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Central Ohio Pulmonary Disease, Inc. Michael L. Corriveau , MD, FACP, FCCP. COPD 2006. Definition of COPD. “A disease state characterized by airflow limitation that is not fully reversible..”. COPD. Normal Damage + Cholinergic tone. Epidemiology of COPD.

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slide1

Central Ohio Pulmonary Disease, Inc.

Michael L. Corriveau, MD, FACP, FCCP

definition of copd
Definition of COPD

“A disease state characterized by

airflow limitation that is not

fully reversible..”

slide4
COPD

Normal

Damage +

Cholinergic tone

epidemiology of copd
Epidemiology of COPD

12.5 million patients with chronic bronchitis

1.6 million patients with emphysema

8 million office visits and 1.5 million ER visits/year

$30 billion/year lost in healthcare/work loss

Fourth leading cause of death in the US

copd patients
COPD Patients

Stereotypical pictures of COPD patients

31

Pink Puffer

Blue Bloater

causes of copd
Causes of COPD

Cigarette smoking

Alpha-1 antitrypsin deficiency

Industrial causes

alpha 1 antitrypsin deficiency
Alpha 1 Antitrypsin Deficiency

2 – 3% of patients with emphysema have AAT deficiency

40,000 – 60,000 Americans have AAT deficiency

Cigarette smoking increases the likelihood of symptomatic disease

Onset of symptoms earlier than non-AAT deficient patients

(mean age at presentation = 46 years)

CXR often shows more prominent bullae in the bases

diagnosis of copd
Diagnosis of COPD

History (dyspnea, cough, wheezing)

Spirometry

value of spirometry in copd
Value of Spirometry in COPD

Early, accurate diagnosis

More sensitive than peak flow or CXR

Document change in lung function over time

Having a “number” may benefit the patient

Helpful in stratifying the degree of disease

spirometry in copd
Spirometry in COPD

Normal FEV1 > 80% of predicted value

Predicted value varies with age, height and sex

Normal FEV1% > 70%

Consider spirometry in past and present smokers

over age 45, and patients with chronic

cough, dyspnea or wheezing

causes of dyspnea in copd
Causes of Dyspnea in COPD

narrowed airways (bronchospasm, increased compliance

airway secretions, airway thickening, increased cholinergic tone)

hyperinflation

DYSPNEA

breathing at

high volumes

diaphragm

flattening

slide19

Dyspnea

Reduced activity

capacity

Inactivity

Deconditioning

management of copd
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

smoking cessation societal interventions
Smoking CessationSocietal Interventions

Restriction of minors’ access to tobacco products

Restriction of smoking in public places

Restriction on advertisements

Increasing prices through taxation

smoking cessation physician interventions
Smoking CessationPhysician Interventions

Ask about tobacco use at every visit

Advise all smokers to quit

Assess smokers readiness to quit

Assist the patient in quitting

Arrange follow up visit

management of copd23
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

pulmonary rehabilitation
Pulmonary Rehabilitation

“Pulmonary rehabilitation is a multidisciplinary service

for patients with pulmonary disease and their families,

provided by an interdisciplinary team of specialists,

with the goal of achieving and maintaining the

individual’s maximum level of independence and functioning

in the community.”

components of pulmonary rehabilitation
Components of Pulmonary Rehabilitation

Education

Exercise

Psychosocial support

benefits of pulmonary rehabilitation
Benefits of Pulmonary Rehabilitation

Improved activity capacity

Improved quality of life

Decrease in hospitalization

Return to work

management of copd27
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

short acting bronchodilators albuterol
Short-Acting Bronchodilators: Albuterol
  • Stimulates 2-receptors on airway smooth muscle
  • Onset of effect: 1-3 minutes
  • Duration of action: 4-6 hrs
  • Reliever/rescue medication: PRN dosing
  • 2:1 Selectivity
    • Albuterol = 1,375:
long acting bronchodilators salmeterol
Long-Acting Bronchodilators: Salmeterol
  • Stimulates 2-receptors on airway smooth muscle
  • Onset of effect: 20-30 minutes
  • Duration of action: 12+ hrs
  • Maintenance medication: 1 inhalation b.i.d.
  • 2:1 Selectivity
    • Albuterol = 1,375:1
    • Salmeterol = 85,000:1
formoterol
Formoterol
  • Long-acting 2-agonist
  • Dosage: 12 µg b.i.d. via dry-powder inhaler
  • Onset of action: 1-3 minutes
  • Duration of action: dose-dependent (12-hour duration with higher dose)

