chronic obstructive pulmonary disease (()copd) · pdf filerole of pt in copd: what we should...

Role of PT in COPD: what we should know and how we could do

Chronic Obstructive Pulmonary Disease (COPD)( )

Benjamas Chuaychoo MD Ph DBenjamas Chuaychoo, MD, Ph.D.Division of Respiratory Diseases and Tuberculosis

Department of MedicineFaculty of Medicine Siriraj HospitalFaculty of Medicine Siriraj Hospital

Mahidol University

24 June 2015

Outline• Definition• Risk factorss acto s• Pathogenesis, pathophysiology• Diagnosis differential diagnosisDiagnosis, differential diagnosis• Co morbidity• Assessment• Assessment• Management• ACOS (Asthma COPD overlap syndrome)• ACOS (Asthma COPD overlap syndrome)• COPD sleep overlap syndrome

Pulmonary hypertension in COPD• Pulmonary hypertension in COPD

Global Strategy for Diagnosis, Management and Prevention of COPD

Definition of COPDDefinition of COPD

COPD a common preventable and treatable COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive andlimitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and theinflammatory response in the airways and the lung to noxious particles or gases

Exacerbations and comorbidities contribute to the overall severity in individual patients

© 2015 Global Initiative for Chronic Obstructive Lung Disease


Risk Factors for COPDRisk Factors for COPD

G Lung growth and development

Gender

Genes Exposure to particles Tobacco smoke Gender

Age Respiratory infections

Tobacco smoke Occupational dusts, organic

and inorganic Respiratory infections Socioeconomic status Asthma/Bronchial

g Indoor air pollution from

heating and cooking with biomass in poorly ventilated hyperreactivity

Chronic Bronchitis

biomass in poorly ventilated dwellings

Outdoor air pollutionOutdoor air pollution



Risk Factors for COPDs acto s o CO

GenesGenes

InfectionsInfections

SocioSocio--economiceconomicSocioSocio--economic economic statusstatus

Aging PopulationsAging PopulationsAging PopulationsAging Populations© 2015 Global Initiative for Chronic Obstructive Lung Disease

Human Airways

no gas exchange

gas exchangegas exchange

Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963, Springer‐Verlag Brashear RE, Rhodes ML. Chronic Obstructive Lung Disease. St. Louis: The CV. Mosby Co. 1978

Anatomical Features of lower airways

Small airway< 2 mm

Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings. Figure 17.3

Emphysema

West JB. Pulmonary pathophysiology, the essentials, 7th ed, 2008

Airway obstruction in COPDAirway obstruction in COPD

Normal

centrilobular

Decreased airway diameter Decreased elastic recoil

centrilobular

Bronchiolitis Emphysema Panlobular

(permanent damage of the airspaces di t l t th t i l b hi l )distal to the terminal bronchiole)

West JB. Pulmonary pathophysiology, the essentials, 7th ed, 2008

Small airway obstructionA B

Normal

C D

Abnormal

(A) Normal (B) Normal small airway with bland mucous plug

Abnormal

(C) Airway with inflammation, thickened wall with inflammatory exudate (D) Airway narrowed by the deposition in the peribronchiolar space

Hogg JC. Lancet 2004; 364: 709–21

EmphysemaEmphysema

Normal Emphysema

Global Strategy for Diagnosis, Management and Prevention of COPDMechanisms Underlying Airflow Limitation in COPD

Small Airways Disease• Airway inflammation• Airway fibrosis luminal plugs

Parenchymal Destruction• Loss of alveolar attachments

Decrease of elastic recoil

Diameter < 2 mm

• Airway fibrosis, luminal plugs• Increased airway resistance

• Decrease of elastic recoil

AIRFLOW LIMITATION

Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK

Lung hyperinflation (LH)g yp ( )• Defined by increased functional residual

it (FRC)*capacity (FRC)*• Conventionally, LH is defined as an

increase in TLC regardless of underlying mechanisms

FRC IC=

* at end of tidal expiration

FRC IC=

TLC = Total lung capacity

Rossi A et.al. Respir Med. 2015 Jul;109(7):785-802.

