An Update on Chronic Obstructive Pulmonary Disease.
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Transcript of An Update on Chronic Obstructive Pulmonary Disease.
An Update on Chronic Obstructive Pulmonary
Disease
No Company Affiliations Graduated from Medical University of South
Carolina in Charleston, 2000 Experience-14+ Years in Cardiology and
Pulmonary Practice in Coastal South Carolina
Now Back in Primary Care for past 9 months. What was I thinking!
80-100 patients per week (60% practice is Pulmonary medicine-40% Cardiology)
Discuss the pathophysiology of COPD, manifestations of disease process and diagnosis of COPD
Name the financial and Social Impact of COPD on U.S. and South Carolina population
Interpret and review effective diagnostic testing for COPD
Discuss current Pharmacologic Treatments of COPD
Discuss Non-Pharmacologic Treatments options
Defined as a common preventable and treatable disease, it is characterized by persistent airflow limitation that is also accompanied by chronic inflammation from exposure to noxious particles or gases
Causes include tobacco smoking, second hand smoke exposure, air pollution and occupational exposure
Clinical Diagnosis of COPD should be considered with patients who have dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors. Spirometry is required to make diagnosis.
Assessment of COPD is based on the patients symptoms, risk of exacerbations, severity of COPD (bases on spirometry) and comorbid conditions.
COPD is the 3rd leading cause of death in the United States
Many are not even aware they have it……
COPD was the 3rd leading cause of Death in the US in 2008
Approximately 13 million adults in US have COPD, however, estimated 24 million have evidence of impaired lung function=under diagnosis of disease
A retrospective analysis of HMO database showed that 81% of patients with COPD were not diagnosed until disease was moderate to severe
The projected annual cost for COPD in the US for 2010 was $50 billion (not million, yes billion!!!!)
Estimated related to cost-between 50% and 75% of all COPD cost are related to exacerbations
Frequency of exacerbations: 2 or more exacerbations in the first year of observational study showed ◦ 22% of patients with stage 2 disease◦ 33% of patients with stage 3 disease◦ 47% of patients with stage 4 disease
COPD Asthma CHF Bronchectasis TB Obliterative Bronchiolitis Diffuse Panbronchiolitis Bronchitis
Chronic Cough (smoker cough) Chronic Phlegm Production Shortness of Breath (limits activity) Not able to take deep breath Wheezing Recurrent Respiratory Infections/Bronchitis Hypoxemia
Goals of assessment to determine severity of disease and it’s impact on patients health to guide treatment therapy◦ Symptoms◦ Degree of airflow limitation (using spirometry)◦ Risk of exacerbations◦ Co-morbidities
May use tools such as CAT-COPD Assessment Tool
In 2015-Updates to Gold Guidelines Spirometry is required to make clinical
diagnosis of COPD Clinical Diagnosis should be considered in
any patient over age 40 who has dyspnea, chronic cough or sputum production, history of exposure to risk factors for disease and/or family history of COPD
In Patients with FEV1/FEC <70
(Based on post-bronchodilator FEV1)
GOLD 1 MILD FEV1 >= 80% PREDICTED
GOLD 2 MODERATE 50%<=FEV1<80% PREDICTED
GOLD 3 SEVERE 30%<=FEV1<50% PREDICTED
GOLD 4 VERY SEVERE FEV1<30% PREDICTED
Measure how well the lungs take in and release air
Measure how well the lungs move gases such as oxygen from the air into the body’s circulation
PFTs add additional information including Lung volume and diffusion capacity
Longer test and more expensive, however helpful in treatment
Use spirometry to make initial diagnosis and Full PFTs to guide therapy
Well trained staff-Does not have to be RT but need to do test well for accurate results.
Patient cooperation-If patient is not following direction and you don’t have good loop, less accurate results (May need full PFT to help make diagnosis)
Patient should not have had any respiratory medications within 4 hours of test and preferable that am (if possible).
Non-PharmacologicPharmacologicManagement of Stable COPDManagement of COPD exacerbations
Symptom relief Increase exercise tolerance Improve health Decrease disease progression Prevent exacerbations Treat exacerbations Decrease Mortality
Smoking Cessation!!!!!!◦ Counseling does help, counseling by physicians
and other health care professionals significantly increases quit rates over self-initiated strategies
◦ Nicotine replacement Therapy-gum, patches◦ Pharmacotherapy-varenicline, bupropion or
nortriptyline are more effective than placebo◦ Smoking prevention-once quit need to stay QUIT,
keep smoke free homes◦ Don’t Give Up! Keep on trying each and every
time you see them.
