Download COPD - Lothian Respiratory MCN

Chronic obstructive pulmonary
disease (COPD)
Professor Bill MacNee
Definition of COPD


COPD, a common preventable and treatable
disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
Exacerbations and comorbidities contribute to
the overall severity in individual patients.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Normal
COPD
Chronic
Bronchitis
COUGH and SPUTUM
Bronchiolitis
Small airways disease
AIRWAYS
OBSTRUCTION
BREATHLESSNESS
Emphysema
COPD:Quality Issues
• Diagnosis and assessment
• Therapy
• Reduction exacerbations
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputumrequires spirometry;
The diagnosis
occupation
shortness of breath
indoor/outdoor pollution

 a post-bronchodilator FEV1/(FVC) <0.7
confirms the presence of airflow limitation
that is not fully reversible.
SPIROMETRY
 Fixed ratio FEV1/FVC <0.7 may over diagnose
COPD in elderly
Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
 Assess comorbidities
Medical Research Council (MRC) Breathlessness Scale
Grade
Degree of
breathless-ness
related to
activities
1
2
3
4
Not troubled by
breathlessness
except on
strenuous
exercise.
Short of breath
when hurrying
or walking up a
slight hill.
Walks slower
than
contemporaries
on level ground
because of
breathlessness
or has to stop
for breath when
walking at own
pace.
Stops for
breath after
walking about
100m or after a
few minutes on
level ground.
5
Too breathless
to leave the
house, or
breathless
when dressing
or undressing.
COPD Assessment Test (CAT)
• Patients read the two
statements for each item, and
decide where on the scale
they fit
• Scores for each of the
8 items are summed to give
single, final score (minimum 0,
maximum 40)
• This is a measure of the
overall impact of a patient’s
condition on their life
1 Jones
P et al. Eur Respir J 2009; 34: 648-654
Severity
Severity
of Airflow
of COPD
Limitation
In patients with FEV1/FVC < 0.70:
Mild
Moderate
Severe
Very Severe
FEV1 > 80% predicted
50% < FEV1 < 80% predicted
30% < FEV1 < 50% predicted
FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Assess Risk of Exacerbations
To assess risk of exacerbations use
history of exacerbations and spirometry:
 Two or more exacerbations within the
last year or an FEV1 < 50 % of predicted
value are indicators of high risk.
 One or more hospitalizations for COPD
exacerbation should be considered high
risk.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Assess COPD Comorbidities
COPD patients are at increased risk for:
•
•
•
•
•
•
•
Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
These comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Manage Stable COPD: Goals of Therapy
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Reduce
symptoms
Reduce
risk
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
Combination long-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Therapeutic Options: Bronchodilators
 Long-acting inhaled bronchodilators are
convenient and more effective for symptom
relief than short-acting bronchodilators.

Long-acting inhaled bronchodilators reduce
exacerbations and related hospitalizations and
improve symptoms and health status.

Combining bronchodilators of different
pharmacological classes may improve efficacy and
decrease the risk of side effects compared to
increasing the dose of a single bronchodilator.
Therapeutic Options: Combination Therapy
 An inhaled corticosteroid combined with a long-acting
beta2-agonist is more effective than the individual
components in improving lung function and health
status and reducing exacerbations in moderate to
very severe COPD.
 Inhaled corticosteroids are associated with an
increased risk of pneumonia.
 Addition of a long-acting beta2-agonist/inhaled
glucorticosteroid combination to an anticholinergic
(tiotropium) provides additional benefits.
Therapeutic Options: Systemic corticosteroids

Chronic treatment with systemic
corticosteroids should be avoided
because of an unfavorable benefitto-risk ratio.
Therapeutic Options: Theophylline

Theophylline is less effective and less well tolerated
than inhaled long-acting bronchodilators.

There is evidence for a modest bronchodilator effect
and some symptomatic benefit compared with placebo in
stable COPD. Addition of theophylline to salmeterol
produces a greater increase in FEV1 and breathlessness
than salmeterol alone.

