Copd And The Gold Guidelines 02 21 2005[2]

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Copd And The Gold Guidelines 02 21 2005[2]

  1. 1. COPD and the GOLD Guidelines Fiona R. Prabhu, MD Assistant Professor, Family & Community Medicine February 21, 2005
  2. 2. Prevalence <ul><li>12.1 million adults aged 25 and over were diagnosed with COPD in 2001 </li></ul><ul><li>24 million adults have evidence of impaired lung function -> underdiagnosis </li></ul>
  3. 3. Mortality <ul><li>4 th leading cause of death in the United States currently </li></ul><ul><li>Projected to be the 3 rd leading cause of death for both males and females by 2020 </li></ul><ul><li>119,000 adults age 25 and over died from COPD in 2000 </li></ul>
  4. 4. Costs <ul><li>1.5 million emergency room visits in 2000 </li></ul><ul><li>726,000 hospitalizations in 2000 </li></ul><ul><li>Total estimated cost of COPD in 2002 was $32.1 billion </li></ul><ul><ul><li>$18 billion in direct costs </li></ul></ul><ul><ul><li>$14.1 billion in indirect costs </li></ul></ul>
  5. 5. Definition <ul><li>Airflow limitation that is NOT fully reversible </li></ul><ul><ul><li>Progressive </li></ul></ul><ul><ul><li>Associated with an abnormal inflammatory response of the lungs to noxious particles or gases </li></ul></ul>
  6. 6. Pathogenesis <ul><li>Three processes: </li></ul><ul><ul><li>Chronic inflammation </li></ul></ul><ul><ul><li>Imbalance of proteinases and anti-proteinases </li></ul></ul><ul><ul><li>Oxidative stress </li></ul></ul>
  7. 7. Chronic Inflammation <ul><li>Chronic inflammation in airways, parenchyma, pulmonary vasculature </li></ul><ul><li>Inflammatory cells involved are: </li></ul><ul><ul><li>Macrophages leukotriene B4 </li></ul></ul><ul><ul><li>T-lymphocytes (CD8) interleukin 8 </li></ul></ul><ul><ul><li>Neutrophils TNF- α </li></ul></ul>
  8. 8. Pathology <ul><li>Central Airways: </li></ul><ul><ul><li>Enlarged mucus secreting glands </li></ul></ul><ul><ul><li>Increase in goblet cells </li></ul></ul><ul><ul><li>Mucus hypersecretion </li></ul></ul><ul><li>Peripheral Airways </li></ul><ul><ul><li>Repeated cycles of injury and repair </li></ul></ul><ul><ul><li>Increased collagen/scarring in airway wall </li></ul></ul>
  9. 9. Pathology <ul><li>Pulmonary vascular changes </li></ul><ul><li>Thickening of vessel wall (intima) </li></ul><ul><li>Increase in smooth muscle </li></ul><ul><li>Infiltration of vessel wall by inflammatory cells </li></ul><ul><li>As COPD worsens, more smooth muscle, proteoglycans and collagen further thicken the vessel wall </li></ul>
  10. 10. Pathophysiology <ul><li>Mucus hypersecretion </li></ul><ul><li>Ciliary dysfunction </li></ul><ul><li>Airflow limitation </li></ul><ul><li>Pulmonary hyperinflation </li></ul><ul><li>Gas exchange abnormalities </li></ul><ul><li>Pulmonary hypertension </li></ul><ul><li>Cor pulmonale </li></ul><ul><li>Mucus hyperserection & ciliary dysfunction -> cough, sputum production </li></ul>
  11. 11. Diagnosis of COPD
  12. 12. History of Present Illness <ul><li>Chronic Cough </li></ul><ul><ul><li>Intermittently or every day </li></ul></ul><ul><ul><li>Present throughout the day; seldom only nocturnal </li></ul></ul><ul><li>Chronic sputum production </li></ul><ul><ul><li>Any pattern </li></ul></ul><ul><li>Repeated episodes of acute bronchitis </li></ul><ul><li>Chronic cough and sputum production often precede development of airflow limitation by many years </li></ul><ul><ul><ul><li>Not all patients with these symptoms develop COPD </li></ul></ul></ul><ul><li>Dyspnea on exertion </li></ul><ul><ul><li>Progressive </li></ul></ul><ul><ul><li>Persistent </li></ul></ul><ul><ul><li>Worse with exercise </li></ul></ul><ul><ul><li>Worse during respiratory infections </li></ul></ul><ul><li>History of exposure to risk factors </li></ul><ul><ul><li>Tobacco smoke </li></ul></ul><ul><ul><li>Occupational dusts and chemicals </li></ul></ul><ul><ul><li>Smoke from home cooking and heating fuels </li></ul></ul>
  13. 13. Medical History <ul><li>Exposure to risk factors , incl. intensity/duration </li></ul><ul><li>History of exacerbations or previous hospitalizations for respiratory disorder </li></ul><ul><li>Past medical history </li></ul><ul><ul><li>Asthma, allergies, sinusitis/nasal polyps, respiratory infections in childhood </li></ul></ul><ul><ul><li>Presence of co-morbid conditions </li></ul></ul><ul><ul><ul><li>Heart disease </li></ul></ul></ul><ul><ul><ul><li>Rheumatic disease </li></ul></ul></ul><ul><li>Family History </li></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Other chronic respiratory diseases </li></ul></ul><ul><li>Social History </li></ul><ul><ul><li>Impact of disease on patient’s life, inc. activity, missed work and economic impact </li></ul></ul><ul><ul><li>Effect on family routines </li></ul></ul><ul><ul><li>Depression/anxiety </li></ul></ul><ul><ul><li>Social and family support available to the patient </li></ul></ul><ul><li>Other: </li></ul><ul><ul><li>Appropriateness of current medical treatments </li></ul></ul><ul><ul><li>Possibilities for reducing risk factors, esp. smoking cessation </li></ul></ul>
