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

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

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

    • 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
    • What’s New in COPD in 2008?
      • The science:
        • COPD as a systemic disease
        • Importance of exacerbations
        • Lung remodeling
        • Exhaled biomarkers
      • New studies:
        • TORCH, INSPIRE, UPLIFT, PULSE, COPD Network
    • What’s New in COPD in 2008?
      • Outcome measures
        • FEV 1  hyperinflation  6-min walk  exacerbations  quality of life
      • Lung-volume-reduction surgery
      • Screening versus case finding
      • Disease management in COPD
    • Current Guidelines: www.goldcopd.org
      • Full workshop report
      • Executive summary
      • Pocket guide for clinicians
      • Slide set
      • Patient teaching materials
    • 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.
    • State-of-the-Art Overview of COPD in 2008
      • Making the diagnosis
      • Determining severity and prognosis
      • Available therapies and what we know about their efficacy
      • Matching the therapy to the patient
      • Barriers to effectiveness
    • Epidemiology of COPD*
      • 10.1 million people in US
      • 120,000 deaths in 2000
      • 750,000 hospitalizations
      • 1.5 million ER visits
      • 8 million office/clinic visits
      *Mannino DM, Respir Care 2003;48(12):1185-91
    • 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%
    • Deaths from COPD in the US *Mannino DM, Respir Care 2003;48(12):1185-91
    • 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?
      • (A) Chronic bronchitis
      • (B) Moderate COPD
      • (C) Severe COPD
      • (D) Insufficient information to make any diagnosis
    • 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?
      • (A) Chronic bronchitis
      • (B) Moderate COPD
      • (C) Severe COPD
      • (D) Insufficient information to make any diagnosis
    • Definition of COPD*
      • A disease state characterized by airflow limitation (obstruction) that is not fully reversible
      • FEV 1 /FVC 70% or less
      *Global Initiative on Obstructive Lung Disease (GOLD)
    • Diagnosing COPD with Spirometry* *www.goldcopd.com
    • Use of Spirometry to Diagnose COPD* *Global Initiative for Obstructive Lung Disease Guideline (2007 Revision); www.goldcopd.org
    • Should the General Public Be Screened for COPD with Spirometry?
    •  
    •  
    • GOLD Staging System for COPD* *www.goldcopd.com
    • Which of the following tests is the best predictor of overall prognosis in patients with COPD?
      • (A) History and physical exam
      • (B) Chest X-ray
      • (C) Spirometry
      • (D) Diffusing capacity
      • (E) 6-minute walk test
    • Which of the following tests is the best predictor of overall prognosis in patients with COPD?
      • (A) History and physical exam
      • (B) Chest X-ray
      • (C) Spirometry
      • (D) Diffusing capacity
      • (E) 6-minute walk test
    • 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
    • Natural History of COPD
      • Making the diagnosis
      • Determining severity and prognosis
      • Available therapies and what we know about their efficacy
      • Matching the therapy to the patient
      • Barriers to effectiveness
      State-of-the-Art Overview of COPD in 2008
    • Components of Effective COPD Management
      • Assess and monitor disease
      • Reduce risk factors
      • Manage stable COPD
      • Manage exacerbations
      *www.goldcopd.com
    • Available Therapies for Managing Stable COPD
      • Smoking cessation
