Transcript Slide 1

COPD Guideline
Ayman Farghaly MD FCCP
Military Medical Academy
G lobal Initiative for Chronic
O bstructive
L ung
D isease
© Global Initiative for Chronic Obstructive Lung Disease
GOLD Objectives
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Increase awareness of COPD among
health professionals, health
authorities, and the general public
Improve diagnosis, management and
prevention
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Decrease morbidity and mortality
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Stimulate research
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
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Definition and Overview
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Diagnosis and Assessment
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Therapeutic Options
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Manage Stable COPD
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Manage Exacerbations
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Manage Comorbidities
REVISED 2011
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
n
Definition and Overview
n
Diagnosis and Assessment
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Therapeutic Options
n
Manage Stable COPD
n
Manage Exacerbations
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Manage Comorbidities
REVISED 2011
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
n
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COPD, a common preventable and treatable
disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
Exacerbations and comorbidities contribute to
the overall severity in individual patients.
Global Strategy for Diagnosis, Management and Prevention of COPD
Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease
Parenchymal Destruction
• Airway inflammation
• Airway fibrosis, luminal plugs
• Increased airway resistance
• Loss of alveolar attachments
• Decrease of elastic recoil
AIRFLOW LIMITATION
Global Strategy for Diagnosis, Management and Prevention of COPD
Burden of COPD
• COPD is a leading cause of morbidity and
mortality worldwide.
• The burden of COPD is projected to increase
in coming decades due to continued
exposure to COPD risk factors and the aging
of the world’s population.
• COPD is associated with significant economic
burden.
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
n
Definition and Overview
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Diagnosis and Assessment
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Therapeutic Options
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Manage Stable COPD
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Manage Exacerbations
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Manage Comorbidities
REVISED 2011
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
 A clinical diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough or sputum production, and/or a
history of exposure to risk factors for the
disease.
 Spirometry is required to make the diagnosis;
the presence of a post-bronchodilator FEV1/FVC
< 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
 The goals of COPD assessment are to determine
the severity of the disease, including the severity
of airflow limitation, the impact on the patient’s
health status, and the risk of future events.
 Comorbidities occur frequently in COPD patients,
and should be actively looked for and treated
appropriately if present.
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
SYMPTOMS
shortness of breath
chronic cough
sputum
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution
SPIROMETRY: Required to establish
diagnosis
Spirometry: Obstructive Disease
Normal
5
Volume, liters
4
3
FEV1 = 1.8L
2
FVC = 3.2L
FEV1/FVC = 0.56
1
1
2
3
4
Time, seconds
5
6
Obstructive
Global Strategy for Diagnosis, Management and Prevention of COPD
Symptoms of COPD
The characteristic symptoms of COPD are chronic and
progressive dyspnea, cough, and sputum production.
Dyspnea: Progressive, persistent and characteristically
worse with exercise.
Chronic cough: May be intermittent and may be
unproductive.
Chronic sputum production: COPD patients commonly
cough up sputum.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
 Assess symptoms
Assess degree of airflow limitation using
spirometry
Use the COPD Assessment Test(CAT)
Assess risk of exacerbations
or
Assess comorbidities
mMRC Breathlessness scale
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item
measure of health status impairment in COPD
(http://catestonline.org).
Breathlessness Measurement using the
Modified British Medical Research Council
(mMRC) Questionnaire: relates well to other
measures of health status and predicts future
mortality risk.
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation
using spirometry
Assess
risk of exacerbations
Use spirometry
for grading severity
Assess
comorbidities
according
to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value
Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow
Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild
FEV1 > 80% predicted
GOLD 2: Moderate
50% < FEV1 < 80% predicted
GOLD 3: Severe
30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation
using spirometry
 Assess risk of exacerbations
Assess
comorbidities
Use history
of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk
Global Strategy for Diagnosis, Management and Prevention of COPD
(C)
(D)
>2
(B)
1
3
2
(A)
1
0
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Use combined assessment
3
(C)
(D)
>2
2
(A)
(B)
1
0
1
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Patient is now in one of
four categories:
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
•
•
•
•
•
•
Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
These comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately.
Global Strategy for Diagnosis, Management and Prevention of COPD
Differential Diagnosis:
COPD and Asthma
COPD
• Onset in mid-life
•
Symptoms slowly
progressive
ASTHMA
• Onset early in life (often
childhood)
• Symptoms vary from day to day
• Long smoking history • Symptoms worse at night/early
morning
• Allergy, rhinitis, and/or eczema
also present
• Family history of asthma
Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude
alternative diagnoses and establish presence of significant
comorbidities.
Lung Volumes and Diffusing Capacity: Help to characterize
severity, but not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can be
used to evaluate a patient’s oxygen saturation and need for
supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD
develops in patients of Caucasian descent under 45 years or
with a strong family history of COPD.
Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
Exercise Testing: Objectively measured exercise
impairment, assessed by a reduction in self-paced walking
distance (such as the 6 min walking test) or during
incremental exercise testing in a laboratory, is a powerful
indicator of health status impairment and predictor of
prognosis.
Composite Scores: Several variables (FEV1, exercise
tolerance assessed by walking distance or peak oxygen
consumption, weight loss and reduction in the arterial
oxygen tension) identify patients at increased risk for
mortality.
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
REVISED 2011
Manage Comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
 Smoking cessation has the greatest capacity to
influence the natural history of COPD. Health care
providers should encourage all patients who smoke
to quit.
 Pharmacotherapy and nicotine replacement reliably
increase long-term smoking abstinence rates.
 All COPD patients benefit from regular physical
activity and should repeatedly be encouraged to
remain active.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
 Appropriate pharmacologic therapy can reduce COPD
symptoms, reduce the frequency and severity of
exacerbations, and improve health status and
exercise tolerance.
 None of the existing medications for COPD has been
shown conclusively to modify the long-term decline
in lung function.
 Influenza and pneumococcal vaccination should be
offered depending on local guidelines.
Brief Strategies to Help the
Patient Willing to Quit Smoking
• ASK
Systematically identify all
tobacco users at every visit
• ADVISE
Strongly urge all tobacco
users to quit
• ASSESS
Determine willingness to
make a quit attempt
• ASSIST
Aid the patient in quitting
• ARRANGE
Schedule follow-up contact.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Risk Reduction
 Encourage comprehensive tobacco-control policies with clear,
consistent, and repeated nonsmoking messages.
 Emphasize primary prevention, best achieved by elimination or
reduction of exposures in the workplace. Secondary
prevention, achieved through surveillance and early detection,
is also important.
 Reduce or avoid indoor air pollution from biomass fuel, burned
for cooking and heating in poorly ventilated dwellings.
 Advise patients to monitor public announcements of air quality
and, depending on the severity of their disease, avoid vigorous
exercise outdoors or stay indoors during pollution episodes.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators

Bronchodilator medications are central to the
symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
 The principal bronchodilator treatments are beta2-
agonists, anticholinergics, theophylline or combination
therapy.
 The choice of treatment depends on the availability of
medications and each patient’s individual response
in terms of symptom relief and side effects..
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
 Long-acting inhaled bronchodilators are
convenient and more effective for symptom relief
than short-acting bronchodilators.

Long-acting inhaled bronchodilators reduce
exacerbations and related hospitalizations and
improve symptoms and health status.

Combining bronchodilators of different
pharmacological classes may improve efficacy and
decrease the risk of side effects compared to
increasing the dose of a single bronchodilator.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Inhaled
Corticosteroids

Regular treatment with inhaled corticosteroids (ICS)
improves symptoms, lung function and quality of life
and reduces frequency of exacerbations for COPD
patients with an FEV1 < 60% predicted.

Inhaled corticosteroid therapy is associated with an
increased risk of pneumonia.

Withdrawal from treatment with inhaled
corticosteroids may lead to exacerbations in some
patients.
Long-term Use of Inhaled Corticosteroids and
the Risk of Pneumonia in Chronic Obstructive
Pulmonary Disease
Sonal Singh, MD, MPH; Aman V. Amin, MD; Yoon K. Loke, MD , Arch
Intern Med. 2009 .
Conclusion Among patients with COPD, inhaled corticosteroid use
for at least 24 weeks is associated with a significantly increased risk
of serious pneumonia, without a significantly increased risk of death
Invasive Aspergillosis
Intermediate Risk
Prolonged corticosteroid therapy
COPD
Autologous HSCT
Cirrhosis with duration of stay >7 days
Solid-organ cancer
HIV infection
Lung transplantation
Systemic disease requiring prolonged
immunosuppression
Meersseman W ,et al .Clin Infect Dis. 2007;45(2):205-216
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Combination
Therapy
 An inhaled corticosteroid combined with a long-
acting beta2-agonist is more effective than the
individual components in improving lung function
and health status and reducing exacerbations in
moderate to very severe COPD.
 Addition of a long-acting beta2-agonist/inhaled
glucorticosteroid combination to an anticholinergic
(tiotropium) appears to provide additional
benefits.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Systemic
Corticosteroids
 Chronic treatment with systemic
corticosteroids should be avoided because of
an unfavorable benefit-to-risk ratio.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options:
Phosphodiesterase-4 Inhibitors
 In patients with severe and very severe
COPD (GOLD 3 and 4) and a history of
exacerbations and chronic bronchitis, the
phospodiesterase-4 inhibitor (PDE-4),
roflumilast, reduces exacerbations treated
with oral glucocorticosteroids.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Theophylline

Theophylline is less effective and less well tolerated than
inhaled long-acting bronchodilators and is not
recommended if those drugs are available and affordable.

There is evidence for a modest bronchodilator effect and
some symptomatic benefit compared with placebo in stable
COPD. Addition of theophylline to salmeterol produces a
greater increase in FEV1 and breathlessness than
salmeterol alone.

