rountable copd jan 2012.ppt

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DIAGNOSIS AND MANAGEMENT OF

CHRONIC OBSTRUCTIVE PULMONARYDISEASE : GOLD 2011

IDA BAGUS NGURAH RAI

21-01-2012


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IV: Very SevereIII: SevereII: ModerateI: Mild

Therapy at Each Stage of COPD

FEV1/FVC < 70%

FEV1 > 80%predicted

FEV1/FVC < 70%

50% < FEV1 < 80%predicted

FEV1/FVC < 70%

30% < FEV1 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10

Symptoms(mMRC or CAT score))


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Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

mMRC>2

CAT >10


If mMRC 0-1 or CAT < 10:

Less Symptoms (A or C)

If mMRC> 2 or CAT >10:

More Symptoms (B or D)

Assess symptoms first


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Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


If GOLD 1 or 2 and only

0 or 1 exacerbations per year:Low Risk (A or B)

If GOLD 3 or 4 or two ormore exacerbations per year:

High Risk (C or D)

Assess risk of exacerbations next


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Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


Patient is now in one offourcategories:

A: Les symptoms, low risk

B: More symtoms, low risk

C: Less symptoms, high risk

D: More Symtoms, high risk

Use combined assessment


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Risk

(GOLD

ClassificationofA

irflow

Limitation

)

Risk

(Exacerbation

history)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC>2

CAT >10


Gl b l St t f Di i M t d


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Patien

t

Characteristic Spirometric

Classification

Exacerbations

per year

mMRC CAT

ALow Risk

Less SymptomsGOLD 1-2 1 0-1 < 10

BLow Risk

More Symptoms GOLD 1-2 1 >2 10

CHigh Risk

Less SymptomsGOLD 3-4 >2 0-1 < 10

DHigh Risk

More SymptomsGOLD 3-4 >2 >2

10

Global Strategy for Diagnosis, Management andPrevention of COPD

Combined Assessment

of COPDWhen assessing risk, choose the highestrisk

according to GOLD grade or exacerbation history


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Assess COPD Comorbidities

COPD patients are at increased risk for:

Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes

Lung cancerThese comorbid conditions may influence mortality

and hospitalizations and should be looked for

routinely, and treated appropriately.


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Additional Investigations

Chest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.

Lung Volumes and Diffusing Capacity:Help to characterizeseverity, but not essential to patient management.

Oximetry and Arterial Blood Gases:Pulse oximetry can be usedto evaluate a patients oxygen saturation and need for

supplemental oxygen therapy.

Alpha-1 Antitrypsin Deficiency Screening:Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD.


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Exercise Testing:Objectively measured exercise impairment,assessed by a reduction in self-paced walking distance (suchas the 6 min walking test) or during incremental exercisetesting in a laboratory, is a powerful indicator of healthstatus impairment and predictor of prognosis.

Composite Scores:Several variables (FEV1, exercisetolerance assessed by walking distance or peak oxygen

consumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality.


Additional Investigations


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Therapeutic Options: Key Points

Smoking cessation has the greatest capacity toinfluence the natural history of COPD. Health care

providers should encourage all patients who smoketoquit.

Pharmacotherapy and nicotine replacement reliablyincrease long-term smoking abstinence rates.

All COPD patients benefit from regular physicalactivity and should repeatedly be encouraged toremain active.


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Appropriate pharmacologic therapy can reduce COPDsymptoms, reduce the frequency and severity of

exacerbations, and improve health status andexercise tolerance.

None of the existing medications for COPD has beenshown conclusively to modify the long-term declinein lung function.

Influenza and pneumococcal vaccination should beoffered depending on local guidelines.


Therapeutic Options: Key Points


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Therapeutic Options: COPD Medications

Beta2-agonists

Short-acting beta2-agonists

Long-acting beta2-agonists

Anticholinergics

Short-acting anticholinergics

Long-acting anticholinergics

Combination short-acting beta2-agonists + anticholinergic in one inhaler

Methylxanthines

Inhaled corticosteroids

Combination long-acting beta2-agonists + corticosteroids in one inhaler

Systemic corticosteroids

Phosphodiesterase-4 inhibitors


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Bronchodilator medications are central to the

symptomatic management of COPD.

Bronchodilators are prescribed on an as-needed or on a

regular basis to prevent or reduce symptoms.

The principal bronchodilator treatments are beta2-agonists, anticholinergics, theophylline or combinationtherapy.

