• Airflow obstruction is usually progressive,
not fully reversible and does not change
markedly over several months. The d...
Management of COPD
BTS Guidelines 2004
• Priorities for implementation
– Diagnose COPD
– Stop smoking
– Effective inhaled ...
• 900,000 (2,000,000) in UK
• >30,000 deaths in UK 1999
• 5% all deaths
• Health District (250,000)
– 700 admissions (10%)...
Chronic Bronchitis
• Irritants in smoke/Pollution
– Mucous gland hypertrophy
– Increased mucus gland secretion
– Increased...
Emphysema
Increased polymorphs → ↑ Elastase
→ loss of alveoli / pulmonary vasculature
→ ↓ area for gas exchange
→ loss of ...
Diagnosis
• History
– Progressive symptoms - Cough/Wheeze/SOB
– Ex tolerance, childhood illness/atopy/ FH
– Occupation
– S...
• CXR (not necessary)
• Spirometry
– FEV1<80% predicted
– FEV%<70% predicted
– Little variability in expiratory flow
Inves...
Monitor Progression
• 15% smokers significant obstruction
• FEV1 (20-30 ml/yr non smokers)
• FEV1 (45-70 ml/yr smokers)
• ...
Peak Flow/Spirometry
• FEV1 reproducible (160 ml)
• FVC reproducible (330 ml)
• FEV% diagnoses obstruction
• Low PEFR obst...
Severity of COPD
• Mild - FEV1 50-80 (60-79)%
– smokers cough
• Moderate- FEV1 30-49 (40-59)%
– Cough, SOBOE, wheeze (sign...
Severity of COPD
MRC Dyspnoea Scale
• 1. SOB strenuous exercise
• 2. SOB hurrying, slight hill
• 3. Unable to keep up with...
Differentiation from Asthma
–Smoker / non smoker
–symptoms <35 yr
–chronic productive cough
–SOB
–Night time waking /wheez...
Reversibility Testing
• Not necessary may be misleading (single test)
–but may help with diagnosis if large response
to br...
Reversibility Testing
• Salbutamol/Ipratropium
–stable free from infection
–post bronchodilator FEV1 best predictor of
pro...
Reversibility Testing
• Steroids
– 30mg day, 2 weeks
– beclomethasone 500mcg bd, 6 weeks
– positive response in 10-20%
– b...
Reversibility Testing
• Question.
• Are we measuring the right thing ?
• Answer
• Probably not !
Reversibility Testing
• Absolute Change
– (FEV, 160 ml, FVC 330 ml) ?
• % change ?
– FEV1 - 1.1 Pre, 1.5 post
– (1.5/1.1) ...
Other Investigations
• BMI, CRP ?
• FBC -PCV >50%, alpha 1 antitrypsin
• Sputum (Pneumococcus, Haemophilus, Moraxella)
• O...
Management of stable COPD
• Smoking
• SOB/SOBOE
• Frequent Exacerbations
• Respiratory failure
• Cor pulmonale
• Abnormal ...
Smoking Cessation
• Stop smoking (10-30% in trials)
– sudden better than gradual
– all smokers in house
– medical advice
–...
Smoking Cessation
• Key Fact:
• Every Cigarette reduces life expectancy by
11 minutes !
Inhaled Bronchodilators
• Improve FEV1/symptoms
• Combination better
• Long acting –greater clinical benefit, health
statu...
Inhaled Bronchodilators
• Tiotropium reduces exacerbations by 25%
compared to ipratropium
• UPLIFT Study
– 3 yr tiotropium...
Phosphodiesterase Inhibitors
• Mild Bronchodilator effect
– upper end of therapeutic range
– effect may take several weeks...
Phosphodiesterase Inhibitors
• Anti inflammatory action - low dose
– suppresses inflammatory genes (HDAC)
– potentiate ant...
Inhaled Steroids
• Improve symptoms ?
• Reduce inflammation ?
• Reduce decline in lung function ?
• Reduce exacerbations ?...
• Smokers with mild COPD
– 912 current smokers
– Randomised, double blind placebo controlled,
parallel group study, 3yr
– ...
Copenhagen Lung Study
• 76% current smokers, n =290
– mild COPD
– Randomised, double blind, placebo controlled,
parallel g...
ISOLDE
– severe COPD (48% smoking at entry)
– 3yr randomised, double blind, placebo
controlled, parallel group study, n=75...
META - ANALYSIS
• 3 studies (1 abstract)
• 2 yr
• Moderate-severe COPD n=95/88
• 800 -1600 mcg Beclomethasone
• Steroid gr...