Lung hyperinflation (LH) • Plays central role in pathophysiology of dyspnea and

poor exercise tolerance in COPD • Static LH :

– Caused by destruction of pulmonary parenchyma and loss of elastic recoilloss of elastic recoil

• Dynamic LH: – develops when COPD patients breathe in beforedevelops when COPD patients breathe in before

achieving a full exhalation and, as a consequence, air is trapped within the lungs with each further breath

– Dynamic LH may also occur at rest but it becomes clinically relevant during exercise and exacerbation


Lung hyperinflation (LH)Lung hyperinflation (LH) • increased ventilatory workloadincreased ventilatory workload • decreased inspiratory muscle pressure

generating capacity g g p y• adverse effects on cardiovascular function• assessment of the presence and severity of LHassessment of the presence and severity of LH

is useful clinical approach to assess impact of therapeutic interventions on symptoms, exercise tolerance and health-related quality of life


Human AirwaysHuman Airways Emphysema - defined pathologically as an abnormal permanent

no gas exchange

as an abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of alveolar walls and without obviousalveolar walls and without obvious fibrosis

gas exchange

Decreased DLCO

Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963,Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963, Springer‐Verlag Brashear RE, Rhodes ML. Chronic Obstructive Lung Disease. St. Louis: The CV. Mosby Co. 1978

Effect of Emphysema on Compliance d Diff i C i (DL )and Diffusing Capacity (DLco)

http://www.netterimages.com/image/1000.htm

Definition

• Chronic bronchitis– is a clinical diagnosis

“Presence of cough and sputum

Chronic bronchitis

– Presence of cough and sputum production for at least 3 months in each of two consecutive years”

C h

• Emphysema, or destruction of the gas exchanging surfaces of the lung (alveoli)

Cough

g g g ( )– is a pathological diagnosis– “Abnormal, permanent enlargement of

the airspaces distal to the terminal Normal

Emphysema

bronchiole, accompanied by destruction of their walls”

Centrilobularemphysema

Panlobularemphysema

Dyspnea

Who is/are COPD patient(s)?Who is/are COPD patient(s)?


Diagnosis and Assessment: Key P iPoints

• A clinical diagnosis of COPD should beA clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and achronic cough or sputum production, and a history of exposure to risk factors for the disease.

• Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV /FVCthe presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.airflow limitation and thus of COPD.


DiagnosisDiagnosis

• Symptoms:• Symptoms:– Dyspnea, chronic cough or sputum production

Exposure to risk factors:• Exposure to risk factors: – Tobacco, occupation, indoor/outdoor pollution

• Post-bronchodilator FEV1/FVC < 0.7 (spirometry)

ทานมความเสยงตอการเกดโรคปอดอดกนเรอรงหรอไม

ไอบอยๆ ใช ไมใชไอบอยๆ ใช ไมใช

มเสมหะบอยๆ ใช ไมใช

เหนอยงายกวาคนอน ใช ไมใช

ทานอายมากกวา 40 ป ใช ไมใช

ทานสบบหรหรอเคยสบ

บหร ใช ไมใช

pack-yeak (ซอง-ป) = จานวนบหรคดเปนซองตอวน x จานวนปทสบ

ตวอยาง สบบหร 1 ซองตอวน นาน 20 ป = 20 ซอง-ปสบบหร 2 ซองตอวน นาน 10 ป = 20 ซอง-ป

Spirometry: Normal Trace Showing FEV and FVCShowing FEV1 and FVC

4

FVC5

3

ume,

lite

rs FEV1 = 4L

FVC = 5L

1

2

Volu

m C 5

FEV1/FVC = 0.8

1 2 3 4 5 611 2 3 4 5 6

Time, sec

1


Spirometry: Obstructive DiseaseDisease

N l5

4

Normal

ume,

lite

rs 3

2

FEV1 = 1.8L

FVC = 3 2L

Volu

m 2

1

FVC 3.2L

FEV1/FVC = 0.56 Obstructive

Time seconds

1 2 3 4 5 6

FEV1/FVC < 0.7

Time, seconds


CRJ5

CRJ5 Sue i have inserted a bracket and shifted the obstructive label. The FVC in this slide is about 3.4 by eyeball - shoudl be moved down to3.2 or the numbers should be changed Christine Jenkins, 4/14/2008

