Management of COPD
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Management of COPD

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Real life practice in COPD, ...

Real life practice in COPD,
รศ.พญ. เบญจมาศ ช่วยชู สาขาวิชาโรคระบบการหายใจและวัณโรค ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ศิริราช พยาบาล มหาวิทยาลัยมหิดล

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  • Full Name Full Name Comment goes here.
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  • LAUGH A WHILE
    Cleanse me from my Sins Lord

    There once was a religious young woman who went to Confession.

    Upon entering the confessional, she said, 'Forgive me, Father, for I have sinned.'

    The priest said, 'Confess your sins and be forgiven.'

    The young woman said, 'Last night my boyfriend made mad, passionate love to me seven times.'

    The priest thought long and hard and then said, 'Squeeze seven Lemons into a glass and then drink the juice.'

    The young woman asked, 'Will this cleanse me of my sins?'

    The priest said, 'No, but it will wipe that smile off of your Face.'

    DR.G. M. SINGH GENERAL MEDICAL SERVICE 3/5 WEST PATEL NAGAR NEW DELHI-110008 INDIA 01142488406;9891635088;9990596297
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  • COPD is a complex disease with pulmonary and extrapulmonary manifestations <br /> The link between these domains of the disease is unclear. <br />
  • The individual capability of dealing with this inflammatory burden and developing protective mechanisms seems to modulate individual susceptibility to common causes of morbidity and mortality in elderly people <br />
  • Dx asthma ที่ ศิริราช age 52 yr. smoking 20 p-y <br />
  • Notes <br /> The management of COPD depends on the stage of disease: <br /> Management of mild-to-moderate COPD involves the avoidance of risk factors to prevent disease progression and pharmacotherapy as needed to control symptoms [p32/col1/par1/ln4–7] <br /> Severe and very severe COPD often require the integration of several different disciplines, a variety of treatment approaches and a commitment of the clinician to the continued support of the patient as the illness progresses. [p32/col1/par1/ln7–11] <br /> In addition to patient education, health advice and pharmacotherapy, COPD patients may need specific counselling about smoking cessation, instruction in physical exercise, nutritional advice and continued nursing support. [p32/col1/par1/ln11–14] <br /> Not all approaches are needed for every patient, and assessing the potential benefit of each approach at each stage of the illness is a crucial aspect of effective disease management. [p32/col1/par1/ln15–19] <br /> Reference <br /> GOLD Guidelines (Updated 2007). Available at http://goldcopd.com. <br />
  • If you were a frequent exacerbator in year 1, chance are that you would also be a frequent exacerbator in year 2 and 3 <br />
  • THIS SLIDE CONTAINS 3 BUILDS <br /> Frequent exacerbators (those reporting 2 or more exacerbations per year) is more common in the very severe GOLD Category but almost ¼ of GOLD Category 2 subjects are frequent exacerbators and 7% of patients in GOLD Category 2 have been hospitalised in year 1 of the study <br />
  • Speaker Notes <br /> In a 12-week prospective, double-blind, parallel-group evaluation, 534 patients with moderately severe stable COPD received by metered-dose inhaler a combination of β2-adrenergic agonist albuterol plus ipratropium or either agent separately. <br /> Results on days 1, 29, 57, and 85 showed that the combination treatment was statistically superior to either single agent alone in peak effect on FEV1, in the effect during the first 4 hours after dosing, and in total AUC for the FEV1 response. <br /> The graph in this slide shows the percent change above test day baseline in FEV1 response on day 85. The combination produced a significantly greater change than either agent alone (P&lt;0.001 for each comparison). <br /> Additional Information <br /> The mean peak percent increases in FEV1 over baseline on the four test days were 31 to 33 percent for the combination, 24 to 25 percent for ipratropium, and 24 to 27 percent for albuterol. The differences between the combination and its components were statistically significant on all test days. <br /> The AUC0-4 means for the combination were 21 to 44 percent greater than the ipratropium mean values and 30 to 46 percent greater than for albuterol. <br /> Reference <br /> COMBIVENT Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. Chest. 1994;105:1411-1419. <br />
  • Speaker Notes <br /> Systemic side effects can occur from inhaled β2-agonists, including palpitations and tremor most commonly, and additionally hypokalaemia and ventricular arrhythmias. <br /> The systemic effects are mediated by drug absorbed through the lung and also by drug deposited in the pharynx and swallowed. <br /> Additional Information <br /> Although there are some differences, all of these bronchodilators currently used to achieve bronchodilation are selective for the β2 receptor. These adrenoceptors are also present in the heart where they mediate a complex array of effects. <br /> It is thus likely that cardiac effects of currently used β2-agonists are due to these cardiac receptors, rather than to lack of selectivity. <br /> Reference <br /> Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802. <br />   <br />
  • Speaker Notes <br /> Dry mouth is the most common symptom reported with the anticholinergic agent tiotropium, probably due to systemic absorption. <br /> Urinary retention could be a problem, especially for those with concurrent bladder outlet disease. <br /> Local effects can occur if tiotropium is accidentally sprayed directly into the eye. <br /> Additional Information <br /> Currently used inhaled anticholinergics are quaternary amines, and side-effects are markedly less than with systemic anticholinergics, such as atropine. <br /> Reference <br /> Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802. <br />   <br />
