Transcript available now - Grand Strand Advanced Practice Nurse Association

An Update on Chronic
Obstructive Pulmonary
Disease





No Company Affiliations
Graduated from Medical University of South
Carolina in Charleston, 2000
Experience-14+ Years in Cardiology and
Pulmonary Practice in Coastal South Carolina
Now Back in Primary Care for past 9 months.
What was I thinking!
80-100 patients per week (60% practice is
Pulmonary medicine-40% Cardiology)





Discuss the pathophysiology of COPD,
manifestations of disease process and
diagnosis of COPD
Name the financial and Social Impact of COPD
on U.S. and South Carolina population
Interpret and review effective diagnostic
testing for COPD
Discuss current Pharmacologic Treatments of
COPD
Discuss Non-Pharmacologic Treatments
options


Defined as a common preventable and
treatable disease, it is characterized by
persistent airflow limitation that is also
accompanied by chronic inflammation from
exposure to noxious particles or gases
Causes include tobacco smoking, second
hand smoke exposure, air pollution and
occupational exposure




Clinical Diagnosis of COPD should be considered
with patients who have dyspnea, chronic cough
or sputum production, and/or a history of
exposure to risk factors. Spirometry is required
to make diagnosis.
Assessment of COPD is based on the patients
symptoms, risk of exacerbations, severity of
COPD (bases on spirometry) and comorbid
conditions.
COPD is the 3rd leading cause of death in the
United States
Many are not even aware they have it……



COPD was the 3rd leading cause of Death in
the US in 2008
Approximately 13 million adults in US have
COPD, however, estimated 24 million have
evidence of impaired lung function=under
diagnosis of disease
A retrospective analysis of HMO database
showed that 81% of patients with COPD were
not diagnosed until disease was moderate to
severe



The projected annual cost for COPD in the US
for 2010 was $50 billion (not million, yes
billion!!!!)
Estimated related to cost-between 50% and
75% of all COPD cost are related to
exacerbations
Frequency of exacerbations: 2 or more
exacerbations in the first year of
observational study showed
◦ 22% of patients with stage 2 disease
◦ 33% of patients with stage 3 disease
◦ 47% of patients with stage 4 disease








COPD
Asthma
CHF
Bronchectasis
TB
Obliterative Bronchiolitis
Diffuse Panbronchiolitis
Bronchitis







Chronic Cough (smoker cough)
Chronic Phlegm Production
Shortness of Breath (limits activity)
Not able to take deep breath
Wheezing
Recurrent Respiratory Infections/Bronchitis
Hypoxemia

Goals of assessment to determine severity of
disease and it’s impact on patients health to
guide treatment therapy
◦
◦
◦
◦
Symptoms
Degree of airflow limitation (using spirometry)
Risk of exacerbations
Co-morbidities
May use tools such as CAT-COPD Assessment Tool



In 2015-Updates to Gold Guidelines
Spirometry is required to make clinical
diagnosis of COPD
Clinical Diagnosis should be considered in
any patient over age 40 who has dyspnea,
chronic cough or sputum production, history
of exposure to risk factors for disease and/or
family history of COPD
In Patients with
FEV1/FEC <70
(Based on postbronchodilator FEV1)
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





Measure how well the lungs take in and
release air
Measure how well the lungs move gases such
as oxygen from the air into the body’s
circulation
PFTs add additional information including
Lung volume and diffusion capacity
Longer test and more expensive, however
helpful in treatment
Use spirometry to make initial diagnosis and
Full PFTs to guide therapy



Well trained staff-Does not have to be RT but
need to do test well for accurate results.
Patient cooperation-If patient is not following
direction and you don’t have good loop, less
accurate results (May need full PFT to help
make diagnosis)
Patient should not have had any respiratory
medications within 4 hours of test and
preferable that am (if possible).
 Non-Pharmacologic
 Pharmacologic
 Management
of Stable COPD
 Management of COPD
exacerbations







Symptom relief
Increase exercise tolerance
Improve health
Decrease disease progression
Prevent exacerbations
Treat exacerbations
Decrease Mortality

Smoking Cessation!!!!!!
◦ Counseling does help, counseling by physicians and
other health care professionals significantly
increases quit rates over self-initiated strategies
◦ Nicotine replacement Therapy-gum, patches
◦ Pharmacotherapy-varenicline, bupropion or
nortriptyline are more effective than placebo
◦ Smoking prevention-once quit need to stay QUIT,
keep smoke free homes
◦ Don’t Give Up! Keep on trying each and every time
you see them.




