Management of copd by DR TASLEEM ARIF


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  • Management of copd by DR TASLEEM ARIF

    1. 1. COPD Management GOLD Guidelines Dr.Tasleem Arif Dept. of Chest Medicine SKIMS MC/H BEMINA SGR KMR
    2. 2. Goals • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality • Prevent or minimize side effects from treatment • Cessation of cigarette smoking
    3. 3. Components • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Manage acute exacerbations
    4. 4. Assess and Monitor Disease
    5. 5. Initial Visit • Pattern of symptom development • Exposure to risk factors • History of exacerbations or previous hospitalizations for respiratory disorder • Past medical history • Family history • Social history • Impact of disease on patient’s life • Effect on family routines • Feelings of depression or anxiety • Social and family support available to the patient • Possibilities for reducing risk factors, especially smoking cessation
    6. 6. Testing • Spirometry • Initially and yearly • ABG • Obtain if FEV1 < 40% predicted OR • Clinical signs of respiratory or right heart failure • Respiratory Failure • Alpha-1 antitrypsin • If patient <45 years old or strong family history of COPD
    7. 7. Follow-Up Visits • Discuss new or worsening symptoms • Perform spirometry if there is a substantial increase in symptoms OR if a complication occurs • ABG • Patients with an FEV1 <40% predicted • Early signs of respiratory failure or CHF • Monitor pharmacotherapy • Dosages • Adherence • Inhaler technique • Effectiveness of current regimen at controlling symptoms • Side effects of treatment
    8. 8. Follow-up Visits • Monitor co-morbid conditions • Bronchial carcinoma • Tuberculosis • Sleep apnea • Left heart failure • Obtain appropriate information through CXR, ECG whenever symptoms suggest one of these conditions
    9. 9. Reduce Risk Factors
    10. 10. Risk Factors • Tobacco smoke • Occupational dusts and chemicals • Indoor and outdoor air pollutants
    11. 11. Smoking Cessation • The single MOST effective and cost-effective intervention to reduce the risk of developing COPD and to stop its progression • Offer this at EVERY visit to the health care provider • Brief 3 minute period of counseling • Three types of counseling are esp. effective: • Practical counseling • Social support as part of the treatment • Social support arranged outside of the treatment • Several effective medications are available and at least one of these medications should be added to counseling if necessary and if there are no contraindications • Nicotine gum, inhaler, nasal spray, trasndermal patch, sublingual tablet, lozenges • Bupropion • nortriptyline
    12. 12. Ask Systematically identify all tobacco users at every visit Advis e Strongly urge all tobacco users to quit, in a clear, strong, and personalized manner Asses s Determine willingness to make a quit attempt. e.g. within the next 30 days, how willing is this person to make a quit attempt Assist Aid the patient in quitting e.g. quit plan, counseling, intra-treatment social support, extra-treatment social support, approved pharmacotherapy, supplementary materials Arran ge Schedule a follow-up contact, either in person or via telephone
    13. 13. Smoking Prevention – What you can do as a provider: • Encourage comprehensive tobacco- control policies and programs • Work with government officials to pass legislation to establish smoke- free schools, public facilities, and work environments • Encourage patients to keep smoke- free homes Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.