Post bronchodilator FEV1/FVC < 0.7

Spirometryชายไทย อาย 70 ป เหนอยมา 3 ป สบบหร 20 ซอง-ป

ไมเคยเปนโรคหด

Pre-Rx Pred % pred Post-Rx % pred % change

FVC 2 04 2 55 80 0 2 05 80 4 5FVC 2.04 2.55 80.0 2.05 80.4 5

FEV1 0.78 2.17 36 0.85 39.2 9

FEV1/FVC 38 85 45 41 48

FEF25-75% 0.31 3.37 9 0.31 9

PEF 177 388 46 219 56

Post bronchodilator FEV /FVC < 0 70Post-bronchodilator FEV1/FVC < 0.70

Clinical feature Asthma COPD

Differential diagnosis asthma and COPD

Age of onset Usually early childhood, but may any age

Mid-late adult life (>40 yrs)

Smoking history May be non-,ex-, or current smoker

Usually smoker or ex-smoker ( > 10 k )smoker ( > 10 pack-yr)

Atopy common Not a prominent feature

Family history of common Not usually a featureatopy or asthma

Lung function Normal or obstruction Airflow obstruction (hallmark of COPD)(Postbronchodilator FEV1/FVC < 0.7)

R ibili f M l ibl M l i iblReversibility of airflow obstruction

Mostly reversible(Characteristic of asthma)

Mostly irreversible

Peak flow variability Characteristic of asthma, usually > 20%

Not varyusually > 20%

Diffuse capacity Usually normal Decrease in emphysema

inflammation Eosinophilic, CD4 Neutrophilic, CD8

Corticosteroids Steroid responsive Steroid resistance

Asthma and COPD, Basic mechanisms and clinical management. edited by Peter Barnes, et al.2002


Definition of COPDDefinition of COPD

COPD a common preventable and treatable COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated tat o t at s usua y p og ess e a d assoc atedwith an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

Exacerbations and comorbidities contribute to the overall severity in individual patients.


Systemic effects and comorbidities of COPD

Barnes PJ and Celli BR. Eur Respir J 2009; 33: 1165–1185

Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss. 2, pp 43–46, May 1, 2012

Characteristics Total n= 150

Age years (mean + SD range) 72+ 8Age, years (mean + SD, range) 72 8

Male sex, no (%) 137 (91.3)

BMI (kg/m2)a, no. (%)

< 18.5 (underweight) 31(20.7)

18.5-24.9 (normal) 92(61-3)

25-29.9 (overweight) 23(15.3)

> 30 (obese) 4(2.7)

Co-morbidity, no.(%)

Diabetes mellitus 20(13.3)

Hypertension 89(59.3)

Dyslipidemia 67(44.7)

Coronary artery disease 23(30 6)Coronary artery disease 23(30.6)

Cerebrovascular accident 10(6.7)

J Med Assoc Thai. 2012 Aug;95(8):1021-7.Prevalence of osteoporosis and osteopenia in Thai COPD patients.Rittayamai N Chuaychoo B Sriwijitkamol ARittayamai N, Chuaychoo B, Sriwijitkamol A.

• Prevalence of osteoporosis 31.4% p• Prevalence of osteopenia 32.4% • Prevalence of osteoporosis in COPD patients was higher

th th t i t h d Th i l f hi t i l d tthan that in age-matched Thai males from historical data (31.4% vs. 12.6%, respectively).

• The predictive value of BMI < 20.5 kg/m2 and hs-CRP >The predictive value of BMI 20.5 kg/m2 and hs CRP 2.3 mg/L demonstrated risk of osteoporosis in COPD patients (adjusted Odds ratio 7.2 and 4.1, respectively).

ภาวะซมเศราในผปวยโรคปอดอดกนเรอรงจากแบบสอบถาม T-HADS

T-HADS จานวนผปวย รอยละ

< 11 93 87.7

> 11 13 12.3

N =106

Prevalence of MCI in COPD (total n = 122)( ild iti i i t)(mild cognitive impairment)

• Prevalence of MCI in COPD was 38 5 %Prevalence of MCI in COPD was 38.5 %• The main contributing factor in COPD

patients were age education years andpatients were age, education years, and frequent exacerbation.

Pimpawee Kirdsup, et al.

