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Definition

Management of COPD BTS Guidelines 2004. Priorities for implementationDiagnose COPDStop smokingEffective inhaled RxPulmonary rehabilitationManage exacerbations (NIV)Multidisciplinary working. 900,000 (2,000,000) in UK>30,000 deaths in UK 19995% all deathsHealth District (250,000)700 admissi

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    2. Airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking. Definition

    3. Management of COPD BTS Guidelines 2004 Priorities for implementation Diagnose COPD Stop smoking Effective inhaled Rx Pulmonary rehabilitation Manage exacerbations (NIV) Multidisciplinary working

    4. 900,000 (2,000,000) in UK >30,000 deaths in UK 1999 5% all deaths Health District (250,000) 700 admissions (10%) 9,600 bed days 14,000 GP consultations Disease Burden

    7. Chronic Bronchitis Irritants in smoke/Pollution Mucous gland hypertrophy Increased mucus gland secretion Increased polymorphs in airways bronchoconstriction Airway narrowing (small airways) need a lot of damage before spirometry affected

    8. Emphysema Increased polymorphs ® ­ Elastase ® loss of alveoli / pulmonary vasculature ® Ż area for gas exchange ® loss of elastic supporting tissue ® early expiratory airway collapse ® hyperinflation

    11. Diagnosis History Progressive symptoms - Cough/Wheeze/SOB Ex tolerance, childhood illness/atopy/ FH Occupation Smoking - 20 pack years Examination - not diagnostic Objective evidence of airway obstruction that does not return to normal with Rx

    12. CXR (not necessary) Spirometry FEV1<80% predicted FEV%<70% predicted Little variability in expiratory flow Investigations

    14. Monitor Progression 15% smokers significant obstruction FEV1 (20-30 ml/yr non smokers) FEV1 (45-70 ml/yr smokers) Prognosis related to FEV1 Mortality: Renfrew/Paisley Study, BMJ 1996 Drug treatment does may affect natural history (LTOT improves survival)

    16. Peak Flow/Spirometry FEV1 reproducible (160 ml) FVC reproducible (330 ml) FEV% diagnoses obstruction Low PEFR obstruction/restriction PEFR not related to FEV1 PEFR underestimates obstruction in COPD COPD small airways

    17. Severity of COPD Mild - FEV1 50-80 (60-79)% smokers cough Moderate- FEV1 30-49 (40-59)% Cough, SOBOE, wheeze (signs) Severe - FEV1 <30 (<40)% Cough,wheeze,SOB, signs

    18. Severity of COPD MRC Dyspnoea Scale 1. SOB strenuous exercise 2. SOB hurrying, slight hill 3. Unable to keep up with peers* 4. Stops for breath after 100m* 5.Too breathless to leave house SOB washing dressing

    19. Differentiation from Asthma Smoker / non smoker symptoms <35 yr chronic productive cough SOB Night time waking /wheeze Diurnal variability symptoms ABG’s ECG Ex Tests Haematology Sputum

    20. Reversibility Testing Not necessary may be misleading (single test) but may help with diagnosis if large response to bronchodilators or prednisolone (30mg 2/52) ABG’s ECG Ex Tests Haematology Sputum

    21. Reversibility Testing Salbutamol/Ipratropium stable free from infection post bronchodilator FEV1 best predictor of prognosis no bronchodilators for 6 hr 2.5-5mg salbutamol Neb (20min) 500mcg ipratropium Neb (45min) ABG’s ECG Ex Tests Haematology Sputum

    22. Reversibility Testing Steroids 30mg day, 2 weeks beclomethasone 500mcg bd, 6 weeks positive response in 10-20% better prognosis if positive response Steroid responders also respond to bronchodilators

    23. Reversibility Testing Question. Are we measuring the right thing ? Answer Probably not !

    24. Reversibility Testing Absolute Change (FEV, 160 ml, FVC 330 ml) ? % change ? FEV1 - 1.1 Pre, 1.5 post (1.5/1.1) x 100 = 36 % change (1.1/1.5) X 100 = 27 % change {(1.5-1.1)/(1.5+1.1)/2} x100 = 31% change

