diagnosis, treatment, and h1n1 - cdc emergency preparedness
TRANSCRIPT
December 14, 2009
COPD: Diagnosis, Treatment, and H1N1 Influenza Prevention
Clinician Outreach and Communication Activity (COCA) Conference Call
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In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.
CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Thomashow and he wishes to disclose receiving an honorarium for speaking from Boehringer Ingelheim, Pfizer, GlaxoSmithKline and Astra Zeneca and Dr. Mannino and he wishes to disclose receiving an honoraria and research support from GlaxoSmithKline and Pfizer, receiving an honoraria for being on the advisory board and serving as a speaker for Astra-Zeneca and Dey as well as receiving research support from Novartis.
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Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment
David M. Mannino, M.D.
University of Kentucky, College of Public Health
Byron Thomashow, M.D.
Columbia University College of Medicine
Chronic Bronchitis Emphysema
Asthma
IrreversibleAirflow Obstruction
ReversibleAirflow Obstruction
Friedlander et al, COPD 2007; 4: 355-384
COPD Phenotypes (NEW)
ClinicalDyspneaFrequent ExacerbatorLow BMIPulmonary CachexiaICS-responsiveDepression and AnxietyNon-smokers
PhysiologicAirflow limitationRapid declinerBD-responsivenessHyperrresponsivenessHypercapneicPoor exercise toleranceHyperinflationLow DLCOPulmonary hypertension
RadiologicEmphysemaAirways disease
COPD Prevalence, by Sex, in US, 1980–2000(Self-Reported Emphysema or Chronic Bronchitis)
Mannino DM, et al. MMWR. 2002; 51(SS-6):1–20.
0
1
2
3
4
5
6
7
8
1980 1985 1990 1995 2000
Men Women
Millions of adults aged 25 and older
COPD Deaths by SexUS, 1980 –2000
Mannino DM, et al. MMWR. 2002; 51(SS-6):1–20.
0
10
20
30
40
50
60
70
1980 1985 1990 1995 2000
Men Women
Deaths x 1,000 among adults age 25 and older
NHANES III Current Diseases as a Proportional Venn Diagram.NHANES III Current Diseases as a Proportional Venn Diagram.
Soriano et al. Soriano et al. ChestChest. 2003;124:474-481.. 2003;124:474-481.
Diagnosed Lung Disease and Lung Function Impairment in the US Adult Population
AsthmaAsthma 5.5%5.5%
Chronic bronchitisChronic bronchitis 3.2%3.2%
EmphysemaEmphysema 1.5%1.5%
Airflow obstruction int.Airflow obstruction int. 1.6%1.6%
Airflow obstruction ext.Airflow obstruction ext. 3.1%3.1%NHANES IIINHANES III
COPD Progression and Death
Fletcher et al, The Natural History of Chronic Bronchitis and Emphysema, 1976
Adapted from Fletcher and Peto, Burrows
Natural History of Chronic Airflow Obstruction
Baraldi et al, NEJM 2007
0
20
40
60
80
100
120
FEV1/FVC < 70% FEV1/FVC => 70%
Lung Function Categories
Gold 3
Gold 2 Restricted
Gold 0 (if symptoms)or Normal
Gold 1
FEV1 % predicted
Gold 4
Years
121086420
Su
rviv
al
1.0
.9
.8
.7
.6
Survival by Lung Function Impairment
GOLD 3 or 4
GOLD 2
GOLD 0
Normal
Restricted
GOLD 1
Mannino et al, Resp Med, 2006
0 10 20 30 40 50
GOLD 3/4
GOLD 2
GOLD 1
GOLD 0
Restricted
Normal
COPD ASCVD Lung Cancer Other
Mannino et al, Resp Med, Jan 2006
What do COPD Patients Die From? (rate per 1,000 person-years)
Current Smokers Former Smokers Never Smokers
Mannino DM, Watt G, Hole D, et al Eur Respir J. 2006;27:627-643.
COPD – Disease Burden in U.S.
Life Expectancy from Age 65 (Data from NHANES 3 Follow-up)
Females
Survival in GOLD 3/4 COPD By Smoking Status
Follow-up in Years
20100
Pro
po
rtio
n S
urv
ivin
g
1.0
.8
.6
.4
.2
0.0
Survival Among Subjects with GOLD 3 or 4 COPD
Never Smokers
Former Smokers
Current Smokers
From NHANES I follow-up
Smoking and GOLD 2+ COPD in NHANES 3
Life time Asthma and GOLD 2+ COPD Findings from NHANES 3
Per
cent
wit
h C
OP
D
Influence of vapor, dust, gas or fume exposure on COPD prevalence
0
5
10
15
20
25
COPD, Emphysema
Never Smoker/No Exposure Never Smoker/ Yes ExposureEver Smoker/ No Exposure Ever Smoker/ Yes Exposure
Percent of Subjects reporting COPD or Emphysema (n=2061 US adults aged 55-75)
Trupin et al, ERJ 2003; 22:462-469
From the ATS/ERS Guidelines
Adapted from Fletcher et al. BMJ. 1977;1:1645-1648 (B).
