Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Global Initiative for Chronic Obstructive L ung Disease GOLD Website Address http://www.goldcopd.com 18/Oct/2005 Dr. David P. Breen 2 Facts About COPD COPD is the 4th leading cause of death in the United States (behind heart disease, cancer, and cerebrovascular disease). In 2000, the WHO estimated 2.74 million deaths worldwide from COPD. In 1990, COPD was ranked 12th as a burden of disease; by 2020 it is projected to rank 5th. 18/Oct/2005 Dr. David P. Breen 3 Leading Causes of Deaths U.S. 1998 Cause of Death Number Heart Disease 724,269 Cancer 538,947 Cerebrovascular disease (stroke) 158,060 Respiratory Diseases (COPD) 114,381 Accidents 94,828 Pneumonia and influenza 93,207 Diabetes 64,574 Suicide 29,264 Nephritis 26,295 Chronic liver disease 24,936 18/Oct/2005All other causes of death Dr. David P. Breen 469,314 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 4 Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 3.0 2.5 2.5 Coronary Heart Disease Stroke Other CVD COPD All Other Causes –59% –64% –35% +163% –7% 1965 - 1998 1965 - 1998 5 2.0 2.0 1.5 1.5 1.0 1.0 0.5 0.5 0.0 0 18/Oct/2005 1965 - 1998 1965 - 1998 Dr.1965 David P.-Breen 1998 Age-Adjusted Death Rates for COPD, U.S., 1960-1998 Deaths per 100,000 6060 White Male 5050 4040 Black Male 3030 White Female 2020 Black Female 1010 00 18/Oct/2005 1960 1960 1965 1965 1970 1970 P. Breen 1975 Dr. David 1980 1975 1980 1985 1985 1990 1990 1995 1995 6 2000 2000 Facts About COPD: U.S. Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million. The number of hospitalizations for COPD in 2000 was estimated to be 726,000. Medical expenditures in 2002 were estimated to be $18.0 billion. 18/Oct/2005 Dr. David P. Breen 7 Facts About COPD Cigarette smoking is the primary cause of COPD. In the US 47.2 million people (28% of men and 23% of women) smoke. The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are 18/Oct/2005 Dr. David P. Breen 8 increasing at an alarming rate. Irish Figures Diseases of the Respiratory system are the cause of one in five deaths in Ireland today In 1999 , Respiratory disease caused 7100 deaths: 3700 in men and 3400 in women 26% of respiratory deaths were due to COPD =1846 COPD-related deaths Clear social gradient: Respiratory mortality in the lowest occupational class was 200% higher than the highest occupational class Inhale survey 18/Oct/2005 Dr. David P. Breen 9 Clinically apparent disease Subclinical/ undiagnosed disease 18/Oct/2005 Dr. David P. Breen 10 COPD and Smoking 95% of COPD is caused by smoking 45% of young Irish adults are current smokers Prevalence of current smokers is higher in females (46.5% female v 44.2% male) 30% of school-leavers smoke ECRHS Group 18/Oct/2005 Dr. David P. Breen 11 Smoking in Ireland Adults in 1973 29% in 1994 27% now highest in lowest SE groups declining more slowly in women than men 43% Children and teenagers 1/10 6th class pupils smoke regularly, 15% boys, 5% girls 1/2 6th class pupils have tried smoking smoking increases steadily in teens in both sexes 30-35% of 17 yo Dublin schoolchildren smoke regularly, equal in both sexes 18/Oct/2005 Dr. David P. Breen 12 Lung Function decline 18/Oct/2005 Dr. David P. Breen 13 18/Oct/2005 Dr. David P. Breen 14 Global Initiative for Chronic Obstructive L ung Disease GOLD Workshop Report: Contents Introduction Definition and classification Burden of COPD Risk factors Pathogenesis, pathology, and pathophysiology Management Future research 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. 