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COPD
Dr D Dimov
Definition of COPD
Chronic obstructive pulmonary disease
(COPD) is a disease state characterized by
airflow limitation that is not fully
reversible. The airflow limitation is usually
both progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases.
Deterioration in Lung Function in Patients with COPD
Sutherland E and Cherniack R. N Engl J Med 2004;350:2689-2697
Identify population at risk
Identify population at risk
Diagnosis
Identify population at risk
Diagnosis
Initial consultation
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
End of life care
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
End of life care
Assessment
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
End of life care
Assessment
Education
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
End of life care
Assessment
Education
Goals
Identify population at risk
Diagnosis
Initial consultation
Clinical review
…..
Clinical review
End of life care
Assessment
Education
Goals
Care plan
Identify population at risk
Diagnosis
Initial consultation
Clinical review
Assessment
Education
Smoking
Goals
Inhalers
Care plan
Rehabilitation
Nebuliser
Oxygen
…..
Vaccination
…..
Clinical review
End of life care
Identify population at risk
Diagnosis
Initial consultation
Assessment
Education
Smoking
Goals
Inhalers
Care plan
Rehabilitation
Clinical review
Nebuliser
Oxygen
…..
Vaccination
Assessment
Clinical review
Goals
Care plan
End of life care
…..
Identify population at risk
Diagnosis
Initial consultation
Assessment
Education
Smoking
Goals
Inhalers
Care plan
Rehabilitation
Clinical review
Nebuliser
Oxygen
…..
Exacerbation
Vaccination
Assessment
Clinical review
Exacerbation
Goals
Care plan
End of life care
…..
Identify population at risk
Diagnosis
Initial consultation
Assessment
Education
Smoking
Goals
Inhalers
Care plan
Rehabilitation
Clinical review
Nebuliser
Self management
…..
Home
H&H
Exacerbation
Vaccination
Assessment
Clinical review
Hospital
RCU
Oxygen
Exacerbation
Goals
Care plan
End of life care
…..
Diagnose COPD
Consider a diagnosis of COPD for people who are:
– over 35, and
– smokers or ex-smokers, and
– have any of these symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production,
- frequent winter ‘bronchitis’
- wheeze
[2004]
Definition of COPD
• Airflow obstruction is defined as reduced
FEV1/FVC ratio (< 0.7)
• It is no longer necessary to have an FEV1 < 80%
predicted for definition of airflow obstruction
• If FEV1 is ≥ 80% predicted, a diagnosis of COPD
should only be made in the presence of respiratory
symptoms, for example breathlessness or cough
FEV1 = forced expiratory volume in 1 second
FVC = forced vital capacity
Diagnose COPD
– The presence of airflow obstruction should be
confirmed by performing post-bronchodilator spirometry
[new 2010]
– All health professionals involved in the care of people
with COPD should have access to spirometry and be
competent in the interpretation of the results [2004]
• There are multiple interventions with
demonstrated or potential high impact on
COPD patients.
• All high impact interventions are efficient
for a selected group of patients with
certain severity of disease, impact of
disease on patient’s life and phenotype.
• Severity of disease, impact of disease on
patient’s life and sometimes phenotype
change during each individual patient’s
lifetime.
• How do we make sure that the right
interventions are provided for the right
patients?
• We need to know about:
– Severity of disease.
– Impact of disease on patient’s life.
– Patient’s phenotype.
– How the above three change with time?
Assess severity of airflow obstruction
using reduction in FEV1
NICE
clinical
guideline
12 (2004)
ATS/ERS
2004
GOLD 2008
NICE clinical
guideline
101 (2010)
Postbronchodilator
FEV1/FVC
FEV1 %
predicted
Postbronchodilator
Postbronchodilator
Postbronchodilator
< 0.7
80%
Mild
Stage 1
(mild)
Stage 1
(mild)*
< 0.7
50–79%
Mild
Moderate
Stage 2
(moderate)
Stage 2
(moderate)
< 0.7
30–49%
Moderate
Severe
Stage 3
(severe)
Stage 3
(severe)
< 0.7
< 30%
Severe
[new 2010]
Very severe Stage 4 (very Stage 4 (very
severe)**
severe)**
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction
** Or FEV1 < 50% with respiratory failure
Five-year survival according to the staging of disease severity as defined by the ATS
guideline evaluated by the percentage of predicted FEV1.