Occupational Exposure
Indoor and Outdoor Air Pollution
Vaccination Pneumococcal and FLU
Physical Activity
◦ Which leads to PULMONARY REHABILITATON
◦ The more you do the more you can do is so true for
COPD


Defined as evidence –based, multidisciplinary
and comprehensive intervention for patients
with chronic respiratory diseases who are
symptomatic and often have decreased daily
life activities
Pulmonary rehab is designed to reduce
symptoms, optimize functional status,
increase participation and reduce health-care
cost through stabilization




Utilized various healthcare disciplines
Individualized plan of care with realistic goals
for patient
Attention to physical and social function
Each patient plan includes
◦
◦
◦
◦
Patient assessment
Exercise training
Education
Psychosocial support






Medicare has a maximum life-time visits
Private Insurance-Co pays
Maintenance programs
Patient Compliance
Exacerbations
Access to programs






Abbreviations:
SA-short acting
LA-long acting
AC-anticholinergic
BA-beta agonist
ICS-inhaled corticosteroid
PDE-4-phosphodiesterase-4

Patient Types:
◦ Type A-Low risk, Low symptoms
◦ Type B-Low risk, Increased symptoms
◦ Type C-High risk, Low symptoms
◦ Type D-High risk, High symptoms
Patient Type
1st
2nd
Other
Type A-LR,LS
SA AC or SA BA
LA AC or LA BA
Or
SA AC or SA BA
Theophylline
Type B-LR, IS
LA AC or LA BA
LA AC & LA BA
SA AC &/or SA BA
Theophylline
Type C-HR, LS
ICS &
LA AC & LA BA or
LA AC & PDE4
Or
LA BA & PDE4
SA BA &/or SA AC
ICS &
LA BA & LA AC
Or
ICS &
LA BA & PDE4
Or
LA BA & LA AC
Or
LA AC and PDE4
Carbocystiene
LA BA or LA AC
Type D-HR, IS
ICS &
LA BA
&/or LA AC
Theophylline
N-acetylcysteine
SA BA &/or SA AC
Theophylline
Does anything Go?






Proair HFA-Albuterol
Ventolin HFA-Albuterol
Proventil HFA-Albuterol
Xopenex HFA-Salbuterol
Xopenex nebulizer
Albuterol nebulizer






Arcapta Neohaler (Indacterol)-1 cap
inhalation daily
Foradil Aerolizer (Formoterol)-1 inhalation
BID
Serevent Diskus (Salmeterol)-1 inhalation BID
Striverdi Respimat (Olodaterol)-2 inhalations
daily
Performist Nebulizer (Formoterol)-1 neb BID
Brovana Nebulizer (Arformoterol)- 1 neb BID









Aerospan (Flunisolide) 80mcg 2-4 puffs BID
Asmanex Twisthaler (Mometasone)110mcg and 220mcg
1-2 puffs daily-BID (max 440mcg/day)
Asmanex HFA (Mometasone) 100,200mcg 2 puffs BID
(max 800mcg/day)
Alveso (Ciclesonide) 80mcg and 160mcg-1 puff BID (max
320mcg/day)
Pulmicort Flexhaler (Budesonide)90mcg and 180mcg-2
puffs BID
Flovent Diskus (Fluticasone propionate) 50mcg, 100mcg
and 250mcg- 1-2 puffs BID (max 1000mcg/day)
Flovent HFA (Fluticasone propionate) 44mcg, 110mcg,
220mcg-2 puffs BID (max 880mcg/day)
Qvar HFA (Beclomethasone dipropionate)40mcg, 80mcg1-4 puffs BID (max 640mcg/day)
Arnuity Ellipta (Fluticasone furoate)-1 inhalation daily

LA BA and Corticosteroid
◦ Advair Diskus, (Fluticasone Propionate/salmeterol)
100/50, 250/50, 500/50-1 inhalation BID
◦ Advair HFA (Fluticasone Propionate/salmeterol)
45/21, 115/21, 230/21-2 puffs BID
◦ Symbocort HFA (Budesonide/Formoterol) 80/4.5,
160/4.5-2 puffs BID
◦ Breo Elipa (Fluticasone furoate/vilanterol)100/25-1
inhalation Daily
◦ Dulera (Mometasone/formoterol) 100/5, 200/5-2
puffs BID








Atrovent HFA (Ipratropium bromide)-2 puffs qid
Atrovent Nebulizer (Ipratropium)-1 neb qid
Spiriva Handihaler (Tiotropium)-1 inhalation
Daily
Spiriva Respimat (Tiotropium)-2 puffs Daily
Tudorza Pressair (Aclidinium bromide)-1 puff BID
Incruse Ellipta (Umeclidinium)-1 puff Daily
Combivent Respimat (ipratropium
bromide/albuterol)-1 inhalation QID
Anoro Elipta (Umeclidinium/vilanterol)-1
inhalation daily




LA BA and AC
Combivent Respimat (ipratropium
bromide/albuterol)-1 inhalation QID
Anoro Elipta (Umeclidinium/vilanterol)-1
inhalation daily
Duonebs (ipratropium/albuterol) Nebulizer-1
QID





PDE-4 Phosphidiesterase-4 (roflumilastDaliresp)
MexthylxanthinesTheophylline/aminophylline
Mucolytic-Carbocystiene (not available in US)
Mucolytic-N-acetylcysteine (Mucomist) 10%
/ml solution, 6-10 ml nebulized and 20%ml
solution, 3-5ml nebulized. Q 2 hours, max
dose 10% 20ml and 20% 10ml
***must give with albuterol !!!!!**** Due to
bronchospasms