    14. 14. Occupational Exposures • Primary prevention • Eliminate or reduce exposures to various substances in the workplace • Secondary prevention • Surveillance and early detection
    15. 15. Indoor and Outdoor Air Pollution • Implement measures to 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 • Avoid vigorous exercise outdoors or stay indoors during pollution episodes, depending on COPD severity
    16. 16. Manage Stable COPD
    17. 17. General Principles • Determine disease severity • Implement step- wise treatment plan • Educate the patient • Improve skills • Improve ability to cope with illness • Improve health status • Prescribe Treatment • Pharmacologic • Non- pharmacologic • Rehabilitation − Exercise training − Nutrition counseling − education − Oxygen therapy • Surgical interventionsGOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
    18. 18. Stage Characteristics 0: At Risk Normal spirometry Chronic symptoms (cough, sputum) I: Mild FEV1/FVC < 70% FEV1 >= 80% predicted Usu. Chronic cough and sputum production II: Moderate 50% <= FEV1 < 80% predicted Progression of symptoms; dyspnea on exertion III: Severe 30%<= FEV1 < 50% predicted ↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life IV Very severe FEV1< 30% predicted OR FEV1<50% predicted + chronic respiratory failure •Quality of life is appreciably impaired •Exacerbations may be life-threatening
    19. 19. Patient Education • Smoking cessation • Basic information about COPD and pathophysiology of the disease • General approach to therapy and specific aspects of medical treatment • Self-management skills • Strategies to help minimize dyspnea • Advice about when to seek help • Self-management and decision-making in exacerbations • Advance directives and end-of-life issues
    20. 20. Medications • Goals • Prevent and control symptoms • Reduce frequency and severity of exacerbations • Improve health status • Improve exercise tolerance • No existing medications can modify the long-term decline in lung function • Reduction of therapy once symptom control occurs is not normally possible • COPD is progressive and over time will require progressive introduction of more treatments to attempt to limit the impact of these changes
    21. 21. Bronchodilators • Central to symptom management • Used in all stages of COPD severity • Inhaled forms are preferred • Can be prescribed as needed OR regularly to prevent or reduce symptoms • Long-acting inhaled bronchodilators are more effective and convenient (but are more expensive) • Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects • All categories of bronchodilators have been show to increase exercise capacity without necessarily producing significant changes in FEV1
    22. 22. Bronchodilators • Beta2-agonists • Short-acting: albuterol • Long-acting: salmeterol (Serevent™), formoterol (Foradil™) • Anticholinergics • Short acting: ipratropium bromide (Atrovent™) • Long acting: tiotropium bromide (Spiriva™) • Methylxanthines (Theophylline™) • Combination bronchodilators • Fenoterol/ipratropium (Duovent™) • Salbutamol/ipratropium (Combivent™) GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
    23. 23. Glucocorticosteroids • Use if FEV1 < 50% predicted and repeated exacerbations, e.g. three in the last three years • Severe COPD and Very Severe COPD • Does not modify the long-term decline in FEV1 BUT does reduce the frequency of excacerbations and improves health status • The combination of a long-acting beta2- agonist and an inhaled glucocorticosteroid is more effective than the individual components • Long-term treatment with oral glucocorticoids is NOT recommended
    24. 24. Inhaled Glucocorticoids • Beclomethasone (Vanceril™) • Budesonide (Pulmicort™) • Fluticasone (Flovent™) • Triamcinolone (Azmacort™)
    25. 25. Immunizations • Vaccines • Influenza yearly •Reduces serious illness and death in COPD patients by approximately 50% •Give once yearly: autumn OR twice yearly: autumn and winter • Pneumovax •Sufficient data to support its general use in COPD is lacking, but it is commonly used
    26. 26. Other Medications? • Alpha-1 Antitrypsin Augmentation Therapy • Only if this deficiency is present in an individual should they undergo treatment • Antibiotics • Prophylactic use is NOT recommended • Can be used in the treatment of infectious exacerbations of COPD • Mucolytic agents • Overall benefits are small, so currently not recommended for widespread use • Types: • Ambroxol • Erdosteine (Erdostin, Mucotec) • Carbocysteine (Mucodyne) • Iodinated gylerol (Expigen)