The choice of treatment depends on the availability of

medications and each patients individual response

in terms of symptom relief and side effects..


Therapeutic Options: Bronchodilators


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Long-acting inhaled bronchodilators are

convenient and more effective for symptom reliefthan short-acting bronchodilators.

Long-acting inhaled bronchodilators reduceexacerbations and related hospitalizations andimprove symptoms and healthstatus.

Combining bronchodilators of differentpharmacological classes may improve efficacy anddecrease the risk of side effects compared toincreasing the dose of a single bronchodilator.


Therapeutic Options: Bronchodilators



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Regular treatment with inhaled corticosteroids (ICS)

improves symptoms, lung function and quality of lifeand reduces frequency of exacerbations for COPD

patients with an FEV1


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An inhaled corticosteroid combined with a long-acting

beta2-agonist is more effective than the individualcomponents in improving lung function and health

status and reducing exacerbations in moderate to verysevere COPD.

Combination therapy is associated with an increased riskof pneumonia.

Addition of a long-acting beta2-agonist/inhaledglucorticosteroid combination to an anticholinergic(tiotropium) appears to provide additional benefits.


Therapeutic Options: CombinationTherapy



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Chronic treatment with systemic

corticosteroids should be avoided because ofan unfavorable benefit-to-risk ratio.


Therapeutic Options: SystemicCorticosteroids



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In patients with severe and very severeCOPD (GOLD 3 and 4) and a history ofexacerbations and chronic bronchitis, thephospodiesterase-4 inhibitor (PDE-4),roflumilast, reduces exacerbations treated

with oral glucocorticosteroids.

Therapeutic Options:Phosphodiesterase-4 Inhibitors

Gl b l St t f Di i M t d P ti f COPD


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Therapeutic Options: Theophylline

Theophylline is less effective and less well tolerated thaninhaled long-acting bronchodilators and is notrecommended if those drugs are available and affordable.

There is evidence for a modest bronchodilator effect andsome symptomatic benefit compared with placebo in stableCOPD. Addition of theophylline to salmeterol produces agreater increase in FEV1and breathlessness than

salmeterol alone.

Low dose theophylline reduces exacerbations but does notimprove post-bronchodilator lung function.



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Influenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1< 40%predicted.

The use of antibiotics, other than for treating infectiousexacerbations of COPD and other bacterial infections, iscurrently not indicated.

Therapeutic Options: OtherPharmacologic Treatments



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Alpha-1 antitrypsin augmentation therapy:notrecommended for patients with COPD that is unrelatedto the genetic deficiency.

Mucolytics:Patients with viscous sputum may benefitfrom mucolytics; overall benefits are very small.

Antitussives: Not recommended.

Vasodilators:Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associated

with COPD is not recommended.

Therapeutic Options: OtherPharmacologic Treatments

l b l f d f


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All COPD patients benefit from exercise trainingprograms with improvements in exercise toleranceand symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitationprogram is 6 weeks, the longer the programcontinues, the more effective the results.

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


Therapeutic Options: Rehabilitation

Gl b l S f Di i M d P i f COPD


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Oxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increase

survival in patients with severe, resting hypoxemia.

Ventilatory Support:Combination of noninvasiveventilation (NIV) with long-term oxygen therapy may

be of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia.


Therapeutic Options: Other Treatments


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Identification and reduction of exposure to risk factors

are important steps in prevention and treatment.

Individualized assessment of symptoms, airflow

limitation, and future risk of exacerbations should beincorporated into the management strategy.

All COPD patients benefit from rehabilitation andmaintenance of physical activity.

Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.

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Manage Stable COPD: Key Points



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Long-acting formulations of beta2-agonists

and anticholinergicsare preferred over short-acting formulations. Based on efficacy and

side effects, inhaled bronchodilators arepreferred over oral bronchodilators.

Long-term treatment with inhaled

corticosteroids added to long-actingbronchodilators is recommended for patientswith high risk of exacerbations.




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Long-term monotherapy with oral or inhaled

corticosteroids is not recommended inCOPD.

The phospodiesterase-4 inhibitor roflumilastmay be useful to reduce exacerbations forpatients with FEV1 < 50% of predicted,

chronic bronchitis, and frequentexacerbations.




