON.

Introduction
On first glance, a review of pulmonary arterial hypertension (PAH) in a journal that focuses on the health of the elderly may seem out of place. PAH is typically envisioned as a progressively disabling disease in young females. However, PAH is not a disease restricted to the young. Indeed, 20% of the patients followed in our pulmonary hypertension clinic are over the age of 65. Although information regarding the natural course of PAH has been described in a report of the National Registry for Primary Pulmonary Hypertension, this information is not representative of the elderly population.¹ In particular, given the greater prevalence of comorbid conditions in the elderly, one must be particularly vigilant in searching for an underlying secondary cause of PAH. Owing to a paucity of information in this population, most of our comments derive from our own observations of PAH in the elderly and from inferences made from their younger counterparts.

Definition
PAH is defined as an elevation in pulmonary arterial pressure greater than 25mmHg at rest or 30mmHg with exercise.