Transcript CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINICAL …

CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
CLINICAL PRACTICE GUIDELINES REVIEW
WEEK 2: THERAPY
AMBULATORY INTERNAL MEDICINE
GROUP PRACTICE
UNIVERSITY HEALTH NETWORK / MSH
OCTOBER 2007
Prepared by: Dr. D. Panisko
COPD: Guidelines for this Seminar
 Standards for the diagnosis and treatment of patients with
COPD: a summary of the ATS/ERS position paper. Celli BR et
al. Eur Respir J 2004; 23: 932-46. Full document, with updates,
available at: www.thoracic.org, accessed Sept 2007
 Canadian Thoracic Society recommendations for the
management of chronic obstructive pulmonary disease 2003. O’Donnell DE et al. Can Respir J 2003; 10(SupplA): 11A33A
 Global Initiative for Chronic Obstructive Lung Disease.
(GOLD). A collaborative of the NIH and WHO. Updated Nov 2006,
accessed Sept 2007. Available at www.goldcopd.com
COPD: other useful references:
 2 recent review series on COPD:
 5 article series on exacerbations:
Thorax Feb – June, 2006
 12 article series:
BMJ May 13th to July 22nd, 2006
 Excellent recent update:
 Update in Chronic Obstructive Pulmonary
Disease 2006: Rabe KF, et al. Am J Resp Crit
Care 2007; 175: 1222-1232
COPD Therapy: Objectives
 This seminar deals with chronic stable
COPD, not with acute exacerbations.
 After this seminar you should:
 be aware of therapeutic clinical practice
guidelines for stable chronic COPD
 be able to describe interventions that
improve quality of life and mortality in
stable COPD
 be able familiar with a guideline based
therapeutic cascade for chronic stable
COPD
COPD II:
THERAPY
CASE:
As you recall from last week, you are seeing
Mr. X. a 61 year old man who comes to your clinic
as a new patient for follow up.
He had just been admitted to hospital for his
first exacerbation of COPD. He has completed a
10 day antibiotic course and 10 days of oral
Prednisone. Spirometry reveals FEV1 of 65%
pred and FEV1/FVC = 60% pred.
He is now only on an ipratropium puffer, two
puffs qid.
COPD II:
THERAPY
Mr. X. indicates his ipratropium puffer has
helped, especially when compared to his
symptoms before his hospitalization, when he was
using no pharmacotherapy.
However, he still has excess shortness of
breath on exertion, occasional periods of dyspnea
during the day, and awakens at about 5 am with
shortness of breath.
You now begin to consider therapeutic
options for this patient.
COPD II:
THERAPY
What is Mr. X’s...
clinical stage of COPD ?
(See the next slide for a review of spirometric
staging)
Fig 1 Clinical algorithm for the treatment of chronic obstructive pulmonary disease (COPD).
Clinical stages are defined symptomatically (see footnote). GOLD stage refers to the
classification of COPD on the basis of spirometry after using a bronchodilator
Cooper, C B et al. BMJ 2005;330:640-644
Copyright ©2005 BMJ Publishing Group Ltd.
COPD II:
THERAPY
What is Mr. X’s clinical stage of COPD ?
Mr. X has:
persistent symptoms and
stage 2 (Moderate COPD)
The previous slide indicates a progressive
management cascade that will be discussed
further in this seminar. The next slide
demonstrates the relationship between symptoms,
disease progression, and the need for
intervention.
COPD II:
THERAPY
 1)What preventive interventions are
important for this COPD patient ?
Do they have survival benefit ?
COPD II:
THERAPY
 1) Smoking cessation/vaccines
If the patient can stop smoking, the decline of his
FEV1 curve becomes less steep and survival is
prolonged. Some authorities feel this is the most
important intervention of all (Rabe et al 2007)!
The effect of the vaccinations on survival is less
definitive; survival and morbidity benefit of influenza
vaccination has been shown for patients over the age of
65 and patients with COPD. There is less, Gr. B,
evidence for benefit from pneumovax in COPD.