Low dose theophylline reduces exacerbations but does not
improve post-bronchodilator lung function.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments
Influenza vaccines can reduce serious illness.
Pneumococcal polysaccharide vaccine is recommended
for COPD patients 65 years and older and for COPD
patients younger than age 65 with an FEV1 < 40%
predicted.
The use of antibiotics, other than for treating infectious
exacerbations of COPD and other bacterial infections, is
currently not indicated.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other
Pharmacologic Treatments
Alpha-1 antitrypsin augmentation therapy: not
recommended for patients with COPD that is unrelated
to the genetic deficiency.
Mucolytics:
Patients with viscous sputum may
benefit from mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators: Nitric oxide is contraindicated in stable
COPD. The use of endothelium-modulating agents for
the treatment of pulmonary hypertension associated
with COPD is not recommended.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
 All COPD patients benefit from exercise training
programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
 Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective the results.
 If exercise training is maintained at home the
patient's health status remains above prerehabilitation levels.
Cardio-pulmonary Exercise Test in
Assessment of COPD Patients Undergoing
Rehabilitation Programme
Ain Shams Univ. & Aeromedical Inst.
2001
Mohammed Ali , Mona Mansour , Tarek Safwat , Ayman Farghaly
(1) Group I Twenty five patients
pulmonary rehabilitation and received anabolic
steroid
( Nandrolone deconoate 50mg / three-weeks for
twelve weeks)
(2) Group II Twenty-five patients
only pulmonary rehabilitation and no anabolic steroid.
(3) Group III Twenty five patients
considered as a control group,
Cardio-Pulmonary exercise test;a) It was done for all COPD patients included in this
study before and after the exercise training program.
b) There was no reported complications during and after
testing.
c) The cardiopulmonary exercise system supplied by
computer with color monitor, gas analyzer, keyboard,
colored printer connected with treadmill and E.C.G
monitor. It uses Bruce protocol with incremental
increase in the work load every three minutes.
Exercise Training Program
After primary assessment measures, the selected COPD
patients were enrolled into a program of exercise training that
was planned according to exercise rehabilitation program done
by Vogiatzis et al.,1999.
Taking the following into consideration:-
(1) Warm up and cool down
(2) Aerobic exercise (endurance) i.e. Not allow patient to
be exhausted.
(3) Modality:- patients were submitted to lower limb
exercise in the form of walking on flat, treadmill, cycling
and upper limb exercise in the form of lifting objects,
arm rotator and cycling.
(4) Frequency:- three Times weekly.
Comparison between the three groups as regards,
CPET Parameters
(1) Time of test stage ( in minutes):
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
1.37 ± 0.53
3.816± 1.355
8.327
0.000
Group II
1.27 ± 0.4903
3.728 ± 1.9215
7.33
0.000
Group III
1.424 ± 0.6715
1.340 ± 0.660
0.725
0.476
ANOVA