  14. 14. Risk Factors <ul><li>Tobacco Smoke </li></ul><ul><ul><li>Cigarettes, </li></ul></ul><ul><ul><li>Pipes, cigars – lower rates than cigarette smokers but higher than non-smokers </li></ul></ul><ul><li>Occupational dusts and chemicals </li></ul><ul><ul><li>Vapors, irritants, fumes </li></ul></ul><ul><ul><ul><li>Need sufficiently intense or prolonged exposure </li></ul></ul></ul><ul><li>Indoor air pollution </li></ul><ul><ul><li>Biomass fuel used for cooking and heating in poorly vented dwellings </li></ul></ul><ul><li>Outdoor air pollution </li></ul><ul><ul><li>Minor risk factor Passive cigarette smoke exposure </li></ul></ul><ul><li>Respiratory infections in early childhood </li></ul><ul><li>Lower socioeconomic status </li></ul><ul><ul><li>association with COPD </li></ul></ul><ul><ul><li>May be secondary to crowding, poor nutrition, etc. </li></ul></ul>
  15. 15. Physical Examination <ul><li>Thorax: </li></ul><ul><ul><li>Barrel chest </li></ul></ul><ul><li>Lungs </li></ul><ul><ul><li>Decreased breath sounds </li></ul></ul><ul><ul><li>Wheezing </li></ul></ul><ul><li>Cardiac </li></ul><ul><ul><li>Right-sided heart failure </li></ul></ul><ul><ul><ul><li>Edema, tender liver, distended abdomen </li></ul></ul></ul><ul><ul><ul><li>Physical signs are rarely apparent until significant impairment of lung function has occurred </li></ul></ul></ul>
  16. 16. Diagnostic Tests <ul><li>Chest X-ray </li></ul><ul><ul><li>Flattened diaphragms </li></ul></ul><ul><ul><li>Use to exclude other diagnoses </li></ul></ul><ul><li>High resolution CT </li></ul><ul><ul><li>Not routinely recommended </li></ul></ul><ul><ul><li>If in doubt about diagnosis of COPD </li></ul></ul><ul><ul><li>If considering bullectomy or lung volume reduction surgery </li></ul></ul><ul><li>CBC </li></ul><ul><ul><li>May see increased hemoglobin/hematocrit secondary to hemoconcentration </li></ul></ul><ul><li>ABG </li></ul><ul><li>Spirometry </li></ul>
  17. 17. Spirometry <ul><li>Measure of FVC and FEV 1 </li></ul><ul><ul><li>FVC = forced vital capacity </li></ul></ul><ul><ul><ul><li>Maximum volume of air forcibly exhaled from the point of maximal inhalation </li></ul></ul></ul><ul><ul><li>FEV 1 = forced expiratory volume in 1 second </li></ul></ul><ul><ul><ul><li>Volume of air exhaled in the 1 st second of the FVC maneuver </li></ul></ul></ul><ul><li>Calculate the FVC/FEV 1 ratio </li></ul><ul><ul><li>Normal ratio = 70/80% </li></ul></ul><ul><ul><li>COPD ratio = <70% pre-bronchodilator FVC & FEV are </li></ul></ul><ul><ul><li>COPD ratio = <80% post-bronchodilator both decreased </li></ul></ul><ul><li>Essential to making the diagnosis of COPD </li></ul>
  18. 18. Spirometry <ul><li>Best performed with the patient seated </li></ul><ul><li>Optimal results: </li></ul><ul><ul><li>Patient breathes in fully </li></ul></ul><ul><ul><li>Patient must seal their lips around the mouthpiece </li></ul></ul><ul><ul><li>Have the patient force the air out of their chest as hard and fast as they can until their lungs are completely “empty” </li></ul></ul><ul><ul><ul><li>Exhalation must be at least 6 seconds and can take up to 15 seconds </li></ul></ul></ul><ul><ul><li>Breathe in again and relax </li></ul></ul><ul><li>Need 3 technically satisfactory curves </li></ul><ul><ul><li>Vary no more than 5% (or 100 mL) </li></ul></ul><ul><ul><li>Ratio is calculated from the maximum FVC and FEV 1 from any of these curves. </li></ul></ul>
  19. 19. Spirometry <ul><li>Bronchodilator Reversibility Testing </li></ul><ul><ul><li>Perform in the initial assessment of COPD in order to: </li></ul></ul><ul><ul><ul><li>Exclude asthma </li></ul></ul></ul><ul><ul><ul><li>Establish best attainable lung function </li></ul></ul></ul><ul><ul><ul><li>Gauge patient prognosis </li></ul></ul></ul><ul><ul><ul><li>Guide treatment decisions </li></ul></ul></ul>
  20. 20. Arterial Blood Gas (ABG) <ul><li>Obtain in patients with FEV 1 < 40% predicted OR </li></ul><ul><li>Clinical signs of respiratory or right heart failure </li></ul><ul><ul><li>Central cyanosis, ankle swelling, increase in jugular venous pressure (JVP) OR </li></ul></ul><ul><li>Respiratory Failure: </li></ul><ul><ul><li>PaO 2 < 60 mm Hg with or without PaCO 2 > 45 mm Hg while breathing air at sea level </li></ul></ul><ul><li>Technique: </li></ul><ul><ul><li>Obtain by arterial puncture; DO NOT USE finger or ear oximeters </li></ul></ul>
  21. 21. Other Tests <ul><li>Alpha-1 antitrypsin </li></ul><ul><ul><li>Consider in patients with COPD < age 45 </li></ul></ul><ul><ul><li>Strong family hx of early COPD or with alpha-1 antitrypsin deficiency </li></ul></ul>