  • Proposed mechanism of corticosteroid resistance in COPD patients. Stimulation of normal alveolar macrophages activates NF-κB and other transcription factors to switch on histone acetyltransferase leading to histone acetylation and subsequently to transcription of genes encoding inflammatory proteins, such as tumor necrosis factor-α (TNF-α) and IL-8. Corticosteroids reverse this by binding to glucocorticoid receptors (GR) and recruiting HDAC-2. This reverses the histone acetylation induced by NF-κB and switches off the activated inflammatory genes. In COPD patients, cigarette smoke activates macrophages, as in normal subjects, but oxidative stress (acting through the formation of peroxynitrite) impairs the activity of HDAC-2. This amplifies the inflammatory response to NF-κB activation but also reduces the anti-inflammatory effect of corticosteroids, as HDAC-2 is now unable to reverse histone acetylation. MMP = matrix metalloproteinase. <br />
  • Increase PaO2 &gt; 60 mmHg, SaO2 &gt; 90% <br /> ,which will preserve vital organ function by ensuring adequate delivery of oxygen <br />
  • If you were a frequent exacerbator in year 1, chance are that you would also be a frequent exacerbator in year 2 and 3 <br />
  • THIS SLIDE CONTAINS 3 BUILDS <br /> Frequent exacerbators (those reporting 2 or more exacerbations per year) is more common in the very severe GOLD Category but almost ¼ of GOLD Category 2 subjects are frequent exacerbators and 7% of patients in GOLD Category 2 have been hospitalised in year 1 of the study <br />
  • Speaker Notes <br /> In a 12-week prospective, double-blind, parallel-group evaluation, 534 patients with moderately severe stable COPD received by metered-dose inhaler a combination of β2-adrenergic agonist albuterol plus ipratropium or either agent separately. <br /> Results on days 1, 29, 57, and 85 showed that the combination treatment was statistically superior to either single agent alone in peak effect on FEV1, in the effect during the first 4 hours after dosing, and in total AUC for the FEV1 response. <br /> The graph in this slide shows the percent change above test day baseline in FEV1 response on day 85. The combination produced a significantly greater change than either agent alone (P&lt;0.001 for each comparison). <br /> Additional Information <br /> The mean peak percent increases in FEV1 over baseline on the four test days were 31 to 33 percent for the combination, 24 to 25 percent for ipratropium, and 24 to 27 percent for albuterol. The differences between the combination and its components were statistically significant on all test days. <br /> The AUC0-4 means for the combination were 21 to 44 percent greater than the ipratropium mean values and 30 to 46 percent greater than for albuterol. <br /> Reference <br /> COMBIVENT Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. Chest. 1994;105:1411-1419. <br />
  • Speaker Notes <br /> Systemic side effects can occur from inhaled β2-agonists, including palpitations and tremor most commonly, and additionally hypokalaemia and ventricular arrhythmias. <br /> The systemic effects are mediated by drug absorbed through the lung and also by drug deposited in the pharynx and swallowed. <br /> Additional Information <br /> Although there are some differences, all of these bronchodilators currently used to achieve bronchodilation are selective for the β2 receptor. These adrenoceptors are also present in the heart where they mediate a complex array of effects. <br /> It is thus likely that cardiac effects of currently used β2-agonists are due to these cardiac receptors, rather than to lack of selectivity. <br /> Reference <br /> Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802. <br />   <br />
  • Speaker Notes <br /> Dry mouth is the most common symptom reported with the anticholinergic agent tiotropium, probably due to systemic absorption. <br /> Urinary retention could be a problem, especially for those with concurrent bladder outlet disease. <br /> Local effects can occur if tiotropium is accidentally sprayed directly into the eye. <br /> Additional Information <br /> Currently used inhaled anticholinergics are quaternary amines, and side-effects are markedly less than with systemic anticholinergics, such as atropine. <br /> Reference <br /> Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802. <br />   <br />
  • Proposed mechanism of corticosteroid resistance in COPD patients. Stimulation of normal alveolar macrophages activates NF-κB and other transcription factors to switch on histone acetyltransferase leading to histone acetylation and subsequently to transcription of genes encoding inflammatory proteins, such as tumor necrosis factor-α (TNF-α) and IL-8. Corticosteroids reverse this by binding to glucocorticoid receptors (GR) and recruiting HDAC-2. This reverses the histone acetylation induced by NF-κB and switches off the activated inflammatory genes. In COPD patients, cigarette smoke activates macrophages, as in normal subjects, but oxidative stress (acting through the formation of peroxynitrite) impairs the activity of HDAC-2. This amplifies the inflammatory response to NF-κB activation but also reduces the anti-inflammatory effect of corticosteroids, as HDAC-2 is now unable to reverse histone acetylation. MMP = matrix metalloproteinase. <br />
  • Increase PaO2 &gt; 60 mmHg, SaO2 &gt; 90% <br /> ,which will preserve vital organ function by ensuring adequate delivery of oxygen <br />
  • Cycling or walking exercises is the most commonly applied <br /> Optimally, the approach consists of relatively long exercise sessions at high levels of intensity (60% maximal work rate) <br /> The total effective training time should ideally exceed 30 minutes <br /> Interval training may be a reasonable alternative in case difficult to achieve the target time or intensity <br /> Interval training is a modification of endurance training where the longer exercise session is replaced by several smaller sessions separated by periods of rest or lower intensity exercise <br /> Interval training results in significantly lower symptom scores despite high absolute training loads, thus maintaining the training effects <br />