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Relieve symptoms

Improve exercise tolerance

Improve health status

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

Reduce

symptoms

Reducerisk

Manage Stable COPD: Goals of Therapy



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Avoidance of risk factors

- smoking cessation- reduction of indoor pollution

- reduction of occupational exposure Influenza vaccination


Manage Stable COPD: All COPD Patients



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Manage Stable COPD: Non-pharmacologic

Patient Essential Recommended Depending on local

guidelines

A

Smoking cessation (can

include pharmacologic

treatment)

Physical activity

Flu vaccination

Pneumococcal

vaccination

B, C, D

Smoking cessation (caninclude pharmacologic

treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccination

Pneumococcal

vaccination


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Manage Stable COPD: PharmacologicTherapy


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Exa

cerbationsp

eryear

> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC>2

CAT >10

GOLD 3

GOLD 2

GOLD 1

SAMAprn

orSABA prn

LABA

orLAMA

ICS + LABA

or

LAMA


FIRST CHOICE

A B

DC

ICS + LABA

or

LAMA




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> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC> 2

CAT > 10

GOLD 3

GOLD 2

GOLD 1

LAMA or

LABA orSABA and SAMA

LAMA and LABA ICS and LAMA orICS + LABA and LAMA or

ICS + LABA and PDE4-inh or

LAMA and LABA orLAMA and PDE4-inh.

LAMA and LABA


SECOND CHOICE

A

DC

B

Exa

cerbationsperyear




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> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC> 2

CAT >10

GOLD 3

GOLD 2

GOLD 1

Theophylline

PDE4-inh.SABA and/or SAMA

Theophylline

CarbocysteineSABA and/or SAMA

Theophylline

SABA and/or SAMA

Theophylline


ALTERNATIVE CHOICES

A

DC

B

Exa

cerbationsperyear



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An exacerbation of COPD is:

an acute event characterized by a

worsening of the patients respiratorysymptoms that is beyond normal day-to-day variations and leads to a

change in medication.

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Manage Exacerbations



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The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.

Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.

The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.

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Manage Exacerbations: Key Points



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Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an

exacerbation. Systemic corticosteroids and antibiotics can shorten

recovery time, improve lung function (FEV1) andarterial hypoxemia (PaO

2),and reduce the risk of

early relapse, treatment failure, and length ofhospital stay.

COPD exacerbations can often be prevented.

g g g

ManageExacerbations: Key Points



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Arterialblood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa when breathing room airindicates respiratory failure.

Chestradiographs: useful to exclude alternative diagnoses.

ECG: may aid in the diagnosis of coexisting cardiac problems.

Whole bloodcount: identify polycythemia, anemiaor 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.

G oba St ategy o ag os s, a age e t a d e e t o o CO

Manage Exacerbations: Assessments



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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 ofhospital stay. A dose of 30-40 mg prednisolone per day for

10-14 days is recommended.

gy g , g

Manage Exacerbations:Treatment Options



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Antibiotics should be given to patients with:

Three cardinal symptoms: increased

dyspnea, increased sputum volume, andincreased sputum purulence.

Who require mechanical ventilation.

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ManageExacerbations:Treatment Options


ManageExacerbations:


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Noninvasive ventilation (NIV):

Improves respiratory acidosis, reduces

respiratory rate, severity of dyspnea,complications and length of hospital stay.

decreases mortality and needs forintubation.

GOLD Revision 2011

ManageExacerbations:TreatmentOptions


ManageExacerbations:Indications for


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Marked increase in intensity of symptoms

Severe underlying COPD

Onset of new physical signs

Failure of an exacerbation to respond to initialmedical management

Presence of serious comorbidities

Frequent exacerbations

Older age

Insufficient home support

ManageExacerbations:Indications for

Hospital Admission



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COPD often coexists with other diseases

(comorbidities) that may have a significant

impact on prognosis. In general, presence of

comorbidities should not alter COPD treatment

and comorbidities should be treated as if the

patient did not have COPD.

Manage Comorbidities



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Cardiovascular disease (including ischemic

heart disease, heart failure, atrial fibrillation,

and hypertension) is a major comorbidity inCOPD and probably both the most frequent

and most important disease coexisting with

COPD. Cardioselective beta-blockers are notcontraindicated in COPD.

ManageComorbidities



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Osteoporosis andanxiety/depression:often under-diagnosed and associated with poor health status andprognosis.

Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.

Serious infections: respiratory infectionsare especially

frequent.Metabolic syndrome and manifest diabetes: morefrequent in COPD and the latter is likely to impact on

prognosis.

ManageComorbidities


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November 14, 2012

Raising COPD Awareness Worldwide

rountable copd jan 2012.ppt

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