  22. 22. Differential Diagnosis of COPD <ul><li>Asthma </li></ul><ul><ul><li>Reversible airflow limitation </li></ul></ul><ul><ul><li>Early onset (childhood) </li></ul></ul><ul><ul><li>Symptoms vary day to day </li></ul></ul><ul><li>Congestive heart failure </li></ul><ul><ul><li>Volume restriction, NOT airflow limitation </li></ul></ul><ul><ul><li>CXR with dilated heart, pulmonary edema </li></ul></ul><ul><li>Bronchiectasis </li></ul><ul><ul><li>Large volumes of purulent sputum </li></ul></ul><ul><ul><li>Commonly associated with bacterial infection </li></ul></ul><ul><ul><li>Bronchial dilation and bronchial wall thickening on CXR or CT </li></ul></ul><ul><li>Tuberculosis </li></ul><ul><ul><li>Onset at all ages </li></ul></ul><ul><ul><li>Chest x-ray with infiltrate or nodular lesions </li></ul></ul><ul><li>Obliterative bronchiolitis </li></ul><ul><ul><li>Younger patients/non-smokers </li></ul></ul><ul><ul><li>May have a hx of rheumatoid arthritis or fume exposure </li></ul></ul><ul><ul><li>CT shows hypodense areas with expiration </li></ul></ul><ul><li>Diffuse panbronchiolitis </li></ul><ul><ul><li>Male/non-smokers </li></ul></ul><ul><ul><li>Chronic sinusitis </li></ul></ul><ul><ul><li>CXR and high resolution CT show diffuse small centrilobular nodular opacities and hyperinflation </li></ul></ul>
  23. 23. COPD Management Program GOLD (Global Initiative for Chronic Obstructive Lung Disease) Guidelines
  24. 24. Goals <ul><li>Prevent disease progression </li></ul><ul><li>Relieve symptoms </li></ul><ul><li>Improve exercise tolerance </li></ul><ul><li>Improve health status </li></ul><ul><li>Prevent and treat complications </li></ul><ul><li>Prevent and treat exacerbations </li></ul><ul><li>Reduce mortality </li></ul><ul><li>Prevent or minimize side effects from treatment </li></ul><ul><li>Cessation of cigarette smoking </li></ul>
  25. 25. Components <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Manage acute exacerbations </li></ul>
  26. 26. Assess and Monitor Disease
  27. 27. Initial Visit <ul><li>Pattern of symptom development </li></ul><ul><li>Exposure to risk factors </li></ul><ul><li>History of exacerbations or previous hospitalizations for respiratory disorder </li></ul><ul><li>Past medical history </li></ul><ul><li>Family history </li></ul><ul><li>Social history </li></ul><ul><ul><li>Impact of disease on patient’s life </li></ul></ul><ul><ul><li>Effect on family routines </li></ul></ul><ul><ul><li>Feelings of depression or anxiety </li></ul></ul><ul><ul><li>Social and family support available to the patient </li></ul></ul><ul><li>Possibilities for reducing risk factors, especially smoking cessation </li></ul>
  28. 28. Testing <ul><li>Spirometry </li></ul><ul><ul><li>Initially and yearly </li></ul></ul><ul><li>ABG </li></ul><ul><ul><li>Obtain if FEV 1 < 40% predicted OR </li></ul></ul><ul><ul><li>Clinical signs of respiratory or right heart failure </li></ul></ul><ul><ul><li>Respiratory Failure </li></ul></ul><ul><li>Alpha-1 antitrypsin </li></ul><ul><ul><li>If patient <45 years old or strong family history of COPD </li></ul></ul>
  29. 29. Follow-Up Visits <ul><li>Discuss new or worsening symptoms </li></ul><ul><ul><li>Perform spirometry if there is a substantial increase in symptoms OR if a complication occurs </li></ul></ul><ul><li>ABG </li></ul><ul><ul><li>Patients with an FEV1 <40% predicted </li></ul></ul><ul><ul><li>Early signs of respiratory failure or CHF </li></ul></ul><ul><li>Monitor pharmacotherapy </li></ul><ul><ul><li>Dosages </li></ul></ul><ul><ul><li>Adherence </li></ul></ul><ul><ul><li>Inhaler technique </li></ul></ul><ul><ul><li>Effectiveness of current regimen at controlling symptoms </li></ul></ul><ul><ul><li>Side effects of treatment </li></ul></ul>
  30. 30. Follow-up Visits <ul><li>Monitor co-morbid conditions </li></ul><ul><ul><li>Bronchial carcinoma </li></ul></ul><ul><ul><li>Tuberculosis </li></ul></ul><ul><ul><li>Sleep apnea </li></ul></ul><ul><ul><li>Left heart failure </li></ul></ul><ul><ul><ul><li>Obtain appropriate information through CXR, ECG whenever symptoms suggest one of these conditions </li></ul></ul></ul>
  31. 31. Reduce Risk Factors
  32. 32. Risk Factors <ul><li>Tobacco smoke </li></ul><ul><li>Occupational dusts and chemicals </li></ul><ul><li>Indoor and outdoor air pollutants </li></ul>
  33. 33. Smoking Cessation <ul><li>The single MOST effective and cost-effective intervention to reduce the risk of developing COPD and to stop its progression </li></ul><ul><li>Brief tobacco dependence treatment is effective </li></ul><ul><ul><li>Offer this at EVERY visit to the health care provider </li></ul></ul><ul><ul><ul><li>Brief 3 minute period of counseling </li></ul></ul></ul><ul><li>Three types of counseling are esp. effective: </li></ul><ul><ul><li>Practical counseling </li></ul></ul><ul><ul><li>Social support as part of the treatment </li></ul></ul><ul><ul><li>Social support arranged outside of the treatment </li></ul></ul><ul><li>Several effective medications are available and at least one of these medications should be added to counseling if necessary and if there are no contraindications </li></ul><ul><ul><li>Nicotine gum, inhaler, nasal spray, trasndermal patch, sublingual tablet, lozenges </li></ul></ul><ul><ul><li>Bupropion </li></ul></ul><ul><ul><li>nortriptyline </li></ul></ul>Treating Tobacco Use and Dependence . Quick Reference Guide for Clinicians.
