2. GOALS OF ASSESSMENT
In order to eventually guide therapy, goals of assessment
are ascertained as follows :
Determine level of airflow limitation
Impact on patient’s health status
Risk of future events (exacerbations, hospital admissions,
death)
3. GOALS OF ASSESSMENT
In order to achieve these goals, we have to consider:-
Presence and severity of spirometry abnormalities
Current nature and magnitude of patient’s symptoms
History of moderate and severe exacerbations and future
risk
Presence of co-morbidities
4. 1. CLASSIFICATION OF AIRFLOW LIMITATION
SEVERITY
(BASED ON POST BRONCHODILATOR-FEV1)
5. 2. ASSESSMENT OF SYMPTOMS
mMRC Score : measure of breathlessness
: relates to other measures of health status
: predicts future mortality risk
6. Beyond dyspnea, comprehensive assessment is required
Disease specific health status questionnaires used are:
• Chronic Respiratory Questionnaire (CRQ)
• St. George’s Respiratory Questionnaire (SGRQ)
• COPD Assessment Test (CAT)
• COPD Control Questionnaire (CCQ)
9. SGRQ
• Most widely documented comprehensive score with a
score of 25 as the threshold for considering regular
treatment.
• Score < 25 : uncommon in COPD diagnosed patients
• Score > 25 : uncommon in healthy population
10. 3. ASSESSMENT OF EXACERBATION RISK
Defined as acute worsening of symptoms that result in
additional therapy
Classified as
• Mild - treated with Short acting bronchodilators (SABD)
• Moderate ( SABD + antibiotics and/or Oral Corticosteroids)
• Severe ( hospitalization or visits EMR)
11. Best predictor of frequent exacerbations ( ≥2 episodes/year)
is history of earlier treated events
Other predictors:
Deteriorating airflow limitation
Blood eosinophil count
12. 4. ASSESSMENT OF C0-MORBIDITIES
Assess common co-morbidities
Assess common risk factors ( smoking, alcohol, diet, inactivity)
Assess extra pulmonary effects of COPD ( weight loss, nutritional anomalies,
skeletal muscle dysfunction)
• Skeletal muscle dysfunction is characterized by : Sarcopenia (loss of cells) and
abnormal function of remaining cells
• Causes – inactivity, poor diet, inflammation, hypoxia
• Rectifiable source of exercise intolerance
14. ROLE OF SPIROMETRY IN COPD
Diagnosis
Assessment of airflow obstruction severity (Prognosis)
Follow up assessment
• Therapeutic decisions- Pharmacological (discrepancy
between spirometry and level of symptoms)
- Consider alternative diagnosis
- Non-pharmacological (interventional procedures)
• Identification of rapid decline
15. OTHER INVESTIGATIONS
Alpha-1 antitrypsin deficiency screening in:-
• Early onset emphysema (<45 years)
• Emphysema in a non-smoker
• Panacinar
• Necrotizing panniculitis ( Weber- Christian disease)
• c-ANCA positive vasculitis (e.g- Wegner’s granulomatosis)
• Family h/o early onset/ non smoker’s emphysema
• Bronchiectasis without other etiology
Imaging, Lung volumes, DLCO, ABG, exercise testing capacity and
biomarkers ( CRP, Procalcitonin) should also be assessed during
initial work up.
16. PROGNOSIS OF COPD
PREDICTORS OF POOR SURVIVAL
• Low FEV1
• Active smoking status
• Hypoxemia
• Resting tachycardia
• Poor nutrition
• Cor pulmonale
• Low exercise capacity
• Severe dyspnea
• Poor health related quality of life
• Anemia
• Frequent exacerbations
• Co-morbidities
• Low DLCO
• By BODE and ADO
17. BODE INDEX
• BMI
• Obstructive ventilatory defect
severity
• Dyspnea severity
• Exercise capacity
• >7 : 30% 2 year mortality
• 5-6 : 15% 2 year mortality
• <5 : less than 10% 2 year mortality
18. ADO INDEX
• Age
• Dyspnea
• Obstructive ventilatory defect
severity
• 0-10
• Each point increased in index is
associated with a 42% increase in
odds of death at 3 years
19. MANAGEMENT OF STABLE COPD
GOALS
Relieve symptoms
Improve exercise tolerance REDUCE SYMPTOMS
Improve health status
Prevent disease progression
Prevent and treat Exacerbations REDUCE RISK
Reduce mortality
20. MANAGEMENT OF STABLE COPD
DIAGNOSIS INITIAL
ASSESSMENT
INITIAL
MANAGEMENT
Smoking cessation
Vaccination
Active lifestyle and exercise
Initial pharmacotherapy
Self management
education
: risk factor management
: inhaler technique
: breathlessness
: written action plan
Manage co-morbidities
REVIEW
Symptoms (CAT or mMRC)
Exacerbations
Smoking status
Exposure to other risk factors
Inhaler technique and adherence
Physical activity and exercise
Need for pulmonary rehabilitation