Nishimura K et al. Chest 2002;121:1434-1440
©2002 by American College of Chest Physicians
MRC Dyspnoea Scale
Grade 1
Not troubled by breathlessness except on
strenuous exercise
Grade 2
Short of breath when hurrying or walking
up a slight hill
Grade 3
Walks slower than contemporaries on level
ground because of breathlessness, or has to
stop for breath when walking at own pace
Grade 4
Stops for breath after walking about 100m
or after a few minutes on level ground
Grade 5
Too breathless to leave the house, or
breathless when dressing or undressing
Fletcher CM et al, BMJ 1959; 2:257-299.
Five-year survival according to the level of dyspnea as evaluated by the modified 5-point
grading system of Fletcher et al.10.
Nishimura K et al. Chest 2002;121:1434-1440
©2002 by American College of Chest Physicians
Oxygen desaturation during the 6MWT measured using a < 90% value as a threshold, and
Kaplan-Meier survival curves for all-cause mortality for those patients with FEV1 < 50% of
predicted and Pao2 ≥ 60 mm Hg with Spo2 values < 90% or > 90%.
Casanova C et al. Chest 2008;134:746-752
©2008 by American College of Chest Physicians
Pulmonary rehabilitation and the BODE index in COPD
C. G. Cote1 and B. R. Celli2 Eur Respir J 2005; 26:630-636
Kaplan-Meier survival curves for all patients. Patients participating in
pulmonary rehabilitation ( ) manifested a survival advantage compared with
patients who declined participation in pulmonary rehabilitation (•). p<0.0001 by
log rank.
Prognostic influence of BMI.
Chailleux E et al. Chest 2003;123:1460-1466
©2003 by American College of Chest Physicians
• The term “cachexia” highlights the
preferential loss of muscle over fat, with
evidence of increased protein degradation.
Friedlander a et al, COPD, 2007, 4:355-384
Body composition and mortality in chronic obstructive pulmonary disease1,2
Annemie MWJ Schols, Roelinka Broekhuizen, Clarie A Weling-Scheepers and Emiel F Wouters American
Journal of Clinical Nutrition, Vol. 82, No. 1, 53-59, July 2005
Body-composition categories are linked to Global Initiative for Chronic
Obstructive Pulmonary Disease (GOLD) disease severity stage in a category
comparison using the chi-square test. No impairment (n = 232; ); muscle atrophy
(n = 40; ); semistarvation (n = 23; ); cachexia (n = 117; ). Cachexia was
significantly (P = 0.001) more prevalent in GOLD stage IV (n = 207) than in
GOLD stage II (n = 71) or III (n = 134).
Body composition and mortality in chronic obstructive pulmonary disease1,2
Annemie MWJ Schols, Roelinka Broekhuizen, Clarie A Weling-Scheepers and Emiel F Wouters American Journal of
Clinical Nutrition, Vol. 82, No. 1, 53-59, July 2005
Cox regression plot for survival in different body-composition groups adjusted for age, sex, fat mass
index, forced expiratory volume in 1 s, inspiratory vital capacity, arterial oxygen tension, and arterial
carbon dioxide tension. Patients with low fat-free mass index [category 1 (cachexia; n = 117), solid black
line, and category 3 (muscle atrophy; n = 40), dashed gray line] had a significantly greater risk of mortality
than did patients with normal fat-free mass index [category 2 (semistarvation; n = 23), solid gray line, and
category 4 (no impairment; n = 232), dashed black line].
Outcomes of patients by exacerbation status and after 2 years of follow-up.
Cote C G et al. Chest 2007;131:696-704
©2007 by American College of Chest Physicians
All-cause 14.5-year survival.P.
