Download Beyond the Wheez

COPD:
Beyond the Wheeze
KMA Scientific Conference
Ali AlMusawi, BMBCh, FRCPC
Objective
 Treating COPD, NOT only the Wheeze
COPD: Definition
 Chronic obstructive pulmonary disease (COPD): a common
preventable and treatable disease is characterized by 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.
GOLD 2016
 COPD is a respiratory disorder largely caused by smoking, and is
characterized by progressive, partially reversible airway
obstruction and lung hyperinflation, systemic manifestations, and
increasing frequency and severity of exacerbations.
O’Donnell et al, Can Respir J Vol 14 Suppl B September 2007
COPD: Risk Factors
 Cigarette smoke is the main inflammatory trigger in
COPD.
 Alpha1-antitrypsin (AAT) deficiency
 History of severe childhood respiratory infections
 History of Asthma
 Occupational exposures (particularly biomass fuel use)
and air pollution
COPD: Mortality
 In 2004, COPD was the fourth leading cause of death
in both men and women in the world, a significant
increase from 1999 when it was the fifth leading cause
of death.
http://www.who.int/mediacentre/factshe
ets/fs310/en/
COPD: Prevalence
 The reported prevalence of COPD ranged from 0.2% in
Japan to 37% in the USA, but this varied widely across
countries and populations, by diagnosis method, and
by age group analyzed.
International Journal of COPD 2012:7 457–494
 In Middle East ~3.5% based on BREATHE study
Respiratory Medicine (2012) 106(S2), S25–S32
COPD is systemic disease
 In most patients, the disease process affects the
airways (leading to airway remodeling) and
parenchyma (leading to emphysema and poor gas
exchange) leading to chronic (productive) cough and
exertional dyspnea.
COPD is systemic disease
 However, a substantial proportion of COPD patients
have extra-pulmonary symptoms and signs.
CVD
Metabolic
Syndrome &
DM
Cognitive
Decline
Depression
Anxiety
Renal
insufficiency
COPD
Anemia
Cancer
Muscle
weakness
Osteoporosis
Cachexia
COPD is systemic disease
 Prevalence of different comorbidities in COPD
patients by gender and GOLD stage (Dal Negro et al. Multidisciplinary
Respiratory Medicine (2015) 10:24)
 Cross-sectional of an Italian institutional data base over
the period 2012–2015
 At least one comorbidity of clinical significance was
found in 78.6 % of patients, but at least two in 68.8 %,
and three or more were found in 47.9 % of subjects.
COPD is systemic disease
 Comorbidities can occur in patients with mild, moderate
or severe airflow limitation, influence mortality and
hospitalizations independently, and deserve specific
treatment.
 Therefore, comorbidities should be looked for routinely,
and treated appropriately, in any patient with COPD.
Question
 What is the best predictor of having COPD
exacerbation?
 1. FEV1
 2. History of previous COPD exacerbations
 3. BMI
 4. SGRQ
Assessment of COPD
 People with same FEV1 have different health status,
dyspnea scores, comorbidities, exacerbation history,
etc.
 Spirometry is essential for the diagnosis of COPD, but
it doesn’t fully capture the impact of the disease on
individual patients
Assessment of COPD
 There is only a weak correlation between FEV1,
symptoms and impairment of a patient’s health-related
quality of life.
 For this reason, formal symptomatic assessment is also
required.
Assessment of COPD
 FEV1
 mMRC
 BODE (BMI/Obstructive/Dyspnea/exercise capacity) –
ADO (age/Dyspnea/ obstructive)
 HRQL: CRQ – SF-36 – SGRQ – CAT
 Combined COPD Assessment
Global Strategy for Diagnosis, Management and Prevention of COPD
Use combined assessment
3
2
(C)
(D)
>2
(A)
(B)
1
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Patient is now in one of
four categories:
A: Less symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
0
1
D: More symptoms, high risk
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)
Patient
First choice
Second choice
Alternative Choices
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
*LAMA and LABA
*PDE4-inh.
SABA and/or SAMA
Theophylline
ICS and *LAMA or
*ICS + LABA and *LAMA or
*ICS+LABA and *PDE4-inh. or
*LAMA and LABA or
*LAMA and *PDE4-inh.
Carbocysteine
SABA and/or SAMA
Theophylline
C
D
*ICS + LABA
or
*LAMA
*ICS + LABA
or
*LAMA
Question
What is single most important therapy that slows down
the progression of airflow limitation in patients with
COPD?
1. Tiotropium bromide
2. Combination of Inhaled corticosteroid and long acting
beta agonist
3. Smoking cessation
4. Pneumonia vaccine
Beyond the Wheeze:
Smoking cessation
 Cigarette smoking is the major cause of COPD.
 Smoking cessation is the single most important therapy
to retard the progression of airflow limitation and
positively influence survival.
Beyond the Wheeze:
Smoking cessation
 The Lung Health Study showed that patients with earlystage asymptomatic COPD who took part in a smoking
cessation program had a lower risk of all-cause mortality
compared with those who had not (follow-up: 14.5 years)
(Anthonisen et al. 2005)
Beyond the Wheeze:
Education
 Education provides important information to the patient
and family about the disease process, its comorbidity,
and its treatment.
 This information encourages active participation in
health care, promotes adherence to therapy and
provide self-management skills.
 It also helps patient and family to find ways to cope with
chronic illness and its comorbidities.
NEJM 360:1329-1335, 2009
Beyond the Wheeze:
Education
Common topics included in education include:
 Normal pulmonary anatomy and physiology.
 Pathophysiology of lung disease.
 Description and interpretation of medical tests.
 Self-management strategies. (Daily activities/energy
conservation, self-assessment & symptoms management)
 Breathing exercises.
