Transcript COPD - Tulane University

Chronic Obstructive Pulmonary
Disease (COPD)
10.22.09
Jaime Palomino, MD
Pulmonary/CCM
Tulane University
INTRODUCTION
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COPD is the most important lung
disease in U.S.
25% of ED visits for Dyspnea
4th cause of death
Definition
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Disease state characterized by
airflow obstruction that is no longer
fully reversible and is usually
progressive
Accelerated declined in FEV1 from
30ml/year after 30y to 60ml
“Preventable and treatable”
Age-Related Decline in FEV1 Is
Accelerated in Smokers
FEV1 (% of value at age 25 y)
Never smoked or not susceptible to smoke
Stopped at 45 y
Stopped at 65 y
Smoked regularly and susceptible to its effects
100
75
50
Disability
25
Death
0
25
50
Age (y)
FEV1, forced expiratory volume in 1 second.
Adapted with permission from Fletcher C, Peto R. BMJ. 1977;1:1645-1648.
75
Epidemiology
 COPD
is the fourth leading cause of
death in the US.1
 >25 million people in US have
impaired lung fxn
 Annual cost of COPD in the US ~
$30.4 billion (ALA)

office visits, diagnostic procedures,
medications, and emergency and
hospital services
1.Centers for Disease Control and Prevention. Mortality patterns—US, 1997. MMWR. 1999;48:664-678.
Proportion of 1966 mortality rate
Mortality of COPD Is Increasing
2.0
CHD
Stroke
COPD
All Other
Causes
- 45%
- 58%
+ 71%
- 15%
1.5
1.0
0.5
0
1966-1986

