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Managing COPD --- Recent Advance. 蔡熒煌 長庚醫院胸腔暨重症科 長庚大學呼吸照護學系. Revised 2006. Definition of COPD. Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.

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Managing COPD --- Recent Advance


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    1. Managing COPD --- Recent Advance 蔡熒煌 長庚醫院胸腔暨重症科 長庚大學呼吸照護學系

    2. Revised 2006

    3. Definition of COPD • Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. • Its pulmonary component is characterized by airflow limitation that is not fully reversible. • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

    4. Driving pressure(parenchyma) Airflowlimitation = Resistance(small airways) COPD: Linking Structure with Function

    5. The Nature of Small-Airway Obstruction in Chronic Obstructive Pulmonary Disease GOLD stage 4 GOLD stage 3 GOLD stage 2 GOLD stages 0 and 1 0.25 0.20 0.15 V:SA (mm) 0.10 0.05 0.00 0 20 40 60 80 100 120 FEV1 Hogg JC et al., NEJM 2004;350:2645-2653

    6. Mechanisms of Uneven Ventilation in COPD • Unequal lung compliances and airway resistances of lung units leads to a wide distribution of RC-constants • Asynchronously emptying results in a changing gas concentration at the mouth • Contributes to air trapping

    7. COPD Expiratory Flow Limitation Air Trapping Hyperinflation Exacerbations Breathlessness Deconditioning Inactivity Reduced Exercise Capacity Poor Health-Related Quality of Life Disease progression Death Disability Clinical Course of COPD:Disease Progression

    8. age 40-50 50-55 55-60 60-70

    9. Five leading causes of death by the year 2020

    10. Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970. Source: Jemal A. et al. JAMA 2005

    11. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998

    12. COPD Mortality by Gender,U.S., 1980-2000 Number Deaths x 1000

    13. ICD-9 A323: ICD-9 490 Bronchitis, not specified as acute or chronic 491 Chronic bronchitis 492 Emphysema 493 Asthma 22.2 ICD-9 490-493, 496 22 16.4 20 15.1 15.8 18 ICD-9 496 16 14 12 7.1 10 ICD-9 490-493 ( A 323 ) ICD-9 496 Chronic airways obstruction, not elsewhere classified 8 6 0.6 4 1988 2000 1981 1982 1984 1986 1990 1992 1994 1998 1996 2 Mortality rate per 100,000 Trend of Mortality of Chronic Airway Obstruction - Related Diseases in 21 Years in Taiwan

    14. 慢阻肺病患門診就醫狀況

    15. 慢阻肺病患住院治療

    16. Medical Cost --- COPD vs. Asthma Data from BNHI Taiwan : * 1,000 NT

    17. Medical Cost and COPD Severity • There is a striking direct relationship between the severity of COPD and the cost of care, and the distribution of costs changes as the disease progresses. • The hospitalization and ambulatory oxygen costs soar as COPD severity increases

    18. Key Indicators for Considering a COPD Diagnosis • Consider COPD and perform spirometry if any of these indicators are present in an individual over age 40. These indicators are not diagnostic by themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD. Spirometry is needed to establish a diagnosis of COPD.

    19. Key Indicators for Considering a COPD Diagnosis • Dyspnea that is: • Progressive (worsens over time). • Usually worse with exercise. • Persistent (present every day). • Described by the patient as an “increased effort to breathe,”“heaviness,”“air hunger,” or “gasping.” • Chronic cough: May be intermittent and may be unproductive. • Chronic sputum production: Any pattern of chronic sputum production may indicate COPD. • •History of exposure to risk factors: • Tobacco smoke (including popular local preparations). • Occupational dusts and chemicals. • Smoke from home cooking and heating fuel.