  34. 34. Smoking Cessation Strategy Treating Tobacco Use and Dependence . Quick Reference Guide for Clinicians. Schedule a follow-up contact, either in person or via telephone Arrange Aid the patient in quitting e.g. quit plan, counseling, intra-treatment social support, extra-treatment social support, approved pharmacotherapy, supplementary materials Assist Determine willingness to make a quit attempt. e.g. within the next 3 days, how willing is this person to make a quit attempt Assess Strongly urge all tobacco users to quit, in a clear, strong, and personalized manner Advise Systematically identify all tobacco users at every visit Ask
  35. 35. Smoking Prevention – What you can do as a provider: <ul><li>Encourage comprehensive tobacco-control policies and programs </li></ul><ul><li>Work with government officials to pass legislation to establish smoke-free schools, public facilities, and work environments </li></ul><ul><li>Encourage patients to keep smoke-free homes </li></ul>Treating Tobacco Use and Dependence . Quick Reference Guide for Clinicians.
  36. 36. Occupational Exposures <ul><li>Primary prevention </li></ul><ul><ul><li>Eliminate or reduce exposures to various substances in the workplace </li></ul></ul><ul><li>Secondary prevention </li></ul><ul><ul><li>Surveillance and early detection </li></ul></ul>
  37. 37. Indoor and Outdoor Air Pollution <ul><li>Implement measures to reduce or avoid indoor air pollution from biomass fuel burned for cooking and heating in poorly ventilated dwellings </li></ul><ul><li>Advise patients to monitor public announcements of air quality </li></ul><ul><li>Avoid vigorous exercise outdoors or stay indoors during pollution episodes, depending on COPD severity </li></ul>
  38. 38. Manage Stable COPD
  39. 39. General Principles <ul><li>Determine disease severity </li></ul><ul><li>Implement step-wise treatment plan </li></ul><ul><li>Educate the patient </li></ul><ul><ul><li>Improve skills </li></ul></ul><ul><ul><li>Improve ability to cope with illness </li></ul></ul><ul><ul><li>Improve health status </li></ul></ul><ul><li>Prescribe Treatment </li></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><ul><li>Non-pharmacologic </li></ul></ul><ul><ul><ul><li>Rehabilitation </li></ul></ul></ul><ul><ul><ul><ul><li>Exercise training </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Nutrition counseling </li></ul></ul></ul></ul><ul><ul><ul><ul><li>education </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oxygen therapy </li></ul></ul></ul></ul><ul><ul><ul><li>Surgical interventions </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  40. 40. COPD Severity <ul><li>FEV1< 30% predicted OR </li></ul><ul><li>FEV1<50% predicted + chronic respiratory failure </li></ul><ul><li>Quality of life is appreciably impaired </li></ul><ul><li>Exacerbations may be life-threatening </li></ul>IV Very severe Normal spirometry Chronic symptoms (cough, sputum) 0: At Risk 30%<= FEV 1 < 50% predicted ↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life III: Severe 50% <= FEV 1 < 80% predicted Progression of symptoms; dyspnea on exertion II: Moderate FEV 1 /FVC < 70% FEV 1 >= 80% predicted Usu. Chronic cough and sputum production I: Mild Characteristics Stage
  41. 41. Patient Education <ul><li>Smoking cessation </li></ul><ul><li>Basic information about COPD and pathophysiology of the disease </li></ul><ul><li>General approach to therapy and specific aspects of medical treatment </li></ul><ul><li>Self-management skills </li></ul><ul><li>Strategies to help minimize dyspnea </li></ul><ul><li>Advice about when to seek help </li></ul><ul><li>Self-management and decision-making in exacerbations </li></ul><ul><li>Advance directives and end-of-life issues </li></ul>
  42. 42. Medications <ul><li>Goals </li></ul><ul><ul><li>Prevent and control symptoms </li></ul></ul><ul><ul><li>Reduce frequency and severity of exacerbations </li></ul></ul><ul><ul><li>Improve health status </li></ul></ul><ul><ul><li>Improve exercise tolerance </li></ul></ul><ul><li>No existing medications can modify the long-term decline in lung function </li></ul><ul><li>Reduction of therapy once symptom control occurs is not normally possible </li></ul><ul><li>COPD is progressive and over time will require progressive introduction of more treatments to attempt to limit the impact of these changes </li></ul>
  43. 43. Bronchodilators <ul><li>Central to symptom management </li></ul><ul><ul><li>Used in all stages of COPD severity </li></ul></ul><ul><li>Inhaled forms are preferred </li></ul><ul><li>Can be prescribed as needed OR regularly to prevent or reduce symptoms </li></ul><ul><li>Long-acting inhaled bronchodilators are more effective and convenient (but are more expensive) </li></ul><ul><li>Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects </li></ul><ul><li>All categories of bronchodilators have been show to increase exercise capacity without necessarily producing significant changes in FEV 1 </li></ul>