Low dose theophylline reduces exacerbations but does
not improve post-bronchodilator lung function.
Therapeutic Options: Other Pharmacologic
Treatments
Influenza vaccines can reduce serious illness.
Pneumococcal polysaccharide vaccine is recommended
for COPD patients 65 years and older and for COPD
patients younger than age 65 with an FEV1 < 40%
predicted.
The use of antibiotics, other than for treating
infectious exacerbations of COPD and other
bacterial infections, is currently not indicated.
NICE 2010-Inhaled therapies in COPD
Breathlessness and
exercise limitation
Exacerbations
or persistent
breathlessness
SABA or SAMA as required*
FEV1 < 50%
FEV1 ≥ 50%
LABA
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
Combined Assessment of COPD
3
2
1
ICS + LABA
or
(C)
LAMA
ICS + LABA
and/or
(D)
LAMA
SAMA prn
or
(A)
SABA prn
LABA
or
(B)
LAMA
≥2
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
2 CAT <
2 CAT 
Symptoms
10
10
Breathlessness
mMRC 0 mMRC 
1
2
© 2014 Global Initiative for Chronic Obstructive Lung Disease
(Exacerbation / year)
4
Risk
(GOLD classification of airflow limitation)
Risk
Recommended First Choice
Inhalers
Be sure to:
• teach the technique and recheck
• be familiar with different types of inhalers
• change inhalers if a patient is having trouble coping with a certain type
• encourage the use of spacer devices when needed.
The correct delivery system is as important as the drug used.
Nebulisers
•
•
•
nebuliser assessments trials should be done by secondary care
respiratory physicians (this gives an added benefit to the patient of
having the nebuliser maintained)
consider a nebuliser if the patient has excessive or distressing
shortness of breath despite maximum therapy.
nebulised therapy should not continue to be prescribed without
confirming improvement in one or more of the following:
•
a reduction in symptoms and/or
•
an increase in activities of daily living or exercise capacity.
PULMONARY REHABILITATION
Pulmonary rehabilitation benefits all patients with COPD,
particularly those with severe to very severe COPD or an MRC
breathlessness score of 3 or more.
All patients with repeated exacerbations or who are admitted
to hospital with an exacerbation should be fast tracked for
pulmonary rehabilitation.
Pulmonary rehabilitation:
•improves exercise tolerance
•improves the quality of life
•reduces symptoms
•reduces the number of exacerbations
•reduces hospital admissions
•available in all CHPs (In Edinburgh, CHP home-based
rehabilitation is available).
Oxygen therapy
SBOT - short-burst oxygen therapy
There is no good evidence to support the use of short burst oxygen
therapy.
LTOT - Long-term oxygen therapy
LTOT can prolong life. It is indicated in patients with hypoxaemia (PaO2
< 7.3 kPa) when in a stable condition. Secondary care assessment is
required for the provision of long-term oxygen therapy.
Consider long-term oxygen therapy in patients with:
• severe airflow obstruction (FEV1 < 40% predicted)
• cyanosis
• polycythemia
• raised JVP or peripheral oedema
• pulmonary hypertension
• O2 saturation of < 92% while breathing air.
Patients who continue to smoke will rarely be considered for long-term
oxygen therapy.
Consider ambulatory oxygen therapy in mobile patients on long-term
oxygen therapy.
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
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations: Key Points
 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.
 A dose of 40 mg prednisone per day for 5 days
© 2014 Global.Initiative for Chronic Obstructive Lung Disease
is recommended
Manage Exacerbations: Treatment Options
Antibiotics should be given to patients with:
 Three cardinal symptoms: increased
dyspnea, increased sputum volume, and
increased sputum purulence.
 Two cardinal symptoms if one of which
is increased sputum purulence.
ventilation.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
SAS
pulmonary
rehab
IMPACT
LUCS/GP
CRT
smoking
cessation
respiratory
physician
front door
RNS
Referral for Specialist Opinion
Consider referral if:
• diagnosis is unclear
• patient has severe COPD (FEV1 < 30% of predicted)
• cor pulmonale (fluid retention or peripheral oedema)
• increasing shortness of breath
• rapidly decreasing FEV1
• for assessment for O2 therapy if oxygen saturation
(92% or less) while breathing air
• chest x-ray shows bullae in the lung
• patient is less than 40years old
• symptoms are disproportionate to pulmonary function
• patient has frequent infections/exacerbations
• for assessment for nebuliser.