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Management of COPD BTS Guidelines

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Management of COPD BTS Guidelines Management of COPD BTS Guidelines Presentation Transcript

  • Definition • Airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.
  • Management of COPD BTS Guidelines 2004 • Priorities for implementation – Diagnose COPD – Stop smoking – Effective inhaled Rx – Pulmonary rehabilitation – Manage exacerbations (NIV) – Multidisciplinary working
  • Disease Burden • 900,000 (2,000,000) in UK • >30,000 deaths in UK 1999 • 5% all deaths • Health District (250,000) – 700 admissions (10%) – 9,600 bed days – 14,000 GP consultations
  • Chronic Bronchitis • Irritants in smoke/Pollution – Mucous gland hypertrophy – Increased mucus gland secretion – Increased polymorphs in airways – bronchoconstriction – Airway narrowing (small airways) – need a lot of damage before spirometry affected
  • Emphysema Increased polymorphs Elastase loss of alveoli / pulmonary vasculature area for gas exchange loss of elastic supporting tissue early expiratory airway collapse hyperinflation
  • Diagnosis • History – Progressive symptoms - Cough/Wheeze/SOB – Ex tolerance, childhood illness/atopy/ FH – Occupation – Smoking - 20 pack years – Examination - not diagnostic – Objective evidence of airway obstruction that does not return to normal with Rx
  • Investigations • CXR (not necessary) • Spirometry – FEV1<80% predicted – FEV%<70% predicted – Little variability in expiratory flow
  • Monitor Progression • 15% smokers significant obstruction • FEV1 (20-30 ml/yr non smokers) • FEV1 (45-70 ml/yr smokers) • Prognosis related to FEV1 – Mortality: Renfrew/Paisley Study, BMJ 1996 • Drug treatment does may affect natural history (LTOT improves survival)
  • Peak Flow/Spirometry • FEV1 reproducible (160 ml) • FVC reproducible (330 ml) • FEV% diagnoses obstruction • Low PEFR obstruction/restriction • PEFR not related to FEV1 • PEFR underestimates obstruction in COPD – COPD small airways
  • Severity of COPD • Mild - FEV1 50-80 (60-79)% – smokers cough • Moderate- FEV1 30-49 (40-59)% – Cough, SOBOE, wheeze (signs) • Severe - FEV1 <30 (<40)% – Cough,wheeze,SOB, signs
  • Severity of COPD MRC Dyspnoea Scale • 1. SOB strenuous exercise • 2. SOB hurrying, slight hill • 3. Unable to keep up with peers* • 4. Stops for breath after 100m* • 5.Too breathless to leave house – SOB washing dressing
  • Differentiation from Asthma –Smoker / non smoker –symptoms <35 yr –chronic productive cough –SOB –Night time waking /wheeze –Diurnal variability symptoms
  • Reversibility Testing • Not necessary may be misleading (single test) –but may help with diagnosis if large response to bronchodilators or prednisolone (30mg 2/52)
  • Reversibility Testing • Salbutamol/Ipratropium –stable free from infection –post bronchodilator FEV1 best predictor of prognosis –no bronchodilators for 6 hr –2.5-5mg salbutamol Neb (20min) –500mcg ipratropium Neb (45min)
  • Reversibility Testing • Steroids – 30mg day, 2 weeks – beclomethasone 500mcg bd, 6 weeks – positive response in 10-20% – better prognosis if positive response – Steroid responders also respond to bronchodilators
  • Reversibility Testing • Question. • Are we measuring the right thing ? • Answer • Probably not !
  • Reversibility Testing • Absolute Change – (FEV, 160 ml, FVC 330 ml) ? • % change ? – FEV1 - 1.1 Pre, 1.5 post – (1.5/1.1) x 100 = 36 % change – (1.1/1.5) X 100 = 27 % change – {(1.5-1.1)/(1.5+1.1)/2} x100 = 31% change
  • Other Investigations • BMI, CRP ? • FBC -PCV >50%, alpha 1 antitrypsin • Sputum (Pneumococcus, Haemophilus, Moraxella) • Oximetry/ABG (or Sat >92%) • CT - extent/distribution of emphysema • TLC/RV comparison(body box/He dilution) • ECG/ECHO - IHD/ Cor pulmonale
  • Management of stable COPD • Smoking • SOB/SOBOE • Frequent Exacerbations • Respiratory failure • Cor pulmonale • Abnormal BMI • Chronic cough • Anxiety/Depression • Palliative Care
  • Smoking Cessation • Stop smoking (10-30% in trials) – sudden better than gradual – all smokers in house – medical advice – nicotine (doubles quit rate) – monitoring (co,carboxyHb,cotinine) – antidepressant (Bupropion USA) – Varenicline
  • Smoking Cessation • Key Fact: • Every Cigarette reduces life expectancy by 11 minutes !
