Transcript COPD - VMS Foundation

Chronic Obstructive
Pulmonary Disease
Diagnosis and Management
Yolanda Mageto MD, MPH
Professor Department of Medicine Pulmonary and
Critical Care
University of Vermont Medical Center
COPD: Definition
• A disease state characterized by persistent airflow
limitation that:
– is preventable and treatable
– is not fully reversible
– is usually both progressive and
– associated with an Chronic inflammatory response of the
lungs to noxious particles or gases
• Exacerbations and comorbidities contribute to the
overall severity in individual patients
Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). NIH/NHLBI; April 2001, updated Jan
2014 . Available at: www.goldcopd.com.
Underdiagnosis of COPD in the
United States
•
•
•
Over 12 million people in the
United States have been
diagnosed with COPD; another 12
million are estimated to be
undiagnosed1
30%
≥Age
65
Data from NHANES III indicate
that approximately 24 million US
adults have evidence of impaired
lung function indicative of
COPD2,3
Most (70%) of patients with
undiagnosed COPD are <65 years
of age
70%
<Age 65
Percent With Undiagnosed COPD
1. NHLBI; available at http://www.nhlbi.nih.gov/health/public/lung/copd/index.html.
2. Mannino DM, et al. MMWR Surveill Summ. 2002;51:1-16.
3. Mannino DM, et al. Proc Am Thorac Soc. 2007;4:502-306
COPD: Is generally an Ill-Defined mixture of
several disorders
Few Patients Have “Pure” Disease
Chronic
Bronchitis
Emphysema
COPD
Airflow
Obstruction
Asthma
Adapted with permission. Am J Respir Crit Care Med. 1995;152(5, pt 2):S77-S121. © American Thoracic
Society. The Official Journal of the American Thoracic Society.
Mechanisms Underlying Airflow Limitation in
COPD involve chronic inflammation that is
predominantly neutrophilic.
ININFLAMMATION IN COPD
Small airway disease
Parenchymal destruction
Airway inflammation
Airway remodeling
Loss of alveolar attachments
Decrease of elastic recoil
AIRFLOW LIMITATION
2014 Global Initiative for Chronic Obstructive Lung Disease
Diagnosis of COPD: Who should be screened?
Anyone who has the following symptoms and
risk factors
SYMPTOMS
shortness of breath
chronic cough
sputum
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY: Required to establish
diagnosis
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Figure 1
Respiratory Medicine 2005 99, 670-682DOI: (10.1016/j.rmed.2004.11.006)
Copyright © 2004 Elsevier Ltd
Figure 1. Frequency distribution of the breathlessness, as assessed by the modified Medical Research Council (mMRC) questionnaire (A), exercise
capacity, as assessed by the 6-minute walk distance (6MWD) (B), reported exacerbations in the year before inclusion in the study (C), and health
status, as assessed by the St. George’s Respiratory Questionnaire for chronic obstructive pulmonary disease (SGRQ-C) (D) according to severity of
airflow limitation.
Vestbo J et al.; Am J Respir Crit Care Med 189, 1022-1030.
Copyright © 2014 by the American Thoracic Society.
Combined Assessment of COPD 2016
• In the past severity of disease and risk of death was determined
primarily by the FEV1 (degree of airflow limitation) on
spirometry
• Goals of COPD assessment are to :
a.
b.
c.
d.
determine the severity of disease,
the severity of airflow limitation,
the impact on the patient’s health status
the risk of future events.
• Co-morbidities occur frequently in COPD patients and should
be actively sought and treated if present
• Provides a more accurate view of the patients risk for
exacerbations and response to management
HOW DO YOU PERFORM A
COMBINED ASSESMENT FOR COPD?
© 2014 Global Initiative for Chronic Obstructive Lung Disease
1. Start with assessment of Symptoms:
Dyspnea, Cough and Sputum
Production
Only one of the three is required to make an assesment of symptoms
COPD Assessment Test (CAT) :An 8-item measure of health
status impairment in COPD (http://catestonline.org).
or
Clinical COPD Questionnaire (CCQ): Self-administered
questionnaire developed to measure clinical control in patients with COPD
(http://www.ccq.nl).
or
mMRC Breathlessness scale: Breathlessness Measurement using
the Modified British Medical Research Council (mMRC) Questionnaire: relates
© 2014 Global Initiative for Chronic Obstructive Lung Disease
2. Assess Degree of Airflow Limitation in COPD using
spirometry
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
© 2014 Global Initiative for Chronic Obstructive Lung Disease
3. Assess risk of exacerbations
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. Hospitalization for a COPD
exacerbation associated with increased risk of death.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Putting it together we get the
Combined Assessment of
COPD...
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
Patien
t
Characteristic
Spirometric
Classification
Exacerbations
per year
CAT
mMRC
A
Low Risk
Less Symptoms
GOLD 1-2
≤1
< 10
0-1
B
Low Risk
More Symptoms
GOLD 1-2
≤1
> 10
>2
C
High Risk
Less Symptoms
GOLD 3-4
>2
< 10
0-1
D
High Risk
More Symptoms
GOLD 3-4
>2
> 10
© 2014 Global Initiative for Chronic Obstructive Lung Disease
>2
4. Finally it is important to ACTIVELY Assess
COPD Comorbidities
COPD patients are at increased risk for:
•
•
•
•
•
•
Cardiovascular disease
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
These comorbid conditions influence
mortality and hospitalizations and should
be looked for routinely, and treated
appropriately.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
COPD comorbidities:
• Special Case
– Lung Cancer screening recommended for
• Adults age 55-80
• 30 pack year smoking history or greater
– And
» Currently smoke
OR
» Have quit in the last 15 years
• Screening should be discontinued once a
person has not smoked in 15 years
– Or
• Develops a health problem that limits life
expectance or willingness to have curative
treatment.
Reduce Risk Factors:

