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Obstructive airways disease . COPD Asthma Gordon Christie Consultant Respiratory Physician ARI. Objectives. Diagnosis & assessment of severity Appropriate investigation When to refer Empirical treatment Chronic disease Acute exacerbations. Asthma. COPD. What is it?.

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obstructive airways disease

Obstructive airways disease

COPD

Asthma

Gordon Christie

Consultant Respiratory Physician

ARI

objectives
Objectives
  • Diagnosis & assessment of severity
  • Appropriate investigation
  • When to refer
  • Empirical treatment
    • Chronic disease
    • Acute exacerbations
what is it
Asthma

COPD

What is it?
  • No truly satisfactory definition
    • Reversible airflow limitation
    • Bronchial hyperreactivity
    • Eosinophilic airflow inflammation
  • Better defined
    • Irreversible airflow obstruction
    • Gradually progressive
    • Inflammation
    • Usually smoking associated
slide4

Emphysema

(Pathology)

Chronic Bronchitis

(Symptoms)

COPD

(Fixed airflow obstruction)

Asthma

(Reversible Airflow obstruction)

epidemiology
Epidemiology
  • Asthma
    • Point prevalence ~8-10% in children, 5% in adults
      • Severe disease much less common
      • Complex genetic-environmental interaction
  • COPD
    • Point prevalence 1.5-2%
      • Much undiagnosed symptomatic disease
      • Much asymptomatic airflow limitation (?5-8% of adult population)
copd causation
COPD: Causation
  • In the UK
    • Overwhelmingly cigarette smoking
        • Dose response relationship to smoking exposure
        • Rare under 20 pack years
      • Occupational dust exposure of minor (& declining) importance
      • Some individuals at high genetic risk
        • Alpha 1 antitrypsin deficiency
        • Rare familial susceptibility
      • Passive smoking of minor importance
impact on nhs grampian
Impact on NHS Grampian
  • Catchment population 560,000 (~1% of UK)
    • Relatively low deprivation
making a diagnosis
Making a diagnosis
  • Asthma
    • Common at all ages
    • Usually mild
    • Usually variable symptoms
    • Characterised by exacerbations
    • May well be undiagnosed
      • Usually frequent “chest infections” or “bronchitis”
    • Smokers get pure asthma too !
      • But may not respond to inhaled steroid nearly as well
slide9
COPD
  • Predominantly a disease of older adults
    • Rare under 40
    • Uncommon under 50
  • Strong dose response relationship to smoking exposure
    • Uncommon under 20 pack years
assessing the breathless patient
Assessing the breathless patient
  • Is there an existing diagnosis?
    • Is it right??
  • How breathless?
    • MRC1:Breathless on significant exertion
    • MRC2:Breathless on moderate exertion
    • MRC3: Breathless walking with own age
    • MRC4: Breathless on minimal exertion
    • MRC5: Breathless at rest
history
History
  • Duration of breathlessness
    • COPD long history, gradually progressive; may require careful history taking to elicit
    • Asthma classically symptom variability
      • Often associated with triggers
      • Nocturnal symptoms
    • Exacerbations: markers of severity/ instability
    • Childhood symptoms/ school absence
      • Often recurrent “bronchitis” or “pneumonia”
investigations
Investigations
  • Oximetry...hypoxaemia is bad
  • Spirometry
    • Fundamental
    • If normal suspect asthma
  • Peak flow
    • Need to seek variability over time (at least 2 weeks)
  • More detailed pulmonary function
    • Gas transfer
    • 6 minute walk
  • Chest X ray
    • Primarily to exclude other diagnoses (LVF, ILD etc)
spirometry
Severe airflow obstruction

Normal (young, tall, male)

