State-of-the-Art Overview of COPD and its Management

12,852 views
12,249 views

Published on

Presentation by Dr David Pierson, faculty of Pulmonary Medicine Update Course, Egypt. Knowledge resources at Scribe : www.scribeofegypt.com

Published in: Health & Medicine
1 Comment
38 Likes
Statistics
Notes
  • Fioricet is often prescribed for tension headaches caused by contractions of the muscles in the neck and shoulder area. Buy now from http://www.fioricetsupply.com and make a deal for you.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
12,852
On SlideShare
0
From Embeds
0
Number of Embeds
405
Actions
Shares
0
Downloads
0
Comments
1
Likes
38
Embeds 0
No embeds

No notes for slide

State-of-the-Art Overview of COPD and its Management

  1. 1. State-of-the-Art Overview of COPD and its Management David J Pierson MD Professor of Medicine University of Washington Seattle, WA, USA December, 2008
  2. 2. What’s New in COPD in 2008? <ul><li>The science: </li></ul><ul><ul><li>COPD as a systemic disease </li></ul></ul><ul><ul><li>Importance of exacerbations </li></ul></ul><ul><ul><li>Lung remodeling </li></ul></ul><ul><ul><li>Exhaled biomarkers </li></ul></ul><ul><li>New studies: </li></ul><ul><ul><li>TORCH, INSPIRE, UPLIFT, PULSE, COPD Network </li></ul></ul>
  3. 3. What’s New in COPD in 2008? <ul><li>Outcome measures </li></ul><ul><ul><li>FEV 1  hyperinflation  6-min walk  exacerbations  quality of life </li></ul></ul><ul><li>Lung-volume-reduction surgery </li></ul><ul><li>Screening versus case finding </li></ul><ul><li>Disease management in COPD </li></ul>
  4. 4. Current Guidelines: www.goldcopd.org <ul><li>Full workshop report </li></ul><ul><li>Executive summary </li></ul><ul><li>Pocket guide for clinicians </li></ul><ul><li>Slide set </li></ul><ul><li>Patient teaching materials </li></ul>
  5. 5. Consensus Standards and Practice Guidelines for COPD Management GOLD : Respir Care . 2001 Aug;46(8):798-825; Updated Eur Respir J . 2003 Jul;22(1):1-2. www.goldcopd.com American Thoracic Society - European Thoracic Society : Eur Respir J . 2004 Jun;23(6):932-46. www.thoracic.org (Other national guidelines from Australia–New Zealand, Canada, Finland, France, Germany, India, Malaysia, South Africa, Switzerland, the UK, and others) Review and comparison of current guidelines: Pierson DJ, Respir Care 2006 (Mar);51(3):277-288.
  6. 6. State-of-the-Art Overview of COPD in 2008 <ul><li>Making the diagnosis </li></ul><ul><li>Determining severity and prognosis </li></ul><ul><li>Available therapies and what we know about their efficacy </li></ul><ul><li>Matching the therapy to the patient </li></ul><ul><li>Barriers to effectiveness </li></ul>
  7. 7. Epidemiology of COPD* <ul><li>10.1 million people in US </li></ul><ul><li>120,000 deaths in 2000 </li></ul><ul><li>750,000 hospitalizations </li></ul><ul><li>1.5 million ER visits </li></ul><ul><li>8 million office/clinic visits </li></ul>*Mannino DM, Respir Care 2003;48(12):1185-91
  8. 8. Change in Age-Adjusted US Death Rates, 1965-1998* *www.goldcopd.com Percentage of 1965 Rate 50 100 150 200 250 Coronary Heart Disease Stroke Other CVD All Other Causes COPD -59% -64% -35% +163% -7%
  9. 9. Deaths from COPD in the US *Mannino DM, Respir Care 2003;48(12):1185-91
  10. 10. A 72 year old man has smoked 2 PPD for 40 years. He has a daily productive cough and dyspnea on walking 2 blocks. What is his diagnosis? <ul><li>(A) Chronic bronchitis </li></ul><ul><li>(B) Moderate COPD </li></ul><ul><li>(C) Severe COPD </li></ul><ul><li>(D) Insufficient information to make any diagnosis </li></ul>
  11. 11. A 72 year old man has smoked 2 PPD for 40 years. He has a daily productive cough and dyspnea on walking 2 blocks. What is his diagnosis? <ul><li>(A) Chronic bronchitis </li></ul><ul><li>(B) Moderate COPD </li></ul><ul><li>(C) Severe COPD </li></ul><ul><li>(D) Insufficient information to make any diagnosis </li></ul>
  12. 12. Definition of COPD* <ul><li>A disease state characterized by airflow limitation (obstruction) that is not fully reversible </li></ul><ul><li>FEV 1 /FVC 70% or less </li></ul>*Global Initiative on Obstructive Lung Disease (GOLD)
  13. 13. Diagnosing COPD with Spirometry* *www.goldcopd.com
  14. 14. Use of Spirometry to Diagnose COPD* *Global Initiative for Obstructive Lung Disease Guideline (2007 Revision); www.goldcopd.org
  15. 15. Should the General Public Be Screened for COPD with Spirometry?