Physiology of exacerbations in a hypothetical regular smoker with COPD by stage of severity

Hansel TT and Barnes PJ, Lancet 2009; 374: 744–55

Frequent exacerbators represent stable COPD phenotype - independent of severity

• Proportion of subjects experiencing ≥2 exacerbations/year increases year-on-year

• Stable population provides potential to understand the cause(s) of the phenotype

7923

100%

≥2 Exacerb./Yr 1 Exacerb./Yr 0 Exacerb./Yr

• Stable population provides potential to understand the cause(s) of the phenotype

117

63778

60%

80%

296210

40940%

60%

492

0%

20%

ECLIPSE 3 year data

Year 1 Year 2 Year 3

Hurst et al. N Engl J Med 2010

The ‘frequent exacerbator phenotype’: Frequency/severity by GOLD Category (1)q y y y g y ( )

4750 p<0.01

333330

40

ents

p 0.01

1822

20

30

% o

f pat

ie

7

0

10

GOLD II GOLD III GOLD IVGOLD II(N=945)

GOLD III(N=900)

GOLD IV(N=293)

Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more)Hospitalised for exacerbation in yr 1 q ( )

ECLIPSE 1 year data Hurst et al. N Engl J Med 2010


Manage Stable COPD: Goals of Therapy

Relieve symptoms Improve exercise tolerance ReduceImprove exercise tolerance Improve health status

Reducesymptoms

Prevent disease progression Prevent and treat exacerbations Reduce Prevent and treat exacerbations Reduce mortality

Reducerisk


Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPD

Assess symptoms

Assess degree of airflow limitation using Assess degree of airflow limitation using spirometry

Assess risk of exacerbations

Assess comorbidities



Assessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

Assess symptomsAssess symptoms

Assessment of COPDAssessment of COPD

Assess symptomsAssess degree of airflow limitation using spirometry

Assess symptomsAssess degree of airflow limitation using spirometry ( )spirometryAssess risk of exacerbationsAssess comorbidities

spirometryAssess risk of exacerbationsAssess comorbidities

COPD Assessment Test (CAT) orAssess comorbiditiesAssess comorbidities or

Clinical COPD Questionnaire (CCQ)or

mMRC Breathlessness scalemMRC Breathlessness scale© 2015 Global Initiative for Chronic Obstructive Lung Disease

http://www.catestonline.org/english/index_Thai.htm

เกณฑการใหคะแนน ภาวะหายใจลาบาก

(Modified Medical Research Council Dyspnea Scale; mMRC)mMRC)

แนวปฏบตบรการสาธารณสข โรคปอดอดกนเรอรง พ.ศ. 2553


Assess symptoms






Classification of Severity of Airflow *Limitation in COPD*

In patients with FEV1/FVC < 0.70:In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 > 80% predicted 1

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1© 2015 Global Initiative for Chronic Obstructive Lung Disease


Assess symptoms






Assess Risk of ExacerbationsAssess Risk of Exacerbations

Hi h i k f btiHigh risk of exacerbtion:

> 2 exacerbations within the last year ora ba o s as y a o

FEV1 < 50 % of predicted value are indicators of high riskindicators of high risk.

> 1 hospitalizations for COPD exacerbation pshould be considered high risk.


Global Strategy for Diagnosis, Management and Prevention of COPDCombined Assessment of COPD

Assess symptoms Assess degree of airflow limitation using Assess degree of airflow limitation using

spirometryA i k f b ti Assess risk of exacerbations

Combine these assessments for the purpose ofCombine these assessments for the purpose of improving management of COPD



Combined Assessment of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPDCombined Assessment of COPDCombined Assessment of COPDtio

n)) ≥ 2

or4

flow Lim

itat

history)

or> 1 leadingto hospital

(C) (D)3

Risk

catio

n of Airf

Risk

acerbatio

n hadmission

1 (not leading

3

2

OLD

Classific

(Exa( g

to hospitaladmission)

0

(A) (B)2

1

(GO 0

SymptomsCAT < 10 CAT > 10


BreathlessnessmMRC 0–1 mMRC > 2



Combined Assessment of COPDCombined Assessment of COPDCombined Assessment of COPDAssess symptoms first

(C) (D)If CAT < 10 or mMRC 0-1:

Less Symptoms/breathlessness(A C)(C) (D) (A or C)

If CAT > 10 or mMRC > 2:More

(A) (B)More

Symptoms/breathlessness(B or D)

CAT < 10 CAT > 10

Symptoms

© 2015 Global Initiative for Chronic Obstructive Lung DiseaseBreathlessness

mMRC 0–1 mMRC > 2



Combined Assessment of COPDCombined Assessment of COPDCombined Assessment of COPD)