Occupational Exposure Indoor and Outdoor Air Pollution Vaccination Pneumococcal and FLU Physical Activity
◦ Which leads to PULMONARY REHABILITATON◦ The more you do the more you can do is so true
for COPD
Defined as evidence –based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities
Pulmonary rehab is designed to reduce symptoms, optimize functional status, increase participation and reduce health-care cost through stabilization
Utilized various healthcare disciplines Individualized plan of care with realistic
goals for patient Attention to physical and social function Each patient plan includes
◦ Patient assessment◦ Exercise training◦ Education◦ Psychosocial support
Medicare has a maximum life-time visits Private Insurance-Co pays Maintenance programs Patient Compliance Exacerbations Access to programs
Abbreviations: SA-short acting LA-long acting AC-anticholinergic BA-beta agonist ICS-inhaled corticosteroid PDE-4-phosphodiesterase-4
Patient Types:◦Type A-Low risk, Low symptoms◦Type B-Low risk, Increased symptoms◦Type C-High risk, Low symptoms◦Type D-High risk, High symptoms
Patient Type 1st 2nd Other
Type A-LR,LS SA AC or SA BA LA AC or LA BAOrSA AC or SA BA
Theophylline
Type B-LR, IS LA AC or LA BA LA AC & LA BA SA AC &/or SA BATheophylline
Type C-HR, LS ICS &
LA BA or LA AC
LA AC & LA BA or LA AC & PDE4OrLA BA & PDE4
SA BA &/or SA AC
Theophylline
Type D-HR, IS ICS &
LA BA
&/or LA AC
ICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4
Carbocystiene
N-acetylcysteine
SA BA &/or SA AC
Theophylline
Does anything Go?
Proair HFA-Albuterol Ventolin HFA-Albuterol Proventil HFA-Albuterol Xopenex HFA-Salbuterol Xopenex nebulizer Albuterol nebulizer
Arcapta Neohaler (Indacterol)-1 cap inhalation daily
Foradil Aerolizer (Formoterol)-1 inhalation BID
Serevent Diskus (Salmeterol)-1 inhalation BID
Striverdi Respimat (Olodaterol)-2 inhalations daily
Performist Nebulizer (Formoterol)-1 neb BID Brovana Nebulizer (Arformoterol)- 1 neb BID
Aerospan (Flunisolide) 80mcg 2-4 puffs BID Asmanex Twisthaler (Mometasone)110mcg and 220mcg
1-2 puffs daily-BID (max 440mcg/day) Asmanex HFA (Mometasone) 100,200mcg 2 puffs BID
(max 800mcg/day) Alveso (Ciclesonide) 80mcg and 160mcg-1 puff BID (max
320mcg/day) Pulmicort Flexhaler (Budesonide)90mcg and 180mcg-2
puffs BID Flovent Diskus (Fluticasone propionate) 50mcg, 100mcg
and 250mcg- 1-2 puffs BID (max 1000mcg/day) Flovent HFA (Fluticasone propionate) 44mcg, 110mcg,
220mcg-2 puffs BID (max 880mcg/day) Qvar HFA (Beclomethasone dipropionate)40mcg, 80mcg-
1-4 puffs BID (max 640mcg/day) Arnuity Ellipta (Fluticasone furoate)-1 inhalation daily
LA BA and Corticosteroid◦ Advair Diskus, (Fluticasone Propionate/salmeterol)
100/50, 250/50, 500/50-1 inhalation BID◦ Advair HFA (Fluticasone Propionate/salmeterol)
45/21, 115/21, 230/21-2 puffs BID◦ Symbocort HFA (Budesonide/Formoterol) 80/4.5,
160/4.5-2 puffs BID◦ Breo Elipa (Fluticasone furoate/vilanterol)100/25-1
inhalation Daily◦ Dulera (Mometasone/formoterol) 100/5, 200/5-2
puffs BID
Atrovent HFA (Ipratropium bromide)-2 puffs qid Atrovent Nebulizer (Ipratropium)-1 neb qid Spiriva Handihaler (Tiotropium)-1 inhalation
Daily Spiriva Respimat (Tiotropium)-2 puffs Daily Tudorza Pressair (Aclidinium bromide)-1 puff
BID Incruse Ellipta (Umeclidinium)-1 puff Daily Combivent Respimat (ipratropium
bromide/albuterol)-1 inhalation QID Anoro Elipta (Umeclidinium/vilanterol)-1
inhalation daily
LA BA and AC Combivent Respimat (ipratropium
bromide/albuterol)-1 inhalation QID Anoro Elipta (Umeclidinium/vilanterol)-1
inhalation daily Duonebs (ipratropium/albuterol) Nebulizer-1
QID
PDE-4 Phosphidiesterase-4 (roflumilast- Daliresp)
Mexthylxanthines-Theophylline/aminophylline
Mucolytic-Carbocystiene (not available in US) Mucolytic-N-acetylcysteine (Mucomist)
10% /ml solution, 6-10 ml nebulized and 20%ml solution, 3-5ml nebulized. Q 2 hours, max dose 10% 20ml and 20% 10ml
***must give with albuterol !!!!!**** Due to bronchospasms
Therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance◦ Bronchodilators
Inhaled therapy is preferred prescribed on as-needed or on a regular basis to
prevent or reduce symptoms Long-acting inhaled bronchodilators are convenient,
and maintaining symptoms relief compared to short acting bd
Combining bronchodilators (short and long) may improve efficacy and decrease risk of side effects
Inhaled Corticosteroids◦ In patients with FEV1 < 60% predicted, regular tx
with inhaled corticosteroids improves symptoms lung function quality of life reduces frequency of exacerbations
There is associated increased risk of pnemonia, withdrawal may lead to exacerbation.