Indoor/Outdoor air pollution. Requires a combination of
public policy and protective steps taken by individual
patients.

Reduction of exposure to smoke from biomass fuel,
particularly among women and children, is a crucial goal to
reduce the prevalence of COPD worldwide.

Advise patients to monitor news for announcements of air
quality if they live in areas where this is of concern.

Reduction of exposures in the work place.
Therapy:
Points to remember:
•Should be individualized to address symptoms and improve quality of life…
•Health education plays an important role in smoking cessation and can also play a
role in improving skills, ability to cope with illness and health status.
•None of the existing medications for COPD modify the long-term decline in lung
function that is the hallmark of this disease.
Therapy
Therapy is divided into 2 Parts:

Pharmacotherapy
 used to decrease symptoms and/or complications.
 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.

Non Pharmacologic therapy
 All COPD patients benefit from regular physical activity and should
repeatedly be encouraged to remain active.
Non-Pharmacologic Treatments
•
Rehabilitation:
– All COPD patients benefit
from exercise training
programs, improving with
respect to both exercise
tolerance and symptoms of
dyspnea and fatigue.
– The longer the program the
more effective the results
– If exercise training is
maintained at home the
patients health status
remains above pre- rehab
levels.
Oxygen Therapy
Striking mortality benefit, proportional to
length of time spent on oxygen
Oxygen Therapy:
The long-term administration of oxygen (> 15 hours per
day) to patients with chronic respiratory failure has been shown to increase
survival
Titrate oxygen to maintain Saturation above 88%
Ventilatory Support: Combination of noninvasive ventilation
with long term oxygen therapy may be of some use in those
with daytime hypercapnia.
Ann Intern Med 1980; 93:391-398.
Lancet 1981:681-686.
Four Components of COPD
management
1. Assess and monitor
disease
2. Reduce risk factors
3. Manage stable COPD
a.
Education
b.
Pharmacologic
c.
Non-pharmacologic
4. Manage exacerbations
Manage Stable COPD: Goals of Therapy
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
Reduce
symptoms
 Prevent disease progression
 Prevent and treat exacerbations
 Reduce mortality
Reduce
risk
© 2013 Global Initiative for Chronic Obstructive Lung Disease
COPD Management: Immunize
1.
In COPD patients influenza vaccines can reduce serious
illness and mortality
2.
Pneumococcal vaccine is recommended for COPD patients
65 years and older and for COPD patients younger than age
65 with an FEV1 < 40% predicted
3.
There are 2 pneumococcal vaccines for those over 65.
They are the PPSV 23 and PCV 13 (Prevnar).
4.
Patients over 65 who have never had the PPSV23 vaccine
should receive the PCV 13 vaccine FOLLOWED by a dose
of PPSV23 (23 valent) 6-12 months later.
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)
Patient
Recommended
First choice
Alternative choice
Other Possible
Treatments
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
LAMA
or
LABA
LAMA and LABA
SABA and/or SAMA
Theophylline
ICS + LABA
or
LAMA
LAMA and LABA or
LAMA and PDE4-inh. or
LABA and PDE4-inh.
ICS + LABA
and/or
LAMA
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or
LAMA and PDE4-inh.
C
D
SABA and/or SAMA
Theophylline
Carbocysteine
SABA and/or SAMA
Theophylline
Manage Stable COPD: Non-pharmacologic
Patient
Group
Essential
A
Smoking cessation (can
include pharmacologic
treatment)
B, C, D
Smoking cessation (can
include pharmacologic
treatment)
Pulmonary rehabilitation
Recommended
Depending on local
guidelines
Physical activity
Flu vaccination
Pneumococcal
vaccination
Physical activity
Flu vaccination
Pneumococcal
vaccination
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations:
An exacerbation of COPD is:
“an acute event characterized by a
worsening of the patient’s respiratory