  • Improve muscle mass and strength than endurance training <br /> two to four sets of 6 to 12 repetitions at intensities ranging from 50 to 85% of one repetition maximum <br /> Strength training may also result in less dyspnea during the exercise period, thereby making this strategy easier to tolerate than aerobic training <br /> Combination of endurance and strength training is probably the best strategy to treat peripheral muscle dysfunction in chronic respiratory disease, because it results in combined improvements in muscle strength and whole body endurance, without unduly increasing training time <br />
  • &gt; 60% of the peak exercise capacity is empirically considered sufficient to elicit some physiologic training effects, although higher percentages are likely to be more beneficial and are often well tolerated <br /> In clinical practice, symptom scores can be used to adjust training load; these scores are anchored to a stable relative load and can be used throughout the training program <br /> A Borg score of 4 to 6 for dyspnea or fatigue is usually a reasonable target <br /> Alternatively, heart rate at the gas exchange threshold or power output has also been used to target training intensity <br />
  • in daily life. Training using a cycle ergometer is also <br /> beneficial as this modality imposes a greater specific <br /> load on the quadriceps muscles than walking.95 <br /> However, supervised ground-based walking training <br /> results in a significantly greater increase in walking <br /> endurance capacity compared with supervised cyclebased <br /> training. <br />

Management of COPD Management of COPD Presentation Transcript

  • Real life practice in COPD รศ.พญ. เบญจมาศ ช่วยชู สาขาวิชาโรคระบบการหายใจและวัณโรค ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ศิริราช พยาบาล มหาวิทยาลัยมหิดล 19 July 2013
  • หัวข้อ • การวินิจฉัยโรค • การประเมินผู้ป่วย • การรักษา
  • หัวข้อ • การวินิจฉัยโรค • การประเมินผู้ป่วย • การรักษา
  • นิยามโรคปอดอุดกั้นเรื้อรัง • เป็นโรคที่สามารถป้องกันและรักษา ได้ที่พบบ่อย ลักษณะสำาคัญของโรคคือ มีการอุดกั้นของหลอดลมอยู่ตลอด เวลาและมักเป็นมากขึ้นเรื่อยๆ ซึ่ง เกี่ยวข้องกับการอักเสบเรื้อรังที่เพิ่มขึ้น มากกว่าปกติในหลอดลมและเนื้อปอด จากการกระตุ้นของอนุภาคหรือก๊าซที่ เป็นอันตราย • ภาวะกำาเริบของโรคหรือโรคร่วมมีผลดัดแปลงมาจาก 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Barnes PJ and Celli BR. Eur Respir J 2009; 33: 1165–1185 Systemic effects and comorbidities of COPD โรคปอดอุดกั้นเรื้อรังไม่ได้เป็นโรคที่ เกิดปัญหาเฉพาะในปอดเพียงอย่าง เดียว
  • Definition • “Systemic effects” extrapulmonary manifestations which is the consequence of COPD • “Comorbidities” highly prevalent diseases in COPD (e.g. cardiovascular, metabolic, muscular, and bone disorders) in aged patients represent the co-ocurrence. Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss. 2, pp 43–46, May 1, 2012
  • Aging • Almost one-half of people aged > 65 years have > 3 chronic medical conditions, and one-fifth have five or more • Aging itself is associated with a chronic low-grade inflammatory status and the theory that systemic inflammation is the common driver of chronic diseases would explain the high prevalence of chronic diseases with increasing age • This so-called “inflamm-aging” seems to be the consequence of lifelong antigenic exposure leading to genetic modifications Nussbaumer-Ochsner Y and Rabe KF. Chest 2011;139;165-173
  • การวินิจฉัยโรคปอดอุดกั้น เรื้อรัง คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดลFaculty of Medicine Siriraj Hospital, Mahidol University
  • มีอาการ เหนื่อย ไอเรื้อรัง มีเสมหะ (อาจไม่มีก็ได้) สัมผัสปัจจัยเสี่ยง สูบบุหรี่ สัมผัสมลภาวะภายใน หรือภายนอกอาคาร การวินิจฉัยโรคปอดอุดกั้นเรื้อรัง การวินิจฉัยจำาเป็นต้องมีผลการตรวจสไปโรเมตรีย์ (spirometry) โดยมี FEV1/FVC < 0.7 หลังได้ยาขยายหลอดลม ดัดแปลงจาก GOLD 2013
  • Spirometry (pre and post bronchodilator)
  • Pre-Rx Pred % pred Post-Rx % pred % change FVC 2.04 2.55 80.0 2.05 80.4 5 FEV1 0.78 2.17 36 0.85 39.2 9 FEV1/FVC 38 85 45 41 48 FEF25-75% 0.31 3.37 9 0.31 9 PEF 177 388 46 219 56 Spirometry ชายไทย อายุ 70 ปี เหนื่อยมา 3 ปี สูบบุหรี่ 20 ซอง-ปี ไม่เคยเป็นโรคหืด Post-bronchodilator FEV1/FVC < 0.70
  • ข้อแตกต่างระหว่าง COPD และ Asthma ลักษณะทางคลินิก โรคปอดอุดกั้นเรื้อรัง (COPD) โรคหืด (Asthma) อายุที่เริ่มเป็น ส่วนใหญ่อายุมากกว่า 40 ปี ส่วนใหญ่ < 35 ปี แต่เกิดได้ทุกอายุ ประวัติการสูบบุหรี่ ส่วนใหญ่สูบบุหรี่ ( > 10 ซอง-ปี) ส่วนใหญ่ไม่สูบบุหรี่ แต่อาจสูบบุหรี่ได้ Atopy ไม่ค่อยพบ พบได้บ่อย ประวัติครอบครัว ไม่มี มักมีประวัติโรคภูมิแพ้หรือโรคหืด อาการไอ ไอเรื้อรังและมักมีเสมหะร่วมด้วย อาจไอเฉพาะช่วงเช้า ไม่มีไอเรื้อรัง อาจไอมากตอนกลางคืน ช่วงเช้ามืดขณะมีอาการหรือหลังออกกำาลัง อาการเหนื่อย อาการเหนื่อยจะยังคงมีอยู่ระดับหนึ่งไม่หาย ไปและค่อยๆเพิ่มขึ้น มีช่วงปลอดอาการเหนื่อย อาจตื่นกลางดึก เพราะแน่นหน้าอก เหนื่อย หรือ มีเสียงวี้ด ความแปรปรวนของอาการใน ช่วงวันหรือแต่ละวัน ไม่ค่อยพบ พบได้บ่อย สมรรถภาพปอด ต้องมี airflow obstruction (ถือเป็น hallmark ของ COPD) ปกติได้ แต่ในรายที่มีอาการขณะตรวจอาจพบ airflow obstruction Airflow obstruction not fully reversible (FEV1/FVC หลังได้ยาขยายหลอดลม < 0.7) reversible (characteristic ของ asthma) (FEV1 เพิ่มขึ้นหลังได้ยาขยายหลอดลม > 12% และ > 200 มล. Peak flow variability < 20% > 20% (characteristic ของ asthma) Diffusing capacity (DLCO) ลดลง ใน emphysema ปกติ ตำาแหน่งของโรค airways และ parenchyma airways เซลล์อักเสบ neutrophil, CD8+ T cell eosinophil, CD4+ T cell การตอบสนองต่อยาสเตียรอยด์ steroid resistance steroid sensitive * ซอง-ปี หมายถึง จำานวนบุหรี่ที่สูบเป็นซองต่อวัน x จำานวนปีที่สูบ เช่นสูบบุหรี่ 10 มวน (1/2 ซอง) ต่อวัน นาน 20 ปี เท่ากับ 10 ซอง-ปี
  • ปัญหา ผู้ป่วยอายุมากกว่า 40 ปี FEV1/FVC < 0.7 หลังได้รับยาขยาย หลอดลม • สูบบุหรี่ มีประวัติภูมิแพ้ หรือเคยเป็นโรคหืด หรือครอบครัวเป็นโรคหืด • สูบบุหรี่ อาการหอบมักเป็นกลางคืน มีเสียง วี้ด มาห้องฉุกเฉินบ่อย นอนโรงพยาบาลไม่ นาน • ไม่สูบบุหรี่ แต่ FEV1/FVC < 0.7 หลังได้ รับยาขยายหลอดลม
  • At age 61 yr. • Reversible airflow obstruction % change of FEV1 > 12% และ > 200 mL (0.2L) ---- 32% , 240 mL
  • At age 65 yr.
