COPD 2007 Mark Cucuzzella MD LtCol USAFR Associate Professor Family Medicine West Virginia Rural Family Medicine Prog

1. COPD 2007 Mark Cucuzzella MDLtCol USAFRAssociate Professor Family Medicine West Virginia Rural Family Medicine Program

2. Close to the Beltway but a World Apart

4. Wayne McLaren…Former Marlboro Man

5. US Leading Causes of Death 2001

6. % Change in Age Adjusted Death Rate US 1965-1998…gotta die of something

7. Other Sad Facts Direct Cost 2002- 18 Billion Indirect Costs- 14 Billion In US 47 million still smoke 28% males 23% females WHO: 1 billion smokers worldwide…to increase to 1.6 billion 2025. Increasing in lower income areas

8. Objectives of COPD Management Prevent Progression Relieve symptoms Improve exercise tolerance and general health status Prevent and treat exacerbations and complications Minimize treatment side effects

9. The Real Story

10. Pathophysiology Simplified

12. THE Guideline Global Initiative for Chronic Obstructive Lung Disease (GOLD), World Health Organization (WHO), National Heart, Lung and Blood Institute (NHLBI)

13. 4 Keys to Management Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Education Med management Non med management Treat exacerbations

14. Assess and Monitor Disease Classification of COPD Stage 0 At Risk Stage I Mild COPD Stage II Moderate COPD Stage III Severe COPD Stage IV Very Severe COPD

15. Stage 0 At Risk Normal spirometry +/- Chronic symptoms (cough, sputum, production)

16. Stage I Mild COPD FEV1/FVC <70% FEV1 >80% predicted With or without chronic symptoms (cough, sputum production)

17. Stage II Moderate COPD FEV1/FVC <70% 50% <FEV1 <80% predicted With or without chronic symptoms (cough, sputum production)

18. Stage III Severe COPD FEV1/FVC <70% 30% <FEV1 <50% predicted With or without chronic symptoms (cough, sputum production)

19. Stage IV Very Severe COPD FEV1/FVC <70% FEV1 <30% predicted or FEV1 <50% predicted plus chronic respiratory failure

20. GOLD Guideline in Japan

21. Assess: Who Has Early Stages And Who Do You Test? Test patients with: chronic cough and sputum exposure to risk factors even if no dyspnea Early Stage: airflow limitation that is not fully reversible with or without the presence of symptoms

22. Assess for COPD:A Common Story Cough intermittent or daily present throughout day- seldom only nocturnal Sputum Any pattern of chronic sputum production Dyspnea Progressive and Persistent "increased effort to breathe" "heaviness" "air hunger" or "gasping" Worse on exercise Worse during respiratory infections Exposure to risk factors Tobacco smoke Occupational dusts and chemicals Smoke from home cooking and heating fuels

23. Assess: Spirometry to Diagnose FEV1/FVC <70% and a postbronchodilator FEV1 <80% predicted confirms the presence of airflow limitation that is not fully reversible. Must have access to spirometry

24. Assess: Medical History in Those With Established Disease Exacerbations or hospitalizations? Comorbidities that contribute to restriction of activity Appropriateness of current medical treatments Impact of disease on patient's life limitation of activity missed work and economic impact effect on family routines depression or anxiety Social and family support Possibilities for reducing risk factors, esp smoking

25. Assess: Physical Examination Rarely diagnostic in COPD Physical signs of airflow limitation rarely present until significant impairment of lung function low sensitivity and specificity

26. Assess: Measure Airflow Limitation Patients with COPD typically show a decrease in both FEV1 and FVC Postbronchodilator FEV1 <80% predicted + FEV1/FVC <70% confirms the presence of airflow limitation that is not fully reversible FEV1/FVC <70% is an early sign of airflow limitation in patients whose FEV1 remains normal (>80% predicted).

27. Assess: Additional Investigations > Stage II: Moderate COPD Bronchodilator reversibility testing rule out asthma establish best attainable lung function gauge a patient's prognosis guide treatment decisions Chest x-ray seldom diagnostic unless obvious bullous disease valuable in excluding alternative diagnoses CT not routinely recommended

28. Assess: Additional Investigations > Stage II: Moderate COPD Arterial blood gas measurement In advanced COPD: FEV1 <40% predicted or signs suggestive of respiratory failure or right heart failure central cyanosis, ankle swelling, JVD Respiratory failure PaO2 < 60 mm Hg +/- PaCO2 >50 mm Hg Alpha-1 antitrypsin deficiency screening COPD at a young age strong family history of the disease

29. Differential Diagnosis A major differential diagnosis is asthma In some patients with chronic asthma, a clear distinction from COPD is not possible In these cases, current management is similar to that of asthma Other potential diagnoses are usually easier to distinguish from COPD

30. COPD Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation

31. Asthma Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation

32. Congestive Heart Failure Fine basilar crackles on auscultation Chest x-ray shows dilated heart, pulmonary edema PFTs indicate restriction- not obstruction BNP can help

33. Other Diff Dx to Consider Bronchiectasis Large volumes of purulent sputum bacterial infection CXR/CT shows bronchial dilation, bronchial wall thickening TB History with the usual suspects BOO and BOOP nonsmokers environmental exposures CT on expiration shows hypodense areas

