Obstructive Lung Diseases
A group of diseases characterized by reduction of expiratory flow rates:
• Bronchial Asthma: a c...
Chronic
Bronchitis
Emphysema
Bronchial
Asthma
Chronic Obstructive
Pulmonary Disease (COPD)
* Encompasses chronic bronchitis, emphysema
and mixed cases.
* Preventable an...
GLOBAL INITIATIVE FOR
CHRONIC OBSTRUCTIVE LUNG
DISEASE (GOLD)
January 2013
http://www.goldcopd.org
Burden of COPD
 A leading cause of morbidity and mortality
worldwide.
 Burden expected to increase due to
continued expo...
+
-
Risk
FactorsHost factors Exposures
Genetic factors
Airway hyperreactivity
Smoking
Occupation
Environmental pollution
Recur...
Airways Disease
• Luminal Plugs
• Mucosal Inflammation
• Muscle Spasm
• Bronchial wall fibrosis
(Remodelling)
Parenchymal
...
Diagnosis
 Clinical diagnosis based on:
– Dyspnoea.
– Chronic cough.
– Exposure to risk factors.
 Spirometric diagnosis:...
1 2 3 4 5 6
1
2
3
4
Volume,liters
Time, sec
FVC5
1
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
Volume,liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Severity of Airflow Limitation in COPD
In patients with FEV1/FVC < 0.7:
Two exacerbations or more within the last year
or ...
Pulmonary Functions in COPD
 Spirometry
–Decreased FEV1, FEV1/FVC, FEF25-75%
 Lung volumes
–Increased Total Lung Capacit...
Additional
Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude
alternative diagnoses and establish prese...
IV: Very SevereIII: SevereII: ModerateI: Mild
Therapy at Each Stage of COPDTherapy at Each Stage of COPD
* Regular treatme...
Risk Reduction
 Reduction of exposures in the workplace.
 Reduce indoor air pollution eg, from heating in poorly
ventila...
 Bronchodilators are central to the symptomatic
management of COPD.
 Inhaled bronchodilators are preferred over oral
bro...
 Long-acting inhaled bronchodilators are
convenient and more effective for symptom relief
than short-acting bronchodilato...
 Regular treatment with inhaled corticosteroids (ICS)
improves symptoms, lung function and quality of life
and reduces fr...
 An inhaled corticosteroid combined with a long-acting
beta2-agonist is more effective than the individual
components in ...
 Chronic treatment with systemic
corticosteroids should be avoided
because of an unfavorable benefit-to-
risk ratio.
Syst...
Theophylline
 Theophylline is less effective and less well tolerated than
inhaled long-acting bronchodilators and is not
...
In patients with severe and
very severe COPD(GOLD 3
and 4), the selective
hospodiesterase-4 inhibitor
(PDE-4), roflumilast...
Influenza vaccine can reduce serious illness.
Pneumococcal polysaccharide vaccine recommended
for COPD patients 65 years a...
Alpha-1 antitrypsin augmentation (replacement) therapy:
• The only specific therapy for
1 antitrypsin deficiency.
• Prepar...
The long-term administration of oxygen
(> 15 hours per day) to patients with chronic respiratory
failure increases surviva...
 All COPD patients benefit from exercise training
programs with improvements in exercise tolerance
and symptoms of dyspne...
Sleep
Sleep in COPD is associated with oxygen
desaturation, predominantly due to the disease itself
(rather than sleep apn...
Bullectomy and Lung volume reduction surgery
are more efficacious than medical therapy among
patients with upper-lobe pred...
An exacerbation of COPD is:
“an acute event characterized by a worsening
of the patient’s respiratory symptoms that is
bey...
Impact on
symptoms
and lung
function
Negative
impact on
quality of life
Consequences Of COPD Exacerbations
Increased
econo...
Patient education
Check inhalation technique
Consider use of spacer devices
Bronchodilators
↑ Dose and/or frequency of SAB...
In-Patient Treatment
Add:
Supplemental oxygen to prevent tissue hypoxia by maintaining
arterial oxygen saturation (SaO2) a...
Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation,
and hypertension): the most ...
