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December 14, 2009
COPD: Diagnosis, Treatment, and
H1N1 Influenza Prevention
Clinician Outreach and Communication
Activity ...
Continuing Education Disclaimer
In compliance with continuing education requirements, all presenters
must disclose any fin...
Accrediting Statements
CME: The Centers for Disease Control and Prevention is accredited by the Accreditation
Council for ...
Chronic Obstructive Pulmonary Disease:
Diagnosis and Treatment
David M. Mannino, M.D.
University of Kentucky, College of P...
Chronic Bronchitis Emphysema
Asthma
Irreversible
Airflow
Obstruction
Reversible
Airflow
Obstruction
Friedlander et al, COPD 2007; 4: 355-384
COPD Phenotypes (NEW)
Clinical
Dyspnea
Frequent Exacerbator
Low BMI
Pulmonary Cac...
COPD Prevalence, by Sex, in US, 1980–2000
(Self-Reported Emphysema or Chronic Bronchitis)
Mannino DM, et al. MMWR. 2002; 5...
COPD Deaths by Sex
US, 1980 –2000
Mannino DM, et al. MMWR. 2002; 51(SS-6):1–20.
0
10
20
30
40
50
60
70
1980 1985 1990 1995...
NHANES III Current Diseases as a Proportional Venn Diagram.NHANES III Current Diseases as a Proportional Venn Diagram.
Sor...
COPD Progression and Death
he Natural History of Chronic Bronchitis and Emph
Adapted from Fletcher and Peto, Burrows
Natural History of Chronic Airflow Obstruction
Baraldi et al, NEJM 2007
0
20
40
60
80
100
120
FEV1/FVC < 70% FEV1/FVC => 70%
Lung Function Categories
Gold 3
Gold 2 Restricted
Gold 0 (if symptoms...
Years
121086420
Survival
1.0
.9
.8
.7
.6
Survival by Lung Function Impairment
GOLD 3 or 4
GOLD 2
GOLD 0
Normal
Restricted
...
0 10 20 30 40 50
GOLD 3/4
GOLD 2
GOLD 1
GOLD 0
Restricted
Normal
COPD ASCVD Lung Cancer Other
Mannino et al, Resp Med, Jan...
Current Smokers Former Smokers Never Smokers
Mannino DM, Watt G, Hole D, et al Eur Respir J. 2006;27:627-643.
COPD – Disea...
Life Expectancy from Age 65
(Data from NHANES 3 Follow-up)
Females
Survival in GOLD 3/4 COPD
By Smoking Status
Follow-up in Years
20100
ProportionSurviving
1.0
.8
.6
.4
.2
0.0
Survival Amon...
Smoking and GOLD 2+ COPD in NHANES 3
Life time Asthma and GOLD 2+ COPD
Findings from NHANES 3
PercentwithCOPD
Influence of vapor, dust, gas or fume
exposure on COPD prevalence
0
5
10
15
20
25
COPD, Emphysema
Never Smoker/No Exposure...
From the ATS/ERS Guidelines
Adapted from Fletcher et al. BMJ. 1977;1:1645-1648 (B).
Lung Function Over Time
Never smoked or not
susceptible to smoke
S...
When to Perform Spirometry:
Diagnosis of COPD (GOLD Guidelines)
Executive Summary: Global Strategy for the Diagnosis, Mana...
Spirometry Underused in Primary CareSpirometry Underused in Primary Care
 Patient history and physical findings are not e...
GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD
• FEV1/FVC <0.70
• FEV1 ≥80%
predicted
I: Mild II: Mo...
Effects of Bronchodilators on Clinical
Outcomes in Patients With COPD
Agent FEV1
Lung
Volume Dyspnea HRQL*
Exercise
Tolera...
OPTIMAL STUDY
Tiotropium plus Fluticasone/Salmeterol
 Combination did not significantly decrease
exacerbations compared t...
COPD: The Vicious Cycle
Cooper.Cooper. Med Sci Sports Exerc.Med Sci Sports Exerc. 2001;33(7 Suppl):S643-646.2001;33(7 Supp...
GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD
• FEV1/FVC <0.70
• FEV1 ≥80%
predicted
I: Mild II: Mo...
Oxygen reduces mortality in COPD
patients with resting hypoxemia
Cumulative
Survival
(%)
COT = continuous oxygen therapy; ...
Lung volume reduction surgery is
appropriate in subgroups of COPD
All PatientsAll Patients
N = 1218N = 1218
High Risk Pati...
 Defined as an acute change in dyspnea, cough and/or
sputum sufficient enough to warrant therapy change1
 In a 12-month ...
20%-24%20%-24%
(1 year)(1 year)
2.5%-10%2.5%-10%
(5 days)(5 days)
22%-32%22%-32%
(14 days)(14 days)
13%-33%13%-33%
(14 day...
Health Status Changes Following
an Exacerbation
30
35
40
45
50
55
60
4 Weeks 12 Weeks 26 Weeks
65
No Further
Exacerbation
...
COPD Exacerbations
Preventative Measures
 Long acting bronchodilators
 Inhaled corticosteroids
 Phosphodiesterase inhib...
COPD: High Risk For Flu
Complications
•Aging immune system
•On inhaled and oral steroids
•Multiple co-morbidities
•Impaire...
COPD and the Flu
•Everyone with COPD should get vaccinated
against the seasonal flu.
•Everyone with COPD should get the
pn...
COPD and the Flu
•Persons with COPD should not get the live
attenuated nasal spray flu vaccines (i.e.,
FluMist).
•The inac...
COPD Exacerbations
Therapy
 Bronchodilators
 Systemic steroids
 Antibiotics
 Oxygen
 Noninvasive Positive Pressure Ve...
www.LearnAboutCOPD.org
Chronic Obstructive Pulmonary Disease
 COPD is a PREVENTABLE and
TREATABLE disease
ATS/ERS Guidelines for the Treatment o...
Continuing Education Credit/Contact
Hours for COCA Conference Calls
Continuing Education guidelines require that the atten...
Diagnosis, Treatment, and H1N1 - CDC Emergency Preparedness ...
Diagnosis, Treatment, and H1N1 - CDC Emergency Preparedness ...
Diagnosis, Treatment, and H1N1 - CDC Emergency Preparedness ...
Diagnosis, Treatment, and H1N1 - CDC Emergency Preparedness ...
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  • Diagnosed lung disease and lung function impairment, also referred to as obstructive lung disease (OLD), in the United States adult population is shown as a proportional Venn diagram. Data was collected from the US National Health and Nutrition Examination (NHANES) III survey during the years 1988 to 1994 in participants ≥8 years (N=33,994). Asthma is defined as a chronic condition related to reversible airway obstruction, though individuals experiencing relentless symptoms of such are classified as having COPD. Chronic bronchitis and emphysema often occur simultaneously, with a percentage of individuals possessing concurrent asthma. The US NHANES III found that 5.5% of individuals studied had current asthma, 3.2% had current chronic bronchitis, and 1.5% had either present or past history of emphysema. 1.6% of individuals with OLD showed objective obstructions in airflow after undergoing spirometry measurements (airflow obstruction int.). 3.1% of the population experienced airglow obstruction in the absence of OLD diagnosis.
  • Fletcher CM, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;1:1645-1648.
  • Reference: Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J 2006;27:627-643.
  • Decline in FEV1 is accelerated in COPD. Quitting smoking has a profound effect on the rate of decline of FEV1.
    Fletcher et al found that over a lifetime FEV1 falls gradually. However, clinically significant airflow obstruction may never develop in many smokers. In those susceptible to COPD, smoking can cause permanent obstructive changes to air passages. The researchers found that if a susceptible smoker quits smoking, rates of FEV1 loss will revert to normal, but lung function is reduced. It is possible to prevent severe or fatal COPD by screening lung function in middle-aged smokers, who could be urged to stop smoking.