    20. Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations

    21. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY

    22. Airway Patency is Fundamental • Spirometry is the gold standard for the diagnosis and assessment of COPD • Measuring post-bronchodilator FEV1 is essential for the classification of severity of COPD

    23. Spirometry

    24. Diagnosis of COPD in practice (II) • For the diagnosis and assessment of COPD, spirometry is the gold standard • Healthcare workers involved in the diagnosis and management of COPD patients should have access to spirometry • Spirometry should be undertaken whenever respiratory problems are suspected GOLD workshop report 2001

    25. Spirometer

    26. 5 FVC Normal FEV1 FVC 4 3 COPD FEV1 2 1 0 Spirometry: Normal and COPD FEV1 (l) 0 1 2 3 4 5 6 Time (S) Adapted from GOLD workshop report 2001

    27. Diagnosis of COPD • Existing COPD prevalence data show remarkable variation due to differences in survey methods, diagnostic criteria, and analytic approaches • Survey methods can include: • Self-report of a doctor diagnosis of COPD or equivalent condition • Spirometry with or without a bronchodilator • Questionnaires that ask about the presence of respiratory symptoms

    28. COPD is Under-appreciated and Under-diagnosed Example from Japan: • NICE Survey of COPD prevalence • NICE study population was comprised of 2343 Japanese subjects aged ≥ 40 years. • Carried out in several regions of Japan using standardized methods

    29. COPD Prevalence Rate (adjusted)* in Population  40 years 8.5%** 0.3% Study MHW Survey 5.3 vs 0.2M COPD patients in Japan ≥40 years *Adjusted for age, sex, cluster **8.5-10.9% depending on criteria Fukuchi et al. Respirology 2004;9:458-65

    30. COPD Prevalence Survey (NICE) in Japan Had prior diagnosis Did not have prior diagnosis: Fukuchi et al. Respirology 2004;9:458-65

    31. Prevalence of GOLD Stage 1+ COPD1, Guangzhou, China MEN 15.3% WOMEN 7.6% 1 FEV1/FVC<0.70, post BD

    32. The Latin American Project for the Investigation of Obstructive Lung Disease (PLATINO) examined the prevalence of post-bronchodilator airflow limitation (Stage I: Mild COPD and higher) among persons over age 40 in five major Latin American cities each in a different country – Brazil, Chile, Mexico, Uruguay, and Venezuela

    33. 四十歲以上成年人 抽煙或吸入污染接觸者

    34. Is it Inevitably All Downhill ?

    35. How we can change the clinical course of COPD?

    36. Active reduction of risk factor(s); influenza vaccination Addshort-acting bronchodilator (when needed) I: Mild II: Moderate III: Severe IV: Very Severe Addregular treatment with one or more long-acting bronchodilators (when needed); Addrehabilitation Addinhaled glucocorticosteroids if repeated exacerbations Addlong term oxygenif chronic respiratory failure. Considersurgical treatments

    37. The Fletcher-Curve

    38. Smoking Cessation Slows Lung Function Decline in Mild COPD: The Lung Health Study at 11 Years Anthonisen NR et al. Am J Respir Crit Care Med. 2002:166:675-9. Calverley PMA and Walker P. Lancet 2003;362:1053-1061

    39. Smoking Cessation Slows Lung Function Decline in Mild COPD: The Lung Health Study at 11 Years Anthonisen NR et al. Am J Respir Crit Care Med. 2002:166:675-9. Calverley PMA and Walker P. Lancet 2003;362:1053-1061

    40. 3.5 Special Intervention Usual Care 3.0 2.5 2.0 Rate of Death per 1000 Person-Years 1.5 1.0 0.5 0 CHD CVD LungCancer OtherCancer Respiratory Disease Other Unknown Cause of Death Effect of Smoking Cessation on Cause of Mortality Anthonisen et al. Ann Intern Med. 2005;142:233-239

    41. 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 symptoms relief and side effects.

    42. Inhalation Medication • Short acting beta-2 agonist (SABA) • Rescue use • Long acting beta-2 agonist (LABA) • Long acting anticholinergic agent • Steroid • Combination of steroid and LABA

    43. 吸入劑型藥物之吸入道具 Metered-Dose Inhalers (MDI) Nebulizer Dry Powder Inhalers (DPI)

    44. 2003 Canadian COPD Guidelines ISOLDE: Lack of effect of ICS on FEV1 decline 1.50 1.40 1.30 1.20 373 Start of Double-BlindTreatment 372 298 269 246 235 216 FEV1 (L) 168 288 241 222 Randomization andStart of Oral Steroid Trial 174 194 141 FP MDI 500 mcg b.i.d. (n=376) Placebo b.i.d. (n=375) -3 0 3 12 24 36 Time (months) Burge et al. BMJ. 2000; 320:1297-1303.

    45. Effects of Inhaled Steroids:Long Term Placebo-Controlled Studies NR = not reported