  • Effect of Emphysema on Compliance and Diffusing Capacity (DLco) http://www.netterimages.com/image/1000.htm
  • ปัญหา • ผู้ป่วยอายุมากกว่า 40 ปี สูบบุหรี่ อาการเข้าได้ กับ COPD แต่ FEV1/FVC > 0.7 จะวินิจฉัย ว่าเป็น COPD หรือไม่?
  • นิยามโรคปอดอุดกั้นเรื้อรัง • เป็นโรคที่สามารถป้องกันและรักษา ได้ที่พบบ่อย ลักษณะสำาคัญของโรคคือ มีการอุดกั้นของหลอดลมอยู่ตลอด เวลาและมักเป็นมากขึ้นเรื่อยๆ ซึ่ง เกี่ยวข้องกับการอักเสบเรื้อรังที่เพิ่มขึ้น มากกว่าปกติในหลอดลมและเนื้อปอด จากการกระตุ้นของอนุภาคหรือก๊าซที่ เป็นอันตราย • ภาวะกำาเริบของโรคหรือโรคร่วมมีผลดัดแปลงมาจาก 2013 Global Initiative for Chronic Obstructive Lung Disease
  • ปัญหา • ผู้ป่วยอายุมากกว่า 40 ปี สูบบุหรี่ อาการเข้าได้กับ COPD แต่ FEV1/FVC > 0.7 จะวินิจฉัยว่า เป็น COPD หรือไม่? FEV1/FVC < 5 percentile of predicted value ไม่
  • การดูแลรักษาผู้ป่วยโรคปอดอุดกั้น เรื้อรัง
  • หัวข้อ • การวินิจฉัยโรค • การประเมินผู้ป่วย • การรักษา
  •  Relieve symptoms  Improve exercise tolerance  Improve health status  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality ลดอาการ ลดปัจจัยเสี่ยง © 2013 Global Initiative for Chronic Obstructive Lung Disease เป้าหมายในการดูแลรักษาผู้ป่วย โรคปอดอุดกั้นเรื้อรังระยะสงบ (Stable COPD)
  • Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Use the COPD Assessment Test(CAT) or mMRC Breathlessness scale or Clinical COPD Questionnaire© 2013 Global Initiative for Chronic Obstructive Lung Disease Assess symptoms
  • http://www.catestonline.org/english/index_Thai.htm
  • http://www.catestonline.org/english/index_Thai.htm
  • เกณฑ์การให้คะแนน ภาวะหายใจลำาบาก (Modified Medical Research Council Dyspnea Scale; mMRC) แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553
  • Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1> 80% predicted GOLD 2: Moderate 50% < FEV1< 80% predicted GOLD 3: Severe 30% < FEV1< 50% predicted GOLD 4: Very Severe FEV1< 30% predicted *Based on Post-Bronchodilator FEV1 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • นิยามของภาวะกำาเริบเฉียบพลัน (COPD exacerbation) GOLD “An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” Clinical diagnosis Chest 2000;117;398S-401S
  • Bach PB. et al. Ann Intern Med. 2001;134:600-620.
  • Exacerbations • Respiratory symptoms were classified as – “major” symptoms (dyspnea, sputum purulence, sputum amount) – “minor” symptoms (wheeze, sore throat, cough, and symptoms of a common cold which were nasal congestion /discharge) • Exacerbations were defined as the presence for at least two consecutive days of increase in – any two “major” symptoms or – increase in one “major” and one “minor” symptom according to criteria modified from Anthonisen and colleagues • The first of the two consecutive days was taken as the day of onset of exacerbation. Am J Respir Crit Care Med Vol 161. pp 1608–1613, 2000
  • Severity of exacerbations • Moderate : treatment with systemic corticosteroids or antibiotics or both • Severe: Hospitalization
  • Hansel TT and Barnes PJ, Lancet 2009; 374: 744–55 Physiology of exacerbations in a hypothetical regular smoker with COPD by stage of severity
  • Cardiovascular comorbidity Exacerbation symptoms Dynamic hyperinflation Expiratory flow limitation Bronchoconstriction Oedema, mucus Systemic inflammation Greater airway inflammation Inflamed COPD airway TRIGGERS EFFECTS Trigger of COPD exacerbations and associated pathophysiological changes leading to increased exacerbation symptoms Wedzicha JA, Seemungal TA. Lancet. 2007;370:786-796.
  • Wedzicha JA, Seemungal TA. Lancet. 2007;370:786-796.