18/Oct/2005 Dr. David P. Breen 17 Burden of COPD Key Points The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women. Burden of COPD Key Points The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent. Burden of COPD Key Points The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions. Direct and Indirect Costs of COPD, 2002 (US $ Billions) Direct Medical Cost: $18.0 Total Indirect Cost: – Mortality related IDC – Morbidity related IDC $ 14.1 Total Cost 18/Oct/2005 7.3 6.8 $32.1 Dr. David P. Breen Source: NHLBI, NIH, DHHS 21 Risk Factors for COPD Host Factors Genes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth Exposure Tobacco smoke Occupational dusts and chemicals Infections Dr. David P. Breen 22 Socioeconomic status 18/Oct/2005 Pathogenesis of COPD NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) Genetic factors Respiratory infection Other COPD 18/Oct/2005 Dr. David P. Breen 23 Noxious particles and gases Host factors Lung inflammation Anti-oxidants Oxidative stress Anti-proteinases Proteinases Repair mechanisms COPD pathology 18/Oct/2005 Dr. David P. Breen 24 18/Oct/2005 Dr. David P. Breen 25 18/Oct/2005 Dr. David P. Breen 26 Causes of Airflow Limitation Irreversible Fibrosis and narrowing of the airways Loss of elastic recoil due to alveolar destruction Destruction of alveolar support that maintains patency of small airways 18/Oct/2005 Dr. David P. Breen 27 Causes of Airflow Limitation Reversible Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi Smooth muscle contraction in peripheral and central airways Dynamic hyperinflation during exercise 18/Oct/2005 Dr. David P. Breen 28 Objectives of COPD Management 18/Oct/2005 Prevent disease progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat exacerbations Prevent and treat complications Reduce mortality Minimize sideDr.effects David P. Breen from treatment 29 GOLD Workshop Report Four Components of COPD Management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD Education Pharmacologic Non-pharmacologic 4. Manage exacerbations 18/Oct/2005 Dr. David P. Breen 30 Assess and Monitor Disease: Key Points Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms. 18/Oct/2005 Dr. David P. Breen 31 Assess and Monitor Disease: Key Points Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea. 18/Oct/2005 Dr. David P. Breen 32 Assess and Monitor Disease: Key Points For the diagnosis and assessment of COPD, spirometry is the gold standard. Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry. 18/Oct/2005 Dr. David P. Breen 33 Assess and Monitor Disease: Key Points Measurement of arterial blood gas tension should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure. 18/Oct/2005 Dr. David P. Breen 34 Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough sputum dyspnea tobacco occupation indoor/outdoor pollution SPIROMETRY 18/Oct/2005 Dr. David P. Breen 35 Spirometry: Normal and COPD 0 FEV1 Normal COPD 1 Liter 2 FVC FEV1/ FVC 4.150 5.200 80 % 2.350 3.900 60 % FEV1 3 COPD 4 FVC FEV1 Normal 5 1 18/Oct/2005 2 3 FVC 4 Dr. David P. Breen 5 6 Seconds 36 Factors Determining Severity Of Chronic COPD Severity of symptoms Severity of airflow limitation Frequency and severity of exacerbations Presence of complications of COPD Presence of respiratory insufficiency Comorbidity General health status Number of medications needed to manage the disease 18/Oct/2005 Dr. David P. Breen 37 Classification by Severity Stage Characteristics 0: At risk Normal spirometry Chronic symptoms (cough, sputum) I: Mild FEV1/FVC < 70%; FEV1 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV1/FVC < 70%; 50% FEV1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) III: Severe FEV1/FVC < 70%; 30% FEV1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) IV: Very Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 18/Oct/2005 Dr. David P. Breen < 50% predicted plus chronic respiratory failure 38 GOLD Workshop Report Four Components of COPD Management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD Education Pharmacologic Non-pharmacologic 4. Manage exacerbations 18/Oct/2005 Dr. David P. Breen 39 Reduce Risk Factors Key Points • Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. • Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD and stop its progression (Evidence A). Reduce Risk Factors Key Points Brief tobacco dependence treatment is effective (Evidence A), and every tobacco user should be offered at least this treatment at every visit to a health care provider. Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A). Reduce Risk Factors Key Points Several effective pharmacotherapies for tobacco dependence are available (Evidence A), and at least one of these medications should be added to counseling if necessary, and in the absence of contraindications. Reduce Risk Factors Key Points Progression of many occupationallyinduced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases (Evidence B). Brief Strategies To Help The Patient Willing To Quit Smoking • ASK • ADVISE • ASSESS • ASSIST Systematically identify all tobacco users at every visit. Strongly urge all tobacco users to quit. Determine willingness to make a quit attempt. Aid the patient in quitting. • ARRANGE Schedule follow-up contact. GOLD Workshop Report Four Components of COPD Management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD Education Pharmacologic Non-pharmacologic 4. Manage exacerbations 18/Oct/2005 Dr. David P. Breen 45 Manage Stable COPD Key Points The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment, depending on the severity of the disease. For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A). 18/Oct/2005 Dr. David P. Breen 46 Manage Stable COPD Key Points None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A). Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications. 18/Oct/2005 Dr. David P. Breen 47 Manage Stable COPD Key Points Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. The principal bronchodilator treatments are beta2agonists, anticholinergics, theophylline, and a combination of these drugs (Evidence A). 18/Oct/2005 Dr. David P. Breen 48 Bronchodilators in Stable COPD Bronchodilator medications are central to symptom management in COPD. Inhaled therapy is preferred. The choice between beta2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects. 18/Oct/2005 Dr. David P. Breen 49 Bronchodilators in Stable COPD Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms. Regular treatment with long-acting inhaled bronchodilators is more effective and convenient than treatment with short-acting bronchodilators, but more expensive. Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. 18/Oct/2005 Dr. David P. Breen 50 Manage Stable COPD Key Points Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A). This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A). Dr. David P. Breen 18/Oct/2005 51 Manage Stable COPD Key Points Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A). All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A). 18/Oct/2005 Dr. David P. Breen 52 Manage Stable COPD Key Points The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A). 18/Oct/2005 Dr. David P. Breen 53 Management of COPD by Severity of Disease Stage 0: At risk Stage I: Mild COPD Stage II: Moderate COPD Stage III: Severe COPD 18/Oct/2005 Stage IV: Very Severe COPD Dr. David P. Breen 54 Management of COPD: All stages Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure 18/Oct/2005 Influenza vaccination Dr. David P. Breen 55 Management of COPD Stage 0: At Risk Characteristics Recommended Treatment • Chronic symptoms - cough - sputum • No spirometric abnormalities 18/Oct/2005 Dr. David P. Breen 56 Management of COPD Stage I: Mild COPD Characteristics Recommended Treatment • FEV1/FVC < 70 % • FEV1 > 80 % predicted • With or without chronic symptoms 18/Oct/2005 • Short-acting Dr. David P. Breen bronchodilator as needed 57 Management of COPD Stage II: Moderate COPD Characteristics Recommended Treatment • FEV1/FVC < 70% • 50% < FEV1< 80% predicted • With or without chronic symptoms 18/Oct/2005 • Short-acting bronchodilator as needed • Regular treatment with one or more long-acting bronchodilators • Rehabilitation Dr. David P. Breen 58 Management of COPD Stage III: Severe COPD Characteristics Recommended Treatment • FEV1/FVC < 70% • 30% < FEV1 < 50% predicted • With or without chronic symptoms 18/Oct/2005 • Short-acting broncho- dilator as needed • Regular treatment with one or more long-acting bronchodilators • Inhaled glucocorticosteroids if repeated exacerbations