 Medication use.
 Exercise principles.
Beyond the Wheeze:
Education
 A multicenter, randomized clinical trial was carried out in 7
hospitals.
 All patients had advanced COPD with at least 1 hospitalization for
exacerbation in the previous year.
 Patients were assigned to a self-management program or to usual
care.
 Hospital admissions for exacerbation of COPD were reduced by
39.8% (P = .01)
 Admissions for other health problems were reduced by 57.1% (P =
.01).
 Emergency department visits were reduced by 41.0% (P = .02)
 Unscheduled physician visits by 58.9% (P = .003).
Arch Intern Med. 2003;163(5):585-591.
Beyond the Wheeze:
Nutrition
 Cachexia and skeletal dysfunction: frequently
observed in patients with COPD and are associated
with poor functional capacity, reduced health status,
and increased mortality.
 Overall, nutritional depletion has been found in ~2035% of patients with stable COPD. However, among
patients with an FEV1 < 35 % predicted, 50% were
undernourished.
Respir med 87(Suppl B):45-47, 1993.
Proc Am Thorac Soc. 2008 May;5(4):519-23.
Beyond the Wheeze:
Nutrition
 PULMONARY CACHEXIA SYNDROME: Malnutrition
associated with advanced lung disease and is
characterized by loss of fatfree body mass.
 A weight <90 % of ideal body weight or BMI ≤20
 The pulmonary cachexia syndrome is associated with
an accelerated decline in functional status and is
associated with increase mortality.
Hallin et al. 2007, Respiratory Medicine (2007) 101, 1954–1960
Beyond the Wheeze:
Nutrition
 Nutritional support in COPD (eg, dietary advice, oral
supplementation) modestly improves some clinically
important outcomes such as:
 6MWT
 Inspiratory and expiratory muscle strength
 Quality of life
 Handgrip strength
 Weight
X But not mortality, spirometric values, or ABGs.
Beyond the Wheeze:
Nutrition
Respirology. 2013;18(4):616.
Beyond the Wheeze:
Nutrition
Respirology. 2013;18(4):616.
Beyond the Wheeze:
Nutrition
Respirology. 2013;18(4):616.
Beyond the Wheeze:
Nutrition
 Strategies to enhance caloric intake include eating
small frequent meals with nutrientdense foods (eg,
liquid nutritional supplements), eating meals that
require little preparation (eg, microwaveable), resting
before meals, and taking a daily multivitamin.
 Exercise has been shown to improve the effectiveness
of nutritional therapy and to stimulate appetite.
Beyond the Wheeze:
Exercise training
 Limitations to activity/exercise in COPD include:
1. Ventilatory/ gas-exchange limitations
2. Peripheral muscle deconditioning
3. Cardiovascular deconditioning
 Result in early onset anaerobic metabolism and the
production of lactic acidosis during exercise.
Beyond the Wheeze:
Exercise training
Mechanism of skeletal dysfunction:
- Catabolic sate (systemic steroid, ? low level of
testosterone)
- Cytokines ,especially TNF-α, can act synergistically to
inhibit messenger RNA expression for myosin heavy
chain, leading to decreased muscle protein synthesis.
 Vicious cycle: Dyspnea and fatigability (in advanced
COPD) ↓ exercise tolerance  immobility  muscle
dysfunction especially in the thighs and upper arms.
Beyond the Wheeze:
Exercise training
Comparison of Specific Expiratory, Inspiratory, and Combined Muscle Training Programs in COPD*
Chest. 2003;124(4):1357-1364. doi:10.1378/chest.124.4.1357
Figure Legend:
The distance walked in 6 min before and following the training period. 6MW = 6-min walk.
Beyond the Wheeze:
Exercise training
Effect of exercise training:
1. Improves endurance and aids in performance of activities
of daily living.
2. Helps reduce systemic blood pressure
3. Improves lipid profiles
4. Counteract depression and reduce anxiety associated with
dyspnea-producing activities.
5. Facilitates sleep
6. ? Reduce AECOPD and mortality

Beyond the Wheeze:
Exercise training
Am J Respir Crit Care Med 1999; 159:321
Beyond the Wheeze
 Vaccines (flu and pneumonia)
 Oxygen therapy
 Surgical option (Lung transplant, Bronchoscopic,
LVRS)
 Treatment of AECOPD
Beyond the Wheeze
The ultimate weapon
Beyond the Wheeze
Pulmonary Rehabilitation
ATS and ERS define Pulmonary Rehabilitation (PR):
Comprehensive intervention based on thorough patient
assessment followed by patient-tailored therapies that
include, but not limited to, exercise training, education
and behavior change, designed to improve the physical
and psychological condition of people with chronic
respiratory disease and to promote the long-term
adherence to health-enhancing behaviors.
Beyond the Wheeze
Pulmonary Rehabilitation
 PR and exercise training have been incorrectly considered to be
equivalent.
 Although exercise training is a necessary component of PR, other
interventions are integral to rehabilitation program; such as:
 Patient assessment
 Education (especially self-management strategies, inhaler
technique, promotion of activity in home and community)
 Breathing retraining exercise
 Nutritional intervention
 Psychosocial support
 Discussion of advance directives
Beyond the Wheeze
Pulmonary Rehabilitation
 Other therapies provided in PR program if indicated:
 Smoking cessation
 Chest physical therapy
 Oxygen therapy
 Occupational therapy
 Managing sleep disorder breathing (OSA, CSA, …etc)
Beyond the Wheeze
Pulmonary Rehabilitation
GOLD 2016
Beyond the Wheeze
Pulmonary Rehabilitation
GOLD 2016
Beyond the Wheeze
Take Home Message