an update on chronic obstructive pulmonary disease

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An Update on Chronic Obstructive Pulmonary Disease

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  • An Update on Chronic Obstructive Pulmonary Disease

  • No Company AffiliationsGraduated from Medical University of South Carolina in Charleston, 2000Experience-14+ Years in Cardiology and Pulmonary Practice in Coastal South CarolinaNow Back in Primary Care for past 9 months. What was I thinking! 80-100 patients per week (60% practice is Pulmonary medicine-40% Cardiology)

  • Discuss the pathophysiology of COPD, manifestations of disease process and diagnosis of COPDName the financial and Social Impact of COPD on U.S. and South Carolina populationInterpret and review effective diagnostic testing for COPD Discuss current Pharmacologic Treatments of COPDDiscuss Non-Pharmacologic Treatments options

  • Defined as a common preventable and treatable disease, it is characterized by persistent airflow limitation that is also accompanied by chronic inflammation from exposure to noxious particles or gases Causes include tobacco smoking, second hand smoke exposure, air pollution and occupational exposure

  • Clinical Diagnosis of COPD should be considered with patients who have dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors. Spirometry is required to make diagnosis. Assessment of COPD is based on the patients symptoms, risk of exacerbations, severity of COPD (bases on spirometry) and comorbid conditions. COPD is the 3rd leading cause of death in the United StatesMany are not even aware they have it

  • COPD was the 3rd leading cause of Death in the US in 2008Approximately 13 million adults in US have COPD, however, estimated 24 million have evidence of impaired lung function=under diagnosis of diseaseA retrospective analysis of HMO database showed that 81% of patients with COPD were not diagnosed until disease was moderate to severe

  • The projected annual cost for COPD in the US for 2010 was $50 billion (not million, yes billion!!!!)Estimated related to cost-between 50% and 75% of all COPD cost are related to exacerbationsFrequency of exacerbations: 2 or more exacerbations in the first year of observational study showed 22% of patients with stage 2 disease33% of patients with stage 3 disease47% of patients with stage 4 disease

  • COPDAsthmaCHFBronchectasisTBObliterative BronchiolitisDiffuse PanbronchiolitisBronchitis

  • Chronic Cough (smoker cough)Chronic Phlegm ProductionShortness of Breath (limits activity)Not able to take deep breathWheezingRecurrent Respiratory Infections/BronchitisHypoxemia

  • Goals of assessment to determine severity of disease and its impact on patients health to guide treatment therapySymptomsDegree of airflow limitation (using spirometry)Risk of exacerbationsCo-morbidities

    May use tools such as CAT-COPD Assessment Tool

  • In 2015-Updates to Gold GuidelinesSpirometry is required to make clinical diagnosis of COPDClinical Diagnosis should be considered in any patient over age 40 who has dyspnea, chronic cough or sputum production, history of exposure to risk factors for disease and/or family history of COPD

  • In Patients with FEV1/FEC = 80% PREDICTEDGOLD 2MODERATE50%

  • Measure how well the lungs take in and release airMeasure how well the lungs move gases such as oxygen from the air into the bodys circulationPFTs add additional information including Lung volume and diffusion capacityLonger test and more expensive, however helpful in treatmentUse spirometry to make initial diagnosis and Full PFTs to guide therapy

  • Well trained staff-Does not have to be RT but need to do test well for accurate results.Patient cooperation-If patient is not following direction and you dont have good loop, less accurate results (May need full PFT to help make diagnosis)Patient should not have had any respiratory medications within 4 hours of test and preferable that am (if possible).

  • Non-PharmacologicPharmacologicManagement of Stable COPDManagement of COPD exacerbations

  • Symptom reliefIncrease exercise toleranceImprove healthDecrease disease progressionPrevent exacerbationsTreat exacerbationsDecrease Mortality

  • Smoking Cessation!!!!!!Counseling does help, counseling by physicians and other health care professionals significantly increases quit rates over self-initiated strategiesNicotine replacement Therapy-gum, patchesPharmacotherapy-varenicline, bupropion or nortriptyline are more effective than placeboSmoking prevention-once quit need to stay QUIT, keep smoke free homesDont Give Up! Keep on trying each and every time you see them.