    27. 27. • Antioxidant agents • N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst) • Have been shown to reduce the frequency of exacerbations and could have a role in the treatment of patients with recurrent exacerbations • More studies are needed • Immunoregulators • Not recommended at this time • No reproducible studies are available • Antitussives • Regular use is contraindicated in stable COPD since cough has a significant protective role • Vasodilators • Inhaled nitric oxide • Can worsen gas exchange because of altered hypoxic regulation of ventilation-perfusion balance and is contraindicated in stable COPD
    28. 28. • Respiratory stimulants • Doxapram (IV) • Almitrine bismesylate • Not recommended in stable COPD • Narcotics • Oral and parenteral opioids are effective for treating dyspnea in patients with advanced COPD • Use this with caution; benefits may be limited to a few sensitive subjects • nebulized opioids: insufficient evidence . • Miscellaenous: • Nedocromil • Leukotriene modifiers • Alternative healing methods • None have been adequately studied in COPD patients at this time GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
    29. 29. Stage 0: At Risk • Avoid risk factors • Offer influenza vaccination
    30. 30. Stage I: Mild COPD • Avoid risk factors • Offer vaccination • Use short-acting bronchodilators as needed I: Mild FEV1/FVC < 70% FEV1 >= 80% predicted Usu. Chronic cough and sputum production
    31. 31. Stage II: Moderate COPD • Avoid risk factors • Offer influenza vaccine • Add short-acting bronchodilators when needed • Add regular treatment with 1 or more long- acting bronchodilators • Add rehabilitation II: Modera te 50% <= FEV1 < 80% predicted Progression of symptoms; dyspnea on exertion
    32. 32. Stage III: Severe COPD • Avoid risk factors • Offer influenza vaccine • Add short-acting bronchodilators when needed • Add regular treatment with 1 or more long- acting bronchodilators • Add rehabilitation • Add inhaled glucocorticoids if repeated exacerbations III: Sever e 30%<= FEV1 <50% predicted ↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life
    33. 33. Stage IV: Very Severe COPD • Avoid risk factors • Offer influenza vaccination • Add short-acting bronchodilators as needed • Add rehabilitation • Add inhaled glucocorticoids if repeated exacerbations • Add long-term oxygen if chronic respiratory failure • Consider surgical treatments IV Very severe FEV1< 30% predicted OR FEV1<50% predicted + chronic respiratory failure •Quality of life is appreciably impaired •Exacerbations may be life- threatening
    34. 34. Non- Pharmacologic Therapy
    35. 35. Rehabilitation • COPD patients at all stages of severity benefit from exercise training programs • Improves both exercise tolerance and symptoms of dyspnea and fatigue • Goals • Reduce symptoms • Improve quality of life • Increase physical and emotional participation in everyday activities • Comprehensive program should include several types of health professionals: • Exercise training • Nutrition counseling • Education • Minimum effective length of time = 2 months • Setting: inpatient OR outpatient OR home • Baseline and outcome assessments of each participant should be made to quantify individual gains and target areas for improvement • Measurement of spirometry before and after a bronchodilator drug • Assessment of exercise capacity • Assessment of inspiratory and expiratory muscle strength and lower limb strength
    36. 36. Oxygen Therapy • Stage IV - Severe COPD who have • PaO2 at or below 55 mm Hg or SaO2 at or below 88% with or without hypercapnia OR • PaO2 between 55-60 mm Hg or SaO2 88% IF pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (Hct > 55%) • Based on awake PaO2 values • GOAL • Increase baseline PaO2 to at least 60 mm Hg at sea level and rest and/or produce SaO2 at least 90% • Need to use at least 15 hours per day in patients with chronic respiratory failure to improve survival • Can have a beneficial impact on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state
    37. 37. Surgical Treatment • Bullectomy • Effective in reducing dyspnea and improving lung function in appropriately selected patient • Lung volume reduction surgery • Parts of the lung are resected to reduce hyperinflation • Does not improve life expectancy • Does improve exercise capacity in patients with predominantly upper lobe emphysema and a low post-rehabilitation exercise capacity • May improve global health status in patients with heterogeneous emphysema • High hospital costs; still experimental/palliative