    25. Other Investigations BMI, CRP ? FBC -PCV >50%, alpha 1 antitrypsin Sputum (Pneumococcus, Haemophilus, Moraxella) Oximetry/ABG (or Sat >92%) CT - extent/distribution of emphysema TLC/RV comparison(body box/He dilution) ECG/ECHO - IHD/ Cor pulmonale

    27. Management of stable COPD Smoking SOB/SOBOE Frequent Exacerbations Respiratory failure Cor pulmonale Abnormal BMI Chronic cough Anxiety/Depression Palliative Care

    28. Smoking Cessation Stop smoking (10-30% in trials) sudden better than gradual all smokers in house medical advice nicotine (doubles quit rate) monitoring (co,carboxyHb,cotinine) antidepressant (Bupropion USA) Varenicline

    30. Smoking Cessation Key Fact: Every Cigarette reduces life expectancy by 11 minutes !

    31. Inhaled Bronchodilators Improve FEV1/symptoms Combination better Long acting –greater clinical benefit, health status and lower exacerbation rate Steroid /LABA combination –greater improvement than either alone

    32. Inhaled Bronchodilators Tiotropium reduces exacerbations by 25% compared to ipratropium UPLIFT Study 3 yr tiotropium vs placebo. Decline in lung function. Triple therapy ?

    33. Phosphodiesterase Inhibitors Mild Bronchodilator effect upper end of therapeutic range effect may take several weeks Improve respiratory muscle strength Improve mucus clearance Reduce exacerbations ?

    34. Phosphodiesterase Inhibitors Anti inflammatory action - low dose suppresses inflammatory genes (HDAC) potentiate anti-inflammatory effects of Pred caution with macrolides and quinolones Roflumilast, Cilomilast (PDE4 inhibitors)

    35. Inhaled Steroids Improve symptoms ? Reduce inflammation ? Reduce decline in lung function ? Reduce exacerbations ? Increase pneumonia ? Interaction with beta agonists ?

    36. Smokers with mild COPD 912 current smokers Randomised, double blind placebo controlled, parallel group study, 3yr Budesonide 400 ug bd No effect on progressive decline in FEV1 Pauwels et al, NEJM, 1999. European Study

    37. Copenhagen Lung Study 76% current smokers, n =290 mild COPD Randomised, double blind, placebo controlled, parallel group study, 3yr Budesonide 400 ug bd No effect on progressive decline in FEV1 Vestbo et al, Lancet 1999. 353:1819-23

    38. ISOLDE severe COPD (48% smoking at entry) 3yr randomised, double blind, placebo controlled, parallel group study, n=750 Inhaled Fluticasone No effect on progressive decline in FEV1 Fewer exacerbations Fewer symptoms Sub group analysis BMJ 2000 320

    39. META - ANALYSIS 3 studies (1 abstract) 2 yr Moderate-severe COPD n=95/88 800 -1600 mcg Beclomethasone Steroid group FEV1 improved by 80 ml/yr Van Grunsven et al, Thorax 1999.

    40. TORCH 3yr, n = 6,000. smokers or ex, FEV1<60% Fluticasone/salmeterol, Fluticasone, Salmeterol, placebo All cause mortality no difference Exacerbations reduced (25%) with steroid Improved health status with steroid

    41. Steroids/Pneumonia TORCH (NEJM 2007 356: 775-789) Inhaled steroids increased pneumonia ? AJRCCM 2007 176: 162-166 Inhaled steroids increased pneumonia admissions ?

    42. Steroids/Beta Agonists Steroids increase expression of beta2 receptors. decrease loss due to long term exposure Beta 2 Agonists potentiate molecular mechanism of steroid action.

    43. Oral steroids Maintenance therapy not recommended. If necessary keep dose low. Monitor for osteoporosis. Prophylaxis for osteoporosis if >65.