34. Monitoring: This is a progressive disease Lung function worsens over time- even with best care Monitor symptoms and objective measures of airflow limitation to determine when to adjust therapy Spirometry should be performed if there is a substantial increase in symptoms or a complication ABG should be considered in all patients with an FEV1 <40% predicted or clinical signs of respiratory failure or right heart failure (JVD/edema)

35. Reduce Risk Factors

36. Reduce Risk Factors: Key Points Reducting exposure to tobacco smoke, occupational dusts, and chemicals, and indoor and outdoor air pollutants Smoking cessation is the single most effective -- and cost-effective -- intervention to reduce the risk of developing COPD and stop its progression (Evidence A)

37. Reduce Risk Factors: Key Points Brief tobacco dependence treatment is effective (Evidence A) Every tobacco user should be offered at this treatment at every visit Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A)

38. Reduce Risk Factors: Key Points There are effective pharmacotherapies for tobacco dependence (Evidence A) Add meds to counseling if necessary Progression of many occupationally induced respiratory disorders can be reduced or controlled by reducing inhaled particles and gases (Evidence B)

39. Maybe This Would be Better Than Drugs

40. Manage Stable COPD Key Points 1 Stepwise increase in treatment based on disease severity 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). None of the existing medications for COPD affects long-term decline in lung function that is the hallmark of this disease (Evidence A) Pharmacotherapy for COPD is used to decrease symptoms and/or complications

41. Therapy by Stage- Pretty Simple

42. Manage Stable COPD Key Points 2 Bronchodilators central to symptom management (Evidence A) PRN or regular basis to reduce symptoms Use beta2-agonist, anticholinergic, theophylline, or a combination of one or more of these drugs (Evidence A) Regular treatment with LABs is slightly more effective and convenient than with SABs, but more expensive (Evidence A) TECHNIQUE IS KEY MDI BETTER THAN NEB IF USED CORRECTLY

43. Manage Stable COPD Key Points 3 Add inhaled steroids to bronchodilators for symptomatic COPD patients with an FEV1 <50% predicted (Stage III: Severe COPD and Stage IV Very Severe COPD) and repeated exacerbations (Evidence A) Avoid chronic treatment with systemic steroids - unfavorable benefit-to-risk ratio (Evidence A

44. Manage Stable COPD Key Points 3 The long-term O2 with chronic respiratory failure increases survival (Evidence A) Improves exercise tolerance If hypercapnic titrate SpO2 to 88-90% Walk your clinic patients if RA SpO2 OK

45. Manage Stable COPD Key Points 4 All COPD patients benefit from exercise training program Improves both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A)

46. Medications

47. Bronchodilators Beta2-agonists Short-acting Fenoterol Salbutamol (albuterol) Terbutaline Long-acting Formoterol Salmeterol

48. BronchodilatorsAnticholinergics Mode of Action Cholinergic tone is only reversible component of COPD Normal airway have small degree of vagal cholinergic tone Short-acting Ipratropium bromide Oxitropium bromide Long-acting Tiotropium

49. Bronchodilators- Combos and Methylxanthines Combination beta2-agonists plus anticholinergic in one inhaler Fenoterol/Ipratropium Salbutamol/Ipratropium Methylxanthines Aminophylline (slow release preparations) Theophylline (slow release preparations) RARELY OF SIGNIFICNAT BENEFIT LEVEL 8-12 mcg/ml

50. Other Med Adjuncts? Influenza vaccines significantly reduce serious illness and death (Evidence A) Pneumococcal vaccine –OK to use but data lacking (Evidence B) Antibiotics: other than treating infectious exacerbations- not recommended (Evidence A) Mucolytic Agents: a few patients with viscous sputum may benefit but the widespread use cannot be recommended (Evidence D) Antitussives: Cough, a troublesome symptom in COPD, has a protective role. Regular use of antitussives contraindicated (Evidence D) Narcotics: The use of PO and IV opioids effective for dyspnea in advanced disease

51. Therapy by Stage- Pretty Simple

52. “Make everything as simple as possible, but not one bit simpler” Einstein

53. Manage Exacerbations  Do you admit? You and your patient decide….little guidance in the literature

54. Manage Exacerbations 1 Infection of tracheobronchial tree and air pollution are most common causes Cause of about 1/3 of severe exacerbations cannot be identified

55. Manage Exacerbations 2 (Evidence A) treatment Inhaled bronchodilators (beta2-agonists and/or anticholinergics) Systemic, preferably oral, glucocorticosteroids (Evidence B) Antibiotic treatment if signs of airway infection increased volume/change of color of sputum fever O2 of course….but caution with retainers Little evidence for Methyxanthines

56. Manage Exacerbations 3  Noninvasive intermittent positive pressure ventilation (NIPPV) 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) BIPAP is Best! Set FiO2, inspiratory (IPAP) and expiratory (EPAP) Difference between IPAP and EPAP augments tidal volume and improves minute ventilation CO2 gets blown off

57. Best References Stoller J. Acute Exacerbations of COPD, NEJM Mar 28, 2002 Sutherland E. Management of COPD, NEJM June 24, 2004 GOLD (Global Initiative for Chronic Obstructive Lung Disease) Executive Summary www.goldcopd.org New….TORCH NEJM Feb 22, 2007

58. Questions?