  • Inhaled Bronchodilators • Improve FEV1/symptoms • Combination better • Long acting –greater clinical benefit, health status and lower exacerbation rate • Steroid /LABA combination –greater improvement than either alone
  • Inhaled Bronchodilators • Tiotropium reduces exacerbations by 25% compared to ipratropium • UPLIFT Study – 3 yr tiotropium vs placebo. Decline in lung function. • Triple therapy ?
  • Phosphodiesterase Inhibitors • Mild Bronchodilator effect – upper end of therapeutic range – effect may take several weeks • Improve respiratory muscle strength • Improve mucus clearance • Reduce exacerbations ?
  • Phosphodiesterase Inhibitors • Anti inflammatory action - low dose – suppresses inflammatory genes (HDAC) – potentiate anti-inflammatory effects of Pred – caution with macrolides and quinolones – Roflumilast, Cilomilast (PDE4 inhibitors)
  • Inhaled Steroids • Improve symptoms ? • Reduce inflammation ? • Reduce decline in lung function ? • Reduce exacerbations ? • Increase pneumonia ? • Interaction with beta agonists ?
  • European Study • Smokers with mild COPD – 912 current smokers – Randomised, double blind placebo controlled, parallel group study, 3yr – Budesonide 400 ug bd – No effect on progressive decline in FEV1 – Pauwels et al, NEJM, 1999.
  • Copenhagen Lung Study • 76% current smokers, n =290 – mild COPD – Randomised, double blind, placebo controlled, parallel group study, 3yr – Budesonide 400 ug bd • No effect on progressive decline in FEV1 – Vestbo et al, Lancet 1999. 353:1819-23
  • ISOLDE – severe COPD (48% smoking at entry) – 3yr randomised, double blind, placebo controlled, parallel group study, n=750 – Inhaled Fluticasone – No effect on progressive decline in FEV1 – Fewer exacerbations – Fewer symptoms – Sub group analysis – BMJ 2000 320
  • META - ANALYSIS • 3 studies (1 abstract) • 2 yr • Moderate-severe COPD n=95/88 • 800 -1600 mcg Beclomethasone • Steroid group FEV1 improved by 80 ml/yr – Van Grunsven et al, Thorax 1999.
  • TORCH • 3yr, n = 6,000. smokers or ex, FEV1<60% – Fluticasone/salmeterol, Fluticasone, – Salmeterol, placebo • All cause mortality no difference • Exacerbations reduced (25%) with steroid • Improved health status with steroid
  • Steroids/Pneumonia • TORCH (NEJM 2007 356: 775-789) – Inhaled steroids increased pneumonia ? • AJRCCM 2007 176: 162-166 – Inhaled steroids increased pneumonia admissions ?
  • Steroids/Beta Agonists • Steroids – increase expression of beta2 receptors. – decrease loss due to long term exposure • Beta 2 Agonists – potentiate molecular mechanism of steroid action.
  • Oral steroids • Maintenance therapy not recommended. • If necessary keep dose low. • Monitor for osteoporosis. • Prophylaxis for osteoporosis if >65.
  • Home Nebuliser Therapy • SOB despite maximal Rx • MDI v Neb trials in stable COPD inconsistent • Assessment – home trial (St George’s AQ20), optimise Rx – technical support/FU – Neb Rx 3-4x more expensive than HHI
  • Other measures • Exercise – Safe and desirable • Nutrition • Vaccination -Flu /Pneumococcus • Treat depression (50%) • Travel (900-2,400 m, PaO2 15 -18 kPa) – bullae, pneumothorax, PaO2<6.7 kPa air
  • Prevent Exacerbations • Vaccination. • Self management advice. • Optimise bronchodilator Rx. • Add inhaled steroids if FEV1 <50% and 2 or more exacerbations per year. • Rotating antibiotics.
