Download Systemic Corticosteroids

Management of Stable
COPD
Goals of Therapy :
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
Reduce
symptoms
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
Reduce
risk
© 2016 Global Initiative for Chronic Obstructive Lung Disease
Key points

Smoking cessation has the greatest capacity to influence the natural
history of COPD. Health care providers should encourage all patients
who smoke to quit.

Pharmacotherapy and nicotine replacement reliably increase long-term
smoking abstinence rates.

All COPD patients benefit from regular physical activity and should
repeatedly be encouraged to remain active.
Key points

Appropriate pharmacologic therapy can reduce COPD symptoms,
reduce the frequency and severity of exacerbations, and improve
health status and exercise tolerance.

None of the existing medications for COPD has been shown
conclusively to modify the long-term decline in lung function.

Influenza and pneumococcal vaccination should be offered
depending on local guidelines.
Smoking Cessation:

Counseling delivered by physicians and other health professionals
significantly increases quit rates over self-initiated strategies. Even
a brief (3-minute) period of counseling to urge a smoker to quit
results in smoking quit rates of 5-10%.

Nicotine replacement therapy (nicotine gum, inhaler, nasal spray,
transdermal patch, sublingual tablet) as well as pharmacotherapy
with varenicline, bupropion, and nortriptyline reliably increases
long-term smoking abstinence rates and are significantly more
effective than placebo.
Risk Reduction:

Encourage comprehensive tobacco-control policies with clear,
consistent, and repeated nonsmoking messages.

Emphasize primary prevention, best achieved by elimination or
reduction of exposures in the workplace

Reduce or avoid indoor air pollution from biomass fuel, burned for
cooking and heating in poorly ventilated dwellings.

Advise patients to monitor public announcements of air quality and,
depending on the severity of their disease, avoid vigorous exercise
outdoors or stay indoors during pollution episodes.
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
Combination long-acting beta2-agonist + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
© 2016 Global Initiative for Chronic Obstructive Lung Disease
COPD Medications
Key points:
 Long-acting formulations of beta2-agonists and anticholinergics are
preferred over short-acting formulations. Based on efficacy and side
effects, inhaled bronchodilators are preferred over oral
bronchodilators.
 Long-term treatment with inhaled corticosteroids added to long-acting
bronchodilators is recommended for patients with high risk of
exacerbations.
 Long-term monotherapy with oral or inhaled corticosteroids is not
recommended in COPD.
 The phospodiesterase-4 inhibitor roflumilast may be useful to reduce
exacerbations for patients with FEV1 < 50% of predicted, chronic
bronchitis, and frequent exacerbations.
Global Strategy for Diagnosis, Management and
Prevention of COPD
Combined Assessment
of COPD
Patient
Characteristic
Spirometric
Classification
Exacerbations
per year
CAT
mMR
C
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
© 2015 Global Initiative for Chronic Obstructive Lung Disease
>2
Manage Stable COPD: Non-pharmacologic
Patient
Group
Essential
A
Smoking cessation (can
include pharmacologic
treatment)
B, C, D
Smoking cessation (can
include pharmacologic
treatment)
Pulmonary rehabilitation
Recommended
Depending on local
guidelines
Physical activity
Flu vaccination
Pneumococcal
vaccination
Physical activity
Flu vaccination
Pneumococcal
vaccination
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
Patient
RecommendedFir
st choice
Alternative choice
Other Possible
Treatments
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
LAMA
or
LABA
LAMA and LABA
SABA and/or SAMA
Theophylline
ICS + LABA
or
LAMA
LAMA and LABA or
LAMA and PDE4-inh. or
LABA and PDE4-inh.
SABA and/or SAMA
Theophylline
ICS + LABA
and/or
LAMA
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or
LAMA and PDE4-inh.
Carbocysteine
N-acetylcysteine
SABA and/or SAMA
Theophylline
C
D
Group A :
low risk, less symptoms

GOLD stages 1-2 : FEV1 ≥ %50

0 - 1 Exacerbation in a year( not leading to hospital admission)

CAT score < 10
First choice: SAMA ( Atrovent) or SABA ( Salbutamol) Prn
Alternatives: LAMA(Tiotropium) or LABA(Salmeterol) or SABA+ SAMA
Other possible treatment: Theophyline
Group B :
low risk, more symptoms

GOLD stages 1-2 : FEV1 ≥ %50

0 -1 Exacerbation in a year (not leading to hospital admission)