TORCH
• 3yr, n = 6,000. smokers or ex, FEV1<60%
– Fluticasone/salmeterol, Fluticasone,
– Salmeterol, placebo
• All cause m...
Steroids/Pneumonia
• TORCH (NEJM 2007 356: 775-789)
– Inhaled steroids increased pneumonia ?
• AJRCCM 2007 176: 162-166
– ...
Steroids/Beta Agonists
• Steroids
– increase expression of beta2 receptors.
– decrease loss due to long term exposure
• Be...
Oral steroids
• Maintenance therapy not recommended.
• If necessary keep dose low.
• Monitor for osteoporosis.
• Prophylax...
Home Nebuliser Therapy
• SOB despite maximal Rx
• MDI v Neb trials in stable COPD
inconsistent
• Assessment
– home trial (...
Other measures
• Exercise
– Safe and desirable
• Nutrition
• Vaccination -Flu /Pneumococcus
• Treat depression (50%)
• Tra...
Prevent Exacerbations
• Vaccination.
• Self management advice.
• Optimise bronchodilator Rx.
• Add inhaled steroids if FEV...
Pulmonary Rehabilitation
• Proven value (randomised trials)
• MRC grade 3 and above
• Ex tolerance, Psychosocial
• Reduce ...
LTOT
• MRC study(1981) -15 hr/day
– 5 yr survival 25% / 41%
– Less polycythaemia
– Prevention of progression of PHT
– Impr...
LTOT
• ABG x 2 (3 weeks apart) - clinically stable
• PaO2 < 7.3 kPa on air
• FEV1 < 1.5
• Non-smokers
• 6 monthly follow-u...
Ambulatory Oxygen
• Exercise desaturation
• Exercise Test
– Symptoms
– Walk distance
– saturation
• Follow up
Nocturnal Hypoventilation
in COPD
• Reduced ventilatory drive during sleep
• Sleep deprivation (sleep apnoea) reduces
chem...
NIV
• No recommendations at present
• May prolong survival in patients
deteriorating on LTOT with associated
hypercapnoea
...
Cor Pulmonale
• Lung disease → Hypoxia → Pulmonary
arterial vasoconstriction → Pulmonary
Hypertension→RVF→ Oedema
• Lung d...
Surgery
• Bullectomy
• Lung volume reduction
– improves symptoms/ex tolerance/QOL
– VATS/Sternotomy
– low morbidity (<70yr...
ACUTE EXACERBATIONS ?
• Referral Criteria
– Cope at home?
– Absence of cyanosis?
– Normal level of conciousness?
– Mild br...
ACUTE EXACERBATIONS
• Hospital Investigations
– CXR
– ABG
– ECG
– FBC/U+E
– Sputum culture if purulent
– Blood cultures if...
ACUTE EXACERBATIONS
• Bronchodilators
– Neb or HHI +Spacer
– Pred 30mg 14/7
– Oxygen (controlled)
– Antibiotics if sputum ...
STEROIDS/EXACERBATIONS
– 80 8/52 High dose oral Prednisolone
– 80 2/52 High dose oral prednisolone
– 111 Placebo
• Steroid...
ACUTE EXACERBATIONS
• NIV
– better ABG
– reduced LOS
– reduced complications
– reduced mortality
– reduced intubation
• Ox...
ACUTE EXACERBATIONS
• Hospital at Home
– various models
– 1/3 patients suitable
– nurses, physios, OT’s
– average hospital...
Follow Up
– Mild Yearly, Severe 6 monthly
• smoking status
• symptom control(SOB ex tolerance
exacerbations)
• inhaler tec...
• Onset cor pulmonale
• LTOT
• Neb
• Oral steroids
• Bullous disease
• Rapid decline in FEV1
• Diagnostic advice
Referral
• Stop smoking
• LABA better than SABA, combination Rx
• Inhaler technique
• ICS if FEV1 <50% + exacerbations
• LTOT if O2...
• Management plan
– Antibiotics
• pneumococci, moraxella, H influenzae
– PO steroids for exacerbations
• 24% O2 or 2 l/min...
• PD4 inhibitors
• Leukotriene B4 inhibitors
• Adhesion molecule blockers
• Antioxidants
– resveratrol (red wine), N-acety...