  44. 44. Bronchodilators <ul><li>Beta 2 -agonists </li></ul><ul><ul><li>Short-acting: albuterol </li></ul></ul><ul><ul><li>Long-acting: salmeterol (Serevent ™ ), formoterol (Foradil ™) </li></ul></ul><ul><li>Anticholinergics </li></ul><ul><ul><li>Short acting: ipratropium bromide (Atrovent ™) </li></ul></ul><ul><ul><li>Long acting: tiotropium bromide (Spiriva ™) </li></ul></ul><ul><li>Methylxanthines (Theophylline ™ ) </li></ul><ul><li>Combination bronchodilators </li></ul><ul><ul><li>Fenoterol/ipratropium (Duovent ™) </li></ul></ul><ul><ul><li>Salbutamol/ipratropium (Combivent ™) </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  45. 45. Glucocorticosteroids <ul><li>Use if FEV 1 < 50% predicted and repeated exacerbations, e.g. three in the last three years </li></ul><ul><ul><li>Severe COPD and Very Severe COPD </li></ul></ul><ul><li>Does not modify the long-term decline in FEV 1 BUT does reduce the frequency of excacerbations and improves health status </li></ul><ul><li>The combination of a long-acting beta2-agonist and an inhaled glucocorticosteroid is more effective than the individual components </li></ul><ul><li>Long-term treatment with oral glucocorticoids is NOT recommended </li></ul><ul><li>Glucocorticosteroid (inhaled) reversibility testing </li></ul><ul><ul><li>Treatment trial of inhaled glucocorticosteroids for 6 to 12 weeks then repeat spirometry with and without bronchodilators </li></ul></ul><ul><ul><li>Patients most likely to respond to inhaled steroids have an FEV 1 increase of 200 mL and 15% above baseline post-bronchodilator </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  46. 46. Inhaled Glucocorticoids <ul><li>Beclomethasone (Vanceril ™ ) </li></ul><ul><li>Budesonide (Pulmicort ™ ) </li></ul><ul><li>Fluticasone (Flovent ™ ) </li></ul><ul><li>Triamcinolone (Azmacort ™ ) </li></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  47. 47. Immunizations <ul><li>Vaccines </li></ul><ul><ul><li>Influenza yearly </li></ul></ul><ul><ul><ul><li>Reduces serious illness and death in COPD patients by approximately 50% </li></ul></ul></ul><ul><ul><ul><li>Give once yearly: autumn OR twice yearly: autumn and winter </li></ul></ul></ul><ul><ul><li>Pneumovax </li></ul></ul><ul><ul><ul><li>Sufficient data to support its general use in COPD is lacking, but it is commonly used </li></ul></ul></ul>
  48. 48. Other Medications? <ul><li>Alpha-1 Antitrypsin Augmentation Therapy </li></ul><ul><ul><li>Only if this deficiency is present in an individual should they undergo treatment </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Prophylactic use is NOT recommended </li></ul></ul><ul><ul><li>Can be used in the treatment of infectious exacerbations of COPD </li></ul></ul><ul><li>Mucolytic agents </li></ul><ul><ul><li>Overall benefits are small, so currently not recommended for widespread use </li></ul></ul><ul><ul><li>Types: </li></ul></ul><ul><ul><ul><li>Ambroxol </li></ul></ul></ul><ul><ul><ul><li>Erdosteine (Erdostin, Mucotec) </li></ul></ul></ul><ul><ul><ul><li>Carbocysteine (Mucodyne) </li></ul></ul></ul><ul><ul><ul><li>Iodinated gylerol (Expigen) </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  49. 49. Other Medications? <ul><li>Antioxidant agents </li></ul><ul><ul><li>N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst) </li></ul></ul><ul><ul><li>Have been shown to reduce the frequency of exacerbations and could have a role in the treatment of patients with recurrent exacerbations </li></ul></ul><ul><ul><ul><li>More studies are needed </li></ul></ul></ul><ul><li>Immunoregulators </li></ul><ul><ul><li>Not recommended at this time </li></ul></ul><ul><ul><li>No reproducible studies are available </li></ul></ul><ul><li>Antitussives </li></ul><ul><ul><li>Regular use is contraindicated in stable COPD since cough has a significant protective role </li></ul></ul><ul><li>Vasodilators </li></ul><ul><ul><li>Inhaled nitric oxide </li></ul></ul><ul><ul><ul><li>Can worsen gas exchange because of altered hypoxic regulation of ventilation-perfusion balance and is contraindicated in stable COPD </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  50. 50. Other Medications? <ul><li>Respiratory stimulants </li></ul><ul><ul><li>Doxapram (IV) </li></ul></ul><ul><ul><li>Almitrine bismesylate </li></ul></ul><ul><ul><ul><li>Not recommended in stable COPD </li></ul></ul></ul><ul><li>Narcotics </li></ul><ul><ul><li>Oral and parenteral opioids are effective for treating dyspnea in patients with advanced COPD </li></ul></ul><ul><ul><ul><li>Use this with caution; benefits may be limited to a few sensitive subjects </li></ul></ul></ul><ul><ul><li>nebulized opioids: insufficient evidence re: efficacy </li></ul></ul><ul><li>Miscellaenous: </li></ul><ul><ul><li>Nedocromil </li></ul></ul><ul><ul><li>Leukotriene modifiers </li></ul></ul><ul><ul><li>Alternative healing methods </li></ul></ul><ul><ul><ul><li>None have been adequately studied in COPD patients at this time </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  51. 51. Stage 0: At Risk <ul><li>Avoid risk factors </li></ul><ul><li>Offer influenza vaccination </li></ul>
  52. 52. Stage I: Mild COPD <ul><li>Avoid risk factors </li></ul><ul><li>Offer vaccination </li></ul><ul><li>Use short-acting bronchodilators as needed </li></ul>FEV 1 /FVC < 70% FEV 1 >= 80% predicted Usu. Chronic cough and sputum production I: Mild
  53. 53. Stage II: Moderate COPD <ul><li>Avoid risk factors </li></ul><ul><li>Offer influenza vaccine </li></ul><ul><li>Add short-acting bronchodilators when needed </li></ul><ul><li>Add regular treatment with 1 or more long-acting bronchodilators </li></ul><ul><li>Add rehabilitation </li></ul>50% <= FEV 1 < 80% predicted Progression of symptoms; dyspnea on exertion II: Moderate