  • Risk of exacerbations  > 2 exacerbations within the last yearor  FEV1 < 50 % of predicted © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Frequent exacerbators represent stable COPD phenotype - independent of severity ECLIPSE 3 year data 492 296 210 409 117 63 778 79 23 0% 20% 40% 60% 80% 100% Year 1 Year 2 Year 3 ≥2 Exacerb./Yr 1 Exacerb./Yr 0 Exacerb./Yr • Proportion of subjects experiencing ≥2 exacerbations/year increases year-on-year • Stable population provides potential to understand the cause(s) of the phenotype Hurst et al. N Engl J Med 2010
  • The ‘frequent exacerbator phenotype’: Frequency/severity by GOLD Category 7 18 33 22 33 47 0 10 20 30 40 50 GOLD II (N=945) GOLD III (N=900) GOLD IV (N=293) %ofpatients p<0.01 Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more) ECLIPSE 1 year data Hurst et al. N Engl J Med 2010
  • Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss. 2, pp 43–46, May 1, 2012
  • Combined Assessment of COPD Risk (GOLDClassificationofAirflowLimitation) Risk (Exacerbationhistory) > 2 1 0 (C) (D) (A) (B) mMRC 0-1 CAT < 10 4 3 2 1 mMRC>2 CAT >10 Symptoms (mMRC or CAT score))
  • Exacerbations/year > 2 1 0 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA Manage Stable COPD: PharmacologicTherapy FIRST CHOICE A B DC ICS + LABA or LAMA
  • Manage Stable COPD: Non-pharmacologic Patient Group Essential Recommended Depending on local guidelines A Smoking cessation Physical activity Flu vaccination Pneumococcal vaccination B, C, D Smoking cessation Pulmonary rehabilitation Physical activity Flu vaccination Pneumococcal vaccination © 2013A Global Initiative for Chronic Obstructive Lung Disease
  • Mackay AJ, Hurst JR. Med Clin N Am 96 (2012) 789–809 Interventions to reduce COPD exacerbations
  • Michael Rudolf
  • หัวข้อ • การวินิจฉัยโรค • การประเมินผู้ป่วย • การรักษา
  • COPD Stable Exacerbation • Pharmacologic Rx • Bronchodilator • Corticosteroid • Vaccination • Non-pharmacologic Rx • Stop smoking • Pulmonary rehabilitation • Oxygen therapy • Surgical treatment • Bronchodilator • Systemic corticosteroid • Oxygen • Antibiotics • Ventilatory support • Pulmonary rehabilitation Home management Hospital management Dyspnea Cough Sputum Co-morbid diseases • Bronchodilator • Corticosteroid • Antibiotics • Pulmonary rehabilitation
  • แผนการรักษาผู้ป่วยโรคปอดอุดกั้นเรื้อรังตาม ระดับความรุนแรงของโรค แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553 Exacerbationsperyear > 2 1 0 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA A B DC ICS + LABA or LAMA 0 Less symptoms Low risk More symptoms Low risk Less symptoms High risk A B DC More symptoms High risk
  • ชนิดของยาขยายหลอดลม กลไกการ ออกฤทธิ์ ระยะเวลาใน การออกฤทธิ์ วิธีบริหารยา ตัวอย่างยา β2 - agonists สั้น (4-6 ชั่วโมง)* สูด, รับ ประทาน, ฉีด Salbutamol, terbutaline, fenoterol ยาว (> 12 ชั่วโมง) สูด Salmeterol Formoterol* Anticholi nergics สั้น (6-8 ชั่วโมง) สูด Ipratropium bromide ยาว (> 24 ชั่วโมง) สูด Tiotropium Methylxa nthines ไม่แน่นอน อาจ > 24 ชั่วโมง รับประทาน, ฉีด Theophylline , aminophyllin * Rapid onset β2-agonist
  • Post-dose (hours) ChangeinFEV1 (%) Ipratropium + Albuterol Albuterol Ipratropium COMBIVENT Inhalation Aerosol Study Group. Chest. 1994;105:1411-1419. Reproduced with permission from American College of Chest Physicians. Short-acting Bronchodilators: Onset and Duration of Action P<0.001 for the combination versus each agent alone N=534
  • Potential Side Effects of COPD Therapy: β2-Agonists Rennard SI. Lancet. 2004;364:791-802. • Side effects include: – Palpitations – Ventricular arrhythmias (rare) – Sleep disturbance/poor sleep quality – Tremor – Hypokalaemia
  • Potential Side Effects of COPD Therapy: Anticholinergic Agents • Side effects are less common versus systemic agents (e.g., atropine) • Dry mouth is most commonly reported adverse event • Urinary retention may be a problem for patients with bladder outlet disease Rennard SI. Lancet. 2004;364:791-802.
  • Sustained-release theophylline • Narrow safety margin (10 -20 µg/ml) (monitoring of theophylline blood level may be necessary) • 400 µg/day (low dose 200 µg/day) • Side effects – CNS : seizures – CVS : hypotension, arrhythmia – GI : Nausea & vomiting Theodur® , Nuelin SR® หักครึ่งได้ห้ามบดห้ามเคี้ยว
  • Proposed mechanism of corticosteroid resistance in COPD patients. Barnes P J Chest 2006;129:151-155 ©2006 by American College of Chest Physicians
  • Side effect: corticosteroids • Oral candidiasis • Esophageal candidiasis • Hoarseness
  • Oxygen therapy • Three ways of administration – Longterm continuous therapy – During exercise – Relieve acute dyspnea • Primary goal – Increase PaO2 > 60 mmHg, SaO2 > 90% 90
  • ข้อบ่งชี้ในการให้ Long-term oxygen therapy (> 15 hrs/day) • PaO2 < 55 mm Hg หรือ SaO2 < 88% • 55 mmHg < PaO2 < 60 mm Hg หรือ SaO2 of 88% ที่มี ภาวะที่บ่งชี้ว่ามี chronic hypoxemia ได้แก่ – pulmonary hypertension – peripheral edema suggesting congestive cardiac failure – polycythemia (hematocrit > 55%) LTOT จะให้ใน stable COPD ที่มี chronic hypoxemia ตามเกณฑ์ดังกล่าวข้าง ต้น กรณีที่ผู้ป่วยมีอาการกำาเริบเฉียบพลันและมี hypoxemia อาจให้ ออกซิเจนเป็นการชั่วคราว ถ้าหากยังมีภาวะ hypoxemia หลังจาก 3 เดือน จึงมีข้อบ่งชี้สำาหรับ LTOT
  • Wongsurakiat P, Maranetra KN, Wasi C, Kositanont U, Dejsomritrutai W, Charoenratanakul S. Acute Respiratory Illness in Patients With COPD and the Effectiveness of Influenza Vaccination: A Randomized Controlled Study. CHEST 2004; 125:2011–2020
  • วัคซีนไข้หวัดใหญ่ • เป็นเชื้อไวรัสไข้หวัดใหญ่ที่ตาย แล้ว (Inactivated (killed) vaccine) • ฉีดปีละครั้ง • ฉีดได้ตลอดปี ที่ดีที่สุดก่อนเข้าฤดู ฝน ( –มิถุนายน ตุลาคม) • ร่างกายจะสร้างภูมิคุ้มกันถึงระดับที่ ป้องกันไข้หวัดใหญ่ หลังจากฉีด วัคซีนไปแล้ว 2 สัปดาห์ • ใช้เพื่อป้องกันไข้หวัดใหญ่ แต่ไม่ ได้ป้องกันไข้หวัดที่เกิดจากไวรัส ตัวอื่น ขนาด 15 mcg (0.5 ซีซี) ฉีดเข้ากล้ามเนื้อ (IM) หรือ ขนาด 15 mcg ฉีดเข้าในผิวหนัง (ID) in aged > 60 ปี ขนาด 9 microgram ID in aged < 60 ปี
  • Pulmonary rehabilitation Evidence A • Improves exercise capacity • Reduces the perceived intensity of breathlessness • Improves health-related quality of life • Reduces the number of hospitalizations and days in the hospital • Improve recovery after hospitalization for an exacerbation • Reduces anxiety and depression associated with COPD Evidence B • Strength and endurance training of the upper limbs improves arm function • Benefits extend well beyond the immediate period of training • Improves survival • Enhances the effect of long-acting bronchodilators Evidence C • Respiratory muscle training can be beneficial, especially when combined with general exercise training GOLD 2013
  • Components of pulmonary rehabilitation • Patient assessment • Exercise training (strongest level of evidence for benefit) • Education • Nutritional intervention • Psychosocial support Ries AL et al. Chest. 2007;131:4S-42S.