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
Management of COPD BTS Guidelines
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Management of COPD BTS Guidelines

  1. 1. • Airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking. Definition
  2. 2. Management of COPD BTS Guidelines 2004 • Priorities for implementation – Diagnose COPD – Stop smoking – Effective inhaled Rx – Pulmonary rehabilitation – Manage exacerbations (NIV) – Multidisciplinary working
  3. 3. • 900,000 (2,000,000) in UK • >30,000 deaths in UK 1999 • 5% all deaths • Health District (250,000) – 700 admissions (10%) – 9,600 bed days – 14,000 GP consultations Disease Burden
  4. 4. Chronic Bronchitis • Irritants in smoke/Pollution – Mucous gland hypertrophy – Increased mucus gland secretion – Increased polymorphs in airways – bronchoconstriction – Airway narrowing (small airways) – need a lot of damage before spirometry affected
  5. 5. Emphysema Increased polymorphs → ↑ Elastase → loss of alveoli / pulmonary vasculature → ↓ area for gas exchange → loss of elastic supporting tissue → early expiratory airway collapse → hyperinflation
  6. 6. Diagnosis • History – Progressive symptoms - Cough/Wheeze/SOB – Ex tolerance, childhood illness/atopy/ FH – Occupation – Smoking - 20 pack years – Examination - not diagnostic – Objective evidence of airway obstruction that does not return to normal with Rx
  7. 7. • CXR (not necessary) • Spirometry – FEV1<80% predicted – FEV%<70% predicted – Little variability in expiratory flow Investigations
  8. 8. Monitor Progression • 15% smokers significant obstruction • FEV1 (20-30 ml/yr non smokers) • FEV1 (45-70 ml/yr smokers) • Prognosis related to FEV1 – Mortality: Renfrew/Paisley Study, BMJ 1996 • Drug treatment does may affect natural history (LTOT improves survival)
  9. 9. Peak Flow/Spirometry • FEV1 reproducible (160 ml) • FVC reproducible (330 ml) • FEV% diagnoses obstruction • Low PEFR obstruction/restriction • PEFR not related to FEV1 • PEFR underestimates obstruction in COPD – COPD small airways
  10. 10. Severity of COPD • Mild - FEV1 50-80 (60-79)% – smokers cough • Moderate- FEV1 30-49 (40-59)% – Cough, SOBOE, wheeze (signs) • Severe - FEV1 <30 (<40)% – Cough,wheeze,SOB, signs
  11. 11. Severity of COPD MRC Dyspnoea Scale • 1. SOB strenuous exercise • 2. SOB hurrying, slight hill • 3. Unable to keep up with peers* • 4. Stops for breath after 100m* • 5.Too breathless to leave house – SOB washing dressing
  12. 12. Differentiation from Asthma –Smoker / non smoker –symptoms <35 yr –chronic productive cough –SOB –Night time waking /wheeze –Diurnal variability symptoms
  13. 13. Reversibility Testing • Not necessary may be misleading (single test) –but may help with diagnosis if large response to bronchodilators or prednisolone (30mg 2/52)
  14. 14. Reversibility Testing • Salbutamol/Ipratropium –stable free from infection –post bronchodilator FEV1 best predictor of prognosis –no bronchodilators for 6 hr –2.5-5mg salbutamol Neb (20min) –500mcg ipratropium Neb (45min)
  15. 15. Reversibility Testing • Steroids – 30mg day, 2 weeks – beclomethasone 500mcg bd, 6 weeks – positive response in 10-20% – better prognosis if positive response – Steroid responders also respond to bronchodilators
  16. 16. Reversibility Testing • Question. • Are we measuring the right thing ? • Answer • Probably not !
  17. 17. Reversibility Testing • Absolute Change – (FEV, 160 ml, FVC 330 ml) ? • % change ? – FEV1 - 1.1 Pre, 1.5 post – (1.5/1.1) x 100 = 36 % change – (1.1/1.5) X 100 = 27 % change – {(1.5-1.1)/(1.5+1.1)/2} x100 = 31% change
  18. 18. Other Investigations • BMI, CRP ? • FBC -PCV >50%, alpha 1 antitrypsin • Sputum (Pneumococcus, Haemophilus, Moraxella) • Oximetry/ABG (or Sat >92%) • CT - extent/distribution of emphysema • TLC/RV comparison(body box/He dilution) • ECG/ECHO - IHD/ Cor pulmonale
  19. 19. Management of stable COPD • Smoking • SOB/SOBOE • Frequent Exacerbations • Respiratory failure • Cor pulmonale • Abnormal BMI • Chronic cough • Anxiety/Depression • Palliative Care
  20. 20. Smoking Cessation • Stop smoking (10-30% in trials) – sudden better than gradual – all smokers in house – medical advice – nicotine (doubles quit rate) – monitoring (co,carboxyHb,cotinine) – antidepressant (Bupropion USA) – Varenicline
  21. 21. Smoking Cessation • Key Fact: • Every Cigarette reduces life expectancy by 11 minutes !
