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Central Ohio Pulmonary Disease, Inc.

Central Ohio Pulmonary Disease, Inc. Michael L. Corriveau , MD, FACP, FCCP. COPD 2006. Definition of COPD. “A disease state characterized by airflow limitation that is not fully reversible..”. COPD. Normal Damage + Cholinergic tone. Epidemiology of COPD.

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Central Ohio Pulmonary Disease, Inc.

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  1. Central Ohio Pulmonary Disease, Inc. Michael L. Corriveau, MD, FACP, FCCP

  2. COPD2006

  3. Definition of COPD “A disease state characterized by airflow limitation that is not fully reversible..”

  4. COPD Normal Damage + Cholinergic tone

  5. Epidemiology of COPD 12.5 million patients with chronic bronchitis 1.6 million patients with emphysema 8 million office visits and 1.5 million ER visits/year $30 billion/year lost in healthcare/work loss Fourth leading cause of death in the US

  6. “You’ve come a long way, baby.”

  7. COPD Patients Stereotypical pictures of COPD patients 31 Pink Puffer Blue Bloater

  8. Causes of COPD Cigarette smoking Alpha-1 antitrypsin deficiency Industrial causes

  9. Alpha 1 Antitrypsin Deficiency 2 – 3% of patients with emphysema have AAT deficiency 40,000 – 60,000 Americans have AAT deficiency Cigarette smoking increases the likelihood of symptomatic disease Onset of symptoms earlier than non-AAT deficient patients (mean age at presentation = 46 years) CXR often shows more prominent bullae in the bases

  10. Diagnosis of COPD History (dyspnea, cough, wheezing) Spirometry

  11. Value of Spirometry in COPD Early, accurate diagnosis More sensitive than peak flow or CXR Document change in lung function over time Having a “number” may benefit the patient Helpful in stratifying the degree of disease

  12. Spirometry in COPD Normal FEV1 > 80% of predicted value Predicted value varies with age, height and sex Normal FEV1% > 70% Consider spirometry in past and present smokers over age 45, and patients with chronic cough, dyspnea or wheezing

  13. Causes of Dyspnea in COPD narrowed airways (bronchospasm, increased compliance airway secretions, airway thickening, increased cholinergic tone) hyperinflation DYSPNEA breathing at high volumes diaphragm flattening

  14. Dyspnea Reduced activity capacity Inactivity Deconditioning

  15. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  16. Smoking CessationSocietal Interventions Restriction of minors’ access to tobacco products Restriction of smoking in public places Restriction on advertisements Increasing prices through taxation

  17. Smoking CessationPhysician Interventions Ask about tobacco use at every visit Advise all smokers to quit Assess smokers readiness to quit Assist the patient in quitting Arrange follow up visit

  18. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  19. Pulmonary Rehabilitation “Pulmonary rehabilitation is a multidisciplinary service for patients with pulmonary disease and their families, provided by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual’s maximum level of independence and functioning in the community.”

  20. Components of Pulmonary Rehabilitation Education Exercise Psychosocial support

  21. Benefits of Pulmonary Rehabilitation Improved activity capacity Improved quality of life Decrease in hospitalization Return to work

  22. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  23. Short-Acting Bronchodilators: Albuterol • Stimulates 2-receptors on airway smooth muscle • Onset of effect: 1-3 minutes • Duration of action: 4-6 hrs • Reliever/rescue medication: PRN dosing • 2:1 Selectivity • Albuterol = 1,375:

  24. Long-Acting Bronchodilators: Salmeterol • Stimulates 2-receptors on airway smooth muscle • Onset of effect: 20-30 minutes • Duration of action: 12+ hrs • Maintenance medication: 1 inhalation b.i.d. • 2:1 Selectivity • Albuterol = 1,375:1 • Salmeterol = 85,000:1

  25. Formoterol • Long-acting 2-agonist • Dosage: 12 µg b.i.d. via dry-powder inhaler • Onset of action: 1-3 minutes • Duration of action: dose-dependent (12-hour duration with higher dose) Bartow RA, Brogden RN. Drugs. 1998;55:303-322.

  26. Theophylline Bronchodilation Increase in central respiratory drive Increased cardiac output Increased muco-ciliary clearance Increased fatigue threshold of the diaphragm

  27. Mucokinetic Agents • Guiafenesin • SSKI • Mucomyst • P & PD

  28. Advair now approved by the FDA for use in COPD with chronic bronchitis Package insert recommendation for initial and follow-up dexa scan Package insert recommendation for periodic eye examinations

  29. peak and trough

  30. Medical Letter, May 24, 2004tiotropium Improved lung function Decrease symptoms of COPD Increases quality of life Decreases number of exacerbations “an important advance in the treatment of COPD”

  31. GOLD Stages of COPD NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated 2003).

  32. LA Bronchodilators in COPD Drugs lung symptoms exercise decrease function tolerance exacerbations Salmeterol ++ + - +/- Formoterol ++ + - + Tiotropium +++ ++ ? ++ CHEST 2004; 125:249-259

  33. GOLD Stage 0 I prn short-acting bronchodilator tiotropium + SABA salmeterol or formoterol + SABA II tiotropium + salmeterol or formoterol salmeterol or formoterol + tiotropium III IV add inhaled corticosteroid CHEST 2004; 125:249-259

  34. Choice of Long-Acting Bronchodilator in COPD Efficacy Compliance Safety Cost

  35. Alpha 1 Antitrypsin DeficiencyTreatment NIH National Registry showed improved survival and decreased rate of decline in patients receiving augmentation therapy AAT levels increased Trough levels maintained above minimal threshhold Weekly infusions of 60 mg/kg

  36. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  37. Indications for O2 Therapy PaO2 55 mmHg or less PaO2 56 – 59 mmHg with complication, such as erythrocytosis or cor pulmonale SaO2 88% or less

  38. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  39. Noninvasive Ventilation Stable outpatient management Acute exacerbation treated in hospital increases pH reduces PaCO2 reduces breathlessness 1st 4 hours of Rx decreases length of hospital stay reduces intubation rate

  40. Management of COPD Smoking cessation Pulmonary rehabilitation Pharmacologic Supplemental oxygen Non-invasive ventilation Surgical remedies

  41. Volume Reduction Surgery A procedure in which 20-30% of the most diseased portions of the lung are removed Reduces lung hyperinflation Dilates bronchi by increased traction forces Places diaphragm at better mechanical advantage

  42. Volume Reduction SurgeryOutcomes Improved dyspnea index scores Improved elastic recoil of the lung Decreased residual volume and FRC Decreased PaCO2 Improved FEV1 Improved 6-minute walk distance

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