    38. 38. Surgical Treatment • Lung transplantation • Improves quality of life and functional capacity in appropriately selected patient • Criteria for referral: • FEV1 < 35% predicted • PaO2 < 55-60 mm Hg • PaCO2 > 50 mm Hg • Secondary pulmonary hypertension • All four criteria must be present
    39. 39. COPD Patients and Surgery • Increased risk of post-operative pulmonary complications • Risk of complications increases as the incision approaches the diaphragm • Epidural and spinal anesthesia have a lower risk than general anesthesia • Postpone surgery if the patient has a COPD exacerbation
    40. 40. Manage Exacerbations
    41. 41. General Points • Most common causes of exacerbations are: • Infection of the tracheobronchial tree • Air pollution • In 1/3 of severe exacerbations a cause cannot be identified • Inhaled bronchodilators, theophylline, and systemic (preferably oral) glucocorticosteroids are effective treatments • Patients with clinical signs of airway infection may benefit from antibiotic treatment • Increased volume of sputum • Change in color of sputum • Fever • Non-invasive intermittent positive pressure ventilation (NIPPV) in exacerbations is helpful: • Improves blood gases and pH • Reduces in-hospital mortality • Decreases the need for invasive mechanical ventilation and intubation • Decreases the length of hospital stay
    42. 42. Diagnosis and Assessment of Severity • History • Increased breathlessness • Chest tightness • Increased cough and sputum • Change of color and/or tenacity of sputum • Fever • Non-specific: • Malaise, insomnia, sleepiness, fatigue, depression, or confusion
    43. 43. Assessment of Severity • Lung Function Tests • PEF < 100 L/min. or FEV1 < 1 L = severe exacerbation • Arterial Blood Gas • PaO2 < 60 mmHg and/or SaO2 < 90% with or without PaCO2 < 50 mmHg when breathing room air = respiratory failure • Chest x-ray • Look for complications • Pneumonia • Alternative diagnoses • ECG • Right ventricular hypertrophy • Arrhythmias • Ischemia • Sputum • Culture/sensitivity • Comprehensive Metabolic Profile • Assess for electrolyte disturbances, diabetes • Albumin to assess nutrition
    44. 44. PLACE OF RX • Home? • Hospital admission? • Floor? • ICU? GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
    45. 45. Indications for Hospital Admission • Marked increase in intensity of symptoms such as sudden development of resting dyspnea • Severe background COPD • Onset of new physical signs • Cyanosis, peripheral edema • Failure of exacerbation to respond to initial medical management • Significant co-morbidities • Newly occurring arrhythmias • Diagnostic uncertainty • Older age • Insufficient home support
    46. 46. Indications for ICU Admission • Severe dyspnea that responds inadequately to initial emergency therapy • Confusion, lethargy, coma • Persistent or worsening hypoxemia (PaO2 < 40 mm Hg) and/or • Severe/worsening hypercapnia (PaCO2 > 60 mm Hg) and/or • Severe/worsening respiratory acidosis (pH < 7.25) despite supplemental oxygen and NIPPV
    47. 47. Management of Exacerbations • Risk of dying from an exacerbation is closely related to: • Development of respiratory acidosis • Presence of significant co- morbidities • Need for ventilatory support
    48. 48. Severe Exacerbation, Non Life Threatening • Assess severity of symptoms • Obtain arterial blood gas and chest x-ray • Administer controlled oxygen therapy • Repeat ABG after 30 minutes • Bronchodilators • Glucocorticosteroids • Consider antibiotics • Consider non-invasive mechanical ventilation • Monitor fluid balance and nutrition • Consider subcutaneous heparin therapy • Identify and treat associated conditions (CHF, arrhythmias)
    49. 49. Management of COPD Exacerbations • Controlled oxygen therapy • Administer enough to maintain PaO2 > 60 mmHG or SaO2 > 90% • Monitor patient closely for CO2 retention or acidosis • Bronchodilators (inhaled) • Increase doses or frequency • Combine ß2 agonists and anticholinergics • Use spacers or air-driven nebulizers • Consider adding IV methylxanthine (aminophylline) if needed
    50. 50. Management of COPD Exacerbations • Glucocorticosteroids (oral or IV) • Recommended as an addition to bronchodilator therapy • If baseline FEV1 < 50% predicted • 30-40 mg oral prednisolone x 7-10 days OR nebulized budesonide (Pulmicort™) • Antibiotics • IF breathlessness and cough are increased AND sputum is purulent and increased in volume • Choice of antibiotics should reflect local antibiotic sensitivity for the following microbes: • S. pneumoniae • H. influenzae • M. catarrhalis
    51. 51. Management of COPD Exacerbations • Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing > 25 mL sputum per day OR with lobar atelectasis.