  • Lung function measurement, or spirometry, as a diagnostic tool for COPD is indicated by an individual’s exposure to risk factors and/or evidence of symptoms.
    Lung function measurement is important in the diagnosis of COPD. The reason for testing can be either an individual’s exposure to risk factors or evidence of symptoms. Tobacco, occupational exposure, and pollution are examples of exposure indications for lung function measurement. Symptoms can include exercise impairment, dyspnea, wheezing, cough, with or without sputum.
  • References
    Han MK, Kim MG, Mardon R, et al. Spirometry utilization for COPD: how do we measure up? Chest 2007; 132:403–409.
    Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following diagnosis of COPD. Chest 2006; 129:1509–1515.
  • Gold Guidelines: COPD Treatment by Stage
    All Stages
    Active reduction of risk factor(s): influenza vaccination
    Add short-acting bronchodilator (when needed)
    Moderate through Very Severe
    Add regular treatment with one or more long-acting bronchodilators (when needed):
    Add pulmonary rehabilitation
    Severe through Very Severe
    Add inhaled glucocorticosteroids if repeated exacerbations
    Add long term oxygen if chronic respiratory failure
    Consider surgical treatments
    Lung Transplantation
    Lung Volume Reduction Surgery (LVRS)
    Key Communication Points:
    Bronchodilators are central to the symptomatic management of COPD across all stages.  They can be inhaled as aerosol sprays or via nebulization
    The efficacy of inhaled glucocorticosteroids continues to be under study, however short-term benefit has been demonstrated. 
    ALA COPD Fact Sheet, Global Initiative for Chronic Obstructive Pulmonary Disease.  Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2003.
  • Increased VE requirements, increased breathlessness, decreased exercise capacity, and physical deconditioning caused by COPD remain in a vicious cycle which, among other physical conditions, can lead to immobility. This immobility can, in part, be counteracted upon by pulmonary rehabilitation (PR). Therapeutic intervention that includes PR has been shown to decreased VE requirement, decrease breathlessness, increase exercise capacity, and assist with physical reconditioning.
  • Gold Guidelines: COPD Treatment by Stage
    All Stages
    Active reduction of risk factor(s): influenza vaccination
    Add short-acting bronchodilator (when needed)
    Moderate through Very Severe
    Add regular treatment with one or more long-acting bronchodilators (when needed):
    Add pulmonary rehabilitation
    Severe through Very Severe
    Add inhaled glucocorticosteroids if repeated exacerbations
    Add long term oxygen if chronic respiratory failure
    Consider surgical treatments
    Lung Transplantation
    Lung Volume Reduction Surgery (LVRS)
    Key Communication Points:
    Bronchodilators are central to the symptomatic management of COPD across all stages.  They can be inhaled as aerosol sprays or via nebulization
    The efficacy of inhaled glucocorticosteroids continues to be under study, however short-term benefit has been demonstrated. 
    ALA COPD Fact Sheet, Global Initiative for Chronic Obstructive Pulmonary Disease.  Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2003.
  • Voice-Over:
    Now that we have had the opportunity to review COPD as a disease state, I would like to review the impact of exacerbations on patients with COPD.
    The ATS defines COPD exacerbations as an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.1
    I am sure you have seen exacerbations in your patients with COPD and are familiar with the impact they can have on these patients. The ATS guidelines review several key points for improving disease management in primary care. The ATS recommends that patients with COPD be made aware of the symptoms of an exacerbation and report them early to their physician.1
    There is evidence that frequent exacerbations play a role in the long-term decline in lung function in patients with moderate-to-severe COPD.2 This evidence points out the importance of discussing the symptoms of an exacerbation with your patients so that they are aware and seek treatment at the first sign of an exacerbation. In fact, the prevention and treatment of exacerbations is recognized as a key goal in COPD disease state management.3
    Let’s take a look at the burden of complications of COPD.
  • Treatment failure is defined as not responsive to initial treatment(s).
    Outcomes = health utilizations.
