Copd 2006


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Copd 2006

  1. 1. COPD 2006 Mark Cucuzzella MD LtCol USAFR Associate Professor Family Medicine West Virginia Rural Family Medicine Program
  2. 2. Close to the Beltway but a World Apart
  3. 4. Wayne McLaren…Former Marlboro Man Age 30…a robust young man Age 51…riding into the sunset
  4. 5. US Leading Causes of Death 2001
  5. 6. % Change in Age Adjusted Death Rate US 1965-1998…gotta die of something
  6. 7. Other Sad Facts <ul><li>Direct Cost 2002- 18 Billion </li></ul><ul><li>Indirect Costs- 14 Billion </li></ul><ul><li>In US 47 million still smoke </li></ul><ul><ul><li>28% males </li></ul></ul><ul><ul><li>23% females </li></ul></ul><ul><li>WHO: 1 billion smokers worldwide…to increase to 1.6 billion 2025. Increasing in lower income areas </li></ul>
  7. 8. Objectives of COPD Management <ul><li>Prevent Progression </li></ul><ul><li>Relieve symptoms </li></ul><ul><li>Improve exercise tolerance and general health status </li></ul><ul><li>Prevent and treat exacerbations and complications </li></ul><ul><li>Minimize treatment side effects </li></ul>
  8. 9. Pathophysiology Simplified Bad Genes Breathe Noxious Crap COPD
  9. 10. The Real Story
  10. 12. THE Guideline <ul><li>Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National Heart, Lung and Blood Institute (NHLBI) </li></ul>
  11. 13. 4 Keys to Management <ul><li>Assess and Monitor Disease </li></ul><ul><li>Reduce Risk Factors </li></ul><ul><li>Manage Stable COPD </li></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Med management </li></ul></ul><ul><ul><li>Non med management </li></ul></ul><ul><li>Treat exacerbations </li></ul>
  12. 14. Assess and Monitor Disease Classification of COPD <ul><li>Stage 0 At Risk </li></ul><ul><li>Stage I Mild COPD </li></ul><ul><li>Stage II Moderate COPD </li></ul><ul><li>Stage III Severe COPD </li></ul><ul><li>Stage IV Very Severe COPD </li></ul>
  13. 15. Stage 0 At Risk <ul><li>Normal spirometry </li></ul><ul><li>Chronic symptoms (cough, sputum, production) </li></ul>
  14. 16. Stage I Mild COPD <ul><li>FEV1/FVC <70% </li></ul><ul><li>FEV1 > 80% predicted </li></ul><ul><li>With or without chronic symptoms (cough, sputum production) </li></ul>
  15. 17. Stage II Moderate COPD <ul><li>FEV1/FVC <70% </li></ul><ul><li>50% < FEV1 <80% predicted </li></ul><ul><li>With or without chronic symptoms (cough, sputum production) </li></ul>
  16. 18. Stage III Severe COPD <ul><li>FEV1/FVC <70% </li></ul><ul><li>30% < FEV1 <50% predicted </li></ul><ul><li>With or without chronic symptoms (cough, sputum production) </li></ul>
  17. 19. Stage IV Very Severe COPD <ul><li>FEV1/FVC <70% </li></ul><ul><li>FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure </li></ul>
  18. 20. GOLD Guideline in Japan
  19. 21. Assess: Who Has Early Stages And Who Do You Test? <ul><li>Test patients with: </li></ul><ul><ul><li>chronic cough and sputum </li></ul></ul><ul><ul><li>exposure to risk factors </li></ul></ul><ul><ul><li>even if no dyspnea </li></ul></ul><ul><li>Early Stage: </li></ul><ul><ul><li>airflow limitation that is not fully reversible </li></ul></ul><ul><ul><li>with or without the presence of symptoms </li></ul></ul>
  20. 22. Assess for COPD: A Common Story <ul><li>Cough </li></ul><ul><ul><li>intermittent or daily </li></ul></ul><ul><ul><li>present throughout day- seldom only nocturnal </li></ul></ul><ul><li>Sputum </li></ul><ul><ul><li>Any pattern of chronic sputum production </li></ul></ul><ul><li>Dyspnea </li></ul><ul><ul><li>Progressive and Persistent </li></ul></ul><ul><ul><li>&quot;increased effort to breathe&quot; &quot;heaviness&quot; &quot;air hunger&quot; or &quot;gasping&quot; </li></ul></ul><ul><ul><li>Worse on exercise </li></ul></ul><ul><ul><li>Worse during respiratory infections </li></ul></ul><ul><li>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>
