Chronic Obstructive Lung Disease

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COPD - GOLD Guidelines

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  • Very thorough overview of 2013 GOLD update. Tables helpful esp since this update is a major change to how we practice approach to COPD patients. Slide 41- may want to change les to less. I enjoyed reading slides 99 and 100 as the drug names are completely different than the brand names we dispense in United States.
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Chronic Obstructive Lung Disease

  1. 1. CHRONIC OBSTRUCTIVE LUNG DISEASE Medical Unit – 1 March-2013 Dr.Vitrag Shah Second Year Resident, Medicine Dept., GMC,Surat www.medicalgeek.com© Global Initiative for Chronic Obstructive Lung Disease
  2. 2. WORLD COPD DAY November 20, 2013Raising COPD Awareness Worldwide © 2013 Global Initiative for Chronic Obstructive Lung Disease
  3. 3. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUpdated 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  4. 4. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUpdated 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  5. 5. Global Strategy for Diagnosis, Management and Prevention of COPD Definition of COPD COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive, not fully reversible and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  6. 6. COPD : Defination Emphysema, an anatomically defined condition characterized by destruction and enlargement of the lung alveoli Chronic bronchitis, a clinically defined condition with chronic cough and phlegm Small airways disease, a condition in which small bronchioles are narrowed. COPD is present only if chronic airflow obstruction occurs; chronic bronchitis without chronic airflow obstruction is not included within COPD.
  7. 7. Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPDSmall Airways Disease Parenchymal Destruction• Airway inflammation • Loss of alveolar attachments• Airway fibrosis, luminal plugs • Decrease of elastic recoil• Increased airway resistance AIRFLOW LIMITATION © 2013 Global Initiative for Chronic Obstructive Lung Disease
  8. 8. Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
  9. 9. Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
  10. 10. Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
  11. 11. Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
  12. 12. Global Strategy for Diagnosis, Management and Prevention of COPD Burden of COPD COPD is a leading cause of morbidity and mortality worldwide. The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the world’s population. COPD is associated with significant economic burden. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  13. 13. Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPDGenes Lung growth and developmentExposure to particles Gender Tobacco smoke Age Occupational dusts, organic Respiratory infections and inorganic Socioeconomic status Indoor air pollution from Asthma/Bronchial heating and cooking with hyperreactivity biomass in poorly ventilated dwellings Chronic Bronchitis Outdoor air pollution © 2013 Global Initiative for Chronic Obstructive Lung Disease
  14. 14. Smoking– Smoking Pack Years : Average number of packs of cigarettes smoked per day multiplied by the total number of years of smoking.– COPD usually develops after ≥20 pack years.
  15. 15. Global Strategy for Diagnosis, Management and Prevention of COPDRisk Factors for COPD Genes Infections Socio-economic status Aging Populations © 2013 Global Initiative for Chronic Obstructive Lung Disease
  16. 16. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  17. 17. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  18. 18. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact on the patient’s health status, and the risk of future events. Comorbidities occur frequently in COPD patients, and should be actively looked for and treated appropriately if present. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  19. 19. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD EXPOSURE TO RISK SYMPTOMS FACTORSshortness of breath tobacco chronic cough occupation sputum indoor/outdoor pollution  SPIROMETRY: Required to establish diagnosis © 2013 Global Initiative for Chronic Obstructive Lung Disease
  20. 20. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Airflow Limitation: Spirometry Spirometry should be performed after the administration of an adequate dose of a short- acting inhaled bronchodilator to minimize variability. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation. Where possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  21. 21. FEV1 In normal individuals FEV1 peaks upto 25 yrs, then into Plateau Phase following by decline phase in old age.
