Chronic obstructive pulmonary disease

1. Chronic obstructive pulmonary disease Ms. Leonardo Roever

2. Epidemiology • About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK • Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed • Symptoms usually develop insidiously making it difficult to determine the true prevalence of the disease • Most patients are not diagnosed until they are in their fifties

3. Background • COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term • Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment

4. Scope • The scope for the guideline update was to examine: • Diagnosis and severity classification: • spirometry and post-bronchodilator values • multidimensional severity assessment indices (for example, the BODE index) • Management of stable COPD and prevention of disease progression • long-acting bronchodilators: beta2 agonists and anticholinergics (tiotropium, formoterolfumarate, salmeterol) as monotherapy and in combination, both with and without inhaled corticosteroids • mucolytic therapy (carbocisteine and mecysteine hydrochloride) BODE = body mass index, airflow obstruction, dyspnoea and exercise tolerance

5. Definition of COPD • Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7) • It is no longer necessary to have an FEV1 < 80% predicted for definition of airflow obstruction • If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough • COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction. FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity

6. Natural History • The Fletcher-Peto Diagram, illustrating the effects of smoking on rate of decline in FEV1

7. Primary Symptoms • Chronic Bronchitis • Chronic cough • Shortness of breath • Increased mucus • Frequent clearing of throat • Emphysema • Chronic cough • Shortness of breath • Limited activity level

8. Normal versus Diseased Bronchi

9. Emphysema

10. Understanding COPD • Critical to first understand normal lung function

11. Lung structure and function “Biological Science Freeman”, 2010

12. Lungs with copd Image courtesy of The National Institute of health

13. Causes • Most cases of COPD occur as a result of long-term exposure to lung irritants that damage the lungs and the airways •  The most common irritant that causes COPD is cigarette smoke • In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD

14. Risk Factors • Smoking • Major risk factor (duh!) • Risk increases with number of pack years smoked • Secondhand smoke in large amounts presents risk • Environmental pollution • Smog and exhaust from vehicles • Smoke from burning wood or other biomass fuels • Particulates in occupational dust

15. Risk Factors Occupational Irritants

16. Risk Factors Nonmodifiable Risk Factors • Gender (Risk about equal in men and women) • Attributed to smoking habits of both genders • Age • Develops slowly • Most people ≥ 40 years old when symptoms start • Alpha-1 antitrypsin deficiency • Mostly Northern European heritage • Rare cause (2% of COPD population) Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

17. Risk Factors Additional risk factors • Severe lung infections as a child • Previous tuberculosis • Gastroesophageal reflux disease • Possible cause as recurrent irritant • May worsen COPD • Lower socioeconomic status Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009

18. Diagnose COPD Consider a diagnosis of COPD for people who are: • over 35, and • smokers or ex-smokers, and • have any of these symptoms: • - exertional breathlessness • - chronic cough • - regular sputum production, • frequent winter ‘bronchitis’ • Wheeze • And no clinical features of asthma

19. Diagnose COPD: Spirometry • Perform spirometry if COPD seems likely • The presence of airflow obstruction should be confirmed by performing post-bronchodilatorspirometry • Consider alternative diagnoses or investigations in: • - older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7 • - younger people with symptoms of COPD where the FEV1/FVC ratio is ≥ 0.7 • All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results

20. Differentiating COPD from asthma [2004]

21. Differentiating COPD from asthma: 2 • If diagnostic uncertainty remains, the following findings should be used to help identify asthma: • - FEV1 and FEV1/FVC ratio return to normal with drug therapy • - a very large (>400ml) FEV1 response to bronchodilators or to 30mg prednisolone daily for 2 weeks • - serial peak flow measuremenst showing significant (20% or greater) diurnal or day-to-day variability • - remaining diagnostic uncertainty may be resolved by referral for more detailed investigations • [2004]

22. Diagnose COPD: assessment of severity • Assess severity of airflow obstruction using reduction in FEV1 * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV1 < 50% with respiratory failure [new 2010]