  • Establishing pulmonary rehabilitation program Funding and promotion • Where possible, dedicated funding should be sought to establish a PRP • Costing estimates vary depending upon the health-care system, existing infrastructure and equipment, staffing and duration of the program • Low cost programs in existing facilities have been shown to be effective • Lack of resources ought not to deter clinicians from seeking to establish a PRP Jenkins S. Respirology.2010;15:1157–73
  • Conclusions I • Spirometry is required to make diagnosis of COPD: post-bronchodilator FEV1/FVC < 0.7 • Assessment of COPD: – symptoms: CAT, mMRC scale, CCQ – degree of airflow limitation: post-bronchodilator FEV1 % pred (stage 1-4) – risk of exacerbations: previous exacerbation, severe COPD – Comorbidities: cardiovascular disease, osteoporosis, anxiety/depression, DM
  • Conclusions II • Combined assessment of symptoms and risk of exacerbations is the basis for non- pharmacologic and pharmacologic management of COPD – Smoking cessation – Influenza vaccination – Pulmonary rehabilitation – Bronchodilators + Inhaled corticosteroids
  • Thank you
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities GOLD revised 2011
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities GOLD revised 2011
  • COPD Assessment Test (CAT) Modified Medical Research Council Dyspnea Scale (mMRC scale) Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD: assess symptoms GOLD revised 2011
  • http://www.catestonline.org/english/index_Thai.htm
  • เกณฑ์การให้คะแนน ภาวะหายใจ ลำาบาก (Modified Medical Research Council Dyspnea Scale; mMRC) แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities GOLD revised 2011
  • Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1> 80% predicted GOLD 2: Moderate 50% < FEV1< 80% predicted GOLD 3: Severe 30% < FEV1< 50% predicted GOLD 4: Very Severe FEV1< 30% predicted *Based on Post-Bronchodilator FEV1 GOLD revised 2011
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities GOLD revised 2011
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations High risk of exacerbations  > 2 exacerbations within the last year or  FEV1 < 50 % of predicted value GOLD revised 2011
  • Frequent exacerbators represent stable COPD phenotype - independent of severity ECLIPSE 3 year data 492 296 210 409 117 63 778 79 23 0% 20% 40% 60% 80% 100% Year 1 Year 2 Year 3 ≥2 Exacerb./Yr 1 Exacerb./Yr 0 Exacerb./Yr • Proportion of subjects experiencing ≥2 exacerbations/year increases year-on-year • Stable population provides potential to understand the cause(s) of the phenotype Hurst et al. N Engl J Med 2010
  • The ‘frequent exacerbator phenotype’: Frequency/severity by GOLD Category (1) 7 18 33 22 33 47 0 10 20 30 40 50 GOLD II (N=945) GOLD III (N=900) GOLD IV (N=293) %ofpatients p<0.01 Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more) ECLIPSE 1 year data Hurst et al. N Engl J Med 2010
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD  Assess symptoms  Assess degree of airflow limitation using spirometry  Assess risk of exacerbations  Assess comorbidities GOLD revised 2011
  • Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD Comorbidities COPD patients are at increased risk for: • Cardiovascular diseases • Osteoporosis • Respiratory infections • Anxiety and Depression • Diabetes • Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. GOLD revised 2011
  • Michael Rudolf
  •  Relieve symptoms  Improve exercise tolerance  Improve health status  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality Reduce symptoms Reduce risk Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Goals of Therapy
  • Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure Influenza vaccination Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: All COPD Patients
  • Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Risk (GOLDClassificationofAirflowLimitation) Risk (Exacerbationhistory) > 2 1 0 (C) (D) (A) (B) mMRC 0-1 CAT < 10 4 3 2 1 mMRC>2 CAT >10 Symptoms (mMRC or CAT score))
  • Exacerbationsperyear > 2 1 0 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: PharmacologicTherapy FIRST CHOICE A B DC ICS + LABA or LAMA
  • Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: PharmacologicTherapy (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.) Patient First choice Second choice Alternative Choices A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Theophylline B LAMA or LABA LAMA and LABA SABA and/or SAMA Theophylline C ICS +LABA or LAMA LAMA and LABA PDE4-inh. SABA and/or SAMA Theophylline D ICS + LABA or LAMA ICS andLAMA or ICS + LABA and LAMA or ICS+LABA and PDE4-inh.or LAMA and LABA or LAMA and PDE4-inh. Carbocysteine SABA and/or SAMA Theophylline
  • แผนการรักษาผู้ป่วยโรคปอดอุดกั้นเรื้อรังตาม ระดับความรุนแรงของโรค แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553 Exacerbationsperyear > 2 1 0 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA A B DC ICS + LABA or LAMA 0 Less symptoms Low risk More symptoms Low risk Less symptoms High risk A B DC More symptoms High risk
  • ชนิดของยาขยายหลอดลม กลไกการ ออกฤทธิ์ ระยะเวลาใน การออกฤทธิ์ วิธีบริหารยา ตัวอย่างยา β2 - agonists สั้น (4-6 ชั่วโมง)* สูด, รับ ประทาน, ฉีด Salbutamol, terbutaline, fenoterol ยาว (> 12 ชั่วโมง) สูด Salmeterol Formoterol* Anticholi nergics สั้น (6-8 ชั่วโมง) สูด Ipratropium bromide ยาว (> 24 ชั่วโมง) สูด Tiotropium Methylxa nthines ไม่แน่นอน อาจ > 24 ชั่วโมง รับประทาน, ฉีด Theophylline , aminophyllin * Rapid onset β2-agonist
  • Post-dose (hours) ChangeinFEV1 (%) Ipratropium + Albuterol Albuterol Ipratropium COMBIVENT Inhalation Aerosol Study Group. Chest. 1994;105:1411-1419. Reproduced with permission from American College of Chest Physicians. Short-acting Bronchodilators: Onset and Duration of Action P<0.001 for the combination versus each agent alone N=534
  • Potential Side Effects of COPD Therapy: β2-Agonists Rennard SI. Lancet. 2004;364:791-802. • Side effects include: – Palpitations – Ventricular arrhythmias (rare) – Sleep disturbance/poor sleep quality – Tremor – Hypokalaemia
  • Potential Side Effects of COPD Therapy: Anticholinergic Agents • Side effects are less common versus systemic agents (e.g., atropine) • Dry mouth is most commonly reported adverse event • Urinary retention may be a problem for patients with bladder outlet disease Rennard SI. Lancet. 2004;364:791-802.