Therapy is used to reduce symptoms, reduce
frequency and severity of exacerbations, and
improve health status and exercise tolerance
◦ Bronchodilators
 Inhaled therapy is preferred
 prescribed on as-needed or on a regular basis to
prevent or reduce symptoms
 Long-acting inhaled bronchodilators are convenient,
and maintaining symptoms relief compared to short
acting bd
 Combining bronchodilators (short and long) may
improve efficacy and decrease risk of side effects

Inhaled Corticosteroids
◦ In patients with FEV1 < 60% predicted, regular tx
with inhaled corticosteroids




improves symptoms
lung function
quality of life
reduces frequency of exacerbations
There is associated increased risk of pnemonia,
withdrawal may lead to exacerbation.
Long-term monotherapy not recommended

Combined Inhaled Corticosteriod/
Bronchodilator Therapy
◦ The IC/LBD is more effective than either individual
therapy in improving lung function and health
status and reducing exacerbations in patients with
moderate to very severe COPD





Oral Corticosteroids-Long term not
recommended
Phosphodiesterase-4 inhibitors- In Gold 3
and 4 patients with history of exacerbations
and chronic bronchitis.
PD4 inhibitor is roflumilast or Daliresp
Your experience?
Our practice…

Mexthylxanthines
Less effective
Less well tolerated than LBD
Available and affordable
Evidence of modest BD effect
Aminophylline or Theophylline
Theophylline with salmeterol produces a greater
increase in FEV1 and relief of breathlessness than
salmeterol alone.
◦ Low dose theophylline reduce exacerbations but does
not improve post-bronchodilator lung function.
◦ Therapeutic values 10-20 (patient may get benefit and
tolerate better at subtherapeutic levels of approx 8-12)
◦
◦
◦
◦
◦
◦





Vaccines including: Influenza and
Pneumococcal vaccines can reduce serious
illness and death
Alpha 1 Antitrypsin Therapy-For COPD
related to Alpha 1 Defiency
Mucolytic Agents-for patient with excessive
sputum, overall benefits small
Antitussive-use not recommended (however*)
Vasodilators-stable COPD with Pulmonary
HTN




Pulmonary Rehabilitation
Oxygen Therapy
Ventilatory Support
Surgical Treatments
◦ Lung Volume Reduction Surgery (LVRS)-need to
qualify, emphysema upper lobe
◦ Lung Transplant, costly, need to live near transplant
facility for at least 1 year and age requirements






Look at you patient type
Look at spirometry and/or PFTs
Mild/Moderate-start simple and work up
Severe/Very Severe-be aggressive and get
symptoms under control then remember to
back down (if able)
Symptom control/Quality of Life/Reduce
Exacerbations & Mortality are key GOALS
Cost of meds does influence treatment
Patient Type
1st
2nd
Other
Type A-LR,LS
SA AC or SA BA
LA AC or LA BA
Or
SA AC or SA BA
Theophylline
Type B-LR, IS
LA AC or LA BA
LA AC & LA BA
SA AC &/or SA BA
Theophylline
Type C-HR, LS
ICS &
LA AC & LA BA or
LA AC & PDE4
Or
LA BA & PDE4
SA BA &/or SA AC
ICS &
LA BA & LA AC
Or
ICS &
LA BA & PDE4
Or
LA BA & LA AC
Or
LA AC and PDE4
Carbocystiene
LA BA or LA AC
Type D-HR, IS
ICS &
LA BA
&/or LA AC
Theophylline
N-acetylcysteine
SA BA &/or SA AC
Theophylline


Defined as an acute event characterized by a
worsening of the patient’s respiratory
symptoms that is beyond normal day-to-day
variations and leads to a change in
medication
Assess the severity
◦
◦
◦
◦
◦
◦
ABGs
CXR
CBC
Presence of purulent sputum
Sputum C&S
Spirometry NOT RECOMMENDED



Oxygen for hypoxemia with target saturation
of 88-92%
SBD
Systemic Corticosteroids
◦ 30-40mg for 10-14 days
◦ Optional tx tapering dose
◦ Patients with DM may have problems with elevated
glucose
◦ Side effects of steroids

Antibiotics given to patients with
◦ 3 symptoms of increased dyspnea, increased
sputum volume, increased sputum purulence
◦ Increased sputum purulence and one other cardinal
symptoms
◦ Who require mechanical ventilation






CDC – www.cdc.gov/copd/data.htm
Global Initiative for Chronic Obstructive Lung
Disease Pocket Guide (GOLD) 2015
Respiratory Care Connection-GSK Education
connection
U.S. Department of health and human services,
Agency for Healthcare Research and Qualitywww.ahrq.gov and www.guideline.gov and type
in pulmonary rehabilitation
Aanma.org
Mayoclinic.org
Questions? Comments?
Thank You