  21. 23. Assess: Spirometry to Diagnose <ul><ul><li>FEV1/FVC <70% and a postbronchodilator FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible. </li></ul></ul><ul><ul><li>Must have access to spirometry </li></ul></ul>
  22. 24. Assess: Medical History in Those With Established Disease <ul><li>Exacerbations or hospitalizations? </li></ul><ul><li>Comorbidities that contribute to restriction of activity </li></ul><ul><li>Appropriateness of current medical treatments </li></ul><ul><li>Impact of disease on patient's life </li></ul><ul><ul><li>limitation of activity </li></ul></ul><ul><ul><li>missed work and economic impact </li></ul></ul><ul><ul><li>effect on family routines </li></ul></ul><ul><ul><li>depression or anxiety </li></ul></ul><ul><li>Social and family support </li></ul><ul><li>Possibilities for reducing risk factors, esp smoking </li></ul>
  23. 25. Assess: Physical Examination <ul><li>Rarely diagnostic in COPD </li></ul><ul><li>Physical signs of airflow limitation </li></ul><ul><ul><li>rarely present until significant impairment of lung function </li></ul></ul><ul><ul><li>low sensitivity and specificity </li></ul></ul>
  24. 26. Assess: Measure Airflow Limitation <ul><li>Patients with COPD typically show a decrease in both FEV1 and FVC </li></ul><ul><li>Postbronchodilator FEV1 <80% predicted + FEV1/FVC <70% confirms the presence of airflow limitation that is not fully reversible </li></ul><ul><li>FEV1/FVC <70% is an early sign of airflow limitation in patients whose FEV1 remains normal ( > 80% predicted). </li></ul>
  25. 27. Assess: Severity <ul><li>Based on the patient's level of symptoms </li></ul><ul><li>Severity of the spirometric abnormality </li></ul><ul><li>Presence of complications such as respiratory failure and right heart failure </li></ul>
  26. 28. Assess: Additional Investigations > Stage II: Moderate COPD <ul><li>Bronchodilator reversibility testing </li></ul><ul><ul><li>rule out asthma </li></ul></ul><ul><ul><li>establish best attainable lung function </li></ul></ul><ul><ul><li>gauge a patient's prognosis </li></ul></ul><ul><ul><li>guide treatment decisions </li></ul></ul><ul><li>Chest x-ray </li></ul><ul><ul><li>seldom diagnostic unless obvious bullous disease </li></ul></ul><ul><ul><li>valuable in excluding alternative diagnoses </li></ul></ul><ul><ul><li>CT not routinely recommended </li></ul></ul>
  27. 29. Assess: Additional Investigations > Stage II: Moderate COPD <ul><li>Arterial blood gas measurement </li></ul><ul><ul><li>In advanced COPD: FEV1 <40% predicted or with clinical signs suggestive of respiratory failure or right heart failure </li></ul></ul><ul><ul><li>central cyanosis, ankle swelling, JVD </li></ul></ul><ul><ul><li>Respiratory failure </li></ul></ul><ul><ul><ul><li>PaO2 < 60 mm Hg +/- PaCO2 >50 mm Hg at sea level </li></ul></ul></ul><ul><li>Alpha-1 antitrypsin deficiency screening </li></ul><ul><ul><li>COPD at a young age </li></ul></ul><ul><ul><li>strong family history of the disease </li></ul></ul>
  28. 30. Differential Diagnosis <ul><li>A major differential diagnosis is asthma </li></ul><ul><li>In some patients with chronic asthma, a clear distinction from COPD is not possible </li></ul><ul><li>In these cases, current management is similar to that of asthma </li></ul><ul><li>Other potential diagnoses are usually easier to distinguish from COPD </li></ul>
  29. 31. COPD <ul><li>Onset in mid-life </li></ul><ul><li>Symptoms slowly progressive </li></ul><ul><li>Long smoking history </li></ul><ul><li>Dyspnea during exercise </li></ul><ul><li>Largely irreversible airflow limitation </li></ul>
  30. 32. Asthma <ul><li>Onset early in life (often childhood) </li></ul><ul><li>Symptoms vary from day to day </li></ul><ul><li>Symptoms at night/early morning </li></ul><ul><li>Allergy, rhinitis, and/or eczema also present </li></ul><ul><li>Family history of asthma </li></ul><ul><li>Largely reversible airflow limitation </li></ul>
