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ECI COPD Course Lercture 2

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ECI COPD Educator course. www.copdegypt.org

ECI COPD Educator course. www.copdegypt.org

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  • 1. Pharmacology for COPD
  • 2. GOLD Goals for COPD treatmentDisease Management should now be focusing on 2 key areas1. Reducing Symptoms2. Reducing Risk. Adapted from GOLD 2013
  • 3. GOLD 2013 Combined assessment of COPD GOLD 4 ≥2 GOLD 3 Less symptoms More symptomsSPIROMETRIC CLASSIFICATION EXACERBATION /YEAR High risk high risk GOLD 2 <2 Less symptoms More symptoms GOLD 1 Low risk low risk mMRC 01 mMRC ≥2 CAT <10 SYMPTOMS CAT ≥10 Adapted from GOLD 2013
  • 4. Pharmacological Treatment Patient Recommended Alternative Choice Other possible treatments First Choice LAMA SAMA prn or A or LABA Theophylline SABA prn or SABA and SAMA LAMA SABA and/or SAMA B or LAMA and LABA Theophylline LABA ICS + LABA LAMA and LABA SABA and/or SAMA C or LAMA + PDE4-inh. Theophylline LAMA LABA + PDE4-inh. ICS + LABA ICS + LABA and LAMA or Carbocysteine And/ or ICS+LABA and PDE4-inh. or D SABA and/or SAMA LAMA LAMA and LABA or Theophylline LAMA and PDE4-inh.(Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)*Alternative medications can be used alone or in combination with other options in the First and Second columns Adapted from GOLD 2013
  • 5. Patient Type (A) Treatment Options 1st Recommended choice : <2 • SABA Prn Or SAMA Prn GOLD 2 EXACERBATION /YEAR Alternative Choice: • LABA Or LAMA Or GOLD 1 Less symptoms •SABA and SAMA Low risk Other Possible treatments *: mMRC 01 • Theophylline CAT <10* Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 6. Short acting bronchodilatorsUsed as reliever medicationTypes: ▫ Β2 agonists  Salbutamol ▫ Anlicholinergics:  Ipratroium
  • 7. Potential Side Effects of COPDtherapy: β2 AgonistsSide effects include: ▫ Resting sinus tachycardia ▫ Ventricular arrhythmias (rare) ▫ Somatic tremor ▫ Hypokalemia ▫ Mild falls in PaO2
  • 8. Potential Side Effects of COPDTherapy: Anticholinergic AgentsSide effects are less common versus systemic agents (e.g., atropine) ▫ Dry mouth is most commonly reported adverse event (related to local deposition of agent) ▫ Possible worsening of glaucoma ▫ Occasional prostatic symptoms
  • 9. Patient Type (B) Treatment Options 1st Recommended choice : <2 LABA or LAMA EXACERBATION /YEAR GOLD 2 Alternative Choice: • LABA and LAMA GOLD 1 More symptoms Other Possible treatments *: low risk • SABA and/or SAMA • Theophylline mMRC ≥2 CAT ≥10* Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 10. Long-acting Bronchodilators inCOPDPatients with dyspnea that is not relieved by the as-needed use of a short-acting bronchodilator should have a long acting Inhaled bronchodilator added to therapyThese agents include: ▫ Formoterol ▫ Indacaterol ▫ Tiotropium ▫ Salmeterol
  • 11. LABAs in COPD guidelines British Thoracic Society suggest that long-acting bronchodilator therapy should always be considered when patients with COPD are symptomatic GOLD treatment recommendations for patients with stable COPD are characterized by a stepwise increase in therapy according to disease severity ATS/ERS COPD guidelines have indicated the importance of starting regular maintenance therapy based on the presence of persistent symptoms, regardless of the disease stage. The choice of agents may be based primarily on individual response, cost, side-effect profile and availability. International Journal of COPD 2008:3(4) 521–529
  • 12. Patient Type (C) Treatment Options 1st Recommended choice : LABA + ICS ≥2 Or EXACERBATION /YEAR •LAMA GOLD 4 Alternative Choice: •LABA and LAMA Less symptoms GOLD 3 •LAMA + PDE4-inh. High risk •LABA + PDE4-inh. mMRC 01 Other Possible treatments *: CAT <10 •SABA and/or SAMA •Theophylline* Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 13. Patient Type (D) Treatment Options 1st Recommended choice : • LABA + ICS And / or LAMA ≥2 EXACERBATION /YEAR Alternative Choice: GOLD 4 • LABA + ICS and LAMA or • LABA + ICS and PDE4-inh. or • LABA and LAMA or More symptoms GOLD 3 high risk • LAMA and PDE4-inh. Or Other Possible treatments *: • Carbocysteine mMRC ≥2 • SABA and/or SAMA CAT ≥10 • Theophylline* Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 14. Impact of Exacerbations in COPD Patients with Frequent Exacerbations Greater Airway InflammationFast Decline in lung function Higher Mortality Poorer Quality of Life