  16. 18. GOLD Staging System for COPD* *www.goldcopd.com
  17. 19. Which of the following tests is the best predictor of overall prognosis in patients with COPD? <ul><li>(A) History and physical exam </li></ul><ul><li>(B) Chest X-ray </li></ul><ul><li>(C) Spirometry </li></ul><ul><li>(D) Diffusing capacity </li></ul><ul><li>(E) 6-minute walk test </li></ul>
  18. 20. Which of the following tests is the best predictor of overall prognosis in patients with COPD? <ul><li>(A) History and physical exam </li></ul><ul><li>(B) Chest X-ray </li></ul><ul><li>(C) Spirometry </li></ul><ul><li>(D) Diffusing capacity </li></ul><ul><li>(E) 6-minute walk test </li></ul>
  19. 21. Prognostic Value of Spirometry in COPD Survival among patients with COPD as a function of FEV 1 when first enrolled in cohort *  = FEV 1 > 1.25 L  = FEV 1 1.25-0.75 L  = FEV 1 < 0.75 L (Correspond approximately to 2003 GOLD Stages II/III/IV) *Diener CF, Burrows B. Am Rev Respir Dis 1975;111:719-24
  20. 22. Natural History of COPD
  21. 23. <ul><li>Making the diagnosis </li></ul><ul><li>Determining severity and prognosis </li></ul><ul><li>Available therapies and what we know about their efficacy </li></ul><ul><li>Matching the therapy to the patient </li></ul><ul><li>Barriers to effectiveness </li></ul>State-of-the-Art Overview of COPD in 2008
  22. 24. Components of Effective COPD Management <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Manage exacerbations </li></ul>*www.goldcopd.com
  23. 25. Available Therapies for Managing Stable COPD <ul><li>Smoking cessation </li></ul><ul><li>Bronchodilators </li></ul><ul><ul><li>(  -agonists; anticholinergics) </li></ul></ul><ul><li>Inhaled corticosteroids </li></ul><ul><li>Vaccines and other medications </li></ul><ul><li>Pulmonary rehabilitation </li></ul><ul><li>Long-term oxygen therapy </li></ul><ul><li>LVRS and other surgical therapies </li></ul>
  24. 26. Smoking Cessation in COPD* <ul><li>Increases survival </li></ul><ul><li>Slows rate of functional loss </li></ul><ul><li>Improves quality of life </li></ul><ul><li>Most important of all treatment interventions </li></ul>*Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
  25. 27. Using More Different Smoking Cessation Formats Increases the Success Rate *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
  26. 28. More Individual Smoking Cessation Sessions Increase the Success Rate *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
  27. 29. More Contact Time Increases the Likelihood of Success *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
  28. 30. Management of Stable COPD* <ul><li>No medication has been shown to affect the rate of lung function decline [Evidence level A] </li></ul><ul><li>Pharmacotherapy is used to improve symptoms and/or decrease complications </li></ul><ul><ul><li>Bronchodilators [Evidence level A] </li></ul></ul><ul><ul><li>Inhaled corticosteroids (selected patients) [Evidence level A] </li></ul></ul>*www.goldcopd.com
  29. 31. Inhaled Bronchodilators in COPD <ul><li>Beta-agonist sympathomimetics </li></ul><ul><ul><li>Short-acting (albuterol, et al) </li></ul></ul><ul><ul><li>Long-acting (salmeterol, formoterol) </li></ul></ul><ul><li>Anticholinergics </li></ul><ul><ul><li>Short-acting (ipratropium) </li></ul></ul><ul><ul><li>Long-acting (tiotropium) </li></ul></ul><ul><li>Combinations </li></ul>
