1.DR.Y.SAI KRISHNA

2. ROAD MAP APPROACH TO A CASE OF COPD 2014 GUIDELINES OF COPD MANAGEMENT A) Management of Stable COPD B) Management of COPD exacerbations NEWER THERAPIES 3. Approach COPD SHOULD BE CONSIDERED Over the age of 35 to 40 Shortness of breath with chronic cough and sputum production, Frequent winter colds H/O exposure to risk factors for the disease. STEPS Assessment of symptoms Assessment of degree of airflow obstruction by spirometry and other investigations. Assessment of risk of exacerbations Assessment of comorbidities 4. Assessment of symptoms COPD assessment test ( An 8 item measurement of health status in COPD) Clinical COPD Questionnaire ( Self administered questionnaire to measure clinical control in patients with COPD) Modified British Medical Reasearch Questionnaire 5. Assessment of severity (GOLD) 6. OTHER INVESTIGATIONS Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. Lung Volumes and Diffusing Capacity: Help to characterize severity, but no role in management. Oximetry and Arterial Blood Gases: to evaluate need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. 7. BODE Index APPROXIMATE 4 YEAR SURVIVAL INTERPRETATION 0-2 Points: 80% 3-4 Points: 67% 5-6 Points: 57% 7-10 Points: 18% 8. Assessment of risk of exacerbations To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk. One or more hospitalizations for COPD exacerbation should be considered 9. ABG Measurements(in hospital): PaO2 < 8.0 kPa with or without PaCO2 > 6.7 kPa when breathing room air indicates respiratory failure. Chest radiographs: useful to exclude alternative diagnoses. ECG: may aid in the diagnosis of coexisting cardiac problems. Whole blood count: identify polycythemia, anemia or bleeding. Purulent sputum during an exacerbation: indication to begin empirical antibiotic treatment. Biochemical tests: detect electrolyte disturbances, diabetes, and poor nutrition. Spirometric tests: not recommended during an exacerbation. Manage Exacerbations: Assessments 2014 Global Initiative for Chronic Obstructive Lung Disease 10. PATIENT CHARECTERSTIC SPIROMETRIC CLASSIFICATION EXACERBATION PER YEAR CAT mMRC A Low Risk Less Symptoms GOLD 1-2 1 < 10 0-1 B Low Risk More Symptoms GOLD 1-2 1 > 10 > 2 C High Risk Less Symptoms GOLD 3-4 > 2 < 10 0-1 D High Risk More Symptoms GOLD 3-4 > 2 > 10 > 2 Combined assessment of COPD 11. Assess COPD Comorbidities Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer Bronchiectasis 12. A1 Antitrypsin deficiency Alpha 1-antitrypsin deficiency (1-antitrypsin deficiency, A1AD) is a genetic disorder that causes defective production of (A1AT), leading to decreased A1AT activity in the blood and lungs and deposition of excessive abnormal A1AT protein in liver cells Severe A1AT deficiency causes panacinar emphysema or COPD in adult life in many people with the condition (especially if they are exposed to cigarette smoke) along with various other conditions such as Cirrhosis, Asthma, Wegeners Granulomatosis, Pancreatitis, Gallstones, Bronchiectasis, Emphysema, Autoimmune hepatitis, Cancer 13. The serum levels of some of the common genotypes are PiMM: 100% (normal) PiMS: 80% of normal serum level of A1AT PiSS: 60% of normal serum level of A1AT PiMZ: 60% of normal serum level of A1AT PiSZ: 40% of normal serum level of A1AT PiZZ: 10-15% (severe alpha 1-antitrypsin deficiency) Treatment Lung-affected A1AD patients may receive intravenous infusions of alpha-1 antitrypsin, derived from donated human plasma. This augmentation therapy is thought to arrest the course of the disease and halt any further damage to the lungs. 14. 