  54. 54. Stage III: Severe COPD <ul><li>Avoid risk factors </li></ul><ul><li>Offer influenza vaccine </li></ul><ul><li>Add short-acting bronchodilators when needed </li></ul><ul><li>Add regular treatment with 1 or more long-acting bronchodilators </li></ul><ul><li>Add rehabilitation </li></ul><ul><li>Add inhaled glucocorticoids if repeated exacerbations </li></ul>30%<= FEV 1 < 50% predicted ↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life III: Severe
  55. 55. Stage IV: Very Severe COPD <ul><li>Avoid risk factors </li></ul><ul><li>Offer influenza vaccination </li></ul><ul><li>Add short-acting bronchodilators as needed </li></ul><ul><li>Add rehabilitation </li></ul><ul><li>Add inhaled glucocorticoids if repeated exacerbations </li></ul><ul><li>Add long-term oxygen if chronic respiratory failure </li></ul><ul><li>Consider surgical treatments </li></ul><ul><li>FEV1< 30% predicted OR </li></ul><ul><li>FEV1<50% predicted + chronic respiratory failure </li></ul><ul><li>Quality of life is appreciably impaired </li></ul><ul><li>Exacerbations may be life-threatening </li></ul>IV Very severe
  56. 56. Non-Pharmacologic Therapy
  57. 57. Rehabilitation <ul><li>COPD patients at all stages of severity benefit from exercise training programs </li></ul><ul><ul><li>Improves both exercise tolerance and symptoms of dyspnea and fatigue </li></ul></ul><ul><li>Goals </li></ul><ul><ul><li>Reduce symptoms </li></ul></ul><ul><ul><li>Improve quality of life </li></ul></ul><ul><ul><li>Increase physical and emotional participation in everyday activities </li></ul></ul><ul><li>Comprehensive program should include several types of health professionals: </li></ul><ul><ul><li>Exercise training </li></ul></ul><ul><ul><li>Nutrition counseling </li></ul></ul><ul><ul><li>Education </li></ul></ul><ul><li>Minimum effective length of time = 2 months </li></ul><ul><li>Setting: inpatient OR outpatient OR home </li></ul><ul><li>Baseline and outcome assessments of each participant should be made to quantify individual gains and target areas for improvement </li></ul><ul><ul><li>Measurement of spirometry before and after a bronchodilator drug </li></ul></ul><ul><ul><li>Assessment of exercise capacity </li></ul></ul><ul><ul><li>Assessment of inspiratory and expiratory muscle strength and lower limb strength </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  58. 58. Oxygen Therapy <ul><li>Stage IV - Severe COPD </li></ul><ul><ul><li>PaO 2 at or below 55 mm Hg or SaO 2 at or below 88% with or without hypercapnia OR </li></ul></ul><ul><ul><li>PaO 2 between 55-60 mm Hg or SaO 2 89% IF pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (Hct > 55%) </li></ul></ul><ul><ul><ul><li>Based on awake PaO 2 values </li></ul></ul></ul><ul><li>GOAL </li></ul><ul><ul><li>Increase baseline PaO 2 to at least 60 mm Hg at sea level and rest and/or produce SaO 2 at least 89% </li></ul></ul><ul><ul><ul><li>Need to use at least 15 hours per day in patients with chronic respiratory failure to improve survival </li></ul></ul></ul><ul><ul><ul><li>Can have a beneficial impact on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  59. 59. Surgical Treatment <ul><li>Bullectomy </li></ul><ul><ul><li>Effective in reducing dyspnea and improving lung function in appropriately selected patient </li></ul></ul><ul><li>Lung volume reduction surgery </li></ul><ul><ul><li>Parts of the lung are resected to reduce hyperinflation </li></ul></ul><ul><ul><li>Does not improve life expectancy </li></ul></ul><ul><ul><li>Does improve exercise capacity in patients with predominantly upper lobe emphysema and a low post-rehabilitation exercise capacity </li></ul></ul><ul><ul><li>May improve global health status in patients with heterogeneous emphysema </li></ul></ul><ul><ul><li>High hospital costs; still experimental/palliative </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  60. 60. Surgical Treatment <ul><li>Lung transplantation </li></ul><ul><ul><li>Improves quality of life and functional capacity in appropriately selected patient </li></ul></ul><ul><ul><li>Criteria for referral: </li></ul></ul><ul><ul><ul><li>FEV1 < 35% predicted all four </li></ul></ul></ul><ul><ul><ul><li>PaO 2 < 55-60 mm Hg criteria </li></ul></ul></ul><ul><ul><ul><li>PaCO 2 > 50 mm Hg must be </li></ul></ul></ul><ul><ul><ul><li>Secondary pulmonary hypertension present </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  61. 61. COPD Patients and Surgery <ul><li>Increased risk of post-operative pulmonary complications </li></ul><ul><li>Risk of complications increases as the incision approaches the diaphragm </li></ul><ul><li>Epidural and spinal anesthesia have a lower risk than general anesthesia </li></ul><ul><li>Postpone surgery if the patient has a COPD exacerbation </li></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  62. 62. Manage Exacerbations