Anthonisen N R et al. Ann Intern Med 2005;142:233-239
©2005 by American College of Physicians
BODE score
0
1
2
3
FEV1
(%)
> 65
50-65
35-50
35 or
less
Distance
walked in 6
min (m)
>350
250-349 150-250 150 or
less
MRC
dyspnoea
0-1
2
>21
21 or
less
scale
BMI
3
4
Kaplan-Meier Survival Curves for the Four Quartiles of the Body-Mass Index, Degree of Airflow
Obstruction and Dyspnea, and Exercise Capacity Index (Panel A) and the Three Stages of
Severity of Chronic Obstructive Pulmonary Disease as Defined by the American Thoracic Society
(Panel B)
Celli B et al. N Engl J Med 2004;350:1005-1012
Celli B et al. N Engl J Med 2004;350:1005-1012
BOD+activity score
0
1
2
3
FEV1 (%)
> 65
50-65
35-50
35 or
less
Number of hours
dedicated to cycling or
walking per week
>4
2-4
1-2
1 or
less
MRC dyspnoea scale
0-1
2
3
4
BMI
>21
21 or
less
Benzo R et al, ATS 2009, p.A2911
DOSE Index
0
1
2
3
Dyspnea Scale score (MRC)
0-1
2
3
4
Obstruction FEV1 % predicted
>50
30-49
<30
Smoking Status
Nonsmoker
Smoker
Exacerbations per year
0-1
2-3
>3
Jones R, Donaldson G, Chavanes N, et al; AJRCCM Vol 180 2009
The DOSE Index
Distribution of DOSE Index scores in the Devon validation cohort, presented for various
airflow obstruction grades. Solid = severe disease; gray = moderate disease; dashed =
mild disease.
Jones R C et al, American Journal of Respiratory and Critical Care Medicine Vol 180. pp. 1189-1195, (2009)
DOSE Index Correlations
6MWT
r = -0.54
p < 0.01
BMI
r = -0.30
p < 0.01
BODE
r = 0.78
p < 0.01
Jones R, Donaldson G, Chavanes N, et al; AJRCCM Vol 180 2009
Health Care Consumption
DOSE ≤ 4 DOSE > 4 p Value
Hospital admissions in 12
months
6%
34%
< 0.0001
Out-of-hours visits in 12
months (mean)
0.08
0.58
<0.0001
Emergency Department
attendances (mean)
0.1
0.44
0.06
Bed days (mean)
0.30
5.4
<0.0001
Jones R, Donaldson G, Chavanes N, et al; AJRCCM Vol 180 2009
ADO Index
Points 0
1
2
FEV1 (%
predicted
36-64%
<35%
Dyspnoea 0-1
(MRC
scale)
2
3
4
Age
50-59
60-69
70-79
>65%
40-49
3
4
5
80-89
>90
Puhan M, et al; Lancet 2009;374:704-11
ADO Index – Prediction of 3-year mortality
0
1
2
3
A
7.2
%
9.9
%
13.5 18.1 23.9 39.8 38.7 47.2 55.9 64.2
%
%
%
%
%
%
%
%
71.8
%
B
3.0
%
4.0
%
5.4
%
41.7
%
7.3
%
4
9.8
%
5
6
7
8
9
12.9 16.9 21.8 27.6 34.3
%
%
%
%
%
10
A – Patients with longstanding
and severe COPD.
B – Patients after first hospital
admission due to moderate-tosevere COPD.
Puhan M, et al; Lancet 2009;374:704-11
Composite Measures of Severity of COPD
BODE
BOD+activity
DOSE
ADO
Composite Measures of Severity of COPD
BODE
Age
FEV1%
MRC
BMI
Self reported activity
Smoking
Exacerbations
BOD+activity
DOSE
ADO
Composite Measures of Severity of COPD
BODE
Age
FEV1%
MRC
BMI
Self reported activity
Smoking
Exacerbations
BOD+activity
DOSE
ADO
Composite Measures of Severity of COPD
BODE
Age
FEV1%
MRC
BMI
Self reported activity
Smoking
Exacerbations
BOD+activity
DOSE
ADO
Composite Measures of Severity of COPD
BODE
Age
FEV1%
MRC
BMI
Self reported activity
Smoking
Exacerbations
BOD+activity
DOSE
ADO
Psychological Conditions (anxiety,
panic disorder and depression)
• During the last month have you often been
bothered by feeling down, depressed or
helpless?
• During the last month have you been
bothered by having little interest or
pleasure in doing things?
• Do you feel upset or frightened by your
attacks of breathlessness?
GPIAG, 2007
Looking at the Patient with COPD
Rennard S. N Engl J Med 2004;350:965-966
The classic Venn diagram used to describe the overlapping disease entities included in the
definition of COPD and the potential clinical subcategories (American Thoracic Society 1995
Consensus Statement on COPD).
