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Caring for Patients with COPD: Guidelines for Diagnosis and Management. M. Elizabeth Knauft, MD MS September 20, 2007. GOLD Diagnosis and Classification of COPD 4 major components of COPD management Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Manage Exacerbations.

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Caring for Patients with COPD: Guidelines for Diagnosis and Management


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caring for patients with copd guidelines for diagnosis and management

Caring for Patients with COPD: Guidelines for Diagnosis and Management

M. Elizabeth Knauft, MD MS

September 20, 2007

slide2
GOLD
  • Diagnosis and Classification of COPD
  • 4 major components of COPD management
    • Assess and Monitor Disease
    • Reduce Risk Factors
    • Manage Stable COPD
    • Manage Exacerbations
slide3
GOLD
  • 1998: Global Initiative for Chronic Obstructive Lung Disease
  • 2001: Global Strategy for the Diagnosis, Management, and Prevention of COPD
  • 2006: Revision of above
goals of gold
Goals of GOLD
  • “To improve prevention and management of COPD through a concerted worldwide effort of people involved in all facets of healthcare and healthcare policy, and to encourage an expanded level of research interest in this highly prevalent disease.”
slide5
Case
  • CC: Dyspnea
  • HPI: 66 yo F with several years of progressive dyspnea, cough.
  • 60 pack year tobacco, active smoker (2ppd)
  • PMH: DM II
definition of copd
Definition of COPD
  • Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients
  • Pulmonary component characterized by airflow limitation that is not fully reversible.
  • Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases
case con t spirometry
Case Con’tSpirometry
  • FEV1/FVC: 0.50
  • Postbronchodilator FEV1: 1.23L (63% predicted)
case con t spirometry9
Case Con’tSpirometry
  • FEV1/FVC: 0.50
  • Postbronchodilator FEV1: 1.23L (63% predicted)
  • Stage II
mechanism of copd
Mechanism of COPD
  • Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affected
  • Chronic inflammatory changes, amplified by oxidative stress
burden of copd
Burden of COPD
  • Prevalence higher in
    • smokers and ex-smokers than nonsmokers
    • Patients over 40 than those under 40
    • Men than in women
  • Morbidity
  • Mortality
    • 6th leading cause of death in 1990 (Global Burden on Disease Study)
    • Projected to be 3rd leading cause by 2020
risk factors for copd
Risk Factors for COPD
  • Cigarette smoke
  • Occupational dust and chemicals
  • Environmental tobacco smoke
  • Indoor and outdoor pollution
management goals for copd
Management Goals for COPD
  • Relieve symptoms
  • Prevent progression of disease
  • Improve exercise tolerance
  • Improve health status
  • Prevent and treat complications
  • Prevent and treat exacerbations
  • Reduce mortality
four major components of copd management
Four Major Components of COPD Management
  • I: Assess and Monitor Disease
  • II: Reduce Risk Factors
  • III: Manage Stable COPD
  • IV: Manage Exacerbations
assess and monitor disease
Assess and Monitor Disease
  • Dyspnea
    • Progressive, persistent, worse with exercise
    • “increased effort to breathe”, “air hunger”
  • Chronic cough
    • Intermittent, non-productive
  • Chronic sputum production
    • Any pattern
  • History of exposure to risk factors
    • Tobacco, occupational dust/chemicals, home cooking, heating fuels
assess and monitor disease 2
Assess and Monitor Disease-2
  • Confirm diagnosis by spirometry
  • Post bronchodilator FEV1/FVC < 0.70
  • Obtain ABG if FEV1 < 50% predicted or clinical signs right heart failure
  • Alpha-1 antitrypsin level in young pts (<45 years)
  • Identify comorbidities
assess and monitor disease 3
Assess and Monitor Disease-3
  • Differential Diagnosis
    • Asthma
    • CHF
    • Bronchiectesis
    • Tuberculosis
    • Obliterative Bronchioloits
    • Diffuse Panbronchiolitis
reduce risk factors
Reduce Risk Factors
  • Smoking Cessation!
  • Reduction of indoor and outdoor air pollution
manage stable copd
Manage Stable COPD
  • Individualize overall approach to address symptoms and improve quality of life
  • Smoking cessation
  • Pharmacotherapy for COPD used to decrease symptoms and/or complications
    • do NOT modify long-term decline in lung function
manage stable copd 2 bronchodilators
Manage Stable COPD-2Bronchodilators
  • B-2 agonists, anticholinergics,methylxanthines
  • Symptomatic management: prn or scheduled
  • Increase exercise capacity
  • Do not necessarily improve FEV1
  • LABA more effective than SABA
  • Combination therapy more effective than increasing dose of single agent
  • Long acting anticholinergic reduces rate of COPD exacerbations, improves effectiveness of pulmonary rehabilitation
