My presentation on GOLD

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My presentation on GOLD

  1. 1. Global Strategy for Diagnosis, Management and Prevention ofChronic Obstructive Pulmonary Disease Revised 2011 Dr. Mashfiqul Hasan Resident, Phase A Respiratory wing, Dept of Medicine BSMMU 1
  2. 2. G lobal Initiative for ChronicO bstructiveL ungD isease © Global Initiative for Chronic Obstructive Lung Disease 2
  3. 3. WORLD COPD DAY November 14, 2012Raising COPD Awareness Worldwide
  4. 4. “It’s Not Too Late.” 4
  5. 5. Description of Levels of EvidenceEvidence Sources of EvidenceCategory A Randomized controlled trials (RCTs). Rich body of data B Randomized controlled trials (RCTs). Limited body of data C Nonrandomized trials Observational studies. D Panel consensus judgment 5
  6. 6. Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsREVISED 2011  Manage Comorbidities 6
  7. 7. Definition of COPD COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities 7
  8. 8. 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 8
  9. 9. Emphysema & chronic bronchitis Not included in the definition Emphysema  Pathological term  Only one of several structural abnormalities Chronic bronchitis  Independent disease entity  May precede or follow development of airflow limitation 9
  10. 10. Burden of COPD Leading cause of morbidity and mortality worldwide 6th leading cause of death in 1990 Will be the 3rd leading cause of death by the year 2020
  11. 11. Risk Factors for COPD• Genes • Lung growth and• Exposure to particles development Tobacco smoke • Gender Occupational dusts, organic • Age and inorganic • Respiratory infections Indoor air pollution from heating and cooking with • Socioeconomic status biomass in poorly ventilated • Asthma/Bronchial dwellings hyperreactivity Outdoor air pollution • Chronic Bronchitis
  12. 12. Risk Factors for COPD Genes Infections Socio-economic statusAging Populations
  13. 13. Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsREVISED 2011  Manage Comorbidities
  14. 14. Diagnosis of COPD EXPOSURE TO RISK SYMPTOMS FACTORSshortness of breath tobacco chronic cough occupation sputum indoor/outdoor pollution SPIROMETRY : Required to establish diagnosis
  15. 15. 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
  16. 16. 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
  17. 17. Assessment of COPD1. Assess symptoms2. Assess degree of airflow limitation using spirometry3. Assess risk of exacerbations4. Assess comorbidities
  18. 18. Assessment of COPD1. Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Test (CAT) COPD Assessment Assess comorbidities or mMRC Breathlessness scale
  19. 19. Modified MRC (mMRC)Questionnaire
  20. 20. 21
  21. 21. Assessment of COPD1. Assess symptoms2. Assess degree of airflow limitation Spirometry for grading severity
  22. 22. 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
  23. 23. Assessment of COPD1. Assess symptoms2. Assess degree of airflow limitation using spirometry3. Assess risk of exacerbations Assess comorbidities 1. History of exacerbations and 2. Spirometry
  24. 24. Combined Assessment of COPD (GOLD Classification of Airflow Limitation) 4 (C) (D) >2 (Exacerbation history) 3 RiskRisk 2 1 (A) (B) 1 0 mMRC 0-1 mMRC>2 CAT < 10 CAT >10 Symptoms (mMRC or CAT score))
  25. 25. (GOLD Classification of Airflow Limitation) Combined Assessment of COPD Patient is now in one of 4 Four categories: (C) (D) (Exacerbation history) >2 3 A: Les symptoms, low riskRisk Risk B: More symtoms, 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))
  26. 26. Assess COPD Comorbidities • Cardiovascular diseases • Skeletal muscle dysfunction • Osteoporosis • Anxiety and Depression • Metabolic syndrome • Lung cancer May influence mortality and hospitalizationsShould be looked for routinely and treated appropriately
  27. 27. Additional Investigations•Chest X-ray•Lung Volumes and Diffusing Capacity•Oximetry and Arterial Blood Gases•Alpha-1 Antitrypsin Deficiency Screening•Exercise Testing
  28. 28. Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsREVISED 2011  Manage Comorbidities
  29. 29. Smoking cessation• Greatest capacity to influence the natural history of COPD 30