      • Bronchodilators
        • (  -agonists; anticholinergics)
      • Inhaled corticosteroids
      • Vaccines and other medications
      • Pulmonary rehabilitation
      • Long-term oxygen therapy
      • LVRS and other surgical therapies
    • Smoking Cessation in COPD*
      • Increases survival
      • Slows rate of functional loss
      • Improves quality of life
      • Most important of all treatment interventions
      *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
    • Using More Different Smoking Cessation Formats Increases the Success Rate *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
    • More Individual Smoking Cessation Sessions Increase the Success Rate *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
    • More Contact Time Increases the Likelihood of Success *Marlow SP,Stoller JK, Respir Care 2003;48(12):1238-54
    • Management of Stable COPD*
      • No medication has been shown to affect the rate of lung function decline [Evidence level A]
      • Pharmacotherapy is used to improve symptoms and/or decrease complications
        • Bronchodilators [Evidence level A]
        • Inhaled corticosteroids (selected patients) [Evidence level A]
      *www.goldcopd.com
    • Inhaled Bronchodilators in COPD
      • Beta-agonist sympathomimetics
        • Short-acting (albuterol, et al)
        • Long-acting (salmeterol, formoterol)
      • Anticholinergics
        • Short-acting (ipratropium)
        • Long-acting (tiotropium)
      • Combinations
    • Sutherland & Cherniack, NEJM 2004;350:2689-97
    • *Sutherland & Cherniack, NEJM 2004;350:2689-97 Lung Hyperinflation in COPD*
    • 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)
    • Effect of Tiotropium on COPD Exacerbations* *Sin DD et al, JAMA 2003;290:2301-12 Meta-analysis of 5 clinical trials (3574 patients)
    • 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
    • Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789
      • 3-yr double-blind RCT of Advair (50 μ g salmeterol/500 μ g fluticasone) vs each component separately vs placebo
      • COPD patients with FEV 1 < 60 % predicted and < 10 % reversibility
      • 444 centers in 42 countries; 6112 pts
      • Sponsored by GSK
    • Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789
      • All-cause mortality rates:
        • Placebo 15.2%
        • Salmeterol only 13.5%
        • Fluticasone only 16.0%
        • Combination 12.6%
      P = 0.052
    • Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789
      • Other outcomes, placebo vs combination:
      • (all, statistically significant at P < 0.01)
        • Exacerbations/year: 1.13 vs 0.85
        • (Requiring prednisone: 0.80 vs 0.64)
        • FEV 1 change/year: -62 mL vs -21 mL
        • Change in SGRQ score over 3 years:
        • +0.2 vs -3.0
      (Clinically relevant: > 4 points)
    • Salmeterol, Fluticasone, and Their Combination in COPD: The TORCH Study* *Calverley PMA et al, NEJM 2007;356:775-789
      • Other outcomes, placebo vs combination:
      • (all, statistically significant at P < 0.01)
        • Exacerbations/year: 1.13 vs 0.85
        • (Requiring prednisone: 0.80 vs 0.64)
        • FEV 1 change/year: -62 mL vs -21 mL
        • Change in SGRQ score over 3 years:
        • +0.2 vs -3.0 (Clinically relevant: >4 points)
        • Percentage of patients having pneumonia during study: 12.3 vs 19.6
    • 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
      • Mortality was not significantly different.
      • Differences in outcomes that were statistically significant were small and of uncertain clinical significance.
      • Many enrolled patients dropped out of the study.