Mapel D W Chest 2004;126:150S-158S
©2004 by American College of Chest Physicians
Phenotype
Observable structural and functional
characteristics of an organism determined
by its genotype and modulated by its
environment: the interactions between
‘‘nature’’ and ‘‘nurture’’
MeiLan K. Han et al, Am J Respir Crit Care Med Vol 182. pp 598–604, 2010
COPD phenotype - clinical and
patient-centered perspective
Able to classify patients into distinct
subgroups that provide prognostic
information and allow us to better
determine appropriate therapy that
alters clinically meaningful outcomes.
MeiLan K. Han et al, Am J Respir Crit Care Med Vol 182. pp 598–604, 2010
COPD phenotype - research
standpoint
Allow the selection of a uniform group
of patients and assess the most
important outcome measures in that
group for therapeutic clinical trials.
MeiLan K. Han et al, Am J Respir Crit Care Med Vol 182. pp 598–604, 2010
COPD Phenotype
‘‘a single or combination of disease
attributes that describe differences
between individuals with COPD as
they relate to clinically meaningful
outcomes (symptoms, exacerbations,
response to therapy, rate of disease
progression, or death).’’
MeiLan K. Han et al, Am J Respir Crit Care Med Vol 182. pp 598–604, 2010
Phenotypes of COPD
Clinical
Physiologic
Dyspnoea
Frequent exacerbator
Low BMI
Pulmonary cachexia
ICS-responsive
Depression & anxiety
Non-smokers
Airflow limitation
BD responsiveness
Rapid decliner
Airway hyperresponsiveness
Hypercapnic
Impaired exercise tolerance
Hyperinflation
COPD
Radiologic
Emphysema
Airways disease
Low DLco
Pulmonary hypertension
The Chronic Care Model of Wagner
• Promotion of self management.
• Comprehensive system to support clinical
management.
• Evidence based support for decision
making.
• Use of clinical guidelines.
Wagner EH; Effective Clinical Practice, 1998, 1:2-4.
Chronic Disease Management
•
•
•
•
•
•
•
•
Smoking cessation
Vaccinations
Pharmacological management
Exercise and pulmonary rehabilitation
Home oxygen therapy
Lung volume reduction
Treatment of the systemic effects of COPD
Palliative and end of life care.
Govern Balear
Smoking cessation
sustained
quitters
intermittent
quitters
continuous
smokers
Anthonisen N, et al. AJRCCM 2002.
Smoking Cessation
• One year sustained and validated
abstinence:
– Alone - 3%
– Doctor’s advice - 5-7%
– Pharmacotherapy and counsellor – 20%
Campbell Thorax 2001
All-cause 14.5-year survival.P.
Anthonisen N R et al. Ann Intern Med 2005;142:233-239
©2005 by American College of Physicians
UPLIFT Trial
Tashkin D et al.
N Engl J Med
2008;359:1543-1554
TORCH Trial
Calverley et al. NEJM 2007
Breezhaler – single dose dry powder inhaler
Onbrez will be delivered in a new, proprietary dry-powder device known as the
Breezhaler®. This inhaler has been designed to be robust, compact and
straightforward to use by patients.
The Breezhaler is a single-dose dry powder inhaler: one capsule must be inserted per
inhalation.
Onbrez Breezhaler: patient feedback
Hear
Feel
See
The Onbrez Breezhaler is designed to help patients know they have taken their
medication correctly:
Hear: During inhalation, the rotation of the capsule in the Breezhaler causes a
whirring sound.
Feel: The lactose powder results in a sweet taste in the patient’s mouth during
inhalation
See: The transparent capsule allows patients to see if any medication remains
following inhalation
Onbrez Breezhaler – flow rate
The low resistance Breezhaler device allows for high airflow rates: the figure
below shows that it takes less inspiratory effort for the patient to generate a
substantial airflow rate with the Breezhaler than with other widely used Dry
Powder Inhalers such as the HandiHaler®, Turbohaler® and Accuhaler®
Inspiratory Effort (kPa)
Singh et al ATS 2010
Use of inhaled therapies
Breathlessness and
exercise limitation
SABA or SAMA as required*
FEV1 ≥ 50%
Exacerbations
or persistent
breathlessness
LABA
FEV1 < 50%
LAMA
Discontinue
SAMA
________
Offer LAMA in
preference to regular
SAMA four times a
day
Persistent
exacerbations or
breathlessness
Offer
LABA + ICS
in a combination
inhaler
________
Consider LABA +
LAMA if ICS
declined or not
tolerated
Consider
LABA + ICS in a
combination
inhaler
________
Consider LABA +
LAMA if ICS
declined or not
tolerated
LAMA
Discontinue
SAMA
________
Offer LAMA in
preference to
regular SAMA four
times a day
LAMA + LABA + ICS
in a combination
inhaler
* SABAs (as required)
may continue at all stages
PDE4 Inhibitors - Roflumilast
• Patients:
– Smoking history of at least 20 pack years.