Long-term monotherapy not recommended
Combined Inhaled Corticosteriod/ Bronchodilator Therapy◦ The IC/LBD is more effective than either individual
therapy in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD
Oral Corticosteroids-Long term not recommended
Phosphodiesterase-4 inhibitors- In Gold 3 and 4 patients with history of exacerbations and chronic bronchitis.
PD4 inhibitor is roflumilast or Daliresp Your experience? Our practice…
Mexthylxanthines◦ Less effective◦ Less well tolerated than LBD◦ Available and affordable◦ Evidence of modest BD effect◦ Aminophylline or Theophylline◦ Theophylline with salmeterol produces a greater
increase in FEV1 and relief of breathlessness than salmeterol alone.
◦ Low dose theophylline reduce exacerbations but does not improve post-bronchodilator lung function.
◦ Therapeutic values 10-20 (patient may get benefit and tolerate better at subtherapeutic levels of approx 8-12)
Vaccines including: Influenza and Pneumococcal vaccines can reduce serious illness and death
Alpha 1 Antitrypsin Therapy-For COPD related to Alpha 1 Defiency
Mucolytic Agents-for patient with excessive sputum, overall benefits small
Antitussive-use not recommended (however*)
Vasodilators-stable COPD with Pulmonary HTN
Pulmonary Rehabilitation Oxygen Therapy Ventilatory Support Surgical Treatments
◦ Lung Volume Reduction Surgery (LVRS)-need to qualify, emphysema upper lobe
◦ Lung Transplant, costly, need to live near transplant facility for at least 1 year and age requirements
Look at you patient type Look at spirometry and/or PFTs Mild/Moderate-start simple and work up Severe/Very Severe-be aggressive and get
symptoms under control then remember to back down (if able)
Symptom control/Quality of Life/Reduce Exacerbations & Mortality are key GOALS
Cost of meds does influence treatment
Patient Type 1st 2nd Other
Type A-LR,LS SA AC or SA BA LA AC or LA BAOrSA AC or SA BA
Theophylline
Type B-LR, IS LA AC or LA BA LA AC & LA BA SA AC &/or SA BATheophylline
Type C-HR, LS ICS &
LA BA or LA AC
LA AC & LA BA or LA AC & PDE4OrLA BA & PDE4
SA BA &/or SA AC
Theophylline
Type D-HR, IS ICS &
LA BA
&/or LA AC
ICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4
Carbocystiene
N-acetylcysteine
SA BA &/or SA AC
Theophylline
Defined as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication
Assess the severity◦ ABGs◦ CXR◦ CBC◦ Presence of purulent sputum◦ Sputum C&S◦ Spirometry NOT RECOMMENDED
Oxygen for hypoxemia with target saturation of 88-92%
SBD Systemic Corticosteroids
◦ 30-40mg for 10-14 days◦ Optional tx tapering dose◦ Patients with DM may have problems with
elevated glucose◦ Side effects of steroids
Antibiotics given to patients with◦ 3 symptoms of increased dyspnea, increased
sputum volume, increased sputum purulence
◦ Increased sputum purulence and one other cardinal symptoms
◦ Who require mechanical ventilation
CDC – www.cdc.gov/copd/data.htm Global Initiative for Chronic Obstructive Lung
Disease Pocket Guide (GOLD) 2015 Respiratory Care Connection-GSK Education
connection U.S. Department of health and human services,
Agency for Healthcare Research and Quality-www.ahrq.gov and www.guideline.gov and type in pulmonary rehabilitation
Aanma.org Mayoclinic.org
Thank You