    44. Home Nebuliser Therapy SOB despite maximal Rx MDI v Neb trials in stable COPD inconsistent Assessment home trial (St George’s AQ20), optimise Rx technical support/FU Neb Rx 3-4x more expensive than HHI

    45. Other measures Exercise Safe and desirable Nutrition Vaccination -Flu /Pneumococcus Treat depression (50%) Travel (900-2,400 m, PaO2 15 -18 kPa) bullae, pneumothorax, PaO2<6.7 kPa air

    46. Prevent Exacerbations Vaccination. Self management advice. Optimise bronchodilator Rx. Add inhaled steroids if FEV1 <50% and 2 or more exacerbations per year. Rotating antibiotics.

    47. Pulmonary Rehabilitation Proven value (randomised trials) MRC grade 3 and above Ex tolerance, Psychosocial Reduce hospital admissions/LOS ? A cynics definition of Exercise -”An enthusiasm lasting about 3 weeks, which is readily soluble in alcohol” (Newcastle study)

    48. LTOT MRC study(1981) -15 hr/day 5 yr survival 25% / 41% Less polycythaemia Prevention of progression of PHT Improved sleep quality Improved psychologically (QOL) Reduction in cardiac arrhythmias

    50. LTOT ABG x 2 (3 weeks apart) - clinically stable PaO2 < 7.3 kPa on air FEV1 < 1.5 Non-smokers 6 monthly follow-up Prescriber England: GP Scotland: Consultant Chest Physician

    51. Ambulatory Oxygen Exercise desaturation Exercise Test Symptoms Walk distance saturation Follow up

    52. Nocturnal Hypoventilation in COPD Reduced ventilatory drive during sleep Sleep deprivation (sleep apnoea) reduces chemoreceptor sensitivity Reduced muscle performance muscle mechanics acidosis

    53. NIV No recommendations at present May prolong survival in patients deteriorating on LTOT with associated hypercapnoea ? Mechanism of cor pulmonale

    54. Cor Pulmonale Lung disease ® Hypoxia ® Pulmonary arterial vasoconstriction ® Pulmonary Hypertension®RVF® Oedema Lung disease ® Hypoxia / Hypercapnoea ® Ż Renal Perfusion ® Fluid retention

    55. Surgery Bullectomy Lung volume reduction improves symptoms/ex tolerance/QOL VATS/Sternotomy low morbidity (<70yr,FEV1>0.5l, PaO2>7.3) ? Survival advantage (NETT USA) - no ! Transplant (young, alpha 1 antitrypsin)

    58. ACUTE EXACERBATIONS ? Referral Criteria Cope at home? Absence of cyanosis? Normal level of conciousness? Mild breathlessness? Good general condition? Not receiving LTOT? Good level of activity? Good social circumstances?

    59. ACUTE EXACERBATIONS Hospital Investigations CXR ABG ECG FBC/U+E Sputum culture if purulent Blood cultures if pyrexial

    60. ACUTE EXACERBATIONS Bronchodilators Neb or HHI +Spacer Pred 30mg 14/7 Oxygen (controlled) Antibiotics if sputum purulent penicillin, macrolide, Theophylline NIV (Doxapram) Physiotherapy

    61. STEROIDS/EXACERBATIONS 80 8/52 High dose oral Prednisolone 80 2/52 High dose oral prednisolone 111 Placebo Steroids: less treatment failure (intubation etc) faster improvement in FEV1 Shorter Hospital Stay Niewoehner et al, NEJM 1999

    62. ACUTE EXACERBATIONS NIV better ABG reduced LOS reduced complications reduced mortality reduced intubation Oxygen pulse oximeters (beware pCO2 !)

    63. ACUTE EXACERBATIONS Hospital at Home various models 1/3 patients suitable nurses, physios, OT’s average hospital LOS 10 days saves bed days, not money ! Patients like it !

    64. Follow Up Mild Yearly, Severe 6 monthly smoking status symptom control(SOB ex tolerance exacerbations) inhaler technique, review Rx Nutrition ? Pulmonary Rehab ? LTOT Spiro, BMI, MRC dyspnoea (Sa O2 severe)

    65. Referral

    66. Summary

    67. Summary

    68. The Future ?

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