  31. 33. Congestive Heart Failure <ul><li>Fine basilar crackles on auscultation </li></ul><ul><li>Chest x-ray shows dilated heart, pulmonary edema </li></ul><ul><li>PFTs indicate restriction - not obstruction </li></ul><ul><li>BNP can help </li></ul>
  32. 34. Other Diff Dx to Consider <ul><li>Bronchiectasis </li></ul><ul><ul><li>Large volumes of purulent sputum </li></ul></ul><ul><ul><li>bacterial infection </li></ul></ul><ul><ul><li>CXR/CT shows bronchial dilation, bronchial wall thickening </li></ul></ul><ul><li>TB </li></ul><ul><ul><li>History with the usual suspects </li></ul></ul><ul><li>BOO and BOOP </li></ul><ul><ul><li>nonsmokers </li></ul></ul><ul><ul><li>environmental exposures </li></ul></ul><ul><ul><li>CT on expiration shows hypodense areas </li></ul></ul>
  33. 35. Monitoring: This is a progressive disease <ul><li>Lung function worsens over time- even with best care </li></ul><ul><li>Monitor symptoms and objective measures of airflow limitation for development of complications and to determine when to adjust therapy </li></ul><ul><li>Spirometry should be performed if there is a substantial increase in symptoms or a complication </li></ul><ul><li>ABG should be considered in all patients with an FEV1 <40% predicted or clinical signs of respiratory failure or right heart failure (JVD/edema) </li></ul>
  34. 36. Reduce Risk Factors
  35. 37. Reduce Risk Factors: Key Points <ul><li>Reducting exposure to tobacco smoke, occupational dusts, and chemicals, and indoor and outdoor air pollutants </li></ul><ul><li>Smoking cessation is the single most effective -- and cost-effective -- intervention to reduce the risk of developing COPD and stop its progression (Evidence A) </li></ul>
  36. 38. Reduce Risk Factors: Key Points <ul><li>Brief tobacco dependence treatment is effective (Evidence A) and every tobacco user should be offered at least this treatment at every visit </li></ul><ul><li>Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A) </li></ul>
  37. 39. Reduce Risk Factors: Key Points <ul><li>There are effective pharmacotherapies for tobacco dependence (Evidence A) </li></ul><ul><li>Add meds to counseling if necessary </li></ul><ul><li>Progression of many occupationally induced respiratory disorders can be reduced or controlled by reducing inhaled particles and gases (Evidence B) </li></ul>
  38. 40. Maybe This Would be Better Than Drugs
  39. 41. Manage Stable COPD Key Points 1 <ul><li>Stepwise increase in treatment based on disease severity </li></ul><ul><li>Health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A) . </li></ul><ul><li>None of the existing medications for COPD affects long-term decline in lung function that is the hallmark of this disease (Evidence A) </li></ul><ul><li>Pharmacotherapy for COPD is used to decrease symptoms and/or complications </li></ul>
  40. 42. Manage Stable COPD Key Points 2 <ul><li>Bronchodilators central to symptom management (Evidence A) </li></ul><ul><li>PRN or regular basis to reduce symptoms </li></ul><ul><li>Use beta2-agonist, anticholinergic, theophylline, or a combination of one or more of these drugs (Evidence A) </li></ul><ul><li>Regular treatment with LABs is slightly more effective and convenient than with SABs, but more expensive (Evidence A) </li></ul><ul><li>TECHNIQUE IS KEY </li></ul><ul><li>MDI BETTER THAN NEB IF USED CORRECTLY </li></ul>
  41. 43. Manage Stable COPD Key Points 3 <ul><li>Add inhaled steroids to bronchodilators for symptomatic COPD patients with an FEV1 <50% predicted (Stage III: Severe COPD and Stage IV Very Severe COPD) and repeated exacerbations (Evidence A) </li></ul><ul><li>Avoid chronic treatment with systemic steroids - unfavorable benefit-to-risk ratio (Evidence A </li></ul>
  42. 44. Manage Stable COPD Key Points 3 <ul><li>The long-term O2 with chronic respiratory failure increases survival (Evidence A) </li></ul><ul><li>Improves exercise tolerance </li></ul><ul><li>If hypercapnic titrate SpO2 to 88-90% </li></ul><ul><li>Walk your clinic patients if RA SpO2 OK </li></ul>