symptoms that is beyond normal dayto-day variations and leads to a
change in medication.”
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Consequences Of COPD Exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Patients’ Perceptions of
Exacerbations
• Most frequent symptom:
– Shortness of breath (78%)
• Exacerbation symptom having the strongest impact
on well-being:
– Coughing (42%)
• Most frequent complaint:
– Due to their COPD, patients could not complete
the activities they like to do (54%)
• Fear of morbidity and mortality:
– 17% of individuals were afraid that their COPD
would cripple or eventually kill them
Miravitlles M, et al. Respir Med. 2007;101:453-460.
Manage Exacerbations: Key Points
 The most common causes of COPD exacerbations are viral
upper respiratory tract infections and infection of the
tracheobronchial tree.
 Diagnosis relies exclusively on the clinical presentation of
the patient complaining of an acute change of symptoms
that is beyond normal day-to-day variation.
 The goal of treatment is to minimize the impact of the
current exacerbation and to prevent the development of
subsequent exacerbations.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations: Key Points

Short-acting inhaled beta2-agonists with or without shortacting anticholinergics are usually the preferred
bronchodilators for treatment of an exacerbation.

Systemic corticosteroids and antibiotics can shorten
recovery time, improve lung function (FEV1) and arterial
hypoxemia (PaO2), and reduce the risk of early relapse,
treatment failure, and length of hospital stay.

COPD exacerbations can often be prevented.
© 2013 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations: Assessments
Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa
with or without PaCO2 > 6.7 kPa when breathing room air
indicates respiratory failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputum during an exacerbation: indication to begin
empirical antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, and
poor nutrition.
Spirometric tests: not recommended during an exacerbation.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Manage Exacerbations: Treatment Options
Oxygen: titrate to improve the patient’s hypoxemia with a
target saturation of 88-92%.
Bronchodilators: Short-acting inhaled beta2-agonists with or
without short-acting anticholinergics are preferred.
Systemic Corticosteroids: Shorten recovery time, improve
lung function (FEV1) and arterial hypoxemia (PaO2), and
reduce the risk of early relapse, treatment failure, and length
of hospital stay. A dose of 40 mg prednisone per day for 5
days is recommended . But some patients require longer
tapers for up to 2-3 weeks.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
Patients who were lost to follow-up between the end of intervention (day 14) and end of the study (day 180) were included in both
the intention-to-treat and the per-protocol analyses and censored at the time of last study visit.
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
Proportions of patients without reexacerbation in the intention-totreat analysis.
Survival curves did not differ significantly when compared by the log-rank test.
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
Proportions of patients without
reexacerbation in the per-protocol
analysis.
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
A, Proportion of patients alive (intention-to-treat analysis). B, The survival curve for the combined outcome death, reexacerbation, or
both. Survival curves did not differ significantly when compared by the log-rank test (P = .87 for time to death, P = .57 for time to
reexacerbation or death).
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
From: Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive
Pulmonary Disease: The REDUCE Randomized Clinical Trial
JAMA. 2013;309(21):2223-2231. doi:10.1001/jama.2013.5023
Manage Exacerbations: Indications for
Hospital Admission








