Chronic Obstructive Pulmonary Disease (COPD)

Jaime Palomino, MDPulmonary/CCM Tulane University

10.22.09

INTRODUCTION

COPD is the most important lung disease in U.S.

25% of ED visits for Dyspnea 4th cause of death

Definition

Disease state characterized by airflow obstruction that is no longer fully reversible and is usually progressive

Accelerated declined in FEV1 from 30ml/year after 30y to 60ml

“Preventable and treatable”

AgeAge--Related Decline in FEVRelated Decline in FEV11 IsIsAccelerated in SmokersAccelerated in Smokers

FEV1, forced expiratory volume in 1 second.Adapted with permission from Fletcher C, Peto R. BMJ . 1977;1:1645-1648.

Never smoked or not susceptible to smoke

Stopped at 45 y

Stopped at 65 y

Smoked regularly and susceptible to its effects

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25 50 75Age (y)

Disability

Death

Epidemiology COPD is the fourth leading cause of

death in the US.1

>25 million people in US have impaired lung fxn

Annual cost of COPD in the US ~ $30.4 billion (ALA)office visits, diagnostic procedures,

medications, and emergency and hospital services

1.Centers for Disease Control and Prevention. Mortality patterns—US, 1997. MMWR. 1999;48:664-678.

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- 45% - 58% + 71% - 15%

CHD Stroke COPDP

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Adapted with permission from Higgins MW, Thom T. In: Clinical Epidemiology of COPD. 1990:23-43.

Mortality of COPD Is IncreasingMortality of COPD Is Increasing

COPD is the only leading cause of death that is increasing.

COPD – Pathogenesis

Cosio et al. NEJM 2009;360:2445-54

Cosio et al. NEJM 2009;360:2445-54

Cosio et al. NEJM 2009;360:2445-54

COPD – Immunology

Cosio et al. NEJM 2009;360:2445-54

Cosio et al. NEJM 2009;360:2445-54

COPD – Pathogenesis

Sethi et al. NEJM 2008;359:2355-65

ACCP Pulmonary Board Review. 2007

COPD – Risk Factors

Diagnosis of COPD History

Smoking, occupational history Spirometry: FEV1, FEV1/FVC 6 minute walk to monitor fxnl status

distance a patient can walk on a flat path in 6 minutes

practical and reliable way to measure level of everyday impairment and exercise tolerance

Differential Diagnosis:Differential Diagnosis:Asthma Versus COPDAsthma Versus COPD11--33

Age of onset

Smoking history

Positive family history

History of atopy

Pattern of symptomoccurrence

Reversibility of airway obstruction

Triggers of exacerbations

Usually > 35-40 years

Usually 20 pack-years

Uncommon*

Unimportant

Nonspecific

Only partially reversiblewith smoking cessationand bronchodilator use

Infections, inhalant exposure

Any age (usually 40 years)

Minimal

Usually

Often positive

Nocturnal awakenings;early-morning symptoms

Usually near-normal pulmonary function with appropriate therapy

Specific identifiable triggers

COPD Asthma

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121. 3. Kuritzky L. Primary Care (Special Edition). 1999;3.

*Except for 1-antitrypsin deficiency

Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697

A Comparison of Four Sets of Staging Criteria for COPD

ACCP Pulmonary Board Review. 2007

COPD Severity (GOLD Guidelines)

Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697

Deterioration in Lung Function in Patients with COPD

ACCP Pulmonary Board Review. 2007

Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697

Pulmonary Hyperinflation in Patients with COPD

Celli, B. R. et al. N Engl J Med 2004;350:1005-1012

Variables and Point Values Used for the Computation of the Body-Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity (BODE) Index

Celli et al. CHEST 2008;133:1451-1462

Medications – Anticholinergics

Short-Acting: Ipratropium: Inhaled, nebs, (Atrovent-

HFA®) Long-Acting:

Tiotropium (Spiriva®)

Medications – Beta Agonists

Short-Acting: Albuterol (ProAir-HFA®, Proventil-HFA®, Ventolin-

HFA®) Pirbuterol (Maxair®) Metaproterenol (nebs) Levalbuterol (Xopenex® nebs, Xopenex-HFA®)

Long-Acting: Arformoterol (Brovana® nebs) Formoterol (Foradil®, Perforomist® nebs) Salmeterol (Serevent Diskus®)

Medications – ICS

Flunisolide (Aerobid®) Ciclesonide (Alvesco®) Mometasone (Asmanex Twisthaler®) Triamcinolone (Azmacort®) Fluticasone (Flovent Diskus®, Flovent

HFA®) Budesonide (Pulmicort Flexhaler®,

Pulmicort Respules® nebs) Beclomethasone (QVAR®)

Medications – Combinations

SABA + SAMA: Albuterol/Ipratropium (Combivent®, Duoneb®)