  • Sustained-release theophylline • Narrow safety margin (10 -20 µg/ml) (monitoring of theophylline blood level may be necessary) • 400 µg/day (low dose 200 µg/day) • Side effects – CNS : seizures – CVS : hypotension, arrhythmia – GI : Nausea & vomiting Theodur® , Nuelin SR® หักครึ่งได้ห้ามบดห้ามเคี้ยว
  • Proposed mechanism of corticosteroid resistance in COPD patients. Barnes P J Chest 2006;129:151-155 ©2006 by American College of Chest Physicians
  • Oxygen therapy • Three ways of administration – Longterm continuous therapy – During exercise – Relieve acute dyspnea • Primary goal – Increase PaO2 > 60 mmHg, SaO2 > 90% 90
  • ข้อบ่งชี้ในการให้ Long-term oxygen therapy (> 15 hrs/day) • PaO2 < 55 mm Hg หรือ SaO2 < 88% • 55 mmHg < PaO2 < 60 mm Hg หรือ SaO2 of 88% ที่มี ภาวะที่บ่งชี้ว่ามี chronic hypoxemia ได้แก่ – pulmonary hypertension – peripheral edema suggesting congestive cardiac failure – polycythemia (hematocrit > 55%) LTOT จะให้ใน stable COPD ที่มี chronic hypoxemia ตามเกณฑ์ดังกล่าวข้าง ต้น กรณีที่ผู้ป่วยมีอาการกำาเริบเฉียบพลันและมี hypoxemia อาจให้ ออกซิเจนเป็นการชั่วคราว ถ้าหากยังมีภาวะ hypoxemia หลังจาก 3 เดือน จึงมีข้อบ่งชี้สำาหรับ LTOT
  • Pulmonary rehabilitation Evidence A • Improves exercise capacity • Reduces the perceived intensity of breathlessness • Improves health-related quality of life • Reduces the number of hospitalizations and days in the hospital • Reduces anxiety and depression associated with COPD Evidence B • Strength and endurance training of the upper limbs improves arm function • Benefits extend well beyond the immediate period of training • Improves survival • Improve recovery after hospitalization for an exacerbation • Enhances the effect of long-acting bronchodilators Evidence C • Respiratory muscle training can be beneficial, especially when combined with general exercise training GOLD revised 2011
  • Conclusions I • Spirometry is required to make diagnosis of COPD: post-bronchodilator FEV1/FVC < 0.7 • Assessment of COPD: – symptoms: CAT, mMRC scale – degree of airflow limitation: post-bronchodilator FEV1 % pred (stage 1-4) – risk of exacerbations: previous exacerbation, severe COPD – Comorbidities: cardiovascular disease, osteoporosis, anxiety/depression, DM
  • Conclusions II • Combined assessment of symptoms and risk of exacerbations is the basis for non- pharmacologic and pharmacologic management of COPD – Smoking cessation – Influenza vaccination – Pulmonary rehabilitation – Bronchodilators + Inhaled corticosteroids
  • Thank you
  • Establishing pulmonary rehabilitation program Funding and promotion • Where possible, dedicated funding should be sought to establish a PRP • Costing estimates vary depending upon the health-care system, existing infrastructure and equipment, staffing and duration of the program • Low cost programs in existing facilities have been shown to be effective • Lack of resources ought not to deter clinicians from seeking to establish a PRP Jenkins S. Respirology.2010;15:1157–73
  • Minimum requirement Optional Pulse oximeter Weights machine/multigym Polar heart rate monitor Stationary cycle Sphygmomanometer Spirometer Odometer (for walking test/track) Glucometer Stopwatch Inspiratory muscle training device Walking track/treadmill Rollator Hand weights Stairs/step Portable oxygen and nasal prongs Jenkins S. Respirology.2010;15:1157–73 Equipment required for a pulmonary rehabilitation program
  • Program setting • Inpatient pulmonary rehabilitation • Outpatient pulmonary rehabilitation • Home-based rehabilitation ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413
  • Outpatient pulmonary rehabilitation • is the most widely available of settings and may be hospital or community based • Potential advantages include cost-effectiveness, a safe clinical environment, and availability of trained staff • The majority of studies describing the benefits of pulmonary rehabilitation are derived from hospital-based outpatient programs ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413 โรงพยาบาลแม่พริก (Community based)โรงพยาบาลศิริราช (Hospital based)
  • Specificity of exercise training • Lower extremity training is traditionally focused – Cycling or walking • Upper limb exercises should also be incorporated into the training program because many daily activities involve upper extremities – e.g. arm cycle ergometer, free weights, and elastic bands • Upper limb exercise training reduces dyspnea during upper limb activities and reduces ventilatory requirements for arm elevation ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413
  • Walking track, 6 minute walk test
  • Treadmill, bicycle
  • Endurance training • Cycling or walking exercises is the most commonly applied • High levels of intensity (60% maximal work rate) • Total effective training > 30 minutes • Interval training may be a reasonable alternative in case difficult to achieve the target time or intensity • Interval training results in significantly lower symptom scores despite high absolute training loads, thus maintaining the training effects ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413 The recommendations of the ACSM include that the minimum duration of a session is 20 minutes effective exercise training
