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COPD Treatment.ppt
This document discusses chronic obstructive pulmonary disease (COPD), including its diagnosis, treatment according to severity, and management. The key points are: 1. COPD is often missed or misdiagnosed. Early diagnosis, controlling symptoms, improving exercise tolerance, and reducing exacerbations are aims of treatment. 2. Treatment follows GOLD guidelines and depends on severity, ranging from risk reduction to long-term oxygen therapy. Bronchodilators are the cornerstone of drug therapy. 3. Other treatment considerations discussed include inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy, vaccinations, and referral to specialists for complications or uncertain diagnosis. Proper diagnosis and management can improve patients' quality
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COPD Treatment.ppt
- 1. COPD: A CommonDisease - missed and misdiagnosed Surinder K. Jindal (Ex-Professor & Head, Pulm Med, PGIMER, Chandigarh) Medical Director, Jindal Clinics, Sec 20 D, Chandigarh
- 2. AIMS OF TREATMENTIN COPD Early diagnosis Best control of symptoms Improving exercise tolerance Reducing exacerbations and hospitalisations
- 3. COPD treatment accordingto GOLD • Avoid risk factors Avoid risk factors + Bronchodilator prn Avoid risk factors Bronchodilator prn + Regular bronchodilator Consider ICS Rehabilitation Avoid risk factors Bronchodilator prn Regular bronchodilator Consider ICS Rehabilitation + Oxygen Surgery At Risk Mild Moderate Severe
- 4. PFT Normal FEV1/FVC<70% FEV1 >80% predicted FEV1/FVC <70% FEV1 30-80% predicted FEV1/FVC <70% FEV1 <30% predicted Treatment Tobacco cessation Short acting bronchodilators, when needed •Regular treatment with one or more bronchodilators • Pulmonary rehabilitation As in II, plus •Inhaled corticosteroids •Treatment of complications 0 - At risk I - Mild II - Moderate III - Severe Treatment of COPD According to Severity WHO-India 2003
- 5. Fletcher C, PetoR: BMJ 1977 Annual Decline in Lung Function 100 75 50 25 0 25 50 75 Age Years) Stopped smoking aged 60 yr Stopped smoking aged 50 yr Susceptible smoker (10-20%) Death Disability Non smoker Non-susceptible smoker
- 6. Bronchodilators are the cornerstoneof current drug therapy for COPD GOLD Guidelines 2003
- 7. Brief Strategies ToHelp The Patient Willing To Quit Smoking • ASK Systematically identify all tobacco users at every visit. • ADVISE Strongly urge all tobacco users to quit. • ASSESS Determine willingness to make a quit attempt. • ASSIST Aid the patient in quitting. • ARRANGE Schedule follow-up contact.
- 8. Bronchodilators for COPD •Anticholinergics (Ipratropium/ Tiotropium) • LABA (Salmeterol / Formoterol) • SABA (Salbutamol) • Combinations of above • Theophylline
- 9. Theophylline • Anticholinergics andLABAs preferred • Systemic administration; effect on small airways • Anti-inflammatory effects 1 • Improves diaphragmatic efficiency 2 1 Barnes PJ ERJ 1994;7:579 - 591 2 Aubier M NEJM 1981;305:249 - 252
- 10. LABAs (Salmeterol / Formoterol) •Have replaced the short-acting drugs like salbutamol in maintenance therapy • Effective and long-acting bronchodilators • Additive effect with anti-cholinergics • Can be combined in the same inhaler with steroid in severe cases
- 11. Vagal “tone” Vagus nerve ACh NORMAL ANTICHOLINERGIC Resistance1/r4 ACh COPD ANTICHOLINERGICS IN COPD
- 12. Atropine cigarette,1940’s-50’s Rotahaler InIndia 2003 Handihaler In Europe 2002 Tiotropium capsule Ipratropium bromide – 1970’s Datura Old ages
- 13. Tiotropium Bromide • 18mcg/dose • Single daily dose • Selective anticholinergic M3 receptor blocker • First-choice bronchodilator for COPD today
- 14. Tiotropium vs Ipratropium (FEV1) EurResp J 2002; 19: 209-16 160 -80 -40 0 40 80 120 0 100 200 300 400 Test day T rough FEV mL 1 Difference Tiotropium Ipratropium
- 15. Safety and tolerabilityof tiotropium • Most common adverse effect is dry mouth • Up to 10-15% of patients • Generally mild and rarely needs treatment discontinuation • No ECG changes or reports of any other systemic anticholinergic side effects
- 16. Warnings and Precautions •Tiotropium should not be used as rescue therapy • Tiotropium may cause blurred vision and narrow-angle glaucoma • Prostatic hypertrophy, urinary retention • In patients with moderate to severe renal impairment (creatinine clearance <50 ml/min) • Not to use with other antimuscarinic drugs
- 17. Domiciliary Oxygen Therapy •Unique “drug” • Only drug that reduces mortality • Prevents worsening of PH • Improves sleep quality / renal blood flow / decreases cardiac arrhythmias • Flow rate to keep SaO2 > 90 %
- 18. Inhaled steroids inCOPD • Steroids are beneficial in acute exacerbation • Optimal dose unknown but duration should be no more than 2 weeks • ? Inhaled steroids beneficial in symptomatic patients with moderate to severe lung disease. • Role of inhaled steroids not completely known in COPD
- 19. Long-term Oxygen Therapy(LTOT) • Should not be regarded as something to give “when all has failed” • Not addictive • Does not limit mobility around the house
- 20. How do yougive oxygen ? • Oxygen cylinders • Oxygen concentrators • Portable oxygen cylinders ( liquid oxygen esp.)
- 21.
- 22. Vaccination • Pneumococcal: • 43%decrease in hospitalisations • 29 % decrease in death from all causes (2nd dose after 5 years ?) • Influenza: recommended annually ; additive benefit
- 23. Pulmonary rehabilitation Very important •Postural drainage for associated bronchiectasis • Breathing exercises : Pursed-lip breathing Diaphragmatic breathing Limb exercises
- 24. GOLD Guidelines: Not Recommendedfor Chronic Treatment of COPD Mucolytics Cromones Antibiotics Antitussives
- 25. When to referto a specialist ? • Uncertain diagnosis • Patient requests a second opinion • Onset of cor pulmonale • Assessment for home oxygen therapy • Assessment for home nebuliser use • Bullous lung disaese ( surgery ) • Assessment for rehab./LVRS/transplant • COPD below 40 years (α1-AT def.)
- 26. Conclusion • Suspect anddiagnose early • Smoking cessation • Maximum bronchodilation • Consider ICS or ICS-LABA for all severe cases • More Spirometry • Don’t forget Oxygen and Physio
- 27. Patient reporting withsuggestive respiratory symptoms - H/o exposure to risk factors - Physical examination - Exclude other diseases As per details given in text Sputum for AFB Refer to the nearest DOTS centre (Revised National TB Control Programme) or start ani-TB therapy Provisional diagnosis COPD Complications -Spirometry / Chest Xray is feasible - Treatment as per guidelines Good response Poor response Continue treatment Follow up Spirometry / chest Xray Treatment Good response Poor response • Intensive Care for acute exacerbation • Rehabilitation for stabilized patient; domiciliary oxygen, appropriate nutrition and respiratory physiotherapy Good response Secondary Care Level Tertiary Care Level +ve -ve Assess by Complications Primary Care Level Secondary Care Level Primary Care Level Tertiary Care Level