  • 15. Inhaled CorticosteroidsInflammation plays central role in COPD & therapies aimed at halting or reversing inflammation are neededInhaled corticosteroids (ICS) decrease rate of exacerbation & may improve response to bronchodilators & decrease dyspnea in stable COPDNo studies show ICS reduce loss of lung functionStudies have not established a survival benefit when ICS is combined with long-acting B2 agonists
  • 16. Roflumilast Overview First oral COPD specific anti-inflammatory therapy for patients with severe COPD who have symptoms of chronic cough and sputum, history of frequent exncerbations. and on maintenance bronchodilat0r therapy A potent and selective Inhibitor of the PDE4 enzyme, that targets the chronic inflammation underlying COPD Indicated in EU for maintenance treatment of severe COPD associated with chronic bronchitis in adult patients with a history of frequent exacerbations, as add-on to bronchodilator treatment Significantly reduced exacerbations and improved lung function when added to maintenance therapy with bronchodilators, in patients with severe COPD, symptoms of chronic bronchitis, a history of frequent exacerbations
  • 17. Influenza Vaccination:Risk for Any ExacerbationEvaluation of results from randomized clinical trials indicates that inactivated influenza vaccine reduces exacerbations in COPD patientsThe magnitude of this benefit is similar to that seen in large observational studies, and was due to a reduction in exacerbations occurring three or more weeks after vaccination, and due to influenzaThere is a mild increase in transient local adverse effects with vaccination, but no evidence of an increase in early exacerbations.
  • 18. Selecting an Appropriate Aerosol DeliveryDevice is Critical to Successfully Tx COPDThe number of different devices- each with different characteristics, requiring different inhalation techniques -can be confusing for the patient and the clinician.Consider the unique features of the Inhaler In relation to the ventilatory nuances imposed by the disease.Multiple devices are commonly used by patients with more severe disease, but can be confusing – leading to decreased adherence.
  • 19. Pressurized Metered-doseInhalers (pMDIs)Most commonly used handheld aerosol delivery deviceNewer HFA-propellants provide an aerosol with lower forward jet velocity than the older CFC-propelled MDIsPotential issues: ▫ Hand-breath coordination ▫ Taking a slow rather than rapid inhalation ▫ whether to inhale from residual volume or functional capacity ▫ Length of breath-hold at end-inspiration ▫ Priming and shaking before use
  • 20. Dry Powder Inhalers(DPIs)Breath-actuated- thus, eliminate many of the problems associated with coordinating pMDI actuation and inhalationPotential issues: ▫ Need for higher inspiratory flow rate vs. pMDI ▫ Resistance can vary 10"fold depending on design ▫ Inhaler preparation and failure to hold device correctly may contribute to high error rates in some patients
  • 21. NebulizersAlternate to pMDIs and DPIs for providing aerosol therapy, provided that the drug is available in liquid formMost user-friendly of the inhaler devicesFrequently prescribed for patients with COPD ▫ Minimal coordination and effort is required during Inhalation compared to pMDIs and DPIs ▫ Aerosol is continuously produced ▫ Patient can sit comfortable, using tidal-volume breathing
  • 22. Manage Stable COPDKey PointsRegular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV1 <50% predicted (Stage lll: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A).This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A).