Spirometry
peak flow
Peak flow
  • Test for asthma
  • Need 2 weeks or more recorded
    • First 3-4 days can usually be discarded (practice effect)
  • Look for 20% variability
    • Some variability is physiological
  • Look for morning dips & dips with symptomatic periods
  • Useful with trial of treatment
    • But remember timescale of treatment effect
pulmonary function testing
Pulmonary function testing
  • Main test of discriminant value is gas transfer
      • Measure of lung parenchymal function
      • Reduced (usually significantly <50% predicted) in significant COPD
      • Correlates with disease severity
      • Normal or supranormal in asthma
  • Functional tests: primarily assess severity
      • 6 minute walk
        • Desaturation is ominous
      • Shuttle walk
      • Formal cardiopulmonary exercise testing
        • Limited availability
other tests
Other tests
  • CXR: Primarily to exclude obvious LVF, ILD etc.
    • NOT a diagnostic test for airway disease!
  • ECG: Primarily to exclude IHD but remember RV changes
  • Echocardiography
    • Remember PA pressure/ RV hypertrophy & dilatation
  • HRCT
    • Can be helpful assessing structural emphysema (normally unnecessary as diagnosis already made)
    • Invaluable in assessment of interstitial lung disease
making a diagnosis copd
Making a diagnosis:COPD
  • Symptoms
  • Exacerbations
  • Smoking history
  • Signs of hyperinflation clinically if severe
  • Spirometry confirms obstruction & correlates with severity
    • Significant function limitation <50% predicted
    • Often housebound <1 litre absolute FEV1
  • Gas transfer may help if uncertain
  • Beware pulmonary hypertension if advanced disease
    • May merit echo, 6 minute walk
  • HRCT rarely necessary
making a diagnosis asthma
Making a diagnosis: Asthma
  • Variable exertional breathlessness
    • Childhood & family history common
  • History of precipitants (exercise, cats, cold, pollen, paint, perfume)
    • Associated atopy (hayfever, eczema)
    • Peripheral blood eosinophilia, raised total & specific IgE
  • Persistent symptoms (cough, sputum, wheeze) imply poor control
  • Usually no signs on examination & normal spirometry
  • Peak flow variability common, trial of treatment useful
  • Sometimes chronic airflow limitation indistinguishable from COPD but exercise tolerance better than expected from spirometry & gas transfer preserved
when to refer
When to refer
  • Early! (..the drugs take time to work)
  • Concurrent with trial of empirical treatment
  • Concurrent with requests for additional straightforward tests (pulmonary function, echo primarily)
  • If real diagnostic doubt
  • Poorly controlled disease (persistent symptoms, frequent exacerbations)
  • Advanced disease
    • COPD with low absolute FEV1, evidence of right heart failure
    • Asthma with significant fixed airflow limitation
when to treat empirically
When to treat empirically
  • Majority of situations
  • If convincing history & evidence of airflow obstruction
  • Response to treatment often helpful in secondary assessment
  • With monitoring of outcomes (peak flow chart, review with repeat spirometry), usually after 6-8 weeks treatment
empirical treatment
Empirical treatment
  • Should be designed to achieve rapid results in context of preassessment
    • Drugs are (generally) safe in short term at high doses
    • Mainstay is inhaled corticosteroid (beclometasone, budesonide, fluticasone)
    • Usually combined with long acting beta2 agonist (salmeterol, formoterol)
    • Bronchodilator for symptom relief
      • Salbutamol, terbutaline
inhalers made eas ier
Inhalers made eas(ier)..
  • Traditional pressurised MDIs...
    • Deliver 10-15% dose to the lungs
    • Delivered dose doubled by spacers
    • Are difficult to use-require coordination & timing
    • Doses changing with CFC free inhalers
      • Deposition patterns may change with CFC inhalers (smaller inhaled particles)
    • Breath actuated devices (easibreathe etc.)
    • Much liked by health economists extrapolating from RCTs, less favoured by patients & their doctors
dry powder inhalers
Dry powder inhalers
  • Better drug deposition (up to 30-35% delivered dose)
  • Simpler to use (no requirement for timing)
  • Effective even at low peak inspiratory flow
  • Often preferred by patients
  • Better range of combination inhaled steroid/ LABA products available
practical empirical treatment
Practical empirical treatment
  • Start reliever bronchodilator (usually salbutamol 200mcg as required)
  • Start combined ICS/LABA
    • Seretide (50-100-125-250-500 mcg fluticasone; 50mcg salmeterol)
    • Symbicort (100-200-400 mcg budesonide; 6-12 mcg formoterol)
  • Monitor outcomes
    • Peak flow (if asthma)
    • Clinical review with repeat spirometry in 6-8 weeks
treatment copd
Treatment: COPD
  • COPD
    • Recent trials
      • TORCH (COPD, FEV1<60% predicted; RCT, n=6000, placebo vs fluticasone 500 mcg bd alone vs salmeterol 50 mcg bd vs combined fluticasone 500mcg-salmeterol 50mcg bd over 3 years)