    52. 52. Management of COPD Exacerbations • Ventilatory Support • Decrease mortality and morbidity • Relieve symptoms • Used most commonly in Stage IV, Very Severe COPD • Forms: • Non-invasive using negative or positive pressure devices • invasive/mechanical with oro- or naso-tracheal tube OR tracheostomy
    53. 53. NIPPV • Success rates of 80-85% • Increases pH, reduces PaCO2, reduces severity of breathlessness • Decreases length of hospital stay • Decreases mortality/intubation rate
    54. 54. NIPPV (C-PAP, Bi-PAP) • Selection criteria • Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion • Moderate to severe acidosis (pH < 7.35) and hypercapnia (PaCO2 > 45 mmHg) • Respiratory frequency > 25 breaths/minute
    55. 55. NIPPV • Exclusion criteria • Respiratory arrest • Cardiovascular instability • Hypotension • Arrhythmias • Myocardial infarction • Somnolence, impaired mental status, lack of cooperation • High aspiration risk – viscous/copius secretions • Recent facial or gastroesophageal surgery • Cranio-facial trauma, fixed nasopharyngeal abnormalities • Extreme obesity
    56. 56. Indications for Invasive Mechanical Ventilation • Severe dyspnea with use of accessory muscles and paradoxical abdominal motion • Respiratory rate > 35 breaths/minute • Life-threatening hypoxemia: PaO2 < 40 mm Hg • Severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 mm Hg) • Respiratory arrest • Somnolence, impaired mental status • Cardiovascular complications • Hypotension/shock/heart failure • Other complications • Metabolic abnormalities/sepsis/pneumonia/pulmonary embolism/barotrauma/massive pleural effusion • NIPPV failure
    57. 57. Use of Invasive Ventilation in End-Stage COPD • Hazards: • Ventilator-acquired pneumonia • Increased prevalence of multi-resistant organisms • Barotrauma • Failure to wean to spontaneous ventilation • Mortality among COPD patients with respiratory failure is no greater than mortality among patients ventilated for non- COPD reasons
    58. 58. Discharge Criteria • Inhaled Beta2-agonist use is at most every 4 hours • Patient is able to walk across the room • Patient is able to eat and sleep without frequent awakening • Patient has been clinically stable for 12-24 hours • ABGs are stable for 12-24 hours • Patient/home caregiver fully understands correct use of medications • Follow-up and home care arrangements have been completed • Patient, family, and physician are confident that patient can manage successfully
    59. 59. Follow-Up Assessment after Hospital Discharge • 4-6 weeks after discharge • Assess: • Ability to cope in usual environment • Inhaler technique • Understanding of recommended treatment regimen • Measure FEV1 • Determine need for long-term oxygen therapy and/or home nebulizer (for patients with very severe COPD, Stage IV)
    60. 60. THANK YOU
    61. 61. REFERENCES • National Heart, Lung, and Blood Institute Data Fact Sheet for Chronic Obstructive Pulmonary Disease • GOLD (Global Initiative for Chronic Obstructive Lung Disease) Executive Summary, April 2001 • GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. Updated July 2005. – Accessed August 21, 2006. • Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.