  63. 63. General Points <ul><li>Most common causes of exacerbations are: </li></ul><ul><ul><li>Infection of the tracheobronchial tree </li></ul></ul><ul><ul><li>Air pollution </li></ul></ul><ul><ul><li>In 1/3 of severe exacerbations a cause cannot be identified </li></ul></ul><ul><li>Inhaled bronchodilators, theophylline, and systemic (preferably oral) glucocorticosteroids are effective treatments </li></ul><ul><li>Patients with clinical signs of airway infection may benefit from antibiotic treatment </li></ul><ul><ul><li>Increased volume of sputum </li></ul></ul><ul><ul><li>Change in color of sputum </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><li>Non-invasive intermittent positive pressure ventilation (NIPPV) in exacerbations is helpful: </li></ul><ul><ul><li>Improves blood gases and pH </li></ul></ul><ul><ul><li>Reduces in-hospital mortality </li></ul></ul><ul><ul><li>Decreases the need for invasive mechanical ventilation and intubation </li></ul></ul><ul><ul><li>Decreases the length of hospital stay </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  64. 64. Diagnosis and Assessment of Severity <ul><li>History </li></ul><ul><ul><li>Increased breathlessness </li></ul></ul><ul><ul><li>Chest tightness </li></ul></ul><ul><ul><li>Increased cough and sputum </li></ul></ul><ul><ul><li>Change of color and/or tenacity of sputum </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Non-specific: </li></ul></ul><ul><ul><ul><li>Malaise, insomnia, sleepiness, fatigue, depression, or confusion </li></ul></ul></ul>
  65. 65. Assessment of Severity <ul><li>Lung Function Tests </li></ul><ul><ul><li>PEF < 100 L/min. or FEV 1 < 1 L = severe exacerbation </li></ul></ul><ul><li>Arterial Blood Gas </li></ul><ul><ul><li>PaO2 < 60 mmHg and/or SaO2 < 90% with or without PaCO2 < 50 mmHg when breathing room air = respiratory failure </li></ul></ul><ul><ul><li>PaO2 < 50 mmHg, PaCO2 < 70 mmHg and ph < 7.3 = life-threatening episode </li></ul></ul><ul><li>Chest x-ray </li></ul><ul><ul><li>Look for complications </li></ul></ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul><ul><ul><ul><li>Alternative diagnoses </li></ul></ul></ul><ul><li>ECG </li></ul><ul><ul><li>Right ventricular hypertrophy </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><li>Sputum </li></ul><ul><ul><li>Culture/sensitivity </li></ul></ul><ul><li>Comprehensive Metabolic Profile </li></ul><ul><ul><li>Assess for electrolyte disturbances, diabetes </li></ul></ul><ul><ul><li>Albumin to assess nutrition </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  66. 66. <ul><li>Home? </li></ul><ul><li>Hospital admission? </li></ul><ul><ul><li>Floor? </li></ul></ul><ul><ul><li>ICU? </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  67. 67. Indications for Hospital Admission <ul><li>Marked increase in intensity of symptoms such as sudden development of resting dyspnea </li></ul><ul><li>Severe background COPD </li></ul><ul><li>Onset of new physical signs </li></ul><ul><ul><li>Cyanosis, peripheral edema </li></ul></ul><ul><li>Failure of exacerbation to respond to initial medical management </li></ul><ul><li>Significant co-morbidities </li></ul><ul><li>Newly occurring arrhythmias </li></ul><ul><li>Diagnostic uncertainty </li></ul><ul><li>Older age </li></ul><ul><li>Insufficient home support </li></ul>
  68. 68. Indications for ICU Admission <ul><li>Severe dyspnea that responds inadequately to initial emergency therapy </li></ul><ul><li>Confusion, lethargy, coma </li></ul><ul><li>Persistent or worsening hypoxemia (PaO 2 < 50 mm Hg) and/or </li></ul><ul><li>Severe/worsening hypercapnia (PaCO 2 > 70 mm Hg) and/or </li></ul><ul><li>Severe/worsening respiratory acidosis (pH < 7.30) despite supplemental oxygen and NIPPV </li></ul><ul><li>NIPPV = non-invasive positive pressure ventilation </li></ul>
  69. 69. Management of Exacerbations <ul><li>Risk of dying from an exacerbation is closely related to: </li></ul><ul><ul><li>Development of respiratory acidosis </li></ul></ul><ul><ul><li>Presence of significant co-morbidities </li></ul></ul><ul><ul><li>Need for ventilatory support </li></ul></ul>
  70. 70. Severe Exacerbation, Non Life Threatening <ul><li>Assess severity of symptoms </li></ul><ul><li>Obtain arterial blood gas and chest x-ray </li></ul><ul><li>Administer controlled oxygen therapy </li></ul><ul><ul><li>Repeat ABG after 30 minutes </li></ul></ul><ul><li>Bronchodilators </li></ul><ul><li>Glucocorticosteroids </li></ul><ul><li>Consider antibiotics </li></ul><ul><li>Consider non-invasive mechanical ventilation </li></ul><ul><li>Monitor fluid balance and nutrition </li></ul><ul><li>Consider subcutaneous heparin therapy </li></ul><ul><li>Identify and treat associated conditions (CHF, arrhythmias) </li></ul>
  71. 71. Management of COPD Exacerbations <ul><li>Controlled oxygen therapy </li></ul><ul><ul><li>Administer enough to maintain PaO2 > 60 mmHG or SaO2 > 90% </li></ul></ul><ul><ul><li>Monitor patient closely for CO2 retention or acidosis </li></ul></ul><ul><li>Bronchodilators (inhaled) </li></ul><ul><ul><li>Increase doses or frequency </li></ul></ul><ul><ul><li>Combine ß 2 agonists and anticholinergics </li></ul></ul><ul><ul><li>Use spacers or air-driven nebulizers </li></ul></ul><ul><ul><li>Consider adding IV methylxanthine (aminophylline) if needed </li></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  72. 72. Management of COPD Exacerbations <ul><li>Glucocorticosteroids (oral or IV) </li></ul><ul><ul><li>Recommended as an addition to bronchodilator therapy </li></ul></ul><ul><ul><li>If baseline FEV1 < 50% predicted </li></ul></ul><ul><ul><ul><li>30-40 mg oral prednisolone x 10 days OR nebulized budesonide (Pulmicort ™ ) </li></ul></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>IF breathlessness and cough are increased AND sputum is purulent and increased in volume </li></ul></ul><ul><ul><li>Choice of antibiotics should reflect local antibiotic sensitivity for the following microbes: </li></ul></ul><ul><ul><ul><li>S. pneumoniae </li></ul></ul></ul><ul><ul><ul><li>H. influenzae </li></ul></ul></ul><ul><ul><ul><li>M. catarrhalis </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  73. 