Dr. David P. Breen • Rehabilitation 59 Management of COPD Stage IV: Very Severe COPD Characteristics Recommended Treatment • Short-acting bronchodilator as needed • Regular treatment with one or more long-acting bronchodilators • Inhaled glucocorticosteroids if repeated exacerbations • Treat complications • Rehabilitation • Long-term oxygen therapy if respiratory failure Dr. David• P.Consider Breen 60 surgical options • FEV1/FVC < 70% • FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure 18/Oct/2005 Therapy at Each Stage of COPD Old (2001) 0: At Risk I: Mild New (2003) 0: At Risk I: Mild Characteristics Chronic Symptoms Exposure to risk factors Normal spirometry FEV1/FVC < 70% FEV1 80% With or without symptoms II: Moderate IIA IIB II: Moderate III: Severe III: Severe FEV1/FVC < 70% 50% < FEV1 < 80% With or without symptoms FEV1/FVC < 70% 30% < FEV1 < 50% With or without symptoms IV: Very Severe FEV1/FVC < 70% FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more longacting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations 18/Oct/2005 Dr. David P. Breen Add long-term oxygen if chronic respiratory failure 61 Consider surgical treatments GOLD Workshop Report Four Components of COPD Management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD Education Pharmacologic Non-pharmacologic 4. Manage exacerbations 18/Oct/2005 Dr. David P. Breen 62 Manage Exacerbations Key Points Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B). 18/Oct/2005 Dr. David P. Breen 63 Manage Exacerbations Key Points Inhaled bronchodilators (beta2-agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for the treatment of COPD exacerbations (Evidence A). 18/Oct/2005 Dr. David P. Breen 64 Manage Exacerbations Key Points Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, and/or fever) may benefit from antibiotic treatment (Evidence B). 18/Oct/2005 Dr. David P. Breen 65 Manage Exacerbations Key Points Noninvasive intermittent positive pressure ventilation (NIPPV) in exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A). 18/Oct/2005 Dr. David P. Breen 66 Management of COPD In selecting a treatment plan, the benefits and risks to the individual, and the direct and indirect costs to the individual, his or her family, and the community must be considered. 18/Oct/2005 Dr. David P. Breen 67 Could it be COPD? Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and don’t know it. If you answer these questions, it will help you find out if you could have COPD. 1. Do you cough several times most days? Yes ___ No ___ 2. Do you bring up phlegm or mucus most days? Yes ___ No ___ 3. Do you get out of breath more easily than others your age? Yes ___ No ___ 4. Are you older than 40 years? Yes ___ No ___ 5. Are you a current smoker or an ex-smoker? Yes ___ No ___ If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better. 18/Oct/2005 David lungs……Learn P. Breen Take time to think aboutDr.your about COPD! 68 GOLD Website Address http://www.goldcopd.com 18/Oct/2005 Dr. David P. Breen 69 18/Oct/2005 Dr. David P. Breen 70 Spirometry is the GOLD Standard for the diagnosis of COPD 18/Oct/2005 Dr. David P. Breen 71 Smoking Cessation Pre-contemplator Relapse contemplation Action 18/Oct/2005 Dr. David P. Breen 72 18/Oct/2005 Dr. David P. Breen 73 Pharmacological treatment 1st line treatment Nicotine replacement Nicotine polacrilex (gum) Transdermal nicotine Nicotine inhaler Nicotine nasal spray Nicotine lozenges Combined modality Bupropion 2nd line treatment Clonidine Nortripyline 18/Oct/2005 Dr. David P. Breen 74 Management of Stable Disease Smoking cessation Pharmacological treatment LTOT Pulmonary rehabilitation Surgery 18/Oct/2005 Dr. David P. Breen 75 Pharmacological therapy Medications can reduce or abolish symptoms,increase exercise tolerance,reduce no and severity of symptoms and improve health status No treatment alters the rate of decline of lung function Inhaled route is preferable – smaller doses and therefore reduced side effects by inhalation Combining agents have a greater effect on