  43. 45. Manage Stable COPD Key Points 4 <ul><li>All COPD patients benefit from exercise training program </li></ul><ul><li>Improves both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A) </li></ul>
  44. 46. Medications
  45. 47. Bronchodilators Beta2-agonists <ul><li>Short-acting </li></ul><ul><ul><li>Fenoterol </li></ul></ul><ul><ul><li>Salbutamol (albuterol) </li></ul></ul><ul><ul><li>Terbutaline </li></ul></ul><ul><li>Long-acting </li></ul><ul><ul><li>Formoterol </li></ul></ul><ul><ul><li>Salmeterol </li></ul></ul>
  46. 48. Bronchodilators Anticholinergics <ul><li>Mode of Action </li></ul><ul><ul><li>Cholinergic tone is only reversible component of COPD </li></ul></ul><ul><ul><li>Normal airway have small degree of vagal cholinergic tone </li></ul></ul><ul><li>Short-acting </li></ul><ul><ul><li>Ipratropium bromide </li></ul></ul><ul><ul><li>Oxitropium bromide </li></ul></ul><ul><li>Long-acting </li></ul><ul><ul><li>Tiotropium </li></ul></ul>
  47. 49. Bronchodilators- Combos and Methylxanthines <ul><li>Combination beta2-agonists plus anticholinergic in one inhaler </li></ul><ul><ul><li>Fenoterol/Ipratropium </li></ul></ul><ul><ul><li>Salbutamol/Ipratropium </li></ul></ul><ul><li>Methylxanthines </li></ul><ul><ul><li>Aminophylline (slow release preparations) </li></ul></ul><ul><ul><li>Theophylline (slow release preparations) </li></ul></ul><ul><ul><li>RARELY OF SIGNIFICNAT BENEFIT </li></ul></ul><ul><ul><li>LEVEL 8-12 mcg/ml </li></ul></ul>
  48. 50. Other Med Adjuncts? <ul><li>Influenza vaccines significantly reduce serious illness and death (Evidence A) </li></ul><ul><li>Pneumococcal vaccine –OK to use but data lacking (Evidence B) </li></ul><ul><li>Antibiotics: other than treating infectious exacerbations- not recommended (Evidence A) </li></ul><ul><li>Mucolytic Agents : a few patients with viscous sputum may benefit but the widespread use cannot be recommended (Evidence D) </li></ul><ul><li>Antitussives : Cough, a troublesome symptom in COPD, has a protective role. Regular use of antitussives contraindicated (Evidence D) </li></ul><ul><li>Narcotics : The use of PO and IV opioids effective for dyspnea in advanced disease </li></ul>
  49. 51. Therapy by Stage- Pretty Simple
  50. 52. <ul><li>“ Make everything as simple as possible, but not one bit simpler” </li></ul><ul><li>Einstein </li></ul>
  51. 53. Manage Exacerbations <ul><li>Do you admit? You and your patient decide….little guidance in the literature </li></ul>
  52. 54. Manage Exacerbations 1 <ul><li>Infection of tracheobronchial tree and air pollution are most common causes </li></ul><ul><li>Cause of about 1/3 of severe exacerbations cannot be identified </li></ul>
  53. 55. Manage Exacerbations 2 <ul><ul><li>(Evidence A) treatment </li></ul></ul><ul><ul><ul><li>Inhaled bronchodilators (beta2-agonists and/or anticholinergics) </li></ul></ul></ul><ul><ul><ul><li>Systemic, preferably oral, glucocorticosteroids </li></ul></ul></ul><ul><ul><li>(Evidence B) Antibiotic treatment if signs of airway infection </li></ul></ul><ul><ul><ul><ul><li>increased volume/change of color of sputum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>fever </li></ul></ul></ul></ul><ul><ul><li>O2 of course….but caution with retainers….I’m getting sleepy </li></ul></ul><ul><ul><li>Little evidence for Methyxanthines </li></ul></ul>
  54. 56. Manage Exacerbations 3 <ul><ul><li>Noninvasive intermittent positive pressure ventilation (NIPPV) improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A) </li></ul></ul><ul><ul><li>BIPAP is Best! </li></ul></ul><ul><ul><ul><li>Set FiO2, inspiratory (IPAP) and expiratory (EPAP) </li></ul></ul></ul><ul><ul><ul><li>Difference between IPAP and EPAP augments tidal volume and improves minute ventilation </li></ul></ul></ul><ul><ul><ul><li>CO2 gets blown off </li></ul></ul></ul>
  55. 57. Questions?