COPD Management Guidelines
COPD Management Guidelines
COPD Management Guidelines
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COPD Management Guidelines

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Guidelines for diagnosis and management of COPD

Published in: Health & Medicine

COPD Management Guidelines

  1. 1. Obstructive Lung Diseases A group of diseases characterized by reduction of expiratory flow rates: • Bronchial Asthma: a chronic inflammatory disorder of the airways characterized by bronchial hyper-responsiveness to a variety of stimuli which lead to episodes of wide spread bronchial narrowing which is largely reversible either spontaneously or with treatment. • Chronic Bronchitis: chronic cough with expectoration for at least 6 months in a year or 3 months/Y for 2 successive years, not due to lung disease • Emphysema: persistent abnormal dilatation of the air spaces distal to the terminal bronchioles , accompanied by destruction of the elastic tissues of the lungs. • Bronchiectasis. • Cystic Fibrosis.
  2. 2. Chronic Bronchitis Emphysema Bronchial Asthma
  3. 3. Chronic Obstructive Pulmonary Disease (COPD) * Encompasses chronic bronchitis, emphysema and mixed cases. * Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. * Pulmonary component characterized by airflow limitation that is not fully reversible. * Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases.
  4. 4. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD) January 2013 http://www.goldcopd.org
  5. 5. Burden of COPD  A leading cause of morbidity and mortality worldwide.  Burden expected to increase due to continued exposure to risk factors and the aging of the world’s population.  associated with significant economic burden.
  6. 6. + -
  7. 7. Risk FactorsHost factors Exposures Genetic factors Airway hyperreactivity Smoking Occupation Environmental pollution Recurrent bronchopulmonary infections
  8. 8. Airways Disease • Luminal Plugs • Mucosal Inflammation • Muscle Spasm • Bronchial wall fibrosis (Remodelling) Parenchymal Destruction • Loss of alveolar attachments • Decrease of elastic recoil AIRFLOW LIMITATION
  9. 9. Diagnosis  Clinical diagnosis based on: – Dyspnoea. – Chronic cough. – Exposure to risk factors.  Spirometric diagnosis: post-bronchodilator FEV1/FVC < 0.7 (persistent airflow limitation) Why post-bronchodilator? To minimize variability and exclude BA
  10. 10. 1 2 3 4 5 6 1 2 3 4 Volume,liters Time, sec FVC5 1 FEV1 = 4L FVC = 5L FEV1/FVC = 0.8
  11. 11. Volume,liters Time, seconds 5 4 3 2 1 1 2 3 4 5 6 FEV1 = 1.8L FVC = 3.2L FEV1/FVC = 0.56
  12. 12. Severity of Airflow Limitation in COPD In patients with FEV1/FVC < 0.7: Two exacerbations or more within the last year or an FEV1 < 50 % of predicted value are indicators of high risk Mild COPD ≥80 Moderate COPD 50–80 Severe COPD 30–50 Very severe COPD <30 Or chronic respiratory failure FEV1 % Predicted:
  13. 13. Pulmonary Functions in COPD  Spirometry –Decreased FEV1, FEV1/FVC, FEF25-75%  Lung volumes –Increased Total Lung Capacity –Increased Residual Volume –Increased RV/TLC  DLCO—decreased in emphysema due to lung destruction
  14. 14. Additional Investigations Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. Diffusing Capacity: to characterize severity. Oximetry and Arterial Blood Gases: in advanced cases. Alpha-1 Antitrypsin Level: required when: • COPD develops under 45. • COPD develops in non- smoker. • Strong family history of COPD. N: > 150 mg/dL . In disease: < 45 mg/dL
  15. 15. IV: Very SevereIII: SevereII: ModerateI: Mild Therapy at Each Stage of COPDTherapy at Each Stage of COPD * Regular treatment with long-acting bronchodilators * Inhaled glucocorticosteroids if repeated exacerbations Active reduction of risk factor(s); influenza vaccination short-acting bronchodilator (when needed) * Long term oxygen if chronic respiratory failure. * Surgical treatments
  16. 16. Risk Reduction  Reduction of exposures in the workplace.  Reduce indoor air pollution eg, from heating in poorly ventilated home.  Smoking cessation has the greatest capacity to improve the natural history of COPD.