73. Management of COPD Exacerbations <ul><li>Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing > 25 mL sputum per day OR with lobar atelectasis. </li></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  74. 74. Management of COPD Exacerbations <ul><li>Ventilatory Support </li></ul><ul><ul><li>Decrease mortality and morbidity </li></ul></ul><ul><ul><li>Relieve symptoms </li></ul></ul><ul><ul><li>Used most commonly in Stage IV, Very Severe COPD </li></ul></ul><ul><ul><li>Forms: </li></ul></ul><ul><ul><ul><li>Non-invasive using negative or positive pressure devices </li></ul></ul></ul><ul><ul><ul><li>invasive/mechanical with oro- or naso-tracheal tube OR tracheostomy </li></ul></ul></ul>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
  75. 75. NIPPV <ul><li>Success rates of 80-85% </li></ul><ul><li>Increases pH, reduces PaCO2, reduces severity of breathlessness in the first 4 hours of treatment </li></ul><ul><li>Decreases length of hospital stay </li></ul><ul><li>Decreases mortality/intubation rate </li></ul>
  76. 76. NIPPV (C-PAP, Bi-PAP) <ul><li>Selection criteria </li></ul><ul><ul><li>Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion </li></ul></ul><ul><ul><li>Moderate to severe acidosis (pH < 7.35) and hypercapnia (PaCO2 > 45 mmHg) </li></ul></ul><ul><ul><li>Respiratory frequency > 25 breaths/minute </li></ul></ul>
  77. 77. NIPPV <ul><li>Exclusion criteria </li></ul><ul><ul><li>Respiratory arrest </li></ul></ul><ul><ul><li>Cardiovascular instability </li></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Myocardial infarction </li></ul></ul></ul><ul><li>Somnolence, impaired mental status, lack of cooperation </li></ul><ul><li>High aspiration risk – viscous/copius secretions </li></ul><ul><li>Recent facial or gastroesophageal surgery </li></ul><ul><li>Cranio-facial trauma, fixed nasopharyngeal abnormalities </li></ul><ul><li>Extreme obesity </li></ul>
  78. 78. Indications for Invasive Mechanical Ventilation <ul><li>Severe dyspnea with use of accessory muscles and paradoxical abdominal motion </li></ul><ul><li>Respiratory rate > 35 breaths/minute </li></ul><ul><li>Life-threatening hypoxemia: PaO2 < 40 mm Hg </li></ul><ul><li>Severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 mm Hg) </li></ul><ul><li>Respiratory arrest </li></ul><ul><li>Somnolence, impaired mental status </li></ul><ul><li>Cardiovascular complications </li></ul><ul><ul><li>Hypotension/shock/heart failure </li></ul></ul><ul><li>Other complications </li></ul><ul><ul><li>Metabolic abnormalities/sepsis/pneumonia/pulmonary embolism/barotrauma/massive pleural effusion </li></ul></ul><ul><li>NIPPV failure </li></ul>
  79. 79. Use of Invasive Ventilation in End-Stage COPD <ul><li>Hazards: </li></ul><ul><ul><li>Ventilator-acquired pneumonia </li></ul></ul><ul><ul><ul><li>Increased prevalence of multi-resistant organisms </li></ul></ul></ul><ul><ul><li>Barotrauma </li></ul></ul><ul><ul><li>Failure to wean to spontaneous ventilation </li></ul></ul><ul><li>Mortality among COPD patients with respiratory failure is no greater than mortality among patients ventilated for non-COPD reasons </li></ul>
  80. 80. Weaning from Ventilator <ul><li>Methods still debated </li></ul><ul><li>Whatever clinical protocol is adopted, weaning is shorted as long as a protocol is used! </li></ul><ul><li>NIPPV used during the weaning process has shortened weaning time, reduced stay in the ICU, decreased the incidence of nosocomial pneumonia, and improved 60-day survival rates </li></ul>
  81. 81. Discharge Criteria <ul><li>Inhaled Beta2-agonist use is at most every 4 hours </li></ul><ul><li>Patient is able to walk across the room </li></ul><ul><li>Patient is able to eat and sleep without frequent awakening </li></ul><ul><li>Patient has been clinically stable for 12-24 hours </li></ul><ul><li>ABGs are stable for 12-24 hours </li></ul><ul><li>Patient/home caregiver fully understands correct use of medications </li></ul><ul><li>Follow-up and home care arrangements have been completed </li></ul><ul><li>Patient, family, and physician are confident that patient can manage successfully </li></ul>
  82. 82. Follow-Up Assessment after Hospital Discharge <ul><li>4-6 weeks after discharge </li></ul><ul><li>Assess: </li></ul><ul><ul><li>Ability to cope in usual environment </li></ul></ul><ul><ul><li>Inhaler technique </li></ul></ul><ul><ul><li>Understanding of recommended treatment regimen </li></ul></ul><ul><li>Measure FEV1 </li></ul><ul><li>Determine need for long-term oxygen therapy and/or home nebulizer (for patients with very severe COPD, Stage IV) </li></ul><ul><li>Follow-up after this is the same as for Stable COPD monitoring </li></ul>
  83. 83. REFERENCES <ul><li>National Heart, Lung, and Blood Institute Data Fact Sheet for Chronic Obstructive Pulmonary Disease </li></ul><ul><li>GOLD (Global Initiative for Chronic Obstructive Lung Disease) Executive Summary, April 2001 </li></ul><ul><li>GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. Updated July 2005. www.goldcopd.org – Accessed August 21, 2006. </li></ul><ul><li>Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence . Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000. </li></ul>

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