CAT score ≥ 10
First choice: LAMA ( Tiotropium) or LABA ( Salmeterol, Formeterol)
Alternatives: LAMA + LABA
or
Other possible treatment: Theophyline , SAMA and/or SABA
Group C :
High risk, less symptoms

GOLD stages 3-4 : FEV1 < %50
 ≥ 1 Exacerbation in a year leading to hospital admission
≥ 2 Exacerbations in a year
 CAT score < 10
First choice: ICS ( seroflo, seretide, symbicort…) + LAMA or LABA
Alternatives: LAMA + LABA
or
LAMA+ PDE4 inh
LABA + PDE4 inh
or
Other possible treatment: Theophyline , SAMA and/or SABA
Group D :
High risk, more symptoms

GOLD stages 3-4 : FEV1 < %50

≥ 1 Exacerbation in a year leading to hospital admission
≥ 2 Exacerbations in a year

CAT score ≥ 10
First choice: ICS ( seroflo, seretide, symbicort…) + LAMA and/or LABA
Alternatives:
ICS+ LAMA + LABA
or
ICS+ LABA+ PDE4 inh or
LAMA + PDE4 inh
or
LAMA +LABA
Other possible treatment: Theophyline , SAMA and/or SABA, ACC, Carbocystein
Manage
Exacerbation of
COPD
Key points:

The most common causes of COPD exacerbations are viral upper
respiratory tract infections and infection of the tracheobronchial
tree.


Diagnosis relies exclusively on the clinical presentation of the
patient complaining of an acute change of symptoms that is beyond
normal day-to-day variation.

The goal of treatment is to minimize the impact of the current
exacerbation and to prevent the development of subsequent
exacerbations.

Short-acting inhaled beta2-agonists with or without short-acting
anticholinergics are usually the preferred bronchodilators for
treatment of an exacerbation.

Systemic corticosteroids and antibiotics can 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.

COPD exacerbations can often be prevented.
Consequences Of COPD Exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality
© 2016 Global Initiative for Chronic Obstructive Lung Disease
Assessments:

Arterial blood gas measurements (in hospital): PaO2 < 60mmhg
with or without PaCO2 > 50mmhg 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.
Treatment options:

Oxygen: titrate to improve the patient’s 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 .

Nebulized magnesium as an adjuvent to salbutamol treatment in
the setting of acute exacerbations of COPD has no effect on
FEV1.


Antibiotics should be given to patients with:

Three cardinal symptoms: increased dyspnea, increased
sputum volume, and increased sputum purulence.

Who require mechanical ventilation.
Non-invasive ventilation( NIV) :
 Improves respiratory acidosis, decreases respiratory rate, severity
of dyspnea, complications and length of hospital stay.
 Decreases mortality and needs for intubation.
Indications for Hospital Admission
1)
2)
3)
4)
5)
6)
7)
8)
Marked increase in intensity of symptoms
Severe underlying COPD
Onset of new physical signs
Failure of an exacerbation to respond to initial
medical management
Presence of serious comorbidities
Frequent exacerbations
Older age
Insufficient home support
COPD case

A 65 year old male comes to the Emergency department because of
shortness of breath.

He notes that over the last 2-3 years he has had gradual worsening of
his ability to exert himself without feeling out of breath, and it has been
acutely worse for the past week, including a worsening productive
cough.

On questioning, he reveals that he coughs almost every morning as
well, and this has been going on for even longer, perhaps 4-5 years.

The cough is now productive of yellowish-brownish sputum. He denies
chest pain, fevers, chills or night sweats. He has no history of lower
extremity edema. The rest of his review of systems is negative.
 He is 40Pack/year smoker. No history of other medical problems


On exam, his BP is 144/88 mmHg, HR is 98, respiratory rate is
28 breaths per minute. His temp is 37.2.
Oxygen saturation is documented as 93% on 4 L.

You find him sitting up in the bed, leaning forward and his lips
are bluish.

There is no cervical lymphadenopathy, JVD or carotid bruits.

Chest exam shows mild intercostal retractions seen around the
anterolateral costal margins. Wheezes and rhonchi are present
bilaterally, without crackles.

Heart exam is unremarkable, though the heart sounds are distant.

Lower extremities show no cyanosis, clubbing or edema.
Q. What is the most likely diagnosis?
 COPD
with acute exacerbation
Q. What should your target O2 saturation be for this patient?