2014 15. GOLD 2014 16. Managing stable COPD: Stop smoking Encouraging patients with COPD to stop smoking is one of the most important components of their management All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity Record a smoking history, including pack years smoked Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates 17. Anti smoking therapy Nicotine replacement therapy Transdermal patches, gums, sprays, lozenges, inhalers Bupropion (Zyban) ( Anti depressant) Nicotinic receptor partial agonist - Varenicline (Chantix), Cystisine Psychosocial approaches Cognitive behavioral therapy VACCINES Influenza vaccines and Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years or more younger than age 65 with FEV1< 40% predicted 18. Pulmonary rehabitilation It is divided into Pharmacological Non pharmacological Non pharmacological includes exercises, nutritional plan Exercise is the cornerstone of pulmonary rehabilitation programs. Although, exercise training does not directly improves lung function, it causes improvement in physical condition. There are three basic types of exercises to be considered. Aerobic exercise tends to improve the body's ability to use oxygen by decreasing the heart rate and blood pressure. Strengthening or resistance exercises can help build strength in the respiratory muscles. Stretching and flexibility exercises like yoga can enhance breathing coordination. 19. Oxygen: titrate to improve the patients hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended . Manage Exacerbations: Treatment Options 2014 Global Initiative for Chronic Obstructive Lung Disease 20. Alpha-1 antitrypsin augmentation therapy: not recommended for patients with COPD that is unrelated to the genetic deficiency. Mucolytics: Patients with viscous sputum may benefit from mucolytics; overall benefits are very small. Antitussives: Not recommended. Vasodilators: Nitric oxide is contraindicated in stable COPD. The use of endothelium-modulating agents for the treatment of pulmonary hypertension associated with COPD is not recommended. Therapeutic Options: Other Pharmacologic Treatments 2014 Global Initiative for Chronic Obstructive Lung Disease 21. The phospodiesterase-4 inhibitor Roflumilast may be useful to reduce exacerbations for patients with FEV1 < 50% of predicted, chronic bronchitis, and frequent exacerbations Theophylline Theophylline is less effective and less well tolerated than inhaled long- acting bronchodilators and is not recommended if those drugs are available and affordable. There is evidence for a modest bronchodilator effect and some symptomatic benefit in stable COPD. Addition of theophylline to salmeterol produces a greater increase in FEV1 and a decrease in breathlessness than salmeterol alone. Low dose theophylline reduces exacerbations but does not improve post-bronchodilator lung function. 22. Role of Antibiotics Antibiotics should be given to patients with 3 cardinal symptoms A) Increased Dyspnoea B) Increased sputum volume C) Increased sputum prevalence And people who are on mechanical ventilation assistance 23. NEJM Aug 25th 2011 Adding Azithromycin, at a dose of 250 mg daily, for 1 year to the usual treatment of patients who have an increased risk of acute exacerbations of COPD Advantages 1) Decreased the number of exacerbations per year 2) the incidence of colonization with selected respiratory pathogens 3) Increased the quality of life Disadvantages 1) Increased hearing loss in a small % of patients 2) Prolonged QTc 24. Oxygen Therapy: The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival in patients with severe, resting hypoxemia. Ventilatory Support: Combination of noninvasive ventilation (NIV) with long-term oxygen therapy may be of some use in a selected subset of patients, particularly in those with pronounced daytime hypercapnia. Therapeutic Options: Other Treatments 2014 Global Initiative for Chronic Obstructive Lung Disease 25. Advantages Of NIPPV Decreases need for invasive ventilation and may be associated with improved outcome. CPAP alone can reduce work of breathing in COPD during weaning and during sleep. BiPAP weaning may be better than weaning on pressure support via an ETT. A lower rate of treatment failure ;lower mortality rate. Greater improvements in the 1-hour post-treatment pH and PaCO2 levels 26. Indication and Relative contraindication for NIPPV Selection Criteria: Moderate to severe dyspnea with the use of accessory muscles, paradoxical breathing. Moderate to severe acidosis PH 7.35 and/or PaCO2 > 45 mmHg or PaO2/FiO2 < 200 RR > 25 breaths/min,accessory muscle Exclusion Criteria: Respiratory arrest. Cardiovascular instability. Burns Extreme obesity. Craniofacial trauma. APACHE score >29 High aspiration risk(. Cannot protect