Antiviral agents could be considered as preventive
agents or as therapy in early influenzal infection in nonimmunized patients.
COPD II:
THERAPY
 2) What are various methods available for
smoking cessation in specialized programs ?
 3) Where can you refer patients?
COPD II:
THERAPY
 2) The entire topic of smoking cessation will be covered in
an AIMGP Clinic later in the year.
Briefly: support groups, behaviour modification,
reinforcement in pulmonary rehabilitation programs, and
physician and nurse directives are used.
Pharmacological methods include nicotine therapy
(patch, gum, inhaler, spray), bupropion (Zyban) - a
centrally acting noradrenergic agonist and novel
antidepressant, and Buspirone - an anxiolytic.
Combined nicotine and bupropion therapy, with a
support program, achieved a 35% cessation rate at 1 year
in one trial.
A new agent, varencline, a nicotininc Ach receptor
antagonist is undergoing clinical trials and has had some
success.
COPD II:
THERAPY
 3) Smoking cessation resources:
Asthma Clinic (run by the clinical nurse
specialist), and Pulmonary Wellness Clinic
(hospital operator can give you current
telephone numbers) at the UHN.
COPD II:
THERAPY
4) What pharmacologic therapy can be
offered for Mr. X.'s:
a) intermittent dyspnea during the day ?
b) excess dyspnea on exertion ?
c) dyspnea in the early a.m. ?
COPD II:
THERAPY
4a)
If symptoms become regular and more frequent
than those treated by a prn short acting
agent, evidence indicates that regular use of a
long acting bronchodilator provides more
effective treatment than multiple daily usage
of short acting inhalers.
COPD II:
THERAPY
4a) cont.
Add a beta agonist inhaler, preferably a long acting agent
like salmeterol 2 puffs bid. The long acting
anticholinergic inhaler tiotropium, 18 mcg od, can
also be substituted for the ipratropium.
The dose response for ipratropium is linear up to about 6
or 8 puffs q4h... so you can push puffer doses to this
level if your patient is still symptomatic. WE TEND
TO UNDERDOSE !!!
A therapeutic cascade for bronchodilators for the
ATS/ERS guidelines is shown on the next slide
SA-BD = Short Acting Bronchodilator, LA-BD = Long-Acting
Bronchodilator, ICS = Inhaled Corticosteroid
COPD II:
THERAPY
What pharmacologic therapy can be
offered for Mr. X.‘s
 b) excess dyspnea on exertion ?
 b) Use salbutamol puffer 2 to 4 puffs prn preexercise, and improve baseline daytime control as in
a) above. Entry into a pulmonary rehab day program
may improve conditioning and exercise tolerance.
COPD II:
THERAPY
4)c) Nocturnal Symptoms:
 Use a long acting beta agonist (salmeterol) qhs or the
long acting anticholinergic tiotropium, 18 mcg od.
 A long acting oral theophylline preparation qhs may
also work. Theophylline preparations do not need to
be titrated to full therapeutic doses as levels of 30-50
mmol/l are probably as effective as usual
"therapeutic" levels of 55-110 mmol/l. The recent
Canadian guidelines also recommend these agents as
4th line for chronic maintenance therapy in COPD.
COPD II:
THERAPY
4)c) cont.
 For early am or nocturnal symptoms also consider
need for sleep study and examination for night
time desaturations, especially if there is LV or RV
dysfunction. Also consider non-pulmonary
reasons for night time exacerbations of shortness
of breath like microaspiration from esophageal
reflux, and paroxysmal nocturnal dyspnea.
COPD II:
THERAPY
5) Mr. X. has moderate, regularly
symptomatic COPD and therefore needs
multiple medications.

In contrast, what would you prescribe for
a patient with mild and only occasional
symptoms from Chronic Obstructive
Pulmonary Disease ?
COPD II:
THERAPY
 5) A short acting beta agonist puffer prn.
Consider which is the optimal metered dose inhaler
(puffer, turbuhaler, etc.), whether a spacer device is
required (aerochamber, etc.), and observation of the
patient to ensure effective delivery of medication.