  30. 32. Sutherland & Cherniack, NEJM 2004;350:2689-97
  31. 33. *Sutherland & Cherniack, NEJM 2004;350:2689-97 Lung Hyperinflation in COPD*
  32. 34. Effect of Long-Acting Beta 2 -Agonists on COPD Exacerbations* *Sin DD et al, JAMA 2003;290:2301-12 Meta-analysis of 9 clinical trials (4198 patients)
  33. 35. Effect of Tiotropium on COPD Exacerbations* *Sin DD et al, JAMA 2003;290:2301-12 Meta-analysis of 5 clinical trials (3574 patients)
  34. 36. Relationship Between FEV 1 and Effect of Inhaled Corticosteroids in Preventing COPD Exacerbations* Greater Effect in More Severely Obstructed Patients *Sin DD et al, JAMA 2003;290:2301-12
  35. 37. Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789 <ul><li>3-yr double-blind RCT of Advair (50 μ g salmeterol/500 μ g fluticasone) vs each component separately vs placebo </li></ul><ul><li>COPD patients with FEV 1 < 60 % predicted and < 10 % reversibility </li></ul><ul><li>444 centers in 42 countries; 6112 pts </li></ul><ul><li>Sponsored by GSK </li></ul>
  36. 38. Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789 <ul><li>All-cause mortality rates: </li></ul><ul><ul><li>Placebo 15.2% </li></ul></ul><ul><ul><li>Salmeterol only 13.5% </li></ul></ul><ul><ul><li>Fluticasone only 16.0% </li></ul></ul><ul><ul><li>Combination 12.6% </li></ul></ul>P = 0.052
  37. 39. Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789 <ul><li>Other outcomes, placebo vs combination: </li></ul><ul><li>(all, statistically significant at P < 0.01) </li></ul><ul><ul><li>Exacerbations/year: 1.13 vs 0.85 </li></ul></ul><ul><ul><li>(Requiring prednisone: 0.80 vs 0.64) </li></ul></ul><ul><ul><li>FEV 1 change/year: -62 mL vs -21 mL </li></ul></ul><ul><ul><li>Change in SGRQ score over 3 years: </li></ul></ul><ul><ul><li>+0.2 vs -3.0 </li></ul></ul>(Clinically relevant: > 4 points)
  38. 40. Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789 <ul><li>Other outcomes, placebo vs combination: </li></ul><ul><li>(all, statistically significant at P < 0.01) </li></ul><ul><ul><li>Exacerbations/year: 1.13 vs 0.85 </li></ul></ul><ul><ul><li>(Requiring prednisone: 0.80 vs 0.64) </li></ul></ul><ul><ul><li>FEV 1 change/year: -62 mL vs -21 mL </li></ul></ul><ul><ul><li>Change in SGRQ score over 3 years: </li></ul></ul><ul><ul><li>+0.2 vs -3.0 (Clinically relevant: >4 points) </li></ul></ul><ul><ul><li>Percentage of patients having pneumonia during study: 12.3 vs 19.6 </li></ul></ul>
  39. 41. Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study 1 1 Calverley PMA et al, NEJM 2007;356:775-89 2 Rabe KF (Editorial), NEJM 2007;356:851-4 <ul><li>Mortality was not significantly different. </li></ul><ul><li>Differences in outcomes that were statistically significant were small and of uncertain clinical significance. </li></ul><ul><li>Many enrolled patients dropped out of the study. </li></ul><ul><li>Numerous unanswered questions remain. 2 </li></ul>
  40. 42. Additional Therapies in COPD: Recommended* <ul><li>Influenza vaccine (Evidence level A) </li></ul><ul><li>Pneumococcal vaccine (Evidence level B) </li></ul>*www.goldcopd.com