    This slide shows outcomes of patients with acute exacerbations: 20-24% of patients in the ICU with an exacerbation died; 6-12% of patients in general hospital beds, not ICU beds, died. Of those who visited the ER for an acute exacerbation, 22-32% of those patients had to revisit the emergency room after being discharged. Those who were treated as outpatients 13-33% of those patients did not response to initial treatments and needed further medical intervention.
    Main point: Acute exacerbations are a serious matter and should be of concern to the health care provider.
  • This graph shows the health status change following an exacerbation in COPD patients.
    Patients (N=438) with AECB were given either gemifloxacin 320 mg once per day for 5 days or clarithromycin 500 mg twice per day for 7 days. The SGRQ was used to assess health status of patients with AECB at presentation, at 4 weeks, at 12 weeks, and at 26 weeks. The biggest improvement in SGRQ score, or the biggest fall, occurred within 4 weeks of baseline. Patients who experienced no further exacerbations showed little improvement beyond the 6-month mark.
  • Transcript of "Diagnosis, Treatment, and H1N1 - CDC Emergency Preparedness ..."

    1. 1. December 14, 2009 COPD: Diagnosis, Treatment, and H1N1 Influenza Prevention Clinician Outreach and Communication Activity (COCA) Conference Call
    2. 2. Continuing Education Disclaimer In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Thomashow and he wishes to disclose receiving an honorarium for speaking from Boehringer Ingelheim, Pfizer, GlaxoSmithKline and Astra Zeneca and Dr. Mannino and he wishes to disclose receiving an honoraria and research support from GlaxoSmithKline and Pfizer, receiving an honoraria for being on the advisory board and serving as a speaker for Astra-Zeneca and Dey as well as receiving research support from Novartis. There is no commercial support.
    3. 3. Accrediting Statements CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity. CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 1 contact hour. CEU: The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. The CDC is authorized by IACET to offer 0.1 CEU's for this program. CECH: The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I contact hour in health education, CDC provider number GA0082.
    4. 4. Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment David M. Mannino, M.D. University of Kentucky, College of Public Health Byron Thomashow, M.D. Columbia University College of Medicine
    5. 5. Chronic Bronchitis Emphysema Asthma Irreversible Airflow Obstruction Reversible Airflow Obstruction
    6. 6. Friedlander et al, COPD 2007; 4: 355-384 COPD Phenotypes (NEW) Clinical Dyspnea Frequent Exacerbator Low BMI Pulmonary Cachexia ICS-responsive Depression and Anxiety Non-smokers Physiologic Airflow limitation Rapid decliner BD-responsiveness Hyperrresponsiveness Hypercapneic Poor exercise tolerance Hyperinflation Low DLCO Pulmonary hypertension Radiologic Emphysema Airways disease
    7. 7. COPD Prevalence, by Sex, in US, 1980–2000 (Self-Reported Emphysema or Chronic Bronchitis) Mannino DM, et al. MMWR. 2002; 51(SS-6):1–20. 0 1 2 3 4 5 6 7 8 1980 1985 1990 1995 2000 Men Women Millions of adults aged 25 and older
    8. 8. COPD Deaths by Sex US, 1980 –2000 Mannino DM, et al. MMWR. 2002; 51(SS-6):1–20. 0 10 20 30 40 50 60 70 1980 1985 1990 1995 2000 Men Women Deaths x 1,000 among adults age 25 and older