Bartow RA, Brogden RN. Drugs. 1998;55:303-322.

theophylline
Theophylline

Bronchodilation

Increase in central respiratory drive

Increased cardiac output

Increased muco-ciliary clearance

Increased fatigue threshold of the diaphragm

mucokinetic agents
Mucokinetic Agents
  • Guiafenesin
  • SSKI
  • Mucomyst
  • P & PD
slide34

Advair now approved by the FDA for use in

COPD with chronic bronchitis

Package insert recommendation for initial

and follow-up dexa scan

Package insert recommendation for periodic

eye examinations

medical letter may 24 2004 tiotropium
Medical Letter, May 24, 2004tiotropium

Improved lung function

Decrease symptoms of COPD

Increases quality of life

Decreases number of exacerbations

“an important advance in the treatment of COPD”

gold stages of copd
GOLD Stages of COPD

NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated 2003).

la bronchodilators in copd
LA Bronchodilators in COPD

Drugs lung symptoms exercise decrease

function tolerance exacerbations

Salmeterol ++ + - +/-

Formoterol ++ + - +

Tiotropium +++ ++ ? ++

CHEST 2004; 125:249-259

slide41

GOLD Stage

0

I

prn short-acting bronchodilator

tiotropium

+

SABA

salmeterol or

formoterol +

SABA

II

tiotropium +

salmeterol or

formoterol

salmeterol or

formoterol +

tiotropium

III

IV

add inhaled corticosteroid

CHEST 2004; 125:249-259

alpha 1 antitrypsin deficiency treatment
Alpha 1 Antitrypsin DeficiencyTreatment

NIH National Registry showed improved survival and decreased

rate of decline in patients receiving augmentation therapy

AAT levels increased

Trough levels maintained above minimal threshhold

Weekly infusions of 60 mg/kg

management of copd44
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

indications for o2 therapy
Indications for O2 Therapy

PaO2 55 mmHg or less

PaO2 56 – 59 mmHg with complication, such as

erythrocytosis or cor pulmonale

SaO2 88% or less

management of copd46
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

noninvasive ventilation
Noninvasive Ventilation

Stable outpatient management

Acute exacerbation treated in hospital

increases pH

reduces PaCO2

reduces breathlessness 1st 4 hours of Rx

decreases length of hospital stay

reduces intubation rate

management of copd48
Management of COPD

Smoking cessation

Pulmonary rehabilitation

Pharmacologic

Supplemental oxygen

Non-invasive ventilation

Surgical remedies

volume reduction surgery
Volume Reduction Surgery

A procedure in which 20-30% of the most diseased

portions of the lung are removed

Reduces lung hyperinflation

Dilates bronchi by increased traction forces

Places diaphragm at better mechanical advantage

volume reduction surgery outcomes
Volume Reduction SurgeryOutcomes

Improved dyspnea index scores

Improved elastic recoil of the lung

Decreased residual volume and FRC

Decreased PaCO2

Improved FEV1

Improved 6-minute walk distance

lung transplantation
Lung Transplantation

Over 1500 lung transplants/year in the United States

4000 candidates awaiting transplant in the US late 2003

Provides significant improvement in both health-related

and overall quality of life

lung transplantation inclusion criteria
Lung transplantationInclusion Criteria

Life expectancy less than 3 years

Failure of medical therapy

Age less than 60 years

No extrapulmonary organ failures

lung transplantation exclusion criteria
Lung TransplantationExclusion Criteria

Coronary artery disease

Continuing substance abuse

Inadequate psychosocial support

Extreme cachexia or obesity

Recent malignancy (<3 years)

Long term, high dose corticosteroid use

useful informational web sites for copd
Useful Informational Web Sitesfor COPD

www.goldcopd.com

www.ats/copd.com

www.nlhep.org