  22. 22. Spirometry: Normal Trace Showing FEV1 and FVC 5 FVC 4Volume, liters FEV1 = 4L 3 FVC = 5L 2 FEV1/FVC = 0.8 1 1 2 3 4 5 6 Time, sec © 2013 Global Initiative for Chronic Obstructive Lung Disease
  23. 23. Spirometry: Obstructive Disease 5 Normal 4Volume, liters 3 FEV1 = 1.8L 2 FVC = 3.2L Obstructive FEV1/FVC = 0.56 1 1 2 3 4 5 6 Time, seconds © 2013 Global Initiative for Chronic Obstructive Lung Disease
  24. 24. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  25. 25. Global Strategy for Diagnosis, Management and Prevention of COPD Symptoms of COPDThe characteristic symptoms of COPD are chronic andprogressive dyspnea, cough, and sputum productionthat can be variable from day-to-day.Dyspnea: Progressive, persistent and characteristicallyworse with exercise.Chronic cough: May be intermittent and may beunproductive.Chronic sputum production: COPD patients commonlycough up sputum. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  26. 26. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptomsAssess degree of airflow limitation usingspirometryUse the COPD Assessment Test(CAT)Assess risk of exacerbationsAssess comorbidities or mMRC Breathlessness scale or Clinical COPD Questionnaire (CCQ) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  27. 27. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of SymptomsCOPD Assessment Test (CAT): An 8-itemmeasure of health status impairment in COPD(http://catestonline.org). (0-40 points)Breathlessness Measurement using theModified British Medical Research Council(mMRC) Questionnaire: relates well to othermeasures of health status and predicts futuremortality risk. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  28. 28. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of SymptomsClinical COPD Questionnaire (CCQ): Self-administered developed to measure clinicalcontrol in patients with COPD. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  29. 29. Global Strategy for Diagnosis, Management and Prevention of COPDModified MRC (mMRC)Questionnaire © 2013 Global Initiative for Chronic Obstructive Lung Disease
  30. 30. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Use spirometry for grading severity Assess risk of exacerbations Assess comorbidities according to spirometry, using four grades split at 80%, 50% and 30% of predicted value © 2013 Global Initiative for Chronic Obstructive Lung Disease
  31. 31. Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70:GOLD 1: Mild FEV1 > 80% predictedGOLD 2: Moderate 50% < FEV1 < 80% predictedGOLD 3: Severe 30% < FEV1 < 50% predictedGOLD 4: Very Severe FEV1 < 30% predicted*Based on Post-Bronchodilator FEV1 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  32. 32. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities and spirometry. Use history of exacerbations Two exacerbations or more within the last year or an FEV1 < 50 % of predicted value are indicators of high risk © 2013 Global Initiative for Chronic Obstructive Lung Disease
  33. 33. Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of ExacerbationsTo assess risk of exacerbations usehistory of exacerbations andspirometry: Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  34. 34. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Combine these assessments for the purpose of improving management of COPD © 2013 Global Initiative for Chronic Obstructive Lung Disease
  35. 35. Global Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPD (GOLD Classification of Airflow Limitation) 4 >2 (C) (D) (Exacerbation history) 3 RiskRisk 2 1 (A) (B) 1 0 mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  36. 36. Global Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPD Assess symptoms first If mMRC 0-1 or CAT < 10: (C) (D) Less Symptoms (A or C) If mMRC > 2 or CAT > 10: More Symptoms (B or D) (A) (B)mMRC 0-1 mMRC > 2CAT < 10 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  37. 37. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Assess risk of exacerbations next (GOLD Classification of Airflow Limitation) If GOLD 1 or 2 and only 4 0 or 1 exacerbations per year: (Exacerbation history) 3 (C) (D) >2 Low Risk (A or B)Risk Risk If GOLD 3 or 4 or two or more exacerbations per year: 2 1 High Risk (C or D) (A) (B) (One or more hospitalizations 1 0 for COPD exacerbations should be considered high mMRC 0-1 mMRC > 2 risk.) CAT < 10 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  38. 38. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Use combined assessment (GOLD Classification of Airflow Limitation) Patient is now in one of 4 four categories: (Exacerbation history) (C) (D) >2 3 A: Les symptoms, low riskRisk Risk B: More symptoms, low risk 2 1 (A) (B) C: Less symptoms, high risk 1 0 D: More symptoms, high risk mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  39. 39. Global Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPD (GOLD Classification of Airflow Limitation) 4 >2 (C) (D) (Exacerbation history) 3 RiskRisk 2 1 (A) (B) 1 0 mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 Symptoms (mMRC or CAT score)) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  40. 40. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD When assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk.)Patien Characteristic Spirometric Exacerbations mMRC CAT t Classification per year Low Risk A GOLD 1-2 ≤1 0-1 < 10 Less Symptoms Low Risk B GOLD 1-2 ≤1 >2 ≥ 10 More Symptoms High Risk C GOLD 3-4 >2 0-1 < 10 Less Symptoms High Risk ≥ 10 D GOLD 3-4 >2 >2 More Symptoms © 2013 Global Initiative for Chronic Obstructive Lung Disease