    9. 9. NHANES III Current Diseases as a Proportional Venn Diagram.NHANES III Current Diseases as a Proportional Venn Diagram. Soriano et al.Soriano et al. ChestChest. 2003;124:474-481.. 2003;124:474-481. Diagnosed Lung Disease and Lung Function Impairment in the US Adult Population AsthmaAsthma 5.5%5.5% Chronic bronchitisChronic bronchitis 3.2%3.2% EmphysemaEmphysema 1.5%1.5% Airflow obstruction int.Airflow obstruction int. 1.6%1.6% Airflow obstruction ext.Airflow obstruction ext. 3.1%3.1% NHANES IIINHANES III
    10. 10. COPD Progression and Death he Natural History of Chronic Bronchitis and Emph
    11. 11. Adapted from Fletcher and Peto, Burrows Natural History of Chronic Airflow Obstruction
    12. 12. Baraldi et al, NEJM 2007
    13. 13. 0 20 40 60 80 100 120 FEV1/FVC < 70% FEV1/FVC => 70% Lung Function Categories Gold 3 Gold 2 Restricted Gold 0 (if symptoms) or Normal Gold 1 FEV1 % predicted Gold 4
    14. 14. Years 121086420 Survival 1.0 .9 .8 .7 .6 Survival by Lung Function Impairment GOLD 3 or 4 GOLD 2 GOLD 0 Normal Restricted GOLD 1 Mannino et al, Resp Med, 2006
    15. 15. 0 10 20 30 40 50 GOLD 3/4 GOLD 2 GOLD 1 GOLD 0 Restricted Normal COPD ASCVD Lung Cancer Other Mannino et al, Resp Med, Jan 2006 What do COPD Patients Die From? (rate per 1,000 person-years)
    16. 16. Current Smokers Former Smokers Never Smokers Mannino DM, Watt G, Hole D, et al Eur Respir J. 2006;27:627-643. COPD – Disease Burden in U.S.
    17. 17. Life Expectancy from Age 65 (Data from NHANES 3 Follow-up) Females
    18. 18. Survival in GOLD 3/4 COPD By Smoking Status Follow-up in Years 20100 ProportionSurviving 1.0 .8 .6 .4 .2 0.0 Survival Among Subjects with GOLD 3 or 4 COPD Never Smokers Former Smokers Current Smokers From NHANES I follow-up
    19. 19. Smoking and GOLD 2+ COPD in NHANES 3
    20. 20. Life time Asthma and GOLD 2+ COPD Findings from NHANES 3 PercentwithCOPD
    21. 21. Influence of vapor, dust, gas or fume exposure on COPD prevalence 0 5 10 15 20 25 COPD, Emphysema Never Smoker/No Exposure Never Smoker/ Yes Exposure Ever Smoker/ No Exposure Ever Smoker/ Yes Exposure Percent of Subjects reporting COPD or Emphysema (n=2061 US adults aged 55-75) Trupin et al, ERJ 2003; 22:462-469
    22. 22. From the ATS/ERS Guidelines
    23. 23. Adapted from Fletcher et al. BMJ. 1977;1:1645-1648 (B). Lung Function Over Time Never smoked or not susceptible to smoke Stopped smoking at 45 (mild COPD) Stopped smoking at 65 (severe COPD) Death Disability Smoked regularly and susceptible to effects of smoking Age (years) 50 7525 Symptoms 0 25 50 100 75 FEV1(%)RelativetoAge25
    24. 24. When to Perform Spirometry: Diagnosis of COPD (GOLD Guidelines) Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD Updated 2005. Available at: http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2= 1&intId=996. Accessed June 6, 2006 (A). SpirometrySpirometry Symptoms Exercise Impairment Dyspnea, Wheezing Cough ± Sputum Symptoms Exercise Impairment Dyspnea, Wheezing Cough ± Sputum Exposure Tobacco Occupational Pollution Exposure Tobacco Occupational Pollution
    25. 25. Spirometry Underused in Primary CareSpirometry Underused in Primary Care  Patient history and physical findings are not enough to accurately diagnose COPD  Only 1/3 of patients with COPD have undergone spirometry as part of their diagnosis1,2  Spirometry use decreases with increasing age – ≥75 years old vs all other age groups: 25.4% vs 32.7% (P<.0001)1 – Odds ratio (95% CI) of spirometry compared with patients age 50- 59: Age 60-69, 0.82 (0.78-0.86); Age 70-79, 0.68 (0.65-0.71); Age 80+, 0.52 (0.49-0.55)2 1. Han MK et al. Chest. 2007;132:403-409. 2. Lee TA et al. Chest. 2006;129:1509-1515.