0.470
24.816
P-value
0.627
0.000
Comparison between the three groups as regards,
(2) Work Load (in watt):
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
61.84 ± 11.960
123.24 ± 26.912
12.585
0.000
Group II
60.80 ± 19.773
107.84 ± 41.372
6.48
0.000
Group III
59.0 ± 10.29
57.17 ± 12.66
1.52
0.142
ANOVA
0.043
34.411
P-value
0.958
0.000
Comparison between the three groups as regards,
(3)
Maximum Oxygen Consumption (ml/minute) (VO2 max.):
Group I
Group II
Group III
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
1609.16 ± 446.8
2552.68 ± 8.352
4.651
0.001
2192.52 ± 589.9
3.542
0.002
1595.80 ±
529.615
0.171
0.866
1688.72 ±
547.06
1615.35 ±
687.95
ANOVA
0.127
14.816
P-value
0.881
0.000
Comparison between the three groups as regards,
(4) Maximum Oxygen Consumption Percent of Predicted (VO2 max.%):
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
65.76 ± 14.45
97.76 ± 33.05
4.351
0.000
Group II
66.80 ± 17.8699
88.44 ± 24.211
6.098
0.000
Group III
66.36 ± 24.871
65.64 ± 22.009
1.717
0.099
ANOVA
2.827
8.246
P-value
0.66
0.001
Comparison between the three groups as regards,
(5) Normalized VO2 (VO2 per Kg body weight):
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
20.716 ± 5.517
30.592 ± 10.396
3.573
0.002
Group II
20.952 ± 5.9967
24.828 ± 8.9158
2.654
0.014
Group III
23.028 ± 9.329
19.624 ± 7.2048
1.717
0.099
ANOVA
0.791
9.426
P-value
0.457
0.000
Comparison between the three groups as regards,
6) Oxygen Pulse at maximum exercise (VO2 /HR) in
ml/beat:
(
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
14.24 ± 3.929
20.64 ± 9.699
2.784
0.01
Group II
17.60 ± 8.426
20.28 ± 10.998
1.033
0.312
Group III
18.36 ± 9.429
17.24 ± 4.40
1.63
0.11
ANOVA
2.056
2.917
P-value
0.135
0.061
Comparison between the three groups as regards,
(9) Maximum Minute Ventilation (VE max in liters/min):
Paired
t-test
P-value
68.54 ± 21.25
2.844
0.009
54.996 ± 17.6
71.09 ± 20.42
4.629
0.000
Group III
41.52 ± 23.21
44.54 ± 17.62
1.87
0.08
ANOVA
4.277
18.552
P-value
0.18
0.000
Before program
Mean ± SD
After program
Mean ± SD
Group I
57.32 ± 20.68
Group II
Comparison between the three groups as regards,
[2] FVC% (% of predicted):-
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
54.52 ± 10.128
58.52 ± 9.2427
2.316
0.029
Group II
57.8 ± 11.310
58.84 ± 9.800
0.869
0.393
Group III
53.81 ± 8.88
54.67 ± 8.7996
0.841
0.352
ANOVA
1.736
1.379
P-value
0.184
0.259
Comparison between the three groups as regards,
[3] FEV1 (in Liters):-
Before program
Mean ± SD
After program
Mean ± SD
Paired
t-test
P-value
Group I
1.407 ± 0.346
1.623 ± 0.347
4.32
0.01
Group II
1.4404 ± 0.327
1.580 ± 0.3351
3.962
0.04
Group III
1.364 ± 0.3837
1.42 ± 0.391
1.998
0.067
ANOVA
0.295
2.205
P-value
0.746
0.118
Conclusion
Pulmonary rehabilitation is a multidisciplinary
program that attempts to return the patient to the
highest possible functional capacity.
n
• Evidence supports the use of lower extremity exercise
training as it improves exercise tolerance.
• Upper extremity strength and endurance training
is recommended.
• Pulmonary rehabilitation improves dyspnoea,
improves quality-of-life scores, and reduces the
number of hospitalizations and days in the hospital;
the effects on survival are not definite.