Lung Function Over Time
Never smoked or notsusceptible to smoke
Stopped smoking at 45
(mild COPD)
Stopped smoking at 65 (severe COPD)
Death
Disability
Smoked regularly and susceptible to effects of smoking
Age (years)50 7525
Symptoms
0
25
50
100
75
FE
V1
(%)
Rel
ativ
e to
Ag
e 25
When to Perform Spirometry:Diagnosis of COPD (GOLD Guidelines)
Executive Summary: Global Strategy for the Diagnosis, Management, and Prevention of COPD Updated 2005. Available at: http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2= 1&intId=996. Accessed June 6, 2006 (A).
Spirometry Spirometry
SymptomsExercise Impairment
Dyspnea, Wheezing Cough Sputum
SymptomsExercise Impairment
Dyspnea, Wheezing Cough Sputum
ExposureTobacco
OccupationalPollution
ExposureTobacco
OccupationalPollution
Spirometry Underused in Primary CareSpirometry Underused in Primary Care
Patient history and physical findings are not enough to accurately diagnose COPD
Only 1/3 of patients with COPD have undergone spirometry as part of their diagnosis1,2
Spirometry use decreases with increasing age– ≥75 years old vs all other age groups: 25.4% vs 32.7% (P<.0001)1
– Odds ratio (95% CI) of spirometry compared with patients age 50-59: Age 60-69, 0.82 (0.78-0.86); Age 70-79, 0.68 (0.65-0.71); Age 80+, 0.52 (0.49-0.55)2
1. Han MK et al. Chest. 2007;132:403-409.
2. Lee TA et al. Chest. 2006;129:1509-1515.
GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD
• FEV1/FVC <0.70
• FEV1 ≥80% predicted
I: Mild II: Moderate III: Severe IV: Very Severe
• FEV1/FVC <0.70
• 50% ≤FEV1 <80% predicted
• FEV1/FVC <0.70
• 30% ≤FEV1 <50% predicted
• FEV1/FVC <0.70
• FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
Add regular treatment with one or more long-acting bronchodilators (when needed):Add pulmonary rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long-term oxygen if chronic respiratory failureConsider surgical treatments
Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. www.goldcopd.com
Effects of Bronchodilators on Clinical Outcomes in Patients With COPD
Agent FEV1
Lung Volume Dyspnea HRQL*
Exercise Tolerance*
Disease Modifier by FEV1 Side Effects
Short-acting beta2-agonists
Yes Yes Yes N/A Yes N/A Minimal
Short-acting anticholinergic
Yes Yes Yes No Yes No Minimal
Long-acting beta2-agonists
Yes Yes Yes Yes Yes No Minimal
Long-acting anticholinergic
Yes Yes Yes Yes Yes No Minimal
Theophylline Yes Yes Yes Yes Yes N/A Potentially important
*Although the results from a number of drug studies are not uniform, many of the drugs studied provide these results. N/A=evidence not available.Adapted from Celli et al. Eur Respir J. 2004;23:932-946.
OPTIMAL STUDYTiotropium plus Fluticasone/Salmeterol
Combination did not significantly decrease exacerbations compared to Tio alone
Combination: Improved lung function
Combination: Improved quality of life
Combination: Decreased COPD hospitalizations
Combination: Decreased all cause hospitalizations
Aaron et al Annals Internal Med 2007;146:1-14
COPD: The Vicious Cycle
Cooper. Cooper. Med Sci Sports Exerc.Med Sci Sports Exerc. 2001;33(7 Suppl):S643-646. 2001;33(7 Suppl):S643-646.
Chronic Pulmonary DiseaseChronic Pulmonary Disease
Physical Physical DeconditioningDeconditioning
Physical Physical ReconditioningReconditioning
Decreased Decreased Exercise Exercise CapacityCapacity
Increased Increased Exercise Exercise CapacityCapacity
Increased Increased BreathlessnessBreathlessness
Decreased Decreased BreathlessnessBreathlessness
ImmobilityImmobility Pulmonary RehabilitationPulmonary Rehabilitation
Increased VIncreased VEE
RequirementRequirementDecreased VDecreased VEE
RequirementRequirement
GOLD Therapy at Each Stage of COPDGOLD Therapy at Each Stage of COPD
• FEV1/FVC <0.70
• FEV1 ≥80% predicted
I: Mild II: Moderate III: Severe IV: Very Severe
• FEV1/FVC <0.70
• 50% ≤FEV1 <80% predicted
• FEV1/FVC <0.70
• 30% ≤FEV1 <50% predicted
• FEV1/FVC <0.70
• FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure
Add regular treatment with one or more long-acting bronchodilators (when needed):Add pulmonary rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long-term oxygen if chronic respiratory failureConsider surgical treatments
Global Initiative for Chronic Obstructive Lung Disease (GOLD). NHLBI/WHO Workshop report. www.goldcopd.com
Oxygen reduces mortality in COPD patients with resting hypoxemia
CumulativeSurvival
(%)
COT = continuous oxygen therapy; NOT = nocturnal oxygen therapy; MRC controls = no oxygen therapy; MRC = domiciliary oxygen therapy.Flenley DC. Resp Care. 1983;2S:876.