    26. 26. GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD • FEV1/FVC <0.70 • FEV1 ≥80% predicted I: Mild II: Moderate III: Severe IV: Very Severe • FEV1/FVC <0.70 • 50% ≤FEV1 <80% predicted • FEV1/FVC <0.70 • 30% ≤FEV1 <50% predicted • FEV1/FVC <0.70 • FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure Add regular treatment with one or more long-acting bronchodilators (when needed): Add pulmonary rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. www.goldcopd.com
    27. 27. Effects of Bronchodilators on Clinical Outcomes in Patients With COPD Agent FEV1 Lung Volume Dyspnea HRQL* Exercise Tolerance* Disease Modifier by FEV1 Side Effects Short-acting beta2-agonists Yes Yes Yes N/A Yes N/A Minimal Short-acting anticholinergic Yes Yes Yes No Yes No Minimal Long-acting beta2-agonists Yes Yes Yes Yes Yes No Minimal Long-acting anticholinergic Yes Yes Yes Yes Yes No Minimal Theophylline Yes Yes Yes Yes Yes N/A Potentially important *Although the results from a number of drug studies are not uniform, many of the drugs studied provide these results. N/A=evidence not available. Adapted from Celli et al. Eur Respir J. 2004;23:932-946.
    28. 28. OPTIMAL STUDY Tiotropium plus Fluticasone/Salmeterol  Combination did not significantly decrease exacerbations compared to Tio alone  Combination: Improved lung function  Combination: Improved quality of life  Combination: Decreased COPD hospitalizations  Combination: Decreased all cause hospitalizations Aaron et al Annals Internal Med 2007;146:1-14
    29. 29. COPD: The Vicious Cycle Cooper.Cooper. Med Sci Sports Exerc.Med Sci Sports Exerc. 2001;33(7 Suppl):S643-646.2001;33(7 Suppl):S643-646. Chronic Pulmonary DiseaseChronic Pulmonary Disease PhysicalPhysical DeconditioningDeconditioning PhysicalPhysical ReconditioningReconditioning DecreasedDecreased ExerciseExercise CapacityCapacity IncreasedIncreased ExerciseExercise CapacityCapacity IncreasedIncreased BreathlessnessBreathlessness DecreasedDecreased BreathlessnessBreathlessness ImmobilityImmobility Pulmonary RehabilitationPulmonary Rehabilitation Increased VIncreased VEE RequirementRequirement Decreased VDecreased VEE RequirementRequirement
    30. 30. GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD • FEV1/FVC <0.70 • FEV1 ≥80% predicted I: Mild II: Moderate III: Severe IV: Very Severe • FEV1/FVC <0.70 • 50% ≤FEV1 <80% predicted • FEV1/FVC <0.70 • 30% ≤FEV1 <50% predicted • FEV1/FVC <0.70 • FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure Add regular treatment with one or more long-acting bronchodilators (when needed): Add pulmonary rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. www.goldcopd.com
    31. 31. Oxygen reduces mortality in COPD patients with resting hypoxemia Cumulative Survival (%) COT = continuous oxygen therapy; NOT = nocturnal oxygen therapy; MRC controls = no oxygen therapy; MRC = domiciliary oxygen therapy. Flenley DC. Resp Care. 1983;2S:876. Months NIH COT MRC O2 NIH NOT MRC controls 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70
    32. 32. Lung volume reduction surgery is appropriate in subgroups of COPD All PatientsAll Patients N = 1218N = 1218 High Risk PatientsHigh Risk Patients N = 140N = 140 Non High Risk PatientsNon High Risk Patients N = 1078N = 1078 Upper LobeUpper Lobe High ExerciseHigh Exercise N = 419N = 419 Upper LobeUpper Lobe Low ExerciseLow Exercise N = 290N = 290 Non Upper LobeNon Upper Lobe Low ExerciseLow Exercise N = 149N = 149 Non Upper LobeNon Upper Lobe High ExerciseHigh Exercise N = 220N = 220 LVRS LVRS
    33. 33.  Defined as an acute change in dyspnea, cough and/or sputum sufficient enough to warrant therapy change1  In a 12-month observational study (n=127), 77% of patients reported having at least one exacerbation2*  The prevention of exacerbations is recognized as a key goal in COPD disease state management3 1. American Thoracic Society/European Respiratory Society. Standards for the diagnosis and management of patients with COPD [Internet]. Version 1.2. www.thoracic.org/go/copd. Accessed April 30, 2008. 2. O’Reilly, et al. Prim Care Respir J. 2006;15:346-353. 3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease – Updated 2007. www.goldcopd.org. Accessed April 30, 2008. COPD Exacerbations *Based on diary records of symptom-defined and healthcare-defined exacerbations.