  30. 30. Treating tobacco use & dependence• Warrants repeated treatment• Effective treatment exist & should be offered• Smoking cessation counseling• Pharmacotherapies : varenicline, bupropion, nicotine gum, inhaler, nasal spray, patch• Cost effective 31
  31. 31. Brief Strategies to Help the Patient Willing to Quit Smoking1. ASK Systematically identify all tobacco users at every visit2. ADVISE Strongly urge all tobacco users to quit3. ASSESS Determine willingness to make a quit attempt4. ASSIST Aid the patient in quitting5. ARRANGE Schedule follow-up contact
  32. 32. Pharmacological therapy for stable COPDBeta2-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
  33. 33. Bronchodilators in COPD• Central to the symptom management• Inhaled : preferred• Choice depends on availability & individual patient response• As needed or regular• Long acting : convenient, more effective• Combination 34
  34. 34. ICS in COPD• Controversial• Limited to specific indications• Regular treatment with ICS improves symptoms, lung function and quality of life in patients with FEV1 <60% predicted (Evidence A)• Does not modify the long term decline of FEV1 nor mortality (Evidence A)• Adverse effects 35
  35. 35. Other pharmacological treatments• Phosphodiesterase 4 inhibitors: Roflumilast• Vaccines• Antibiotics• Mucolytic & antioxidant agents• Immunoregulators• Antitussive• Vasodilators• Narcotics• Nedocromil & leukotriene modifier 36
  36. 36. Non-pharmacologic therapies : pulmonary rehabilitation Improvements in exercise tolerance and symptoms of dyspnea and fatigue Effective pulmonary rehabilitation program duration: 6 weeks If exercise training is maintained at home the patients health status remains above pre-rehabilitation levels
  37. 37. Other treatments• O2 therapy• Ventilatory support• Surgical treatments – Lung volume reduction surgery – Bronchoscopic lung volume reduction – Lung transplantation – Bullectomy 38
  38. 38. Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Major Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsREVISED 2011  Manage Comorbidities
  39. 39. Goals of Therapy Relieve symptoms Improve exercise tolerance Reduce symptoms Improve health status Prevent disease progression Prevent and treat exacerbations Reduce risk Reduce mortality
  40. 40. Identify & reduce exposure to risk factors• Tobacco smoke – Key intervention (Evidence A)• Occupational exposures – Avoid continued exposures (Evidence D)• Indoor & outdoor air pollution – Biomass fuel – Efficient ventilation, non polluting cooking device (Evidence B) 41
  41. 41. Manage Stable COPD: Non-pharmacologicPatient Essential Recommended Depending on local 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
  42. 42. Manage Stable COPD: PharmacologicPatient First choice Second choice Alternative Choices 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 + PDE4-inh. C LABA or LAMA and LABA SABA and/or SAMA LAMA Theophylline ICS + ICS andLAMA or ICS + LABA and LAMA or Carbocysteine LABA or D ICS+LABA and PDE4-inh.or SABA and/or SAMA LAMA LAMA and LABA or Theophylline LAMA and PDE4-inh.
  43. 43. FIRST CHOICE C DGOLD 4 Exacerbations per year ICS + LABA ICS + LABA >2 or 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
  44. 44. SECOND CHOICE C DGOLD 4 Exacerbations per year LAMA and LABA ICS and LAMA or ICS + LABA and LAMA or >2 ICS + LABA and PDE4-inh orGOLD 3 LAMA and LABA or LAMA and PDE4-inh. A BGOLD 2 LAMA or LAMA and LABA 1 LABA orGOLD 1 SABA and SAMA 0 mMRC 0-1 mMRC> 2 CAT < 10 CAT > 10
  45. 45. ALTERNATIVE CHOICES C DGOLD 4 PDE4-inh. Carbocysteine Exacerbations per year SABA and/or SAMA SABA and/or SAMA >2 Theophylline TheophyllineGOLD 3GOLD 2 A B SABA and/or SAMA 1 Theophylline TheophyllineGOLD 1 0 mMRC 0-1 mMRC> 2 CAT < 10 CAT >10
  46. 46. Monitoring & follow up• Disease progression & development of complications• Monitor pharmacotherapy• Exacerbation history• Comorbidities 47
  47. 47. Global Strategy for Diagnosis, Management andPrevention of COPD, 2011: Chapters  Definition and Overview  Diagnosis and Assessment  Therapeutic Options  Manage Stable COPD  Manage ExacerbationsREVISED 2011  Manage Comorbidities
  48. 48. Acute Exacerbation• 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 medication