COPD is the only leading cause of death that is increasing.
Adapted with permission from Higgins MW, Thom T. In: Clinical Epidemiology of COPD. 1990:23-43.
COPD – Pathogenesis
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
COPD – Immunology
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
Cosio et al. NEJM 2009;360:2445-54
COPD – Pathogenesis
Sethi et al. NEJM 2008;359:2355-65
COPD – Risk Factors
ACCP Pulmonary Board Review. 2007
Diagnosis of COPD
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History
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Smoking, occupational history
Spirometry: FEV1, FEV1/FVC
6 minute walk to monitor fxnl status
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distance a patient can walk on a flat path
in 6 minutes
practical and reliable way to measure level
of everyday impairment and exercise
tolerance
Differential Diagnosis:
Asthma Versus COPD1-3
COPD
Asthma
Age of onset
Usually > 35-40 years
Any age (usually  40 years)
Smoking history
Usually  20 pack-years
Minimal
Positive family history
Uncommon*
Usually
History of atopy
Unimportant
Often positive
Pattern of symptom
occurrence
Nonspecific
Nocturnal awakenings;
early-morning symptoms
Reversibility of airway
obstruction
Only partially reversible
with smoking cessation
and bronchodilator use
Usually near-normal
pulmonary function with
appropriate therapy
Triggers of exacerbations
Infections, inhalant
exposure
Specific identifiable triggers
*Except for 1-antitrypsin deficiency
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. American Thoracic Society. Am J Respir Crit Care Med. 1995;152:S77-S121.
3. Kuritzky L. Primary Care (Special Edition). 1999;3.
A Comparison of Four Sets of Staging Criteria for COPD
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
COPD Severity (GOLD Guidelines)
ACCP Pulmonary Board Review. 2007
Deterioration in Lung Function in Patients with COPD
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
ACCP Pulmonary Board Review. 2007
Pulmonary Hyperinflation in Patients with COPD
Sutherland, E. R. et al. N Engl J Med 2004;350:2689-2697
Variables and Point Values Used for the Computation of the Body-Mass Index, Degree of Airflow
Obstruction and Dyspnea, and Exercise Capacity (BODE) Index
Celli, B. R. et al. N Engl J Med 2004;350:1005-1012
Celli et al. CHEST 2008;133:1451-1462
Medications – Anticholinergics
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Short-Acting:
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Ipratropium: Inhaled, nebs, (AtroventHFA®)
Long-Acting:
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Tiotropium (Spiriva®)
Medications – Beta Agonists
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Short-Acting:
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Albuterol (ProAir-HFA®, Proventil-HFA®,
Ventolin-HFA®)
Pirbuterol (Maxair®)
Metaproterenol (nebs)
Levalbuterol (Xopenex® nebs, Xopenex-HFA®)
Long-Acting:
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Arformoterol (Brovana® nebs)
Formoterol (Foradil®, Perforomist® nebs)
Salmeterol (Serevent Diskus®)
Medications – ICS
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Flunisolide (Aerobid®)
Ciclesonide (Alvesco®)
Mometasone (Asmanex Twisthaler®)
Triamcinolone (Azmacort®)
Fluticasone (Flovent Diskus®, Flovent
HFA®)
Budesonide (Pulmicort Flexhaler®,
Pulmicort Respules® nebs)
Beclomethasone (QVAR®)
Medications – Combinations
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SABA + SAMA:
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Albuterol/Ipratropium (Combivent®, Duoneb®)
LABA + ICS:
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Fluticasone/Salmeterol (Advair Diskus®, Advair
HFA®)
Budesonide/Formoterol (Symbicort®)
Medications – Others
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Theophylline (Theo-24®, Uniphyl®)
Calverley et al. NEJM 2007;356:775-89
Calverley et al. NEJM 2007;356:775-89
Calverley et al. NEJM 2007;356:775-89
Celli et al. AJRCCM 2008;178:332-338
Calverley et al. NEJM 2007;356:775-89
Drummond et al. JAMA 2008;300:2407-2416
Sin et al. Lancet 2009;374:712-19
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Tashkin et al. NEJM 2008;359:1543-54
Lee et al. Arch Intern Med. 2009;169:1403-1410
Welte et al. AJRCCM.2009;180:741-750
Changes in Lung Function
Number of Severe Exacerbations
Welte et al. AJRCCM.2009;180:741-750
Lee et al. Ann Intern Med 2008;149:380-390
Singh et al. JAMA 2008;300:1439-1450
Tashkin et al. NEJM 2008;359:1543-54
Medications
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Theophylline or PDE Inhibitors
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May have a “come-back”
Lower levels (8-13 mg/dL)
Improvement in corticosteroid resistance
(HDAC2)
Phosphodiesterase E4 inhibitors
Calverley et al. Lancet 2009;374:685-694
Smoking cessation
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Smoking cessation: single most effective
way to improve clinical outcomes in
patients at all stages of COPD (asxsevere).1-4
After cessation, FEV1 rate of decline may
decrease to the rate found in healthy
nonsmokers.5,6
35% abstinent at 1 year, 22% at 5 years
1. The National COPD Awareness Panel (NCAP). Guidelines for early detection and management of COPD. J Resp Dis. 2000;21(suppl):S5S21.
2. Centers for Disease Control and Prevention. The Surgeon General’s 1990 report on the health benefits of smoking cessation: executive
summary – introduction, overview, conclusions. MMWR. 1990;39(RR-12):2-10.
3. Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled bronchodilator on the rate of decline
in FEV1: the Lung Health Study. JAMA. 1994;272:1497-1505.
4. Kanner RE. Early intervention in chronic obstructive pulmonary disease: a review of the Lung Health Study results. Med Clin North Am.
1996;80:523-547.
5. Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ. 1977;1:1645-1648.
6. Higgins MW, Enright PL, Kronmal RA, et al. Smoking and lung function in elderly men and women. JAMA. 1993;269:2741-2748.
Smoking cessation
 Ask:
every patient, during
each clinic visit
 Advise: urge to quit
 Assess: willingness to quit
 Assist: quit plan, counseling,
social support,
pharmacotherapy
 Arrange: follow-up contract
Vaccination
 Pneumococcal
vaccination
 Annual influenza vaccination
Long-Term Oxygen Therapy
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Indicated for PaO2 <55 mm Hg or SaO2 <88%1
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Improves1-4:
–
–
–
–
–
Survival in hypoxemic patients
Cognitive function, affect
Exercise performance
Sleep quality
Activities of daily living
1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21. 2. Report of the Medical Research Council Working Party. Lancet. 1981;681-686.
3. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-398. 4. Bye et al. Am Rev Respir Dis. 1985;132:236-240.
Pulmonary Rehabilitation
Casaburi et al. NEJM 2009;360:1329-35
Pulmonary Rehabilitation
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Improves (better than other COPD therapies):
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Exercise capacity
Severity of dyspnea
Health-related quality of life
Reductions in hospitalization
Improvements in cost-effectiveness
Reduction in depression and anxiety
Improves cognitive function and self-efficacy
Survival benefit has not been demonstrated
Reimbursement varies
Casaburi et al. NEJM 2009;360:1329-35
Pulmonary Rehabilitation
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Indications:
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3 times/week. 3-4 hrs/session. 6 – 12 weeks
Endurance exercise leg muscles
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GOLD Stage 3 or 4
Walking, stationary cycling, treadmill
Resistance-exercise component
Upper extremities exercise
Bronchodilators, oxygen, NIPPV, heliox,
anabolic steroids
Education, smoking cessation, nutrition
Casaburi et al. NEJM 2009;360:1329-35
Treatment - COPD
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Lung Transplant
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< 65 y/o
High BODE index
Effects on survival remains controversial
LVRS (pneumoplasty)
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Upper lobe disease
Limited exercise performance after
pulmonary rehabilitation
FEV1 : 20 -35 % predicted
Bronchoscopic placement of one-way
valves or biological substances
Tillie-Leblond et al. Ann Intern Med. 2006;144:390-396
Rizkallah et al. CHEST 2009;135:786-793
Zvezdin et al. CHEST 2009;136:376-380
Treatment - NPPV
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NPPV  fewer intubations,
decreased mortality, and shortened
MICU admissions
Indications for NPPV
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pH < 7.20
RR > 25
MS change
worsening hypercapnia