Assess risk of exacerbations next

Lim

itatio

n)

y)(C) (D)4

If GOLD 3 or 4 or ≥ 2 exacerbations per year or

> 1 leading to hospital

≥ 2or

> 1 leading

sk of A

irflo

w L

isk

atio

n hi

stor

y(C) (D)3

> 1 leading to hospital admission:

High Risk (C or D)

> 1 leadingto hospitaladmission

Ris

ssifi

catio

n o Ri

(Exa

cerb

a

(A) (B)2

1

If GOLD 1 or 2 and only 0 or 1 exacerbations per

year (not leading to hospital admission):

1 (not leadingto hospitaladmission)

0

(GO

LD C

las 1

CAT < 10 CAT > 10 Symptoms

hospital admission): Low Risk (A or B)

0

(

© 2015 Global Initiative for Chronic Obstructive Lung DiseaseBreathlessnessmMRC 0–1 mMRC > 2



Combined Assessment of COPDCombined Assessment of COPDCombined Assessment of COPDtio

n)) ≥ 2

or4

flow Lim

itat

history)

or> 1 leadingto hospital

(C) (D)3

Risk

catio

n of Airf

Risk

acerbatio

n hadmission

1 (not leading

3

2

OLD

Classific

(Exa( g


0

(A) (B)2

1

(GO 0

SymptomsCAT < 10 CAT > 10


BreathlessnessmMRC 0–1 mMRC > 2


Combined Assessment


Combined AssessmentCombined Assessmentof COPDCombined Assessmentof COPDWhen assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk )

Patient Characteristic SpirometricClassification

Exacerbationsper year

CAT mMRC

exacerbations should be considered high risk.)

A Low RiskLess Symptoms GOLD 1-2 ≤ 1 < 10 0-1

B Low RiskM S t GOLD 1-2 ≤ 1 > 10 > 2B More Symptoms GOLD 1 2 ≤ 1 10 2

C High RiskLess Symptoms GOLD 3-4 > 2 < 10 0-1

D High RiskMore Symptoms GOLD 3-4 > 2 > 10 > 2



Assess COPD ComorbiditiesGlobal Strategy for Diagnosis, Management and Prevention of COPD

Assess COPD ComorbiditiesAssess COPD ComorbiditiesAssess COPD ComorbiditiesCOPD patients are at increased risk for: COPD patients are at increased risk for: p

• Cardiovascular diseases• Osteoporosis

p

• Cardiovascular diseases• Osteoporosisp• Respiratory infections• Anxiety and Depression

p• Respiratory infections• Anxiety and Depression• Diabetes• Lung cancer

Bronchiectasis

• Diabetes• Lung cancer

Bronchiectasis• BronchiectasisThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely and

• BronchiectasisThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely andhospitalizations and should be looked for routinely, and

treated appropriately.hospitalizations and should be looked for routinely, and

treated appropriately.© 2015 Global Initiative for Chronic Obstructive Lung Disease


Manage Stable COPD: Goals of TherapyGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Goals of Therapy

Relieve symptoms Improve exercise tolerance Relieve symptoms Improve exercise tolerance Reduce Improve exercise tolerance Improve health status Improve exercise tolerance Improve health status

Reducesymptoms

Prevent disease progressionP d b i Prevent disease progression

P d b i Reduce Prevent and treat exacerbations Reduce mortality Prevent and treat exacerbations Reduce mortality

Reducerisk

yy



Manage Stable COPD: All COPD PatientsGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: All COPD Patientsgg

� Avoidance of risk factors

ki ti

� Avoidance of risk factors

ki ti- smoking cessation

- reduction of indoor pollution

- smoking cessation

- reduction of indoor pollution- reduction of indoor pollution

- reduction of occupational exposure

- reduction of indoor pollution

- reduction of occupational exposurep p

� Influenza vaccination

p p

� Influenza vaccination



Manage Stable COPD: Non-pharmacologicGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Non-pharmacologic

PatientGroup

Essential Recommended Depending on localguidelines

ASmoking cessation (caninclude pharmacologic Physical activity

Flu vaccinationPneumococcal

treatment) vaccination

S ki i (

B, C, D

Smoking cessation (caninclude pharmacologic

treatment)Pulmonary rehabilitation

Physical activityFlu vaccinationPneumococcal

vaccinationPulmonary rehabilitation



Therapeutic Options: Rehabilitation

All COPD patients benefit from exercise training

Therapeutic Options: Rehabilitation

All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigueand symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitation i 6 k th l thprogram is 6 weeks, the longer the program

continues, the more effective the results.