  22. 22. Inhaled Bronchodilators • Improve FEV1/symptoms • Combination better • Long acting –greater clinical benefit, health status and lower exacerbation rate • Steroid /LABA combination –greater improvement than either alone
  23. 23. Inhaled Bronchodilators • Tiotropium reduces exacerbations by 25% compared to ipratropium • UPLIFT Study – 3 yr tiotropium vs placebo. Decline in lung function. • Triple therapy ?
  24. 24. Phosphodiesterase Inhibitors • Mild Bronchodilator effect – upper end of therapeutic range – effect may take several weeks • Improve respiratory muscle strength • Improve mucus clearance • Reduce exacerbations ?
  25. 25. Phosphodiesterase Inhibitors • Anti inflammatory action - low dose – suppresses inflammatory genes (HDAC) – potentiate anti-inflammatory effects of Pred – caution with macrolides and quinolones – Roflumilast, Cilomilast (PDE4 inhibitors)
  26. 26. Inhaled Steroids • Improve symptoms ? • Reduce inflammation ? • Reduce decline in lung function ? • Reduce exacerbations ? • Increase pneumonia ? • Interaction with beta agonists ?
  27. 27. • Smokers with mild COPD – 912 current smokers – Randomised, double blind placebo controlled, parallel group study, 3yr – Budesonide 400 ug bd – No effect on progressive decline in FEV1 – Pauwels et al, NEJM, 1999. European Study
  28. 28. Copenhagen Lung Study • 76% current smokers, n =290 – mild COPD – Randomised, double blind, placebo controlled, parallel group study, 3yr – Budesonide 400 ug bd • No effect on progressive decline in FEV1 – Vestbo et al, Lancet 1999. 353:1819-23
  29. 29. ISOLDE – severe COPD (48% smoking at entry) – 3yr randomised, double blind, placebo controlled, parallel group study, n=750 – Inhaled Fluticasone – No effect on progressive decline in FEV1 – Fewer exacerbations – Fewer symptoms – Sub group analysis – BMJ 2000 320
  30. 30. META - ANALYSIS • 3 studies (1 abstract) • 2 yr • Moderate-severe COPD n=95/88 • 800 -1600 mcg Beclomethasone • Steroid group FEV1 improved by 80 ml/yr – Van Grunsven et al, Thorax 1999.
  31. 31. TORCH • 3yr, n = 6,000. smokers or ex, FEV1<60% – Fluticasone/salmeterol, Fluticasone, – Salmeterol, placebo • All cause mortality no difference • Exacerbations reduced (25%) with steroid • Improved health status with steroid
  32. 32. Steroids/Pneumonia • TORCH (NEJM 2007 356: 775-789) – Inhaled steroids increased pneumonia ? • AJRCCM 2007 176: 162-166 – Inhaled steroids increased pneumonia admissions ?
  33. 33. Steroids/Beta Agonists • Steroids – increase expression of beta2 receptors. – decrease loss due to long term exposure • Beta 2 Agonists – potentiate molecular mechanism of steroid action.
  34. 34. Oral steroids • Maintenance therapy not recommended. • If necessary keep dose low. • Monitor for osteoporosis. • Prophylaxis for osteoporosis if >65.
  35. 35. Home Nebuliser Therapy • SOB despite maximal Rx • MDI v Neb trials in stable COPD inconsistent • Assessment – home trial (St George’s AQ20), optimise Rx – technical support/FU – Neb Rx 3-4x more expensive than HHI
  36. 36. Other measures • Exercise – Safe and desirable • Nutrition • Vaccination -Flu /Pneumococcus • Treat depression (50%) • Travel (900-2,400 m, PaO2 15 -18 kPa) – bullae, pneumothorax, PaO2<6.7 kPa air
  37. 37. Prevent Exacerbations • Vaccination. • Self management advice. • Optimise bronchodilator Rx. • Add inhaled steroids if FEV1 <50% and 2 or more exacerbations per year. • Rotating antibiotics.