  17. 17.  Bronchodilators are central to the symptomatic management of COPD.  Inhaled bronchodilators are preferred over oral bronchodilators.  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 combination therapy. Bronchodilators
  18. 18.  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 side effects compared to increasing the dose of a single bronchodilator. Bronchodilators  Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations.
  19. 19.  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 Corticosteroids
  20. 20.  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.  Addition of a long-acting beta2-agonist/inhaled steroid combination to an anticholinergic appears to provide additional benefits. Combination Therapy
  21. 21.  Chronic treatment with systemic corticosteroids should be avoided because of an unfavorable benefit-to- risk ratio. Systemic Corticosteroids
  22. 22. 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.
  23. 23. In patients with severe and very severe COPD(GOLD 3 and 4), the selective hospodiesterase-4 inhibitor (PDE-4), roflumilast [Daxas], reduces xacerbations. It has also an anti-inflammatory activity. Dose: one tab (0.5 mg) PO once daily. Phosphodiesterase-4 Inhibitors
  24. 24. Influenza vaccine can reduce serious illness. Pneumococcal polysaccharide vaccine recommended for COPD patients 65 years and older. Other Pharmacologic Treatments Mucolytics: Only in patients with viscid sputum; overall benefits are very small. Antitussives: Not recommended.
  25. 25. Alpha-1 antitrypsin augmentation (replacement) therapy: • The only specific therapy for 1 antitrypsin deficiency. • Prepared from pooled plasma of healthy donors. • Given as weekly IV infusion (60 mg/Kg). • Not well tolerated (fever, chills, flu like symptoms. • Very expensive.
  26. 26. The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure increases survival in patients with severe, resting hypoxemia. Reversal of hypoxaemia supersedes concerns about CO2 retention. The therapeutic goal is to maintain Sa,O2 >90% during rest, sleep and exertion. Oxygen Therapy
  27. 27.  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 are the results. Rehabilitation
  28. 28. Sleep Sleep in COPD is associated with oxygen desaturation, predominantly due to the disease itself (rather than sleep apnoea). Desaturation during sleep may be greater than during maximum exercise. Sleep quality is markedly impaired in COPD. Control of cough, dyspnoeal improves sleep quality. Nocturnal oxygen therapy is rarely indicated. Hypnotics should be avoided.
  29. 29. Bullectomy and Lung volume reduction surgery are more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity. In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity. Surgical Treatments
  30. 30. An exacerbation of COPD is: “an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medications.” Management of Exacerbations  Most exacerbations are precipitated by respiratory tract infections.  Diagnosis relies exclusively on the clinical presentation.
  31. 31. Impact on symptoms and lung function Negative impact on quality of life Consequences Of COPD Exacerbations Increased economic costs Accelerated lung function decline Increased Mortality EXACERBATIONS
  32. 32. Patient education Check inhalation technique Consider use of spacer devices Bronchodilators ↑ Dose and/or frequency of SABA and/or anticholinergic MDI with spacer or hand-held nebuliser as needed Consider adding LABA Corticosteroids Prednisone 30–40 mg per os q day for 7 - 10 days Consider using an inhaled corticosteroid Antibiotics May be initiated in patients with altered sputum characteristics (Volume and/or Purulence) Choice should be based on local bacteria resistance patterns Amoxicillin/ampicillin, cephalosporins Doxycycline Macrolides Out-Patient Treatment
  33. 33. In-Patient Treatment Add: Supplemental oxygen to prevent tissue hypoxia by maintaining arterial oxygen saturation (SaO2) at >90%. Ventilatory support Corticosteroids If patient tolerates oral medications, prednisone 30–40 mg per os q day for 10 days If patient can not tolerate, give the equivalent dose i.v.
  34. 34. Cardiovascular disease (including ischemic heart disease, heart failure, atrial fibrillation, and hypertension): the most frequent and most important disease coexisting with COPD. Benefits of cardioselective beta-blocker treatment in heart failure outweigh potential risk even in patients with severe COPD.   Manage Comorbidities
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