  41. 43. Additional Therapies in Stable COPD: Not Recommended* <ul><li>Antibiotics Antitussives </li></ul><ul><li>Mucolytics Respiratory stimulants </li></ul><ul><li>Antioxidants Immunomodulators </li></ul><ul><li>Narcotics Leukotriene modifiers </li></ul>*www.goldcopd.com
  42. 44. Effect of Pulmonary Rehabilitation on Health-Related Quality of Life in COPD* *Sin DD et al, JAMA 2003;290:2301-12 Meta-analysis of 6 clinical trials (491 patients) SGRQ, St George’s Respiratory Questionnaire
  43. 45. Effects of Pulmonary Rehabilitation on Functional Exercise Capacity* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
  44. 46. Effects of Pulmonary Rehabilitation on Dyspnea* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
  45. 47. Effects of Pulmonary Rehabilitation on St Georges Respiratory Questionnaire (Total)* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
  46. 48. Available Therapies for Managing Stable COPD <ul><li>Smoking cessation </li></ul><ul><li>Bronchodilators </li></ul><ul><ul><li>(  -agonists; anticholinergics) </li></ul></ul><ul><li>Inhaled corticostaroids </li></ul><ul><li>Vaccines and other medications </li></ul><ul><li>Pulmonary rehabilitation </li></ul><ul><li>Long-term oxygen therapy </li></ul><ul><li>LVRS and other surgical therapies </li></ul>
  47. 49. Long-Term Oxygen Therapy in COPD <ul><li>Increases survival in appropriate patients [Evidence level A] </li></ul><ul><li>May also improve: </li></ul><ul><ul><li>Hemodynamics </li></ul></ul><ul><ul><li>Hematologic characteristics </li></ul></ul><ul><ul><li>Exercise capacity </li></ul></ul><ul><li>Lung mechanics </li></ul><ul><ul><li>Mental state </li></ul></ul>*www.goldcopd.com
  48. 50. LTOT: Selection of Patients* <ul><li>Stage III or IV COPD </li></ul><ul><ul><li>FEV 1 /FVC < 70% </li></ul></ul><ul><ul><li>FEV 1 < 50% of predicted value </li></ul></ul><ul><li>Hypoxemia while awake, at rest: </li></ul><ul><ul><li>PaO 2 55 mm Hg or less, or SpO 2 88% or less </li></ul></ul><ul><ul><li>Less severe hypoxemia if signs of end-organ effects are present </li></ul></ul>*www.goldcopd.com
  49. 51. LTOT: Selection of Patients <ul><li>Hypoxemia only during exercise: </li></ul><ul><ul><li>Qualifies for reimbursement </li></ul></ul><ul><ul><li>May improve exercise capacity </li></ul></ul><ul><ul><li>Evidence for other benefits weak/absent </li></ul></ul><ul><li>Hypoxemia only during sleep*: </li></ul><ul><ul><li>Qualifies for reimbursement </li></ul></ul><ul><ul><li>Identifies poor prognostic group </li></ul></ul><ul><ul><li>No evidence for beneficial effect on long-term outcomes </li></ul></ul>*Not due to sleep apnea or other sleep disorder
  50. 52. Goals for Oxygen Therapy in COPD <ul><li>As close to 24-hr usage as possible </li></ul><ul><li>PaO 2 > 60 mm Hg (SpO 2 > 90%) </li></ul><ul><ul><li>May need to increase flow: </li></ul></ul><ul><ul><ul><li>during exercise </li></ul></ul></ul><ul><ul><ul><li>during sleep </li></ul></ul></ul>
  51. 53. Surgical Treatments for COPD* <ul><li>Lung volume reduction surgery </li></ul><ul><li>Bullectomy </li></ul><ul><li>Lung transplantation </li></ul>*Benditt JO, Respir Care 2004;49(1):53-61