Self management skills ( breathlessness,
written action plan)
Need for oxygen, NIV, lung volume
reduction, palliative approaches
Vaccination
Management of co-morbidities
Spirometry annually
ADJUST
22. BROCHODILATORS-BETA AGONISTS
Beta 2 adrenergic receptor stimulation inc cAMP
relaxes airway smooth muscles
SABA
• 4-6 hours
• Regular and as needed, improves FEV1 and symptoms
• E.g- Levalbuterol, Salbutamol, Terbutaline
LABA
• 12-24 hours
• Twice daily ( formoterol, salmetrol) improve FEV1, lung volumes, dyspnea, health status,
exacerbation rate
• Once daily ( indacaterol) improves breathlessness, health status, exacerbation rate
23. BROCHODILATORS-BETA AGONISTS
Side Effects:-
• Resting sinus tachycardia
• Exaggerated somatic tremors
• Hypokalemia
• Increased oxygen consumption in patients with CHF
• Tachyphylaxis
• Fall in PaO2
• Cough after inhalation of indacaterol
24. BROCHODILATORS-ANTIMUSCARINIC
Block bronchoconstrictor effect of Ach on M3 receptors of airway
smooth muscle
SAMA
• Also blocks M2 inhibitory neuronal receptor (causes vagally induced broncho constriction)
• Has small benefit over SABA in terms of lung function, health status and requirement of oral
steroids
• E.g- Ipratropium, Oxitropium
LAMA
• Prolonged binding to M3 with faster dissociation from M2 prolong effect
• Improve symptoms, health status, effectiveness of pulmonary rehabilitation, red
exacerbations
• Eg- Tiotropium, aclidinium, glycopyrronium, umeclidinium
28. ANTI-INFLAMMATORY THERAPY
1.INHALED CORTICOSTEROIDS (ICS)
:- More effective when combined with long term bronchodilator therapy rather than the
individual components given alone
(ICS/LAMA/LABA or ICS/LABA or ICS/LAMA)
:- More effective in patients with exacerbation risk
:-E.g- Fluticasone, Beclomethasone
:-Withdrawal leads to FEV1 loss and increase in exacerbation frequency
31. FACTORS TO CONSIDER WHEN INITIATING ICS
STRONG
SUPPORT
CONSIDER USE AGAINST USE
• H/O hospitalization for
exacerbation of COPD (despite
appropriate long term
bronchodilator therapy)
• ≥2 moderate exacerbations of
COPD per year (despite
appropriate long term
bronchodilator therapy)
• Blood eosinophil > 300 cells/µL
• History of or concomitant
asthma
• 1 moderate exacerbation of
COPD per year (despite
appropriate long term
bronchodilator therapy)
• Blood eosinophil 100-300
cells/µL
• Repeated pneumonia events
• H/o mycobacterial infection
• Blood eosinophil <100 cells/µL
32. ANTI-INFLAMMATORY THERAPY
• ORAL CORTICOSTEROIDS
:- Less long term effect in stable COPD, more useful in acute exacerbations
:- Numerous side effects including steroid myopathy which contributes to muscle weakness,
decreased functionality and respiratory failure in very severe COPD patients
33. ANTI-INFLAMMATORY THERAPY
2. PHOSPHODIESTERASE-4-INHIBITORS(PDE-4)
:- Reduces inflammation by inhibiting breakdown of intracellular cAMP
:- Reduces moderate and severe exacerbations in patients with chronic bronchitis,
exacerbations in severe to very severe COPD
:- Effective in patients not controlled on LABA/ICS
:- E.g- Roflumilast (oral OD)
34. Side Effects:-
• Diarrhea, nausea, reduced appetite, abdominal pain
• Weight loss
• Sleep disturbance
• Headache
• Used cautiously in patients suffering from depression
35. ANTI-INFLAMMATORY THERAPY
3.ANTIBIOTICS
:- Azithromycin (250 mg/day or 500 mg three times a week)
:- Erythromycin (500 mg/day BD) x 1 year (reduces the risk in patients prone to exacerbation)
:- S/E Azithromycin- bacterial resistance, QTc prolongation, impaired hearing test
36. ANTI-INFLAMMATORY THERAPY
4.MUCOLYTICS and ANTIOXIDANTS
:- Regular treatment with erdosteine, carbocysteine and N-acetyl cysteine reduces
exacerbations and improves health status
5. OTHER DRUGS
:-Anti IL-5 Monoclonal Ab - Mepolizumab
:- Anti IL-5 Receptor Alpha Ab- Benralizumab
:- Statins (simvastatin) given to patients suffering from cardiac disease with COPD may
show improvement but it is not an indicated therapy.
:- Vitamin D given to patients suffering from Vitamin D deficiency with COPD may
show improvement.
37. OTHER DRUGS
During influenza epidemic-
Neuraminidase inhibitors ( oral - zanamavir, oseltamivir,
inj-peramivir) can minimize infection if taken < 48 hours of
onset
Replacement therapy of alpha 1 antitrypsin ( 60 mg/kg iv
weekly)
38. EFFECTIVE INHALATION THERAPY
• Inhalational devices include nebulizers,MDI,DPI.