the airway ) 27. Indications of IIPPV: Hypoxemia that has not corrected with NIPPV Exclusion criteria of NIPPV Sever acidosis PH60 mmHg Impending respiratory arrest Respiratory rate > 36 breaths/minute Use of all accessory muscles Thoracoabdominal paradox Even minor mental state changes Patient's subjective sense of exhaustion Cardiovascular instability 28. Management of a COPD patient on ventilator Use low tidal volumes to prevent stretching of the lung parenchyma and VIL (Ventilator induced injury) Another adverse effect of invasive mechanical ventilation in COPD is the generation or aggravation of PEEPi Auto (intrinsic) PEEP Incomplete expiration prior to the initiation of the next breath causes progressive air trapping . This accumulation of air increases alveolar pressure at the end of expiration, which is referred to as auto-PEEP. Auto-PEEP develops commonly in high minute ventilation expiratory flow limitation (obstructed airway) and expiratory resistance (narrow airway). Once auto-PEEP is identified, steps should be taken to stop or reduce the pressure build-up. When auto-PEEP persists despite management of its underlying cause, applied PEEP may be helpful if the patient has an expiratory flow limitation (obstruction). 29. Applied (extrinsic) PEEP A small amount of applied PEEP (3 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse. A higher level of applied PEEP (>5 cmH2O) is sometimes used to improve hypoxemia or reduce VILI in patients with acute lung injury, acute respiratory distress syndrome, or other types of hypoxemic respiratory failure. Complications Decrease in systemic venous return Pulmonary baotrauma can be caused. Pulmonary barotrauma is lung injury that results from the hyperinflation of alveoli past the rupture point. Raised ICP Renal functions and electrolyte imbalances, due to decreased venous return metabolism of certain drugs are altered and acid- base balance is impeded 30. Lung volume reduction surgery (LVRS) is more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity. LVRS is costly relative to health-care programs not including surgery. In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity. Surgical Treatments 2014 Global Initiative for Chronic Obstructive Lung Disease 31. LVRS Lung Transplantation Patient Factors Favoring LVRS over Lung Transplantation Age > 65 yr Chronic medical conditions: Chronic active viral hepatitis B, hepatitis C with biopsy-proven histologic evidence of liver disease, or HIV infection Organ system dysfunction precluding appropriate immunosuppressive therapy: renal insufficiency, liver dysfunction, neuropathy, significant osteoporosis, uncontrolled diabetes Refractory gastroesophageal reflux disease Malignancy Inability to maintain long-term follow-up Psychiatric conditions Lack of social support Patient Factors Favoring Lung Transplantation over LVRS FEV1 20% predicted and either homogeneous disease or DlCO 20% predicted Lack of emphysema on HRCT TLC < 100% predicted RV < 150% predicted PaCO2 > 60 mm Hg PaO2 < 45 mm Hg 6MWD 140 m, < 3 min unloaded pedaling on cycle ergometer Pulmonary hypertension Clinically significant bronchiectasis and/or recurrent pulmonary infections 32. Newer modalities A new study called the STASCOPE study funded by the National Heart Lung and Blood Institute is being conducted to determine if Simvastatin might reduce swelling in the lungs in patients with COPD. If it is found that Simvastatin reduces lung inflammation, there is a possibility that the statin drug could also the limit the number or severity of the exacerbations. Beta Blockers may reduce mortality and exacerbations when added to established inhaled stepwise therapy for COPD, independently of CVD and cardiac drugs, and without adverse effects on pulmonary function. 33. Asthma COPD Overlap Syndrome (ACOS) A chapter on Asthma and COPD Overlap Syndrome (ACOS) is in preparation by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). major criteria for ACOS: a physician diagnosis of asthma and COPD in the same patient, history or evidence of atopy, for example, hay fever, elevated total IgE, age 40 years or more, smoking >10 pack-years, postbronchodilator FEV1