  • 23. Manage Stable COPDKey PointsChronic treatment with systemic gluco- corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A).All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).
  • 24. Bronchodilators in Stable COPDBronchodilator medications are central to symptom management in COPDInhaled therapy is preferredThe choice between beta-2 agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects
  • 25. Life-Prolonging COPD TherapiesSupplemental oxygenSmoking cessationSurgery for selected patients: predominantly upper-lobe emphysema and low exercise capacity
  • 26. NOTT StudyPatients received continuous O2 or nocturnal O2O2 dose adjusted for PaO2 of 60 - 80 mm Hg; increased by 1 L/min for exercise and sleep
  • 27. MRC studyTreatment group received O2 at least 15h/d (including sleeping hours) at 2 L/min; higher if needed to achieve PaO2 >60 mmHg
  • 28. NOTT StudyOne year mortality Two-year mortality ▫ ARR: 8.7% ▫ ARR: 18.4% ▫ RRR: 42.2% ▫ RRR: 45.1% ▫ NNT: 11.5 ▫ NNT: 5.4 MRC StudyFive-year mortality ▫ ARR: 21.5% ▫ RRR:32.2% ARR: Absolute Risk Reduction ▫ NNT: 4.65 RRR: Relative Risk Reduction NNT: Number Needed to Treat
  • 29. Indications for LTOT Based on randomized controlled Based on Less Evidence clinical trials  Continuous oxygen use  Intermittent oxygen use ▫ Resting PaO2≤55 mm Hg ▫ Desaturation (Spo2≤ 88%) ▫ Resting PaO2 of 56-59 mm Hg with with activity any one of the following: ▫ Desaturation (Spo2≤ 88%)  Dependent Edema at night  P pulmonale on the electrocardiogram(P wave exceeding 3 mm in standard lead II, III or a VF)  Polycythemia( hematocrit,> 56%)Spo2 = oxygen saturation by pulse oximetry. Stoller, Chest 2010;138:179
  • 30. Oxygen Source: CylindersNot practical as primary systemUsed as a backup for primary O2 system or for portability
  • 31. Oxygen ConcentratorOxygen from air (≈ 90-95%)Most to 5 L/min; some to 10 L/minSimple; low maintenanceElectrically poweredBackup cylinder needed or portable concentratorLess patient phobia than other systemsConventional concentrators not portable
  • 32. Transfilling Concentrators
  • 33. Portable concentrators• Maximum O2 produced and the dosing of the O2 differ by concentrator.• If the patient increases the demand with a higher dose setting orrespiratory rate, either delivered dose. %O2, or both will decrease.
  • 34. Liquid OxygenMore efficientBase unitPortable unit (filled from base)Higher flows availableRequires refillingBackup cylinder neededPatient phobia (thermal injury)
  • 35. Oxygen Conserving DevicesPulse dose (battery powered): fixed volume per breath; use standard cannula ▫ O2 on every breath or on alternate breaths ▫ Vary dose by peak flow or durationDemand devices (pneumatically powered): deliver oxygen only during inhalation; use dual- lumen cannulaReservoir cannulaTranstracheal oxygen
  • 36. Oxygen Conserving DevicesCylinders last longerFewer complications (drying, irritation, taste)Cylinder devices: fit on any cylinderLiquid devices: incorporated into deviceDifferent devices produce different oxygenation and different devices may respond differently to varying conditions (exercise, sleep).Prescription should be device specific
  • 37. Reservoir Oxygen Cannula
  • 38. Transtracheal OxygenOxygen delivered directly into the trachea through a surgically implanted catheterAdvantages: inconspicuous; lack of nasal. ear, and facial irritation; remains in place during sleep and exerciseComplications: subcutaneous emphysema, bronchospasm, and paroxysmal coughing during placement; late complications include dislodged catheters, stomal infections, mucous balls (may be fatal)
  • 39. SummaryO2 therapy for the patient with COPD is life- savingO2 source can be cylinder, concentrator, or liquidPortable O2 is important (necessary!)O2 conserving devices extend the time patient can be away from fixed O2 sourceImportant for the clinician to appreciate differences between LTOT devices