  49. 49. 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
  50. 50. Precipitating factors• Respiratory tract infection (Bacterial or viral)• Exposure to pollutants• Interruption of maintenance therapy• Overlaping
  51. 51. Investigation for acute exacerbation• Pulse oxymetry, ABG• Chest radiograph• ECG• CBC• Sputum for CS• Biochemical tests• Spirometry : Not recommended
  52. 52. Potential indications for hospital assessment and admission• Marked increase in the intensity of symptoms• Onset of new physical signs• Failure to respond to initial medical management• Severe underlying COPD• Frequent exacerbations• Serious comorbidities• Older age• Insufficeint home support
  53. 53. Treatment of exacerbation• Pharmacologic treatment• Respiratory support
  54. 54. Pharmacologic treatment• Short acting bronchodilators• Systemic corticosteroid• Antibiotics
  55. 55. Pharmacologic treatment• Short acting bronchodilators • Short acting inhaled β2 agonist with or without short acting anticholinergic (Evidence C) • No significant difference betweent MDI with or without spacer and nebuliser • IV methylxanthines only to be used in selected cases (Evidence B)
  56. 56. Pharmacologic treatment: Coticosteroids• Shorten recovery time, improve FEV1 & PaO2, reduce the risk of early relapse, treatment failure & length of hospital stay (Evidence A)• 30-40 mg prednisolone for 10-14 days (Evidence D)• Nebulised budesonide may be an alternative
  57. 57. Pharmacologic treatment: Antibiotics• Indications • Increased dyspoea, sputum purulence, sputum volume (Evidence B) • Increased sputum purulence with one other cardinal symptoms (Evidence C) • Mechanical ventilation (Evidence B)• Length of antibiotic therapy : 5-10 days (Evidence D)• The choice of antibiotic• Route of administration
  58. 58. Pharmacologic treatment: others• Appropriate fluid balance• Diuretics• Anticoagulants• Treatment of comorbidities• Nutrition
  59. 59. Respiratory support• Oxygen therapy – Key component of hospital treatment – Target saturation of 88-92% – ABG should be checked 30-60 minutes later – Venturi masks for accurate & controlled delivery
  60. 60. Ventilatory support• Non-invasive• Invasive
  61. 61. Indications for NIVAt least one of following:• Respiratory acidosis• Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of breathing or both (Use of respiratory accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces)
  62. 62. Indications for ICU admission– Severe dyspnoea that responds inadequately to initial emergency therapy– Changes in mental status– Persistent or worsening hypoxemia (PaO2 < 5.3 kPa, 40 mm Hg) and/or severe/worsening respiratory acidosis (PH <7.25) despite supplemental O2 & noninvasive ventilation– Need for invasive mechanical ventilation– Need for vasopressors – hemodynamic instability
  63. 63. Indications for invasive mechanical ventilation– Unable to tolerate NIV or NIV failure– Respiratory or cardiac arrest– Respiratory pauses with loss of consciousness or gasping– Diminished consciousness, psychomotor agitation inadequately controlled by sedation– Massive aspiration– Persistent inability to remove respiratory secretions– Heart rate <50 /min with loss of alertness– Severe hemodynamic instability without response to fluids and vasoactive drugs– Severe ventricuar arrhythmia– Life threatening hypoxemia in patients unable to tolerate NIV
  64. 64. Discharge criteria• Able to use long acting bronchodilators with or without ICS• Inhaled SABA therapy is required no more frequently than every 4 hrs• Able to walk across room• Able to eat & sleep• Stable for 12-24 hrs• Fully understand correct use of medication• F/U & home care arrangement• Patient, family & physician are confident
  65. 65. Checklist at time of discharge• Maintenance pharmacotherapy regimen• Reassessment of inhaler technique• Education regarding role of maintenance regimen• Completion of steroid therapy & antibiotics• Need for LTOT• Follow up visit in 4-6 weeks• Management plan for comorbidities
  66. 66. Home management of exacerbation• Nurse administered home care• Effective & practical alternative to hospitalization in selected patient without acidotic respiratory failure (Evidence A)
  67. 67. 68

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