symptoms than single agents 18/Oct/2005 Dr. David P. Breen 76 General principles Patients must be educated in the device Choose right device for patient – MDI v DPI v Spacer device Spacer good for delivery and reduce oral s/e Compliance is variable – studies show at east 85% of patients take 70% of the prescribed doses - ? Reflect the constant symptoms Education is essential for good adherence and proper use Spirometry essential for diagnosis but not for monitoring 18/Oct/2005 Dr. David P. Breen 77 Bronchodilators Β2 agonist Anticholinergic agents Methylxanthines Mode of action is smooth muscle relaxation – small changes in FEV but decreases in lung volumes resulting in better emptying and less hyperinflation 18/Oct/2005 Dr. David P. Breen 78 Β2 agonist Inhaled (short , long acting), oral Mode of action Increase in c-amp within cells and promote smooth muscle relaxation ?other non bronchodilator effects S/E Palpitations, PVC Tremor Sleep disturbance Metabolic - hypokalaemia 18/Oct/2005 Dr. David P. Breen 79 Anticholinergic drugs Only available via inhaled route Ipratropium Oxitropium Tiotropium Inhibit muscarinic receptors Tiotropium remains bound to receptors for up to 36 hours Onset of bronchodilatation in 30 mins S/E Not associated with significant incidence of prostatism or cardiac S/E Commonest – dry mouth(tiotropium), metallic taste (ipratropium), closed angle glaucoma 18/Oct/2005 Dr. David P. Breen 80 Methylxanthines Oral or I.V prn preparations Non specific PDE inhibitors and increase c-amp Bronchodilatation only occurs at high dose and narrow therapeutic/toxic window Keep at level of 8-14 ug.dl Can be bd or od drugs S/E Major – ventricular and atrial rhythm disturbance, convulsions Minor – headache, nausea, vomiting, diarrhoea and heartburn 18/Oct/2005 Dr. David P. Breen 81 Levels increased Respiratory acidosis CCF Liver cirrhosis Erthyromycin ciprofloxacin 18/Oct/2005 Levels decreased Cigarette smoke Anti-convulsant drugs rifampicin Dr. David P. Breen 82 Glucocorticoids Inhalation Beclomethasone Budesonide Triamcinolone Fluticasone Flunisolide Oral Not 18/Oct/2005 indicated in stable – excessive S/E profile Dr. David P. Breen 83 Pharmacology S/E Effect transcription processes – slow action High dose can be absorbed via the pulmonary circulation Oral – osteoporosis, cataracts, peripheral myopathy Topical/local S/E can be significant Skin bruising Clinical outcomes If FEV<50% and a number of exacerbations/year rate of deterioration in health status can be reduced 3 year prospective studies revealed no effect on rate of decline of FEV1 18/Oct/2005 Dr. David P. Breen 84 Combination therapy Combination treatment is a convenient, safe and improves compliance Initial data show a significant effect on pulmonary function and a reduction in symptoms Largest effects in most severe – FEV<50% and a number of exacerbations 18/Oct/2005 Dr. David P. Breen 85 Other agents Mucolytic agents – carbocysteine, iodinated glycerol Little evidence of any effect on lung function Cochrane review – supports a role for reducing no of exacerbations in chronic bronchitis N-acetylcysteine – at present prospective study ongoing 18/Oct/2005 Dr. David P. Breen 86 Leukotreine receptor antagonist -No data to support role Maintenance antibiotic –no data to suggest that these drugs are effective in modifying symptoms, exacerbations or lung function Respiratory stimulants – oral peripheral chemoreceptor stimulant – improves V/Q matching and improves oxygenation – can result in peripheral neuropathy Vaccination Influenza – can reduce serious illness and death by 50% Pneumococcal – reduces bacteraemia 18/Oct/2005 Dr. David P. Breen 87 Alpha1-antitrypsin deficiency Augmentation therapy Licensed for i.v. use twice a week Expensive No RCT showing benefit Suggestio that rate of decline in those receiving drug is less than historical controls. 18/Oct/2005 Dr. David P. Breen 88 18/Oct/2005 Dr. David P. Breen 89 18/Oct/2005 Dr. David P. Breen 90 18/Oct/2005 Dr. David P. Breen 91 18/Oct/2005 Dr. David P. Breen 92