23. Non-pulmonary Congestive Heart Failure Hyperventilation syndrome/panic attacks Vocal cord dysfunction Obstructive sleep apnea – undiagnosed Aspergillosis Chronic Fatigue Syndrome Pulmonary Asthma Bronchogenic carcinoma Bronchiectasis Tuberculosis Cystic fibrosis Interstitial lung disease Bronchiolitis obliterans Alpha-1 antitrypsin deficiency Pleural effusion Pulmonary edema Recurrent aspiration Tracheobronchomalacia Recurrent pulmonary emboli Foreign body Differential Diagnoses

24. Managing stable COPD Patient with COPD Assess symptoms/problems Manage those that are present as below Patients with COPD should have access to the wide range of skills available from a multidisciplinary team Palliative care

25. Managing stable COPD: Stop smoking • Encouraging patients with COPD to stop smoking is one of the most important components of their management • All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity • Record a smoking history, including pack years smoked • Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [2010] [2004]

26. Managing stable COPD: Promote effective inhaled therapy • In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: • if FEV1 ≥ 50% predicted: either LABA or LAMA • if FEV1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA • Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS,irrespective of their FEV1 ICS = inhaled corticosteroid LABA = long-acting beta2 agonist LAMA = long-acting muscarinic agonist [new 2010]

27. Managing stable COPD: inhaled therapies

28. Managing stable COPD: Oral corticosteroids • Maintenance use of oral corticosteroid therapy in COPD is not recommended • Some patients with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation • The does of oral corticosteroids should be kept as low as possible • Any patient treated with long term corticosteroid therapy should be monitored for the development of osteoporosis and given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment without the need for monitoring

29. Managing stable COPD: Oxygen • Clinicians should be aware that inappropriate oxygen therapy in • people with COPD may cause respiratory depression • Use appropriate oxygen therapy: • Long-term oxygen therapy • Ambulatory • Short burst

30. Managing stable COPD: Cor pulmonale • A diagnosis of corpulmonale should be considered if patients have: • - Peripheral odema, raised venous pressure, systolic parasternal heave, a loud pulmonary second heart sound. • Assess need for oxygen • Use diuretics • [2004]

31. Managing stable COPD: pulmonary rehabilitation Make available to all appropriate people, including those recently hospitalised for an acute exacerbation Hold at times that suit patients, and in buildings with good access Pulmonary rehabilitation An individually tailored multidisciplinary programme of care to optimise patients’ physical and social performance and autonomy Offer to all patients who consider themselves functionally disabled by COPD Tailor multi-component, multidisciplinary interventions to individual patient’s needs [new 2010]

32. Multidisciplinary working • COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists • Consider referral to specialist departments (not just respiratory physicians) [2004]

33. Follow-up of patients with COPD • Follow-up of patients should include: • -Highlighting the diagnosis in the case record • -Recording the values of spirometric tests • -Offering stop smoking advice • -Recording the opportunistic measurement of spirometric parameters • Patients should be reviewed at least once per year • For most patients with stable severe disease regular hospital review is not necessary

34. Managing exacerbations • Minimise impact of exacerbations by: • - giving self-management advice on responding promptly to symptoms of exacerbation • - starting appropriate treatment with oral steroids and/or antibiotics • - use of non-invasive ventilation when indicated • - use of hospital-at-home or assisted-discharge schemes • The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations

35. Use non-invasive ventilation (NIV) • Use NIV as the treatment of choice for persistent hypercapnicventilatory failure during exacerbations not responding to medical therapy • NIV should be delivered by staff trained in its application, experienced in its use and aware of its limitations • When starting NIV, make a clear plan covering what to do in the event of deterioration and agree ceilings of therapy • [2004]

36. Palliative care • Palliative care depends on good understanding of patients’: • - Perception of their quality of life • - Satisfaction with current functioning • - Expectations • Opioids, benzodiazepines, tricyclic antidepressants, major tranquilisers and oxygen can be used for the palliation of breathlessness in patients with end stage COPD unresponsive to other medical therapy • Providers of care should adopt an effective and equitable standardised approach to palliative care such as that provided by the Liverpool care pathway or equivalent • [2004]