Target oxygen saturation should be 90-92%.

Hypercapnia can accompany the aggressive use of supplemental oxygen.

This O2 target can help maximize hemoglobin saturation, and lessen the
likelihood of hypercapnia from ventilation/perfusion mismatches. Placing
patients with chronic COPD and acute respiratory failure on 100% O2 has
been shown to increased Pa Co2 by 23+,- 5 mmhg
Q. If this patient also had a history of heart failure, what test
might be helpful to exclude CHF as playing a role in the patients
dyspnea?

B-type natriuretic peptide (BNP) can be used to help
distinguish heart failure from other causes of dyspnea
Optimal Cut
Point (pg/mL)
Sensitivity
(%)
Specificity
(%)
PPV (%)
NPV (%)
All Patients
900
90
85
76
94
<50 years old
450
93
95
67
99
≥ 50 years olf
900
91
80
77
92
300
99
68
62
99
RULE-IN Cut Points
RULE-OUT Cut Point
All Patients

Chest X.ray showed mild hyperinflation without any obvious infiltrate

EKG revealed mild sinus tachycardia

On emergent cardiac echocardiography : EF=50% , mild RV dilation, 2+TR

Hct= 59% , Electrolytes were in normal ranges.
Q. What are the mainstays of treatment of acute COPD
Exacerbations in this patient?
 Bronchodilators:
the mainstay of therapy for acute
exacerbations. Data indicate similar efficacy with nebulizer or
MDI, but MDI requires patients to be more alert, and nebs still
recommended by many experts.
Short acting beta agonist ± Short acting anti cholinergic
combination nebulizer = Daulin
 Systemic
corticosteroids: Reduce 30 day treatment failure rate
(23% vs 33%), 90 day treatment failure rate (37-48%) and length
of hospital stay (8 vs 10 days), while improving lung function.
* 40mg/day for 5 days
 Antibiotics
Antibiotics are recommended for acute exacerbations of COPD that are
characterized by “increased volume and purulence of secretions.”
They decrease mortality and treatment failure rates, while accelerating
improvement of peak expiratory flow rates
 Mucolytics
The use of mucolytic agents, chest physiotherapy, intermittent positive
pressure breathing and directed coughing have not been shown to be
effective

The internal medicine resident is called by the emergency ward
nurse that admitted patient with COPD looks worse, and is now
somnolent and confused.
What is your recommended order?
1. Injection of a sedative drug
2. Increased the inhaled O2
3. Injection of another dose of corticosteroide
4. re- assessing of a new ABG

ABG revealed an increase of 25mmHg in Pa CO2, PH = 7.12
What do you prefer to do?
Non invasive ventilation or
Intubation and using of mechanical ventilation

Benefits of positive pressure-ventilation are lower rates of intubation,
lower in-hospital mortality rates and shorter hospital stays.

Patients with *respiratory arrest, *medical instability (hypotensive
shock, cardiac ischemia), *an inability to protect their airway,
*excessive secretions, *agitation or *uncooperativeness (or those with
*a facial structure that precludes proper mask fitting) are likely to
need intubation.

The patient was discharged after 5 days with administration of
Atrovent MDI prn and Theophyline 100mg bid.

8 months later a spirometry exam was done in stable situation and
it showed FEV1 = 58% and FEV1/FVC = 60%.

He has not experienced another admission due to exacerbation
during a one year of follow-up.

He complained of a large amount of sputum, daytime coughing
and difficult sleeping due to respiratory problem.
Q. In which stage he is? A, B, C or D
Stage B

Q. What is your recommended treatment right now?
1.
Increased the dose of Atrovent
2.
LAMA( Tiotropium Bromide) should be added
3.
ICS should be added
4.
SABA(salbutamol) added to Atrovent
Manage Stable COPD: Pharmacologic Therapy
RECOMMENDED FIRST CHOICE
ICS + LABA
or
LAMA
GOLD 3
GOLD 2
GOLD 1
D
2 or more
or
> 1 leading
to hospital
admission
ICS + LABA
and/or
LAMA
A
B
SAMA prn
or
SABA prn
CAT < 10
mMRC 0-1
LABA
or
LAMA
CAT > 10
mMRC > 2
© 2015 Global Initiative for Chronic Obstructive Lung Disease
1 (not leading
to hospital
admission)
0
Exacerbations per year
GOLD 4
C