  41. 41. Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD ComorbiditiesCOPD patients are at increased risk for: • Cardiovascular diseases • Osteoporosis • Respiratory infections • Anxiety and Depression • Diabetes • Lung cancerThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  42. 42. Global Strategy for Diagnosis, Management and Prevention of COPD Differential Diagnosis: COPD and Asthma COPD ASTHMA• Onset in mid-life • Onset early in life (often childhood)• Symptoms slowly progressive • Symptoms vary from day to day• Long smoking history • Symptoms worse at night/early morning • Allergy, rhinitis, and/or eczema also present • Family history of asthma © 2013 Global Initiative for Chronic Obstructive Lung Disease
  43. 43. Global Strategy for Diagnosis, Management and Prevention of COPD Additional InvestigationsChest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.Lung Volumes and Diffusing Capacity: Help to characterizeseverity, but not essential to patient management.Oximetry and Arterial Blood Gases: Pulse oximetry can beused to evaluate a patient’s oxygen saturation and need forsupplemental oxygen therapy.Alpha-1 Antitrypsin Deficiency Screening: Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  44. 44. Global Strategy for Diagnosis, Management and Prevention of COPD Additional InvestigationsExercise Testing: Objectively measured exerciseimpairment, assessed by a reduction in self-paced walkingdistance (such as the 6 min walking test) or duringincremental exercise testing in a laboratory, is a powerfulindicator of health status impairment and predictor ofprognosis.Composite Scores: Several variables (FEV1, exercisetolerance assessed by walking distance or peak oxygenconsumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality. BODE Index : BMI, Obstruction, Dyspnea,Exersice © 2013 Global Initiative for Chronic Obstructive Lung Disease
  45. 45. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  46. 46. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  47. 47. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function. Influenza and pneumococcal vaccination should be offered depending on local guidelines. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  48. 48. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Smoking Cessation Counseling delivered by physicians and other health professionals significantly increases quit rates over self- initiated strategies. Even a brief (3-minute) period of counseling to urge a smoker to quit results in smoking quit rates of 5-10%. Nicotine replacement therapy (nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, or lozenge) as well as pharmacotherapy with varenicline, bupropion(150mg qd for 3 days f/b 150mg bd), and nortriptyline reliably increases long-term smoking abstinence rates and are significantly more effective than placebo. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  49. 49. Brief Strategies to Help the Patient Willing to Quit Smoking• ASK Systematically identify all tobacco users at every visit• ADVISE Strongly urge all tobacco users to quit• ASSESS Determine willingness to make a quit attempt• ASSIST Aid the patient in quitting• ARRANGE Schedule follow-up contact. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  50. 50. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Risk Reduction Encourage comprehensive tobacco-control policies with clear, consistent, and repeated nonsmoking messages. Emphasize primary prevention, best achieved by elimination or reduction of exposures in the workplace. Secondary prevention, achieved through surveillance and early detection, is also important. Reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings. Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors during pollution episodes. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  51. 51. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: COPD MedicationsBeta2-agonists Short-acting beta2-agonists Long-acting beta2-agonistsAnticholinergics Short-acting anticholinergics Long-acting anticholinergicsCombination short-acting beta2-agonists + anticholinergic in one inhalerMethylxanthinesInhaled corticosteroidsCombination long-acting beta2-agonists + corticosteroids in one inhalerSystemic corticosteroidsPhosphodiesterase-4 inhibitors © 2013 Global Initiative for Chronic Obstructive Lung Disease
  52. 52. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators Bronchodilator medications are central to the symptomatic management of COPD. Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.The principal bronchodilator treatments are beta2- agonists, anticholinergics, theophylline or combinationtherapy.The choice of treatment depends on the availability ofmedications and each patient’s individual response interms of symptom relief and side effects.. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  53. 53. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators. Long-acting inhaled bronchodilators reduce exacerbations and related hospitalizations and improve symptoms and health status. Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  54. 54. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Inhaled Corticosteroids Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1 < 60% predicted. Inhaled corticosteroid therapy is associated with an increased risk of pneumonia. Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patients. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  55. 55. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Combination Therapy An inhaled corticosteroid combined with a long-acting beta2-agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD. Combination therapy is associated with an increased risk of pneumonia. Addition of a long-acting beta2-agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) appears to provide additional benefits. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  56. 56. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Systemic Corticosteroids Chronic treatment with systemic corticosteroids should be avoided because of an unfavorable benefit-to- risk ratio. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  57. 57. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Phosphodiesterase-4 Inhibitors In patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis, the phospodiesterase-4 inhibitor (PDE-4), roflumilast, reduces exacerbations treated with oral glucocorticosteroids. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  58. 58. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Theophylline Theophylline is less effective and less well tolerated than inhaled long-acting bronchodilators and is not recommended if those drugs are available and affordable. There is evidence for a modest bronchodilator effect and some symptomatic benefit compared with placebo in stable COPD. Addition of theophylline to salmeterol produces a greater increase in FEV1 and breathlessness than salmeterol alone. Low dose theophylline reduces exacerbations but does not improve post-bronchodilator lung function. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  59. 59. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other Pharmacologic TreatmentsInfluenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1 < 40%predicted.The use of antibiotics, other than for treating infectiousexacerbations of COPD and other bacterial infections, iscurrently not indicated. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  60. 60. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other Pharmacologic TreatmentsAlpha-1 antitrypsin augmentation therapy: notrecommended for patients with COPD that is unrelatedto the genetic deficiency.Mucolytics: Patients with viscous sputum maybenefit from mucolytics; overall benefits are very small.Antitussives: Not recommended.Vasodilators: Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associatedwith COPD is not recommended. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  61. 61. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Rehabilitation All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue. Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results. If exercise training is maintained at home, the patients health status remains above pre- rehabilitation levels. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  62. 62. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other TreatmentsOxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increasesurvival in patients with severe, resting hypoxemia.Ventilatory Support: Combination of noninvasiveventilation (NIV) with long-term oxygen therapy maybe of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  63. 63. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Surgical TreatmentsLung volume reduction surgery (LVRS) is moreefficacious than medical therapy among patientswith upper-lobe predominant emphysema and lowexercise capacity.LVRS is costly relative to health-care programs notincluding surgery.In appropriately selected patients with very severeCOPD, lung transplantation has been shown toimprove quality of life and functional capacity. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  64. 64. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other TreatmentsPalliative Care, End-of-life Care, Hospice Care: Communication with advanced COPD patients about end-of-life care and advance care planning gives patients and their families the opportunity to make informed decisions. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  65. 65. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Major Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  66. 66. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Key Points Identification and reduction of exposure to risk factors are important steps in prevention and treatment. Individualized assessment of symptoms, airflow limitation, and future risk of exacerbations should be incorporated into the management strategy. All COPD patients benefit from rehabilitation and maintenance of physical activity. Pharmacologic therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  67. 67. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Key Points Long-acting formulations of beta2-agonists and anticholinergics are preferred over short-acting formulations. Based on efficacy and side effects, inhaled bronchodilators are preferred over oral bronchodilators. Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  68. 68. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Key Points Long-term monotherapy with oral or inhaled corticosteroids is not recommended in COPD. The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV1 < 50% of predicted, chronic bronchitis, and frequent exacerbations. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  69. 69. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Goals of Therapy Relieve symptoms Improve exercise tolerance Reduce symptoms Improve health status Prevent disease progression Reduce Prevent and treat exacerbations risk Reduce mortality © 2013 Global Initiative for Chronic Obstructive Lung Disease
  70. 70. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: All COPD Patients Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure Influenza vaccination © 2013 Global Initiative for Chronic Obstructive Lung Disease
  71. 71. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Non-pharmacologicPatient Essential Recommended Depending on localGroup guidelines Smoking cessation (can Flu vaccination A include pharmacologic Physical activity Pneumococcal treatment) vaccination Smoking cessation (can Flu vaccination include pharmacologicB, C, D Physical activity Pneumococcal treatment) vaccination Pulmonary rehabilitation © 2013 Global Initiative for Chronic Obstructive Lung Disease
  72. 72. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)Patient Recommended Alternative choice Other Possible First choice Treatments 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 or or LAMA and PDE4-inh. or SABA and/or SAMA C LAMA LABA and PDE4-inh. Theophylline 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.