  38. 38. Pulmonary Rehabilitation • Proven value (randomised trials) • MRC grade 3 and above • Ex tolerance, Psychosocial • Reduce hospital admissions/LOS ? • A cynics definition of Exercise -”An enthusiasm lasting about 3 weeks, which is readily soluble in alcohol” (Newcastle study)
  39. 39. LTOT • MRC study(1981) -15 hr/day – 5 yr survival 25% / 41% – Less polycythaemia – Prevention of progression of PHT – Improved sleep quality – Improved psychologically (QOL) – Reduction in cardiac arrhythmias
  40. 40. LTOT • ABG x 2 (3 weeks apart) - clinically stable • PaO2 < 7.3 kPa on air • FEV1 < 1.5 • Non-smokers • 6 monthly follow-up • Prescriber – England: GP – Scotland: Consultant Chest Physician
  41. 41. Ambulatory Oxygen • Exercise desaturation • Exercise Test – Symptoms – Walk distance – saturation • Follow up
  42. 42. Nocturnal Hypoventilation in COPD • Reduced ventilatory drive during sleep • Sleep deprivation (sleep apnoea) reduces chemoreceptor sensitivity • Reduced muscle performance – muscle mechanics – acidosis
  43. 43. NIV • No recommendations at present • May prolong survival in patients deteriorating on LTOT with associated hypercapnoea • ? Mechanism of cor pulmonale
  44. 44. Cor Pulmonale • Lung disease → Hypoxia → Pulmonary arterial vasoconstriction → Pulmonary Hypertension→RVF→ Oedema • Lung disease → Hypoxia / Hypercapnoea → ↓ Renal Perfusion → Fluid retention
  45. 45. Surgery • Bullectomy • Lung volume reduction – improves symptoms/ex tolerance/QOL – VATS/Sternotomy – low morbidity (<70yr,FEV1>0.5l, PaO2>7.3) – ? Survival advantage (NETT USA) - no ! • Transplant (young, alpha 1 antitrypsin)
  46. 46. ACUTE EXACERBATIONS ? • Referral Criteria – Cope at home? – Absence of cyanosis? – Normal level of conciousness? – Mild breathlessness? – Good general condition? – Not receiving LTOT? – Good level of activity? – Good social circumstances?
  47. 47. ACUTE EXACERBATIONS • Hospital Investigations – CXR – ABG – ECG – FBC/U+E – Sputum culture if purulent – Blood cultures if pyrexial
  48. 48. ACUTE EXACERBATIONS • Bronchodilators – Neb or HHI +Spacer – Pred 30mg 14/7 – Oxygen (controlled) – Antibiotics if sputum purulent • penicillin, macrolide, • Theophylline – NIV (Doxapram) – Physiotherapy
  49. 49. STEROIDS/EXACERBATIONS – 80 8/52 High dose oral Prednisolone – 80 2/52 High dose oral prednisolone – 111 Placebo • Steroids: – less treatment failure (intubation etc) – faster improvement in FEV1 – Shorter Hospital Stay – Niewoehner et al, NEJM 1999
  50. 50. ACUTE EXACERBATIONS • NIV – better ABG – reduced LOS – reduced complications – reduced mortality – reduced intubation • Oxygen – pulse oximeters (beware pCO2 !)
  51. 51. ACUTE EXACERBATIONS • Hospital at Home – various models – 1/3 patients suitable – nurses, physios, OT’s – average hospital LOS 10 days – saves bed days, not money ! – Patients like it !
  52. 52. Follow Up – Mild Yearly, Severe 6 monthly • smoking status • symptom control(SOB ex tolerance exacerbations) • inhaler technique, review Rx • Nutrition • ? Pulmonary Rehab ? LTOT • Spiro, BMI, MRC dyspnoea (Sa O2 severe)
  53. 53. • Onset cor pulmonale • LTOT • Neb • Oral steroids • Bullous disease • Rapid decline in FEV1 • Diagnostic advice Referral
  54. 54. • Stop smoking • LABA better than SABA, combination Rx • Inhaler technique • ICS if FEV1 <50% + exacerbations • LTOT if O2 sats < 90% +/- cor pulmonale • Sudden change in symptoms - CXR • Unsure - refer Summary
  55. 55. • Management plan – Antibiotics • pneumococci, moraxella, H influenzae – PO steroids for exacerbations • 24% O2 or 2 l/min via nasal cannulae safe • Useful tool - AQ 20 ? Summary
  56. 56. • PD4 inhibitors • Leukotriene B4 inhibitors • Adhesion molecule blockers • Antioxidants – resveratrol (red wine), N-acetylcysteine • Biomarkers The Future ?

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