Months
NIHCOT
MRCO2
NIHNOT
MRCcontrols
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70
Lung volume reduction surgery is appropriate in subgroups of COPD
All PatientsAll Patients
N = 1218N = 1218
High Risk PatientsHigh Risk Patients
N = 140N = 140
Non High Risk Non High Risk PatientsPatients
N = 1078N = 1078
Upper LobeUpper Lobe
High ExerciseHigh Exercise
N = 419N = 419
Upper LobeUpper Lobe
Low ExerciseLow Exercise
N = 290N = 290
Non Upper Non Upper LobeLobe
Low ExerciseLow Exercise
N = 149N = 149
Non Upper Non Upper LobeLobe
High ExerciseHigh Exercise
N = 220N = 220
LVRS
LVRS
Defined as an acute change in dyspnea, cough and/or sputum sufficient enough to warrant therapy change1
In a 12-month observational study (n=127), 77% of patients reported having at least one exacerbation2*
The prevention of exacerbations is recognized as a key goal in COPD disease state management3
1. American Thoracic Society/European Respiratory Society. Standards for the diagnosis and management of patients with COPD [Internet]. Version 1.2. www.thoracic.org/go/copd. Accessed April 30, 2008.
2. O’Reilly, et al. Prim Care Respir J. 2006;15:346-353.3. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic
obstructive pulmonary disease – Updated 2007. www.goldcopd.org. Accessed April 30, 2008.
COPD Exacerbations
*Based on diary records of symptom-defined and healthcare-defined exacerbations.
20%-24%20%-24%(1 year)(1 year)
2.5%-10%2.5%-10%(5 days)(5 days)
22%-32%22%-32%(14 days)(14 days)
13%-33%13%-33%(14 days)(14 days)
Hospital mortalityHospital mortality
Hospital mortalityHospital mortality
Relapse (repeat ER visit)Relapse (repeat ER visit)
Treatment failure rateTreatment failure rate
Outcome of COPD Exacerbations
Seneff et al. JAMA. 1995; 274:1852-1857; Murata et al. Ann Emerg Med. 1991;20:125-129; Adams et al. Chest. 2000; 117:1345-1352; Patil et al. Arch Int Med. 2003; 163:1180-1186.
In hospitalized In hospitalized patientspatients
In ER patientsIn ER patients
In ICU patientsIn ICU patients
In outpatientsIn outpatients
Health Status Changes Following an Exacerbation
30
35
40
45
50
55
60
4 Weeks 12 Weeks 26 Weeks
65
No Further Exacerbation
Baseline(At presentation with acute exacerbation)
Further ExacerbationWithin 6 Months
SG
RQ
Sc
ore
Spencer et al. Thorax. 2003;58:589-593 (A).
COPD ExacerbationsPreventative Measures
Long acting bronchodilators
Inhaled corticosteroids
Phosphodiesterase inhibitors
Mucolytics/Antioxidants
Immunizations-influenza vaccine pneumococcal vaccine
OM-85(Broncho-vaxim)
Macrolides
Case management
Lung Volume Reduction Surgery
COPD: High Risk For Flu Complications
•Aging immune system•On inhaled and oral steroids•Multiple co-morbidities•Impaired airway defenses•Reduced lung reserve
COPD and the Flu
•Everyone with COPD should get vaccinated against the seasonal flu.•Everyone with COPD should get the pneumococcal polysaccharide vaccine (PPSV).•Everyone with COPD should get vaccinated for the 2009 H1N1 influenza, using the shot (injectable) form.
COPD and the Flu
•Persons with COPD should not get the live attenuated nasal spray flu vaccines (i.e., FluMist).
•The inactivated 2009 H1N1 influenza vaccine can be administered at the same visit as any other vaccine, including the PPSV.
COPD ExacerbationsTherapy
Bronchodilators
Systemic steroids
Antibiotics
Oxygen
Noninvasive Positive Pressure Ventilation
Intubation
www.LearnAboutCOPD.org
Chronic Obstructive Pulmonary Disease
COPD is a PREVENTABLE and TREATABLE disease
ATS/ERS Guidelines for the Treatment of COPD, 2004
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