If exercise training is maintained at home, the patient's health status remains above pre-rehabilitation levels.


Oxygen therapyOxygen therapy • Three ways ofThree ways of

administration– Longterm continuous

90

gtherapy

– During exerciseg– Relieve acute dyspnea

• Primary goal y g– Increase PaO2 > 60

mmHg, SaO2 > 90%g,

ขอบงชในการให Long-term oxygen therapy (> 15 hrs/day)

• PaO2 < 55 mm Hg หรอ SaO2 < 88% • 55 mmHg < PaO2 < 60 mm Hg หรอ SaO2 of 88%

ทมภาวะทบงชวาม chronic hypoxemia ไดแก – pulmonary hypertension

peripheral edema s ggesting congesti e– peripheral edema suggesting congestive cardiac failure

– polycythemia (hematocrit > 55%)p y y ( )

LTOT จะใหใน stable COPD ทม chronic hypoxemia ตามเกณฑดงกลาวLTOT จะใหใน stable COPD ทม chronic hypoxemia ตามเกณฑดงกลาว

ขางตน กรณทผปวยมอาการกาเรบเฉยบพลนและม hypoxemia อาจใหออกซเจนเปนการชวคราว ถาหากยงมภาวะ hypoxemia หลงจาก 3 เดอน

จงมขอบงชสาหรบ LTOT


Manage Stable COPD: Pharmacologic TherapyRECOMMENDED FIRST CHOICE


Manage Stable COPD: Pharmacologic TherapyRECOMMENDED FIRST CHOICERECOMMENDED FIRST CHOICERECOMMENDED FIRST CHOICE

DC

r yea

rGOLD 4 ICS + LABAor

DCICS + LABA

and/or2 or more

or1 l di

ons

per

GOLD 3 LAMA LAMA > 1 leadingto hospitaladmission

acer

bati

GOLD 2SAMA prn

orLABA

or

A B1 (not leading


Exa

0GOLD 1

orSABA prn

orLAMA

admission)

CAT < 10mMRC 0-1

CAT > 10 mMRC > 2



Therapeutic Options: Bronchodilators

are central to symptomatic management of COPD

Therapeutic Options: Bronchodilators

are central to symptomatic management of COPD

prescribed on an as-needed or on a regular basis to prevent or reduce symptomsprevent or reduce symptoms

The principal bronchodilator treatments are

beta2-agonists

Anticholinergics

Theophylline

or combination therapyor combination therapy



Manage ExacerbationsGlobal Strategy for Diagnosis, Management and Prevention of COPD

Manage Exacerbations

A b ti f COPD i

Manage ExacerbationsManage Exacerbations

An exacerbation of COPD is:

“an acute event characterized by aan acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal daysymptoms that is beyond normal day-to-day variations and leads to a h i di i ”change in medication.”


Diagnosis COPD exacerbations

• Clinical diagnosis• Acute worsening of symptoms (beyond normal day• Acute worsening of symptoms (beyond normal day-

to-day variations and leads to a change in medication)– Dyspnea– Cough and/or

S t d ti– Sputum production

Chest 2000;117;398S-401S

2014 Global Initiative for Chronic Obstructive Lung Disease

Consequences Of COPD Exacerbations

Impact on t

Negativesymptoms

and lungfunction

impact onquality of life

EXACERBATIONSIncreasedeconomic

Acceleratedlung function

EXACERBATIONS

costsdecline

IncreasedMortality


DefinitionsDefinitions

AsthmaAsthma is a heterogeneous disease usually characterized by chronic airwayAsthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. [GINA 2014]

COPDCOPD is a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronicairflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. [GOLD 2015]

Asthma-COPD overlap syndrome (ACOS) [a description]

Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features

© Global Initiative for Asthma

yusually associated with COPD. ACOS is therefore identified by the features that it shares with both asthma and COPD.

GINA 2014, Box 5-1

Why is asthma–COPD overlap important?