  52. 54. Apical Bullae in COPD* *Dunnill MS. Pulmonary Pathology. Edinburgh, Churchill Livingstone, 1987:115
  53. 55. <ul><li>Making the diagnosis </li></ul><ul><li>Determining severity and prognosis </li></ul><ul><li>Available therapies and what we know about their efficacy </li></ul><ul><li>Matching the therapy to the patient </li></ul><ul><li>Barriers to effectiveness </li></ul>State-of-the-Art Overview of COPD in 2008
  54. 56. GOLD Guidelines for Stepwise COPD Management
  55. 57. <ul><li>Making the diagnosis </li></ul><ul><li>Determining severity and prognosis </li></ul><ul><li>Available therapies and what we know about their efficacy </li></ul><ul><li>Matching the therapy to the patient </li></ul><ul><li>Barriers to effectiveness </li></ul>State-of-the-Art Overview of COPD in 2008
  56. 58. Barriers to Adherence with Prescribed Therapy in COPD* <ul><li>Related to the therapy itself </li></ul><ul><li>Related to the patient </li></ul><ul><li>Related to us—the providers </li></ul>*Make BJ, Respir Care 2003;48(12):1225-34
  57. 59. Barriers to Adherence with Prescribed Therapy in COPD* <ul><li>Related to the treatment itself </li></ul><ul><ul><li>Purpose </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><li>Expense </li></ul></ul><ul><ul><li>Complexity </li></ul></ul>*Make BJ, Respir Care 2003;48(12):1225-34
  58. 60. Cost of Managing COPD According to Current Guidelines (Pierson DJ, Respir Care 2006;51(3):277-288) Monthly Cost ($) add LTOT add ICS add LABD SABD as needed 0 100 200 300 400 500 600 700 800 Mild (GOLD I) Moderate (GOLD II) Severe (GOLD III) Very Severe (GOLD IV)
  59. 64. Barriers to Adherence with Prescribed Therapy in COPD* <ul><li>Related to the patient </li></ul><ul><ul><li>Motivation </li></ul></ul><ul><ul><li>Acceptance of disease, goals, therapies </li></ul></ul><ul><ul><li>Cultural and family factors </li></ul></ul><ul><ul><li>Economic factors </li></ul></ul><ul><ul><li>Access to health care, Rx, etc </li></ul></ul>*Make BJ, Respir Care 2003;48(12):1225-34
  60. 65. Language Barriers to Health Care in the US* *Data from US Census Bureau; Flores G, NEJM 2006;355(3):229-31 *
  61. 66. * Prose Literacy Levels Among US Adults in 2003. Marcus EN, NEJM 2006;355(4):339-41 Barriers to Effective Health Care: Literacy in the US*
  62. 67. Barriers to Adherence with Prescribed Therapy in COPD* <ul><li>Related to healthcare providers </li></ul><ul><ul><li>Practitioner-patient relationship </li></ul></ul><ul><ul><li>Accessability to patients </li></ul></ul><ul><ul><li>Lack of patient-centered goals </li></ul></ul><ul><ul><li>Inadequate patient education </li></ul></ul>*Make BJ, Respir Care 2003;48(12):1225-34
  63. 68. Improving COPD Management: The Easy Stuff & The Hard Stuff* <ul><li>The Easy Stuff </li></ul><ul><ul><li>Prescribing drugs, O 2 , etc </li></ul></ul>*Pierson DJ, Respir Care 2004;49:99-109 <ul><li>The Hard Stuff (for both clinician & pt) </li></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Using inhaled medications & O 2 optimally </li></ul></ul><ul><ul><li>Pulmonary rehab </li></ul></ul><ul><ul><li>Navigating the system </li></ul></ul>

×