        • Exacerbations, lung function & quality of life all improved with all active teatment
        • Lung function improved with combination, salmeterol alone
        • Effects of combination treatment additive compared to single drugs alone
        • Borderline effect on mortality (p=0.052!)
      • Combination probably represents current standard of care
        • Some concern about increased incidence of pneumonia over 3 year followup
copd drug choices
COPD: Drug choices
  • INSPIRE: ICS/LABA vs Tiotropium (long acting anticholinergic bronchodilator)
    • Both improved quality of life, lung function, reduced exacerbations
    • Combination superior to tiotropium
  • Cochrane review suggests combination treatment does not have mortality benefit
    • Clear benefits in exacerbation frequency (down 30-40%), quality of life & lung function (although latter are modest)
  • UPLIFT: Tiotropium vs placebo
    • Reduction in exacerbation frequency & improved quality of life
    • No mortality benefit (P=0.09)
    • Increased rate of vascular death reported in US meta analysis of anticholinergic treatment in COPD (but not UPLIFT)
  • No trials of combination ICS/LABA/long acting anticholinergic
other drugs
Other drugs
  • Mucolytics
    • 2 good trials (BRONCUS, PEACE) suggesting reduced exacerbation frequency in inhaled steroid naive only
      • Much cheaper & relevant in resource poor settings, less so in UK
  • Theophylline
    • Few good trials but extensively used
    • Probably safer than was believed used at low doses; no need to chase “therapeutic” drug levels
    • Narrow therapeutic index
    • “Boutique” theophyllines (rofilumilast, cilomilast on horizon)-unclear if additional benefit justifies expense
  • Nebulisers
    • Inefficient-delivered drug dose usually ~5%
    • Useful acutely
    • Not for maintenance treatment
pulmonary rehabilitation
Pulmonary rehabilitation
  • Usually physiotherapist led
    • 10 week course, twice weekly sessions
    • Variety of programmes but usually
      • Exercise (circuits, upper body)
      • Breathing control, pacing
      • Education/ anticipatory care
      • Smoking cessation
  • Impressive effects
    • Significant improvement in exercise function
    • Improvement in quality of life (greater than drug effects)
    • Shorter readmissions (though not necessarily fewer)
  • Developing interest in “acute” pulmonary rehabilitation around acute exacerbations
so what do i do
..so what do I do?
  • ENCOURAGE SMOKING CESSATION!
    • Brief advice
    • Refer to local service
  • Bronchodilator for symptom relief
  • Combined inhaled steroid/ long acting bronchodilator
    • Currently Seretide 500 bd via dry powder device (accuhaler) for simplicity & concordance
    • Probably a class effect
  • Tiotropium
  • Low dose theophylline (200mg bd) as next step
  • Refer for pulmonary rehabilitation (where available)
treatment asthma
Treatment: Asthma
  • Empirical treatment:
    • Step 1: Bronchodilator only
    • Step 2: Bronchodilator & regular inhaled steroid
    • Step 3: Add LABA (in practice combination inhalers, as in COPD) or theophylline or leukotriene receptor antagonist
    • Step 4: Maximise inhaled steroid
    • Step 5: Add regular oral steroid
empirical treatment32
Empirical treatment
  • Depends on previous treatment step & current symptoms
  • Aiming for good perioperative control
    • Increase to BTS 3-4 if concerned
    • Will usually take 2-4 weeks to see effect of additional drug & 6-8 weeks to see effect of increased inhaled steroid
    • GOAL study suggests that benefit of increasing ICS continues to increase over up to 12 months
asthma other issues
Asthma: Other issues
  • Treat nasal symptoms aggressively if present (“one airway”) in addition to lower airway
    • Nasal steroid
    • Leukotriene receptor antagonists
    • Antihistamines
  • Gastro oesophageal reflux also worth treating vigorously
acute exacerbations
Acute exacerbations
  • Asthma
    • Oxygen
    • Nebulised bronchodilators, add ipratropium if severe
    • IV then Oral steroid (~0.5mg/kg; usually 30-40mg/ day)
    • Consider magnesium, possibly repeat if severe
    • Consider IV aminophylline
    • Antibiotics rarely indicated, some evidence of macrolides
acute exacerbations35
Acute exacerbations
  • COPD
    • Oxygen (controlled!)
    • Nebulised bronchodilators
    • Reasonable evidence for oral steroid
    • Appropriate antibiotics
    • Consider aminophylline
    • NIV....
slide36
NIV
  • Good evidence for mortality benefit in acute exacerbations with hypercarbia
  • Widely available; can be used in ward setting
  • Preferable to intubation in many circumstances
  • Provides ventilatory support while other treatment works
  • Not (routinely) for hypoxic respiratory failure in most circumstances
summary
Summary
  • Diagnosis & assessment of severity
  • Appropriate investigation
  • Empirical treatment
    • Chronic disease
    • Acute exacerbations
  • When to refer