manage stable copd 3 glucocorticosteroids
Manage Stable COPD-3Glucocorticosteroids
  • Inhaled corticosteroids (ICS) do not modify long term decline in FEV1
  • ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very Severe) pts
  • Regular use of ICS reduces frequency of exacerbations
  • Long term use systemic glucocorticosteroids is NOT recommended
manage stable copd 4
Manage Stable COPD-4
  • Influenza vaccine
  • Pneumococcal vacine (>65years; < 65 years with FEV1 < 40 % predicted)
manage stable copd 5 therapies not recommended
Manage Stable COPD-5Therapies NOT recommended
  • No benefit from prophylactic antibiotic therapy
  • Overall benefit from mucolytics is small
  • N-acetylcysteine: no reduction in exacerbations
  • Antitussives (cough has a protective role)
  • Vasodilators (inhaled nitric oxide)
manage stable copd 6 non pharmacologic treatments
Manage Stable COPD-6Non-Pharmacologic Treatments
  • Pulmonary rehabilitation
    • Goals: Reduce symptoms, improve quality of life, increase physical and emotional participation in everyday activities
  • Supplemental oxygen
    • Use > 15 h/day improves survival in patients with chronic respiratory failure
    • PaO2<55, SaO2 <88%
    • PaO2 55-60, SaO2 = 88% and pulmonary hypertension, evidence of CHF, polycythemia (HCT > 55%)
case con t
Case Con’t
  • Short acting B2 agonist
  • Long acting bronchodilator (B2 agonist or anticholinergic)
  • Influenza vaccine
  • Pneumococcal vaccine
  • Smoking cessation
manage exacerbations
Manage Exacerbations
  • Exacerbation:
    • “…an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”
    • Infection of tracheobronchial tree and air pollution most common causes
    • No cause identified in 1/3 exacerbations
manage exacerbations28
Manage Exacerbations
  • Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color or tenacity of sputum
  • Assess severity
    • Dependent on pt’s baseline prior to exacerbation
    • ABG
    • FEV1 not practical
    • CXR
    • Sputum culture
manage exacerbations home management
Manage ExacerbationsHome management
  • Increase dose and/or frequency of short acting bronchodilator therapy
  • Consider adding anticholinergic agent
  • Systemic glucocorticosteroids
    • Shorten recovery time
    • Improve FEV1 and hypoxemia
    • Consider (in addition to bronchodilators) if FEV1 < 50%
    • 30-40 mg prednisone/d x 7-10 days
case con t30
Case Con’t
  • Increased dyspnea
  • Increase in sputum, now purulent
case con t31
Case Con’t
  • Increased dyspnea
  • Increase in sputum, now purulent
  • Increase frequency of bronchodilators (nebulized or inhaled)
  • Consider oral glucocorticosteroids
manage exacerbations hospital management
Manage ExacerbationsHospital management
  • Risk of death related to development of respiratory acidosis
  • Indications for hospital assessment/admission
    • Marked increase in intensity of symptoms
    • Severe underlying COPD
    • New physical signs (cyanosis, peripheral edema)
    • Failure to respond to outpatient management
    • Significant comorbidities
    • Frequent exacerbations
    • New arrythmia
    • Diagnostic uncertainty
    • Older age
    • Insufficient home support
manage exacerbations hospital management 2
Manage ExacerbationsHospital management-2
  • Assess severity of symptoms- ABG, CXR
  • Oxygen
  • Bronchodilators
    • B-2 agonist
    • Add anticholinergic if no response
    • Role of methylzanthines is controversial
  • Add oral or IV glucocorticosteroids
manage exacerbations hospital management 3
Manage ExacerbationsHospital management-3

Give antibiotics if:

  • Increased dyspnea, increased sputum volume, increased sputum purulence
  • Two of the above three criteria are met, and one is presence of purulent sputum
  • Severe exacerbation requiring mechanical ventilation (invasive or noninvasive)
  • H. influenza, S. pneumoniae, M. catarrhalis
manage exacerbations hospital management 4
Manage ExacerbationsHospital management-4
  • Ventilatory support
  • Noninvasive mechanical ventilation : 80% success rate
    • Moderate/severe dyspnea with use of accessory muscles and paradoxical abdominal muscle motion
    • Moderate/severe respiratory acidosis (pH < 7.35, paCO2 > 45)
    • Tachypnea (RR > 25 bpm)
manage exacerbations discharge criteria
Manage ExacerbationsDischarge Criteria
  • Inhaled B2 agonist therapy is required no more than every 4 hours
  • Pt able to walk across room (if previously ambulatory)
  • Clinically stable for 12-24 h
  • Stable ABG for 12-24 h
  • Patient/caregiver understands proper medication use
  • Home care/follow-up arrangements made
summary
Summary
  • Diagnosis of COPD requires post-bronchodilator FEV1
  • Tobacco cessation
  • Layer treatment according to stage of COPD