  • Pulmonary Rehabilitation • Proven value (randomised trials) • MRC grade 3 and above • Ex tolerance, Psychosocial • Reduce hospital admissions/LOS ? • A cynics definition of Exercise -”An enthusiasm lasting about 3 weeks, which is readily soluble in alcohol” (Newcastle study)
  • LTOT • MRC study(1981) -15 hr/day – 5 yr survival 25% / 41% – Less polycythaemia – Prevention of progression of PHT – Improved sleep quality – Improved psychologically (QOL) – Reduction in cardiac arrhythmias
  • LTOT • ABG x 2 (3 weeks apart) - clinically stable • PaO2 < 7.3 kPa on air • FEV1 < 1.5 • Non-smokers • 6 monthly follow-up • Prescriber – England: GP – Scotland: Consultant Chest Physician
  • Ambulatory Oxygen • Exercise desaturation • Exercise Test – Symptoms – Walk distance – saturation • Follow up
  • Nocturnal Hypoventilation in COPD • Reduced ventilatory drive during sleep • Sleep deprivation (sleep apnoea) reduces chemoreceptor sensitivity • Reduced muscle performance – muscle mechanics – acidosis
  • NIV • No recommendations at present • May prolong survival in patients deteriorating on LTOT with associated hypercapnoea • ? Mechanism of cor pulmonale
  • Cor Pulmonale • Lung disease Hypoxia Pulmonary arterial vasoconstriction Pulmonary Hypertension RVF Oedema • Lung disease Hypoxia / Hypercapnoea Renal Perfusion Fluid retention
  • Surgery • Bullectomy • Lung volume reduction – improves symptoms/ex tolerance/QOL – VATS/Sternotomy – low morbidity (<70yr,FEV1>0.5l, PaO2>7.3) – ? Survival advantage (NETT USA) - no ! • Transplant (young, alpha 1 antitrypsin)
  • ACUTE EXACERBATIONS ? • Referral Criteria – Cope at home? – Absence of cyanosis? – Normal level of conciousness? – Mild breathlessness? – Good general condition? – Not receiving LTOT? – Good level of activity? – Good social circumstances?
  • ACUTE EXACERBATIONS • Hospital Investigations – CXR – ABG – ECG – FBC/U+E – Sputum culture if purulent – Blood cultures if pyrexial
  • ACUTE EXACERBATIONS • Bronchodilators – Neb or HHI +Spacer – Pred 30mg 14/7 – Oxygen (controlled) – Antibiotics if sputum purulent • penicillin, macrolide, • Theophylline – NIV (Doxapram) – Physiotherapy
  • STEROIDS/EXACERBATIONS – 80 8/52 High dose oral Prednisolone – 80 2/52 High dose oral prednisolone – 111 Placebo • Steroids: – less treatment failure (intubation etc) – faster improvement in FEV1 – Shorter Hospital Stay – Niewoehner et al, NEJM 1999
  • ACUTE EXACERBATIONS • NIV – better ABG – reduced LOS – reduced complications – reduced mortality – reduced intubation • Oxygen – pulse oximeters (beware pCO2 !)
  • ACUTE EXACERBATIONS • Hospital at Home – various models – 1/3 patients suitable – nurses, physios, OT’s – average hospital LOS 10 days – saves bed days, not money ! – Patients like it !
  • Follow Up – Mild Yearly, Severe 6 monthly • smoking status • symptom control(SOB ex tolerance exacerbations) • inhaler technique, review Rx • Nutrition • ? Pulmonary Rehab ? LTOT • Spiro, BMI, MRC dyspnoea (Sa O2 severe)
  • Referral • Onset cor pulmonale • LTOT • Neb • Oral steroids • Bullous disease • Rapid decline in FEV1 • Diagnostic advice
  • Summary • Stop smoking • LABA better than SABA, combination Rx • Inhaler technique • ICS if FEV1 <50% + exacerbations • LTOT if O2 sats < 90% +/- cor pulmonale • Sudden change in symptoms - CXR • Unsure - refer
  • Summary • Management plan – Antibiotics • pneumococci, moraxella, H influenzae – PO steroids for exacerbations • 24% O2 or 2 l/min via nasal cannulae safe • Useful tool - AQ 20 ?
  • The Future ? • PD4 inhibitors • Leukotriene B4 inhibitors • Adhesion molecule blockers • Antioxidants – resveratrol (red wine), N-acetylcysteine • Biomarkers