Marked increase in intensity of symptoms
Severe underlying COPD
Onset of new physical signs
Failure of an exacerbation to respond to initial
medical management
Presence of serious comorbidities
Frequent exacerbations
Older age
Insufficient home support
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Hospital Exacerbations of COPD: Risk
Factors and Outcomes
Exacerbations of COPD requiring hospital admission have important
clinical and societal implications.
Mullerova etal, Using Eclipse Cohort evaluated the




incidence,
recurrence,
risk factors, and
mortality
of patients with COPD exacerbations requiring hospital admission was
compared with those without hospital admission during 3-year followup.with COPD
Mullerova et al. ; Chest. 2015;147(4):999-1007.
ECLIPSE: Evaluation of COPD Longitudinally
to Identify Predictive Surrogate Endpoints
1. Patients between 40- 75 years of age
2. History of > 10 Pack years of smoking
3. Fev1 < 80% predicted
4. Ratio of FE1/FVC < 0.7
5. COPD severity graded according to GOLD criteria
From: Hospitalized Exacerbations of COPD: Risk Factors and Outcomes in the ECLIPSE Cohort
Study flow diagram. ECLIPSE = Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints.
Chest. 2015;147(4):999-1007.
From: Hospitalized Exacerbations of COPD: Risk Factors and Outcomes in the ECLIPSE Cohort
Frequency distribution of hospitalized exacerbations during the follow-up, split by severity of airflow limitation assessed by GOLD
grade.3 GOLD = Global Initiative for Chronic Obstructive Lung Disease.
Chest. 2015;147(4):999-1007.
From: Hospitalized Exacerbations of COPD: Risk Factors and Outcomes in the ECLIPSE Cohort
Kaplan-Meier plot
showing risk of recurrent
hospital admissions for
COPD in patients with and
without hospitalized
exacerbations during the
first 12 mo of follow-up.
Kaplan-Meier plot showing
risk of mortality in patients
with COPD with and
without hospitalized
exacerbations during the
first 12 mo of follow-up.
Hosp = hospitalization
Chest. 2015;147(4):999-1007. doi:10.1378/chest.14-0655
Chest. 2015;147(4):999-1007
Findings
COPD exacerbations requiring hospital admission are relatively frequent events occurring in about 30% of patients
during the 3 year follow up
Past history of hospitalized exacerbations is the most predictive of future events
Other risk factors include
severity of airflow limitation
Poor health status
radiologic evidence of emphysema
older age
presence of systemic inflammation
History of hospitalized exacerbations heralds poor survival
Management of Exacerbations
Acute
Objective
Strategy
Relieve dyspnea
SABA +/- short acting
anticholinergic
Reduce airway
inflammation
Systemic corticosteroids
Improve lung
function
Systemic corticosteroids
Eradicate infections
Antibiotics
Smoking cessation
Pharmacotherapy
Maintenance
Reduce risk of new
exacerbation
•Salmeterol +/- fluticasone
•Formoterol +/- budesonide
•Tiotropium
Immunizations
•Influenza
•Pneumonia
Pulmonary rehab
Self-management support
Anzueto A. Am J Med Sci. 2010 Jul 9
Manage Exacerbations: Treatment Options
Antibiotics should be given to patients with:
 Three cardinal symptoms: increased
dyspnea, increased sputum volume, and
increased sputum purulence. (evidence B)
 Who require mechanical ventilation.
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Overall Clinical Course of COPD
COPD
COPD
Expiratory Flow Limitation
Air Trapping
Exacerbations
Hyperinflation
Breathlessness
Deconditioning
Inactivity
Reduced Exercise
Capacity
Poor Health-Related Quality of Life
Disability
Disease progression
Adapted from Decramer M. Eur Respir Rev. 2006;15:51-57.
Death
Emerging Profile of COPD Patients
in the Last Year of Life
• Severely reduced FEV1
• Severely reduced and declining
performance status
• Multiple recent hospitalizations
• Comorbidities
• Lives alone
• Depressed
Palliation of COPD
• Offer an honest prognosis
• Encourage planning for death
• Manage dyspnea and psychological
distress
• Promote hospice care
Palliative care begins with shared
awareness by clinician and patient that
death may be near.