  • Occupational ExposureIndoor and Outdoor Air PollutionVaccination Pneumococcal and FLU Physical ActivityWhich leads to PULMONARY REHABILITATONThe more you do the more you can do is so true for COPD

  • Defined as evidence based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activitiesPulmonary rehab is designed to reduce symptoms, optimize functional status, increase participation and reduce health-care cost through stabilization

  • Utilized various healthcare disciplinesIndividualized plan of care with realistic goals for patientAttention to physical and social functionEach patient plan includes Patient assessmentExercise trainingEducationPsychosocial support

  • Medicare has a maximum life-time visitsPrivate Insurance-Co paysMaintenance programsPatient ComplianceExacerbationsAccess to programs

  • Abbreviations:SA-short actingLA-long actingAC-anticholinergicBA-beta agonistICS-inhaled corticosteroidPDE-4-phosphodiesterase-4

  • Patient Types:Type A-Low risk, Low symptomsType B-Low risk, Increased symptomsType C-High risk, Low symptomsType D-High risk, High symptoms

  • Patient Type1st 2ndOther Type A-LR,LSSA AC or SA BALA AC or LA BAOrSA AC or SA BATheophyllineType B-LR, ISLA AC or LA BALA AC & LA BASA AC &/or SA BATheophyllineType C-HR, LSICS &

    LA BA or LA ACLA AC & LA BA or LA AC & PDE4OrLA BA & PDE4SA BA &/or SA AC

    Theophylline

    Type D-HR, ISICS &

    LA BA

    &/or LA ACICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4Carbocystiene

    N-acetylcysteine

    SA BA &/or SA AC

    Theophylline

  • Does anything Go?

  • Proair HFA-AlbuterolVentolin HFA-AlbuterolProventil HFA-AlbuterolXopenex HFA-SalbuterolXopenex nebulizer Albuterol nebulizer

  • Arcapta Neohaler (Indacterol)-1 cap inhalation dailyForadil Aerolizer (Formoterol)-1 inhalation BIDSerevent Diskus (Salmeterol)-1 inhalation BIDStriverdi Respimat (Olodaterol)-2 inhalations dailyPerformist Nebulizer (Formoterol)-1 neb BIDBrovana Nebulizer (Arformoterol)- 1 neb BID

  • Aerospan (Flunisolide) 80mcg 2-4 puffs BIDAsmanex Twisthaler (Mometasone)110mcg and 220mcg 1-2 puffs daily-BID (max 440mcg/day)Asmanex HFA (Mometasone) 100,200mcg 2 puffs BID (max 800mcg/day)Alveso (Ciclesonide) 80mcg and 160mcg-1 puff BID (max 320mcg/day)Pulmicort Flexhaler (Budesonide)90mcg and 180mcg-2 puffs BIDFlovent Diskus (Fluticasone propionate) 50mcg, 100mcg and 250mcg- 1-2 puffs BID (max 1000mcg/day)Flovent HFA (Fluticasone propionate) 44mcg, 110mcg, 220mcg-2 puffs BID (max 880mcg/day)Qvar HFA (Beclomethasone dipropionate)40mcg, 80mcg-1-4 puffs BID (max 640mcg/day)Arnuity Ellipta (Fluticasone furoate)-1 inhalation daily

  • LA BA and CorticosteroidAdvair Diskus, (Fluticasone Propionate/salmeterol) 100/50, 250/50, 500/50-1 inhalation BIDAdvair HFA (Fluticasone Propionate/salmeterol) 45/21, 115/21, 230/21-2 puffs BIDSymbocort HFA (Budesonide/Formoterol) 80/4.5, 160/4.5-2 puffs BIDBreo Elipa (Fluticasone furoate/vilanterol)100/25-1 inhalation DailyDulera (Mometasone/formoterol) 100/5, 200/5-2 puffs BID

  • Atrovent HFA (Ipratropium bromide)-2 puffs qidAtrovent Nebulizer (Ipratropium)-1 neb qidSpiriva Handihaler (Tiotropium)-1 inhalation DailySpiriva Respimat (Tiotropium)-2 puffs DailyTudorza Pressair (Aclidinium bromide)-1 puff BIDIncruse Ellipta (Umeclidinium)-1 puff DailyCombivent Respimat (ipratropium bromide/albuterol)-1 inhalation QIDAnoro Elipta (Umeclidinium/vilanterol)-1 inhalation daily

  • LA BA and ACCombivent Respimat (ipratropium bromide/albuterol)-1 inhalation QIDAnoro Elipta (Umeclidinium/vilanterol)-1 inhalation dailyDuonebs (ipratropium/albuterol) Nebulizer-1 QID