  73. 73. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy RECOMMENDED FIRST CHOICE C D Exacerbations per yearGOLD 4 ICS + LABA ICS + LABA >2 or and/or LAMA LAMAGOLD 3 A BGOLD 2 SAMA prn LABA 1 or orGOLD 1 SABA prn LAMA 0 mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  74. 74. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy ALTERNATIVE CHOICE C ICS + LABA and LAMA D Exacerbations per yearGOLD 4 LAMA and LABA or or ICS + LABA and PDE4-inh >2 LAMA and PDE4-inh or or LAMA and LABAGOLD 3 or LABA and PDE4-inh LAMA and PDE4-inh. A BGOLD 2 LAMA or LAMA and LABA 1 LABAGOLD 1 or SABA and SAMA 0 mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  75. 75. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy OTHER POSSIBLE TREATMENTS C D Carbocysteine SABA and/or SAMA Exacerbations per yearGOLD 4 SABA and/or SAMA >2 TheophyllineGOLD 3 TheophyllineGOLD 2 A B 1 Theophylline SABA and/or SAMAGOLD 1 Theophylline 0 mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  76. 76. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  77. 77. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations An exacerbation of COPD is:“an acute event characterized by aworsening of the patient’s respiratorysymptoms that is beyond normal day-to-day variations and leads to achange in medication.” © 2013 Global Initiative for Chronic Obstructive Lung Disease
  78. 78. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Key Points The most common causes of COPD exacerbations are viral upper respiratory tract infections and infection of the tracheobronchial tree. Diagnosis relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms that is beyond normal day-to- day variation. The goal of treatment is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  79. 79. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Key Points Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation. Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. COPD exacerbations can often be prevented. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  80. 80. Consequences Of COPD Exacerbations Negative Impact on impact on symptoms quality of life and lung function EXACERBATIONS Accelerated Increasedlung function economic decline costs Increased Mortality © 2013 Global Initiative for Chronic Obstructive Lung Disease
  81. 81. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: AssessmentsArterial blood gas measurements (in hospital): PaO2 < 8.0 kPawith or without PaCO2 > 6.7 kPa when breathing room airindicates respiratory failure.Chest radiographs: useful to exclude alternative diagnoses.ECG: may aid in the diagnosis of coexisting cardiac problems.Whole blood count: identify polycythemia, anemia or bleeding.Purulent sputum during an exacerbation: indication to beginempirical antibiotic treatment.Biochemical tests: detect electrolyte disturbances, diabetes, andpoor nutrition.Spirometric tests: not recommended during an exacerbation. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  82. 82. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment OptionsOxygen: titrate to improve the patient’s hypoxemia with atarget saturation of 88-92%.Bronchodilators: Short-acting inhaled beta2-agonists with orwithout short-acting anticholinergics are preferred.Systemic Corticosteroids: Shorten recovery time, improvelung function (FEV1) and arterial hypoxemia (PaO2), andreduce the risk of early relapse, treatment failure, and lengthof hospital stay. A dose of 30-40 mg prednisolone per day for10-14 days is recommended. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  83. 83. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment OptionsAntibiotics should be given to patients with:  Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.  Who require mechanical ventilation. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  84. 84. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment OptionsNoninvasive ventilation (NIV) for patientshospitalized for acute exacerbations ofCOPD: Improves respiratory acidosis, decreases respiratory rate, severity of dyspnea, complications and length of hospital stay. Decreases mortality and needs for intubation. GOLD Revision 2011 © 2013 Global Initiative for Chronic Obstructive Lung Disease
  85. 85. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Indications for Hospital Admission Marked increase in intensity of symptoms Severe underlying COPD Onset of new physical signs Failure of an exacerbation to respond to initial medical management Presence of serious comorbidities Frequent exacerbations Older age Insufficient home support © 2013 Global Initiative for Chronic Obstructive Lung Disease