    34. 34. 20%-24%20%-24% (1 year)(1 year) 2.5%-10%2.5%-10% (5 days)(5 days) 22%-32%22%-32% (14 days)(14 days) 13%-33%13%-33% (14 days)(14 days) Hospital mortalityHospital mortality Hospital mortalityHospital mortality Relapse (repeat ER visit)Relapse (repeat ER visit) Treatment failure rateTreatment failure rate Outcome of COPD Exacerbations Seneff et al. JAMA. 1995; 274:1852-1857; Murata et al. Ann Emerg Med. 1991;20:125-129; Adams et al. Chest. 2000; 117:1345-1352; Patil et al. Arch Int Med. 2003; 163:1180-1186. In hospitalizedIn hospitalized patientspatients In ER patientsIn ER patients In ICU patientsIn ICU patients In outpatientsIn outpatients
    35. 35. Health Status Changes Following an Exacerbation 30 35 40 45 50 55 60 4 Weeks 12 Weeks 26 Weeks 65 No Further Exacerbation Baseline (At presentation with acute exacerbation) Further Exacerbation Within 6 Months SGRQScore Spencer et al. Thorax. 2003;58:589-593 (A).
    36. 36. COPD Exacerbations Preventative Measures  Long acting bronchodilators  Inhaled corticosteroids  Phosphodiesterase inhibitors  Mucolytics/Antioxidants  Immunizations-influenza vaccine pneumococcal vaccine  OM-85(Broncho-vaxim)  Macrolides  Case management  Lung Volume Reduction Surgery
    37. 37. COPD: High Risk For Flu Complications •Aging immune system •On inhaled and oral steroids •Multiple co-morbidities •Impaired airway defenses •Reduced lung reserve
    38. 38. COPD and the Flu •Everyone with COPD should get vaccinated against the seasonal flu. •Everyone with COPD should get the pneumococcal polysaccharide vaccine (PPSV). •Everyone with COPD should get vaccinated for the 2009 H1N1 influenza, using the shot (injectable) form.
    39. 39. COPD and the Flu •Persons with COPD should not get the live attenuated nasal spray flu vaccines (i.e., FluMist). •The inactivated 2009 H1N1 influenza vaccine can be administered at the same visit as any other vaccine, including the PPSV.
    40. 40. COPD Exacerbations Therapy  Bronchodilators  Systemic steroids  Antibiotics  Oxygen  Noninvasive Positive Pressure Ventilation  Intubation
    41. 41. www.LearnAboutCOPD.org
    42. 42. Chronic Obstructive Pulmonary Disease  COPD is a PREVENTABLE and TREATABLE disease ATS/ERS Guidelines for the Treatment of COPD, 2004
    43. 43. Continuing Education Credit/Contact Hours for COCA Conference Calls Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits/contact hours (CME, CNE, CEU and CECH) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system http://www2a.cdc.gov/TCEOnline/. Those who participate in the COCA Conference Calls and who wish to receive CE credit/contact hours and will complete the online evaluation by January 13, 2010 will use the course code EC1265. Those who wish to receive CE credits/contact hours and will complete the online evaluation between January 14, 2010 and January 14, 2011 will use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.
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