– Age older than 40 years.
– Confirmed diagnosis of COPD.
– Chronic cough and sputum production.
– At least one recorded exacerbation requiring
steroids or hospital admission in the previous
year.
Calverley PMA et al: Lancet 2009;374:685-94
Fabbri LM et al: Lancet 2009;374:695-703
PDE4 Inhibitors - Roflumilast
• Outcomes:
– Improved lung function and reduced
exacerbation rate:
• Compared to placebo.
• When added to Salmeterol.
• When added to Tiotropium
Calverley PMA et al: Lancet 2009;374:685-94
Fabbri LM et al: Lancet 2009;374:695-703
PDE4 Inhibitors - Roflumilast
• Adverse effects:
– Diarrhoea.
– Nausea.
– Headache.
– Weight loss.
Calverley PMA et al: Lancet 2009;374:685-94
Fabbri LM et al: Lancet 2009;374:695-703
PDE4 Inhibitors - Roflumilast
• Problems:
– High level of discontinuation in the first 12
weeks.
– Selection of a particular clinical phenotype of
COPD patients.
– No clear comparison with treatment with
inhaled corticosteroids.
Calverley PMA et al: Lancet 2009;374:685-94
Fabbri LM et al: Lancet 2009;374:695-703
Other Pharmacological
Interventions
•
•
•
•
•
Mucolytics
Long term antibiotics
Theophylline
PDE4 inhibitors – Roflumilast
New generation once-daily LABA Indacaterol
• Anti TNF antibodies
Home Oxygen Therapy
•
•
•
•
•
LTOT.
Ambulatory oxygen therapy.
Short burst oxygen therapy.
Palliative oxygen therapy.
Nocturnal oxygen therapy for ChainStokes respiration with central sleep
apnoea.
• Air travel
Govern Balear
LTOT
MRC. Lancet 1981.
NOTT. Ann Intern Med 1980.
Over an 18 day period
Over a 13 day period
Effects of breathing room air and 60% oxygen
O’Donnell DE, et al; AJRCCM, 2001 Mar;163(4):892-8.
4 hours plus
<90 mins/ day
90min 4hour
Borg score for breathlessness before and after exercise in (A)
patients breathing oxygen (open symbols) or air (solid symbols)
Stevenson, N J, Calverley PMA Thorax 2004;59:668-672
With nose clip
With face mask
Copyright ©2004 BMJ Publishing Group Ltd.
O’Donnell ED et al, Am. J. Respir. Crit. Care Med., Volume 164, Number 5, September 2001, 770-777
NETT trial – high risk subgroup
• Patients who should not have LVRS:
FEV1<20% and either homogenous
emphysema on CT-thorax or carbon
monoxide diffuse capacity
(uncorrected)<20%
– 140 such patients enroled – 70 for LVRS and 70 for
medical treatment.
– 30 day mortality:
medical teratment
- 0%
LVRS
-16%
LVRS (all risk factors) - 25%
NETT trial – non high risk patients
Predominantly
upper lobe
emphysema
Predominantly
non-upper lobe
emphysema
Low exercise
capacity
RR 0.47
p=0.005
RR 0.81
p=0.49
High exercise
capacity
RR 0.98
p=0.70
RR 2.06
p=0.02
A, Endobronchial valve (Emphasys, Redwood City, Calif)
Yim A. P. C. et al.; J Thorac Cardiovasc Surg 2004;127:1564-1573
Copyright ©2004 The American Association for Thoracic Surgery
IBV
Catheter Deployment
Regular physical activity reduces hospital
admission and mortality in Chronic
Obstructive Pulmonary Disease: a
population based cohort study
Garcia-Aymerich J, et al. Thorax 2006
Provide pulmonary rehabilitation
Make available to all
appropriate people, including
those recently hospitalised
for an acute exacerbation
Tailor multi-component,
multidisciplinary
interventions to individual
patient’s needs
[new 2010]
Pulmonary
rehabilitation
An individually tailored
multidisciplinary programme of
care to optimise patients’
physical and social
performance and autonomy
Hold at times that
suit patients, and in
buildings with good
access
Offer to all patients who
consider themselves
functionally disabled by
COPD
Multidisciplinary working
– COPD care should be delivered by a multidisciplinary team that
includes respiratory nurse specialists
– Consider referral to specialist departments (not just respiratory
physicians)
Specialist department Who might benefit?