• Particle size >5 um are deposited in oropharynx.
• 2-5 um or < 2um are deposited in lower respiratory tract.
• Importance of education and training for inhaler device technique is very
important.
• Essential to provide instructions and demonstrate proper inhalation
techniques when prescribing the device.
• “Teach back approach” is important.
• Choice of inhaler device has to be individually tailored and depends on access
, cost, prescriber and patient’s ability and preference.
• Determinants of poor inhaler techniques –
Lack of education about inhaler techniques
Older age
Use of multiple devices
39.
40. NON-PHARMACOLOGICAL TREATMENT OF
STABLE COPD
PATIENT GROUP ESSENTIAL RECOMMENDED DEPENDING ON
LOCAL GUIDELINES
A SMOKING CESSATION PHYSICAL ACTIVITY VACCINATION
B,C,D SMOKING CESSATION
PULMONARY REHABILITATION
PHYSICAL ACTIVITY VACCINATION
41. IDENTIFY AND REDUCE EXPOSURE TO RISK
FACTORS
Tobacco smoke
• Smoking cessation has the greatest capacity to influence the natural history of COPD
• Five step program for intervention provides a strategic framework
1. ASK (Identify smokers)
2. ADVISE (To quit)
3. ASSESS (Willingness to quit)
4. ASSIST (Counseling and pharmacotherapy)
5. ARRANGE (follow up visits)
42. • Pharmacotherapies for smoking cessation
1. Nicotine Replacement Products
:-Nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet, lozenges
:- C/I are recent MI, stroke
:- Should be started 2 weeks after occurrence of a cardiovascular event
:- S/E are nausea
2. Other drugs
:- Varenicline
:- Bupropion
:- Clonidine
:- Nortriptyline
44. Indoor and outdoor air pollution
• Efficient ventilation, non-polluting cooking stoves
Occupational exposures
• Avoid exposures to potential irritants
45. VACCINATION
INFLUENZA
• Reduce LRTI, exacerbations and deaths in COPD
• More effective in elderly
PNEUMOCOCCAL
• PPSV23 reduces exacerbations, CAP in patients < 65 yrs with FEV1< 40% and
co-morbidities
• PCV 13 is given in > 65 yrs , significant efficacy in reducing bacteremia and
serious invasive pneumococcal disease
46. EDUCATION
Patient education topics for COPD
• Risk factors
• Smoking cessation
• Reduction of noxious environmental exposures
• Immunization
• Respiratory hygiene
• Nature and prognosis
• Indication, benefits and s/e drugs
• Proper inhaler and nebulizer use
• Strategies to improve adherence to treatment
• Pulmonary rehabilitation programs
47. SELF MANAGEMENT
• Structured, personalized multi-component map with
goals of motivating, engaging and supporting the
patient and develop skills to better manage the
disease on day to day basis
• Written action plan
48.
49. PULMONARY REHABILITATION
• Group B,C and D
• Improves health status, dyspnea and exercise
intolerance in patients.
• Leads to reduction in symptoms of anxiety and
depression.
• Reduces hospitalization among patients who had
recent exacerbations.
• Supervised exercise training (twice weekly)
50. PRESCRIPTION OF SUPPLEMENTAL OXYGEN TO COPD
PATIENTS
• Relieves dyspnea
• Increases survival in
patients with severe
resting hypoxemia
51. VENTILATORY SUPPORT IN STABLE PATIENT
• NPPV improves survival in recently hospitalized patients
particularly in those who have pronounced day time persistent
hypercapnia ( PaCo2 > 53 mmHg)
• CPAP in patients with COPD with OSA improves survival and risk of
hospital administration
52. INTERVENTIONAL THERAPY IN STABLE COPD
THERAPY DESCRIPTION
LUNG VOLUME REDUCTION SURGERY ( LVRS) Improves survival in severe emphysema patients with
upper lobe emphysema and low post rehabilitation
exercise capacity
BULLECTOMY Helps to decrease dyspnea, improved lung function
and exercise tolerance in large bullae formation
TRANSPLANTATION Improves quality of life and functional capacity in
appropriately selected patients.
BRONCHOSCOPIC INTERVENTIONS Reduce end expiratory lung volume
Improves exercise tolerance and lung function 6-12
post treatment
Include- endobronchial valves, lung coils, vapor
ablation
53. PALLIATIVE CARE
• DYSPNEA- Opiates, Neuromuscular electrical stimulation (NMES), Chest
wall vibration and fans blowing air onto the face.
NIV can reduce daytime breathlessness
• NUTRITIONAL SUPPORT- Low BMI and Low fat free mass have poor
outcome . Improve nutrition and add Antioxidants ( Vit C,E, Zn, Se)
• PANIC,ANXIETY, DEPRESSION- CBT and mind body interventions (yoga etc)
• FATIGUE- Self management, pulmonary rehabilitation , physical activity