  86. 86. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Major Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  87. 87. Global Strategy for Diagnosis, Management and Prevention of COPD Manage ComorbiditiesCOPD often coexists with other diseases(comorbidities) that may have a significantimpact on prognosis. In general, presence ofcomorbidities should not alter COPD treatmentand comorbidities should be treated as if thepatient did not have COPD. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  88. 88. Global Strategy for Diagnosis, Management and Prevention of COPD Manage ComorbiditiesCardiovascular disease (including ischemicheart disease, heart failure, atrial fibrillation,and hypertension) is a major comorbidity inCOPD and probably both the most frequentand most important disease coexisting withCOPD. Benefits of cardioselective beta-blockertreatment in heart failure outweigh potentialrisk even in patients with severe COPD. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  89. 89. Global Strategy for Diagnosis, Management and Prevention of COPD Manage ComorbiditiesOsteoporosis and anxiety/depression: often under-diagnosed and associated with poor health status andprognosis.Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.Serious infections: respiratory infections are especiallyfrequent.Metabolic syndrome and manifest diabetes: morefrequent in COPD and the latter is likely to impact onprognosis. © 2013 Global Initiative for Chronic Obstructive Lung Disease
  90. 90. Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsUPDATED 2013  Manage Comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease
  91. 91. Global Strategy for Diagnosis, Management and Prevention of COPD, 2013: Summary Prevention of COPD is to a large extent possible and should have high priority Spirometry is required to make the diagnosis of COPD; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD The beneficial effects of pulmonary rehabilitation and physical activity cannot be overstated © 2013 Global Initiative for Chronic Obstructive Lung Disease
  92. 92. Global Strategy for Diagnosis, Management and Prevention of COPD, 2013: Summary Assessment of COPD requires assessment of symptoms, degree of airflow limitation, risk of exacerbations, and comorbidities Combined assessment of symptoms and risk of exacerbations is the basis for non-pharmacologic and pharmacologic management of COPD © 2013 Global Initiative for Chronic Obstructive Lung Disease
  93. 93. Global Strategy for Diagnosis, Management and Prevention of COPD, 2013: Summary Treat COPD exacerbations to minimize their impact and to prevent the development of subsequent exacerbations Look for comorbidities – and if present treat to the same extent as if the patient did not have COPD © 2013 Global Initiative for Chronic Obstructive Lung Disease
  94. 94. SR. BRAND NAME DRUG PRICENO1. SERETIDE-250 SALMETEROL 25µg 405/- EVOHALER FLUTICASONE 250µg2. FLUTICASONE FLUTICASONE 157/- NASAL SPRAY 100 METERED DOSES FLUTIFLO3. QUICKHALE FB - FORMETEROL FUMARATE 6µg 278/- 200 BUDESONIDE 200µg4. SEROFLO-125 SALMETEROL 125µg 150/- INHALER FLUTICASONE PROPIONATE 125µg5. SALBAIR LEVOSALBUTAMOL SULPHATE 96.25/- TRANSHALER 50µg INHALER6. TRIOHALE TIOTROPIUM BROMIDE 9µg 570/- INHALER FORMOTEROL FUMARATE 6µg CICLESONIDE INHALER 200µg
  95. 95. SR BRAND NAME DRUGS PRICENO.7. FLUTICONE-FT FLUTICASONE FUROATE 6.9µg 257/- AQUEAS NASAL SPRAY 120 METERED DOSES8. FURAMIS A2 FLUTICASONE FUROATE 27.5µg 270/- NASAL SRRAY HYDROCHLORIDE 140µg9. TIOVA INHALER TIOTROPIUM BROMIDE 410/- INHALER 9µg10. MAXIFLO FLUTICASONE 425/- INHALER PROPIONATE 25µg FORMOTEROL FUMARATE 6µg11. DERIHALER SALBUTAMOL INHALER 100µg 134.33/- 200 METERED DOSES12. EZICAS FLUTICASONE 50µg 210/- NASAL SPRAY13. TIOMATE TIOTROPIUMBROMIDE 9µg 400.86/- TRANSHALER FORMOTEROL FUMARATE 6µg 180 METERED DOSES
  96. 96. SR BRAND NAME DRUGS PRICENO.14. FURAMIST NASAL FLUTICASONE FUROATE 27.5µg 240/- SPRAY15. FORACORT FORMOTEROL FUROATE 6µg 360/- INHALER BUDESONIDE 200µg16. AEROCORT BECLOMETHASONE 148/- DIPROPIONATE50µg LEVOSALBUTAMOL 50µg17. COMBITIDE 125 SALMETEROL 25µg 322/- INHALER FLUTICASONE125µg18. BECLATE INHALER BECLOMETHASONE 200µg 308/- 20019. ASTHALIN SALMETEROL INHALATION 107/- INHALER 100µg/DOSE20. LEVOLIN INHALER LEVOSALBUTAMOL 50µg 105/-21. DUOVA INHALER TIOTROPIUM BROMIDE 310/- FORMOTEROL FUROATE 120 METERED DOSES22. FORAIR 125 SALMETEROL 25µg 317.19/- INHALER FLUTICASONE 125µg
  97. 97. References GOLD Guidelines - http://www.goldcopd.org CMDT 2013 Harrison’s Principles of Internal Medicine : Eighteenth Edition UpToDate http://www.uptodate.com) eMedicine (http://www.emedicine.com) © 2013 Global Initiative for Chronic Obstructive Lung Disease
  98. 98. Thank You

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