LABA + ICS: Fluticasone/Salmeterol (Advair Diskus®, Advair

HFA®) Budesonide/Formoterol (Symbicort®)

Medications – Others

Theophylline (Theo-24®, Uniphyl®)

Calverley et al. NEJM 2007;356:775-89

Calverley et al. NEJM 2007;356:775-89

Calverley et al. NEJM 2007;356:775-89

Celli et al. AJRCCM 2008;178:332-338

Calverley et al. NEJM 2007;356:775-89

Drummond et al. JAMA 2008;300:2407-2416

Sin et al. Lancet 2009;374:712-19

Tashkin et al. NEJM 2008;359:1543-54

Tashkin et al. NEJM 2008;359:1543-54

Tashkin et al. NEJM 2008;359:1543-54

Tashkin et al. NEJM 2008;359:1543-54

Lee et al. Arch Intern Med. 2009;169:1403-1410

Welte et al. AJRCCM.2009;180:741-750

Welte et al. AJRCCM.2009;180:741-750

Changes in Lung Function Number of Severe Exacerbations

Lee et al. Ann Intern Med 2008;149:380-390

Singh et al. JAMA 2008;300:1439-1450

Tashkin et al. NEJM 2008;359:1543-54

Medications

Theophylline or PDE Inhibitors May have a “come-back” Lower levels (8-13 mg/dL) Improvement in corticosteroid resistance

(HDAC2) Phosphodiesterase E4 inhibitors

Calverley et al. Lancet 2009;374:685-694

Smoking cessation Smoking cessation: single most effective

way to improve clinical outcomes in patients at all stages of COPD (asx-severe).1-4

After cessation, FEV1 rate of decline may decrease to the rate found in healthy nonsmokers.5,6

35% abstinent at 1 year, 22% at 5 years1. The National COPD Awareness Panel (NCAP). Guidelines for early detection and management of COPD. J Resp Dis. 2000;21(suppl):S5-S21.2. Centers for Disease Control and Prevention. The Surgeon General’s 1990 report on the health benefits of smoking cessation: executive summary – introduction, overview, conclusions. MMWR. 1990;39(RR-12):2-10.3. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled bronchodilator on the rate of decline in FEV1: the Lung Health Study. JAMA. 1994;272:1497-1505.4. Kanner RE. Early intervention in chronic obstructive pulmonary disease: a review of the Lung Health Study results. Med Clin North Am. 1996;80:523-547.5. Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ. 1977;1:1645-1648. 6. Higgins MW, Enright PL, Kronmal RA, et al. Smoking and lung function in elderly men and women. JAMA. 1993;269:2741-2748.

Smoking cessation

Ask: every patient, during each clinic visit

Advise: urge to quit Assess: willingness to quit Assist: quit plan, counseling,

social support, pharmacotherapy Arrange: follow-up contract

Vaccination

Pneumococcal vaccination Annual influenza vaccination

LongLong--Term Oxygen TherapyTerm Oxygen Therapy

Indicated for PaO2 <55 mm Hg or SaO2 <88%1

Improves1-4:

– Survival in hypoxemic patients

– Cognitive function, affect

– Exercise performance

– Sleep quality

– Activities of daily living

1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Report of the Medical Research Council Working Party. Lancet. 1981;681-686.3. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-398. 4. Bye et al. Am Rev Respir Dis. 1985;132:236-240.

Pulmonary Rehabilitation

Casaburi et al. NEJM 2009;360:1329-35

Pulmonary Rehabilitation Improves (better than other COPD therapies):

Exercise capacity Severity of dyspnea Health-related quality of life

Reductions in hospitalization Improvements in cost-effectiveness Reduction in depression and anxiety Improves cognitive function and self-efficacy Survival benefit has not been demonstrated Reimbursement varies

Casaburi et al. NEJM 2009;360:1329-35

Pulmonary Rehabilitation Indications:

GOLD Stage 3 or 4 3 times/week. 3-4 hrs/session. 6 – 12 weeks Endurance exercise leg muscles

Walking, stationary cycling, treadmill Resistance-exercise component Upper extremities exercise Bronchodilators, oxygen, NIPPV, heliox,

anabolic steroids Education, smoking cessation, nutrition

Casaburi et al. NEJM 2009;360:1329-35

Treatment - COPD Lung Transplant

< 65 y/o High BODE index Effects on survival remains controversial

LVRS (pneumoplasty) Upper lobe disease Limited exercise performance after pulmonary

rehabilitation FEV1 : 20 -35 % predicted Bronchoscopic placement of one-way valves

or biological substances

Tillie-Leblond et al. Ann Intern Med. 2006;144:390-396

Rizkallah et al. CHEST 2009;135:786-793

Zvezdin et al. CHEST 2009;136:376-380

Treatment - NPPV

NPPV fewer intubations, decreased mortality, and shortened MICU admissions

Indications for NPPV pH < 7.20 RR > 25 MS change worsening hypercapnia