  • PDE-4 Phosphidiesterase-4 (roflumilast- Daliresp)Mexthylxanthines-Theophylline/aminophyllineMucolytic-Carbocystiene (not available in US)Mucolytic-N-acetylcysteine (Mucomist) 10% /ml solution, 6-10 ml nebulized and 20%ml solution, 3-5ml nebulized. Q 2 hours, max dose 10% 20ml and 20% 10ml***must give with albuterol !!!!!**** Due to bronchospasms

  • Therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise toleranceBronchodilatorsInhaled therapy is preferredprescribed on as-needed or on a regular basis to prevent or reduce symptomsLong-acting inhaled bronchodilators are convenient, and maintaining symptoms relief compared to short acting bdCombining bronchodilators (short and long) may improve efficacy and decrease risk of side effects

  • Inhaled CorticosteroidsIn patients with FEV1 < 60% predicted, regular tx with inhaled corticosteroids improves symptoms lung functionquality of lifereduces frequency of exacerbations

    There is associated increased risk of pnemonia, withdrawal may lead to exacerbation.Long-term monotherapy not recommended

  • Combined Inhaled Corticosteriod/ Bronchodilator TherapyThe IC/LBD is more effective than either individual therapy in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD

  • Oral Corticosteroids-Long term not recommendedPhosphodiesterase-4 inhibitors- In Gold 3 and 4 patients with history of exacerbations and chronic bronchitis. PD4 inhibitor is roflumilast or DalirespYour experience?Our practice

  • MexthylxanthinesLess effectiveLess well tolerated than LBDAvailable and affordableEvidence of modest BD effectAminophylline or TheophyllineTheophylline with salmeterol produces a greater increase in FEV1 and relief of breathlessness than salmeterol alone.Low dose theophylline reduce exacerbations but does not improve post-bronchodilator lung function.Therapeutic values 10-20 (patient may get benefit and tolerate better at subtherapeutic levels of approx 8-12)

  • Vaccines including: Influenza and Pneumococcal vaccines can reduce serious illness and deathAlpha 1 Antitrypsin Therapy-For COPD related to Alpha 1 Defiency Mucolytic Agents-for patient with excessive sputum, overall benefits smallAntitussive-use not recommended (however*)Vasodilators-stable COPD with Pulmonary HTN

  • Pulmonary RehabilitationOxygen TherapyVentilatory SupportSurgical TreatmentsLung Volume Reduction Surgery (LVRS)-need to qualify, emphysema upper lobeLung Transplant, costly, need to live near transplant facility for at least 1 year and age requirements

  • Look at you patient typeLook at spirometry and/or PFTsMild/Moderate-start simple and work upSevere/Very Severe-be aggressive and get symptoms under control then remember to back down (if able)Symptom control/Quality of Life/Reduce Exacerbations & Mortality are key GOALSCost of meds does influence treatment

  • Patient Type1st 2ndOther Type A-LR,LSSA AC or SA BALA AC or LA BAOrSA AC or SA BATheophyllineType B-LR, ISLA AC or LA BALA AC & LA BASA AC &/or SA BATheophyllineType C-HR, LSICS &

    LA BA or LA ACLA AC & LA BA or LA AC & PDE4OrLA BA & PDE4SA BA &/or SA AC

    Theophylline

    Type D-HR, ISICS &

    LA BA

    &/or LA ACICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4Carbocystiene

    N-acetylcysteine

    SA BA &/or SA AC

    Theophylline

  • Defined as an acute event characterized by a worsening of the patients respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medicationAssess the severityABGsCXRCBCPresence of purulent sputumSputum C&SSpirometry NOT RECOMMENDED

  • Oxygen for hypoxemia with target saturation of 88-92%SBDSystemic Corticosteroids30-40mg for 10-14 daysOptional tx tapering dosePatients with DM may have problems with elevated glucoseSide effects of steroids

  • Antibiotics given to patients with3 symptoms of increased dyspnea, increased sputum volume, increased sputum purulence

    Increased sputum purulence and one other cardinal symptoms

    Who require mechanical ventilation

  • CDC www.cdc.gov/copd/data.htmGlobal Initiative for Chronic Obstructive Lung Disease Pocket Guide (GOLD) 2015Respiratory Care Connection-GSK Education connectionU.S. Department of health and human services, Agency for Healthcare Research and Quality-www.ahrq.gov and www.guideline.gov and type in pulmonary rehabilitationAanma.orgMayoclinic.org

  • Thank You