• Prevalence: ACOS 20% of patients with obstructive airway disease (asthma or COPD) and 2% in general population

• Increased illness burden: ACOS leads to significant health status impairment, increased exacerbations and increased hospitalizationshospitalizations

• Treatment implications: – When asthma is not recognized, there is potential for increased

adverse events and drug toxicity from LABAadverse events and drug toxicity from LABA – Increased response to ICS and LABA in COPD patients with

asthmali it d id f t t t d ti b ACOS– limited evidence for treatment recommendations because ACOS patients are excluded from randomized controlled trials

LABA = long‐acting β2 agonists, ICS = inhaled corticosteroids

Gibson PG, et al. Thorax 2015;70:683–691.

Usual features of asthma, COPD and ACOSUsual features of asthma, COPD and ACOSACOS ACOS

Feature Asthma COPD ACOS

Age of onset Usually childhood but can Usually >40 years Usually ≥40 years but may

Pattern of i t

Symptoms vary over time(d t d l

Chronic usually continuoust ti l l

Respiratory symptomsi l di ti l d

Age of onset Usually childhood but cancommence at any age

Usually >40 years Usually ≥40 years, but mayhave had symptoms aschild/early adult

respiratorysymptoms

(day to day, or over longerperiod), often limitingactivity. Often triggered byexercise, emotionsincluding laughter dust or

symptoms, particularlyduring exercise, with ‘better’and ‘worse’ days

including exertional dyspneaare persistent, but variabilitymay be prominent

including laughter, dust, orexposure to allergens

Lung function Current and/or historicalvariable airflow limitation, e g BD reversibility AHR

FEV1 may be improved bytherapy, but post-BDFEV /FVC <0 7 persists

-Airflow limitation not fullyreversible, but often withcurrent or historicale.g. BD reversibility, AHR FEV1/FVC <0.7 persists current or historicalvariability

Lung functionbetween symptoms

May be normal Persistent airflow limitation Persistent airflow limitation

© Global Initiative for AsthmaGINA 2014, Box 5-2A (1/3)

symptoms

Usual features of asthma, COPD and ACOS (continued)Usual features of asthma, COPD and ACOS (continued)ACOS (continued)ACOS (continued)

Feature Asthma COPD ACOS

Past history or Many patients have History of exposure to Frequently a history ofPast history orfamily history

Many patients haveallergies and a personalhistory of asthma in childhood and/or familyhistory of asthma

History of exposure tonoxious particles or gases(mainly tobacco smoking orbiomass fuels)

Frequently a history ofdoctor-diagnosed asthma(current or previous),allergies, family history ofasthma, and/or a history of

-

history of asthma asthma, and/or a history ofnoxious exposures

Time course Often improvesspontaneously or withtreatment but may result in

Generally slowly progressiveover years despite treatment

Symptoms are partly butsignificantly reduced bytreatment Progression istreatment, but may result in

fixed airflow limitation treatment. Progression isusual and treatment needsare high.

Chest X-ray- Usually normal Severe hyperinflation andother changes of COPD

Similar to COPDother changes of COPD

Exacerbations Exacerbations occur, butrisk can be substantiallyreduced by treatment

Exacerbations can bereduced by treatment. Ifpresent comorbidities

Exacerbations may be morecommon than in COPD but are reduced by treatment


reduced by treatment present, comorbiditiescontribute to impairment

are reduced by treatment. Comorbidities can contributeto impairment.

GINA 2014, Box 5-2A (2/3)

Features that (when present) favorasthma or COPDFeatures that (when present) favorasthma or COPDasthma or COPDasthma or COPD

Feature Favors asthma Favors COPDAge of onset Before age 20 years After age 40 yearsg g y g y

Pattern of respiratorysymptoms

Symptoms vary overminutes, hours or daysWorse during night or early morningTriggered by exercise, emotions including

laughter dust or exposure to allergens

Symptoms persist despite treatmentGood and bad days, but always daily

symptoms and exertional dyspneaChronic cough and sputum precededS d i di i f i di

Lung function Record of variable airflow limitation (spirometry, peak flow)

Normal between symptoms

Record of persistent airflow limitation (post-BD FEV1/FVC <0.7)

Abnormal between symptoms

laughter, dust, or exposure to allergens Chronic cough and sputum preceded onset of dyspnea, unrelated to triggersSyndromic diagnosis of airways disease

The shaded columns list features that, when present, best distinguish between asthma and COPD. Normal between symptoms Abnormal between symptoms

Past history or family history

Previous doctor diagnosis of asthmaFamily history of asthma, and other allergic

conditions (allergic rhinitis or eczema)

Previous doctor diagnosis of COPD, chronic bronchitis or emphysema

Heavy exposure to a risk factor: tobacco smoke biomass fuels

gFor a patient, count the number of check boxes in each column. If 3 or more boxes are checked for either asthma orsmoke, biomass fuels

Time course No worseningof symptoms over time. Symptoms vary seasonally, or from year to year

May improve spontaneously or respond

Symptomsslowly worsening over time (progressive course over years)

Rapid-acting bronchodilator treatment provides only limited relief

If 3 or more boxes are checked for either asthma or COPD, that diagnosis is suggested.