  • Strength (or resistance) training • Improve muscle mass and strength than endurance training • two to four sets of 6 to 12 repetitions at intensities ranging from 50 to 85% of one repetition maximum • Strength training may also result in less dyspnea during the exercise period, thereby making this strategy easier to tolerate than aerobic training • Combination of endurance and strength training is probably the best strategy to treat peripheral muscle dysfunction in chronic respiratory disease, because it results in combined improvements in muscle strength and whole body endurance, without unduly increasing training time ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413
  • Intensity of exercise • > 60% of the peak exercise capacity • A Borg score of 4 to 6 for dyspnea or fatigue is usually a reasonable target • Alternatively, heart rate at the gas exchange threshold or power output has also been used to target training intensity ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413
  • Modified BORG scale 0 ไม่เหนื่อยเลย 0.5 แทบไม่เหนื่อย 1 เหนื่อยน้อยมาก 2 เหนื่อยเล็กน้อย 3 เหนื่อยปานกลาง 4 เหนื่อยค่อนข้างมาก 5 เหนื่อยมาก 6 7 เหนื่อยมากๆ 8 9 เหนื่อยมากเกือบที่สุด 10 เหนื่อยมากที่สุดจนทนไม่ ไหว
  • Lower limb endurance training – walking, cycling • Training the muscles of ambulation is a mandatory • Walking, ground-based or utilizes a treadmill, is an essential component as it is an important activity in daily life • Training using a cycle ergometer is also beneficial as this modality imposes a greater specific load on the quadriceps muscles than walking • Supervised ground-based walking training results in a significantly greater increase in walking endurance capacity compared with supervised cycle based training Jenkins S. Respirology.2010;15:1157–73
  • Tests and measurements recommended for patient assessment Exercise capacity - Field-based walking test* Tests most commonly used: – six-minute walk test (6MWT) – Incremental shuttle walk test (ISWT) – Endurance shuttle walk test (ESWT) • Measures recorded before a PRP should be the best of two tests • Two 6MWTs do not appear to be required at post-program assessment • 6MWT and ISWT can be used to prescribe initial training intensity MID • 6MWT: ranges from 25 to 54 m, approximately 10% of the 6MWD measured before commencing the PRP • ISWT: approximately 48 m • ESWT: unknown Jenkins S. Respirology.2010;15:1157–73 MID = minimal important difference in patients with COPD PRP = pulmonary rehabilitation program * - Indicates that the assessment is essential
  • Less symptoms High risk More symptoms High risk
  • Definition of COPD • COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. • Exacerbations and comorbidities contribute to the overall severity in individual patients. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease •Airway inflammation •Airway fibrosis, luminal plugs •Increased airway resistance Parenchymal Destruction •Loss of alveolar attachments •Decrease of elastic recoil AIRFLOW LIMITATIONGOLD revised 2011
  •  Relieve symptoms  Improve exercise tolerance  Improve health status  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality Reduce symptoms Reduce risk Manage Stable COPD: Goals of Therapy © 2013 Global Initiative for Chronic Obstructive Lung Disease
  • Burden of COPD Mathers CD, Loncar D. PLoS Med 3(11): e442. doi:10.1371/journal.pmed.0030442
  • การวินิจฉัย • มีปัจจัยเสี่ยงต่อการเกิดโรคปอดอุดกั้นเรื้อรัง • ที่สำาคัญได้แก่ สูบบุหรี่ (โดยเฉพาะสูบตั้งแต่ 10 ซอง-ปี*ขึ้นไป) สัมผัส มลภาวะภายในและภายนอกอาคาร เป็นต้น • 2. ผู้ป่วยมีอาการ เหนื่อย ไอเรื้อรัง หรือ มีเสมหะเรื้อรัง ซึ่งอาการ เหนื่อยมักเป็นมากขึ้นเรื่อยๆ แต่บางรายอาจไม่มีอาการโดยเฉพาะในระยะ แรกของโรค • 3. ผลการตรวจสมรรถภาพปอดมีค่าของ FEV1/FVC < 0.7 หลังได้ รับยาขยายหลอดลม ซึ่งเป็นการยืนยันว่าผู้ป่วยยังคงมีภาวะหลอดลมอุด กั้นแม้ได้ยาขยายหลอดลม ซึ่งเป็นลักษณะสำาคัญของโรคปอดอุดกั้นเรื้อรัง ผู้ ป่วยที่สงสัยโรคปอดอุดกั้นเรื้อรังควรส่งตรวจสไปโรเมตรีย์เพื่อยืนยันการ วินิจฉัย * ซอง-ปี หมายถึง จำานวนบุหรี่ที่สูบเป็นซองต่อวัน x จำานวนปีที่สูบ เช่นสูบบุหรี่ 10 มวน (1/2 ซอง) ต่อวัน นาน 20 ปี เท่ากับ 10 ซอง-ปี
  • Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Lung growth and development Gender Age Respiratory infections Socioeconomic status Asthma/Bronchial hyperreactivity Chronic Bronchitis Genes Exposure to particles  Tobacco smoke  Occupational dusts, organic and inorganic  Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings  Outdoor air pollution GOLD revised 2011
  • Diagnosis of exacerbations • A worsening of the following two or more major symtoms for at least 2 consecutive days • Dyspnea • Sputum volume • Sputum purulence • Or • A worsening of any 1 major symptom together with an increase in any one of the following minor symptoms for at least 2 consecutive days • Sore throat • Colds (nasal discharge and/or nasal congestion) • Fever without other cause • Cough • Wheeze