      • Numerous unanswered questions remain. 2
    • Additional Therapies in COPD: Recommended*
      • Influenza vaccine (Evidence level A)
      • Pneumococcal vaccine (Evidence level B)
      *www.goldcopd.com
    • Additional Therapies in Stable COPD: Not Recommended*
      • Antibiotics Antitussives
      • Mucolytics Respiratory stimulants
      • Antioxidants Immunomodulators
      • Narcotics Leukotriene modifiers
      *www.goldcopd.com
    • 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
    • Effects of Pulmonary Rehabilitation on Functional Exercise Capacity* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
    • Effects of Pulmonary Rehabilitation on Dyspnea* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
    • Effects of Pulmonary Rehabilitation on St Georges Respiratory Questionnaire (Total)* *Lacasse Y et al, Cochrane Database Syst Rev 2006;Oct 18(4):CD007793
    • Available Therapies for Managing Stable COPD
      • Smoking cessation
      • Bronchodilators
        • (  -agonists; anticholinergics)
      • Inhaled corticostaroids
      • Vaccines and other medications
      • Pulmonary rehabilitation
      • Long-term oxygen therapy
      • LVRS and other surgical therapies
    • Long-Term Oxygen Therapy in COPD
      • Increases survival in appropriate patients [Evidence level A]
      • May also improve:
        • Hemodynamics
        • Hematologic characteristics
        • Exercise capacity
      • Lung mechanics
        • Mental state
      *www.goldcopd.com
    • LTOT: Selection of Patients*
      • Stage III or IV COPD
        • FEV 1 /FVC < 70%
        • FEV 1 < 50% of predicted value
      • Hypoxemia while awake, at rest:
        • PaO 2 55 mm Hg or less, or SpO 2 88% or less
        • Less severe hypoxemia if signs of end-organ effects are present
      *www.goldcopd.com
    • LTOT: Selection of Patients
      • Hypoxemia only during exercise:
        • Qualifies for reimbursement
        • May improve exercise capacity
        • Evidence for other benefits weak/absent
      • Hypoxemia only during sleep*:
        • Qualifies for reimbursement
        • Identifies poor prognostic group
        • No evidence for beneficial effect on long-term outcomes
      *Not due to sleep apnea or other sleep disorder
    • Goals for Oxygen Therapy in COPD
      • As close to 24-hr usage as possible
      • PaO 2 > 60 mm Hg (SpO 2 > 90%)
        • May need to increase flow:
          • during exercise
          • during sleep
    • Surgical Treatments for COPD*
      • Lung volume reduction surgery
      • Bullectomy
      • Lung transplantation
      *Benditt JO, Respir Care 2004;49(1):53-61
    • Apical Bullae in COPD* *Dunnill MS. Pulmonary Pathology. Edinburgh, Churchill Livingstone, 1987:115
      • Making the diagnosis
      • Determining severity and prognosis
      • Available therapies and what we know about their efficacy
      • Matching the therapy to the patient
      • Barriers to effectiveness
      State-of-the-Art Overview of COPD in 2008
    • GOLD Guidelines for Stepwise COPD Management
      • Making the diagnosis
      • Determining severity and prognosis
      • Available therapies and what we know about their efficacy
      • Matching the therapy to the patient
      • Barriers to effectiveness
      State-of-the-Art Overview of COPD in 2008
    • Barriers to Adherence with Prescribed Therapy in COPD*
      • Related to the therapy itself
      • Related to the patient
      • Related to us—the providers
      *Make BJ, Respir Care 2003;48(12):1225-34
    • Barriers to Adherence with Prescribed Therapy in COPD*
      • Related to the treatment itself
        • Purpose
        • Duration
        • Onset
        • Expense
        • Complexity
      *Make BJ, Respir Care 2003;48(12):1225-34
    • 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)
    •  
    •  
    •  
    • Barriers to Adherence with Prescribed Therapy in COPD*
      • Related to the patient
        • Motivation
        • Acceptance of disease, goals, therapies
        • Cultural and family factors
        • Economic factors
        • Access to health care, Rx, etc
      *Make BJ, Respir Care 2003;48(12):1225-34
    • Language Barriers to Health Care in the US* *Data from US Census Bureau; Flores G, NEJM 2006;355(3):229-31 *
    • * 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*
    • Barriers to Adherence with Prescribed Therapy in COPD*
      • Related to healthcare providers
        • Practitioner-patient relationship
        • Accessability to patients
        • Lack of patient-centered goals
        • Inadequate patient education
      *Make BJ, Respir Care 2003;48(12):1225-34
    • Improving COPD Management: The Easy Stuff & The Hard Stuff*
      • The Easy Stuff
        • Prescribing drugs, O 2 , etc
      *Pierson DJ, Respir Care 2004;49:99-109
      • The Hard Stuff (for both clinician & pt)
        • Smoking cessation
        • Using inhaled medications & O 2 optimally
        • Pulmonary rehab
        • Navigating the system