If there are similar numbers of checked boxes in h l th di i f ACOS h ld b

© Global Initiative for AsthmaGINA 2014, Box 5-2B (3/3)

Chest X-ray Normal Severe hyperinflation

May improve spontaneously, or respond immediately to BD or to ICS over weeks

provides only limited reliefeach column, the diagnosis of ACOS should be considered.

Step 3 - SpirometryStep 3 - Spirometry

Spirometric variableAsthma COPD ACOSNormal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless pre- or post-BD diagnosis (GOLD) other evidence of chronic

airflow limitation

Post-BD FEV1/FVC <0.7 Indicatesairflow limitation; may improve

Required for diagnosis by GOLDcriteria

Usual in ACOS

FEV1 =80% predicted Compatible with asthma (good control, or interval between symptoms)

Compatible with GOLD category A or B if post-BD FEV1/FVC <0.7

Compatible with mild ACOS

y p y

FEV <80% di t d C tibl ith th I di t it f I di t it f

P t BD i i U l t ti i C i COPD d C i ACOS d

FEV1 <80% predicted Compatible with asthma. A risk factor for exacerbations

Indicates severity of airflow limitation and risk of exacerbations and mortality

Indicates severity of airflow limitation and risk of exacerbations and mortality

Post-BD increase in FEV1 >12% and 200mL from baseline (reversible airflow limitation)

Usual at some time in course of asthma; not always present

Common in COPD and more likely when FEV1 is low, but consider ACOS

Common in ACOS, and more likely when FEV1 is low


Post-BD increase in FEV1 >12% and 400mL from baseline

High probability ofasthma

Unusual in COPD. Consider ACOS

Compatible with diagnosis of ACOS

GINA 2014, Box 5-3

Summary: Diagnosis of COPD

• Symptoms:• Symptoms:– Dyspnea, chronic cough or sputum production

Exposure to risk factors:• Exposure to risk factors: – Tobacco, occupation, indoor/outdoor pollution

• Required spirometry: post-bronchodilator FEV1/FVC < 0.7

Management of COPDCOPD Co‐morbid diseases

Stable Exacerbation DyspneaCough Sputum

• Pharmacologic treatment• Bronchodilator• CorticosteroidV i ti

Home Hospital • Vaccination

• Non‐pharmacologic treatment• Stop smoking• Pulmonary rehabilitation

• Bronchodilator• Systemic corticosteroid

management management

• Bronchodilator• Systemic corticosteroidPulmonary rehabilitation

• Oxygen therapy• Surgical treatment

• Oxygen • Antibiotics• Ventilatory support

• Antibiotics

Summary: Manage stable COPDSummary: Manage stable COPD• Goals of therapy:

– reduced symptoms, reduced risk of exacerbations

• Assessment : – Assess symptoms: CAT, CCQ, mMRCAssess symptoms: CAT, CCQ, mMRC– Assess degree of airflow limitation : post bronchodilator FEV1%

predicted (stage 1-4) – Assess risk of exacerbations : previous exacerbation (frequent– Assess risk of exacerbations : previous exacerbation (frequent

exacerbations > 2 /year or 1 of hospitalization) , severe COPD by FEV1% predicted

– Assess comorbidities: e g cardiovascular disease metabolic– Assess comorbidities: e.g. cardiovascular disease, metabolic syndrome, anxiety/depression, osteoporosis

Summary: Manage stable COPD• Combined assessment of symptoms and risk of

exacerbations is the basis for non-pharmacologic and h l i t f COPDpharmacologic management of COPD

• Pharmacologic treatment– bronchodilator + inhaled corticosteroidbronchodilator + inhaled corticosteroid

• Non-pharmacologic treatment– smoking cessation– influenza vaccination + pneumococcal vaccination– pulmonary rehabilitation

physical activity– physical activity

Thank you for your attentionThank you for your attention

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