Physiotherapy
People with excessive sputum
Dietetic advice
People with BMI that is high, low or
changing over time
Occupational therapy
People needing help with daily living
activities
Social services
People disabled by COPD
Multidisciplinary
palliative care teams
People with end-stage COPD (and
their families and carers)
[2004]
Self-management Plan
• The main aim of self-management is to
prevent exacerbations by life style
adaption and to allow patients to acquire
the skills to treat their exacerbation at an
early stage .
Monninkof EM, The Cochrane Library, 2003.
Personalised Care Planning
• It is widely recognised that personalised
care planning underpins excellent
management of LTCs.
• SHAs have also been asked to ensure
that the care plan commitment is included
in organisations’ plans for 2010/11 and is
cited in the Planning Checklist.
DH, LONG TERM CONDITIONS CARE PLANNING COMMITMENT, 04/03/2010
Systemic effects of COPD
• Cardiovascular disease
• Cachexia
• Osteoporosis
Managing exacerbations
– Minimise impact of exacerbations by:
• giving self-management advice on responding promptly to
symptoms of exacerbation
• starting appropriate treatment with oral steroids and/or antibiotics
• use of non-invasive ventilation when indicated
• use of hospital-at-home or assisted-discharge schemes
– The frequency of exacerbations should be reduced by appropriate
use of inhaled corticosteroids and bronchodilators, and vaccinations
[2004]
Breathlessness
“a subjective experience of breathing
discomfort”
“derives from interactions among multiple
physiological, psychological, social, and
environmental factors”
ATS. Am J Respir Crit Care Med, 1999, 159:321-40.
Breathlessness
“Patients whose dyspnoea can not be
alleviated through further treatment of their
COPD have intractable dyspnoea or
refractory dyspnoea.”
Abernethy AP et al. BMJ, 2003, 327:523-8.
Breathlessness – Oxygen Therapy
• Palliative oxygen is prescribed when primary goal is
relief of breathlessness.
• Inconclusive evidence.
• Prescribing on case by case basis.
• Clear goals of therapy in terms of relief of dyspnoea,
improvement in function and improvement in quality of
life.
• Evaluation of benefit before continuing therapy.
Uronis HE et al. International Journal of COPD, 2006:1(3) 289-304
Breathlessness – Pharmacological
interventions
Opioids
• Sustained release morphine preparation – 20 mg od.
• Long acting morphine product – 15 mg od increased to
15 mg bd after 5-7 days if the treatment is well tolerated
and there is residual breathlessness.
• Oxycodone 10 mg od increased to 10 mg bd after 5-7
days in patients not able to take morphine.
• Fentanyl transdermal patch is not recommended.
• Paients already on morphine – sequential increase of the
opioid by 20% of the total daily dose every 3-5 days.
Uronis HE et al. International Journal of COPD, 2006:1(3) 289-304
Breathlessness – Pharmacological
interventions
• Psychotropic drugs.
– Benzodiazepines – Diazepam
– Anxiolytics – Buspirone
– Phenothiazines – Promethazine
– SSRIs - Sertraline
• Emerging data.
– Nebulised furosemide.
– Heliox28
Breathlessness – Non-pharmacological
interventions
• Pulmonary rehabilitation.
• Breathing techniques.
• “Breathlessness clinics”.
–
–
–
–
Counseling.
Breathing re-training.
Relaxation.
Coping-adaptation strategies.
• Nutrition.
• Psychosocial support.
Key Priorities of the NICE
Clinical Guideline on COPD
•
•
•
•
Diagnose COPD
Stop smoking
Promote effective inhaled therapy
Provide pulmonary rehabilitation for all
who need it
• Use non-invasive ventilation
• Manage exacerbations
• Ensure multidisciplinary working