COPD II:
THERAPY
Mr. X. returns in 4 weeks after you have added
salbutamol 2-4 puffs prn with exercise and replaced his
regular ipratropium with tiotropium. You have prescribed
rescue salbutamol/ipratropium combination (Combivent)
You have monitored his puffer technique, felt it was very
good and did not prescribe a spacer.
He has enrolled in a smoking cessation program and feels
he is making progress.
COPD II:
THERAPY
His nocturnal symptoms have markedly improved with 2
puffs of salmeterol qam and qhs.
He continues to have productive cough of whitish yellow
sputum - 2 tablespoons each morning and less,
intermittently, throughout the day.
However, while feeling much better overall, he still notes
residual dyspnea on exercise and some dyspnea and
discomfort at rest.
COPD II:
THERAPY
 7)What is the next step in the
therapeutic cascade for this patient ?
How do you implement this therapy ?
COPD II:
THERAPY
 7) Could also consider inhaled corticosteroids.
ATS/ERS guidelines now suggest initiation of this
therapy with FEV1<50% predicted or if the patient is
experiencing frequent exacerbations.
Could consider regular long acting theophylline therapy
(Canadian and ATS/ERS guidelines).
The next slide illustrates (again) the cascade of therapy
recommended and based on ATS/ERS guidelines.
COPD II:
THERAPY
 7) The TORCH trial (Calverley et al N Engl J Med 2007;
356: 775-89) did not show a mortality benefit for
combined LABA/CS but demonstrated an improvement in
many clinical outcomes for this combined mode of therapy
(i.e. quality of life measures, decrease in exacerbations).
Another randomized trial showed no additive preventive
effect of LABA/CS for COPD exacerbations on top of
existing tiotropium therapy. However combined therapy
improved lung function, quality of life, and did decrease
hospitalizations (Aaron et al 2007; 146: 545-555).
SA-BD = Short Acting Bronchodilator, LA-BD = Long-Acting
Bronchodilator, ICS = Inhaled Corticosteroid
COPD II:
THERAPY
Two years later, Mr. X. has begun to feel much
more short of breath, despite compliance with
maximal medical therapy.
Spirometry reveals an FEV1 of 38% predicted.
You now note some peripheral cyanosis at rest,
even though Mr. X. is at baseline and not in an
exacerbation.
COPD II:
THERAPY
 9)What additional diagnostic and
potential therapeutic interventions are
appropriate ?
 10)
How can you refer patients for
pulmonary rehabilitation from the
AIMGP clinic ?
COPD II:
THERAPY
9) Diagnostic and Therapeutic Interventions:
 Resting, exercise, and possibly overnight oximetry.
 ABG to determine whether long term oxygen
therapy is indicated. ABG required for ODB approval
for funding of O2 therapy (PaO2<55mmHg or
<60mmHg if cor pulmonale is present). Call
Respiratory Therapist to your clinic for home O2
forms and for help in setting up home O2. Consider
ABG whenever FEV1 falls below 50% predicted.
COPD II:
THERAPY
9) Diagnostic and Therapeutic Interventions:
 Consider a complication accounting for the decline (like
recurrent chronic pulmonary embolization).
 Consider referral to a respirologist.
 Consider referral to a pulmonary rehabilitation program.
 If advance directives for care have not been established,
they should be discussed with the patient now or at an
opportune time.
COPD II:
THERAPY
9) Diagnostic and Therapeutic Interventions:
 Bullectomy and lung volume reduction surgery may result in
improved spirometry, lung volume, exercise capacity, dyspnoea,
health-related quality of life and possibly survival in highly selected
patients (e.g. with assymetrical bullae and poor exercise capacity).

Lung transplantation results in improved pulmonary function,
exercise capacity, quality of life and possibly survival in highly
selected patients.
10) Referral to Pulmonary Rehab:
 Pulmonary Wellness Clinic at the University Health Network (call
hospital operator for clinic #) or Residential and outpatient
programs at West Park Hospital.