THERAPY & MANAGEMENT ASTHMA & COPD

1. THERAPY & MANAGEMENTASTHMA & COPD Dr. Mike Iredale October 2010

2. www.brit-thoracic.org.ukwww.asthma.org.uk

3. ASTHMA • “a chronic inflammatory disorder of the airways….in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.”

4. ACUTE ASTHMA • Assessment • - able to complete sentences ? • - peak expiratory flow rate • - respiratory rate • - pulse • - oxygen saturation • - arterial blood gases

5. ACUTE ASTHMA - Treatment • Oxygen - high flow / concentration • Nebulised (high dose) B2-agonist • - salbutamol • - terbutaline

6. ACUTE ASTHMA - Treatment (2) • Steroids • - prednisolone (40-50 mg daily) • - hydrocortisone (100mg qds) • no need to taper dose • continue inhaled steroid

7. ACUTE ASTHMA - Treatment (3) • Ipratropium Bromide • - nebulised 500mcg qds • - acute severe asthma • - life-threatening asthma • - poor initial response to nebulised B2-agonist • - only for initial phase of treatment

8. ACUTE ASTHMA - Treatment (4) • Intravenous Magnesium Sulphate • - 1.2 - 2g IV infusion over 20 min (single dose) • consider if: • life-threatening or near fatal asthma • acute severe asthma with poor initial response • after consultation with senior medical staff

9. ACUTE ASTHMA - Treatment (5) • Intravenous Infusions • Aminophylline - 0.5 mg / kg / hr • - omit bolus if on oral aminohylline / theophylline • - check levels • B2-agonist - limited evidence • - ventilated patients

10. ACUTE ASTHMA - Treatment (6) • Antibiotics • Routine prescription of antibiotics is • NOT • indicated for acute asthma.

11. ACUTE ASTHMA • ITU Referral: • - deteriorating peak flow • - persisting / worsening hypoxia • - hypercapnea • - falling pH on ABG • - exhaustion / feeble respiration • - drowsiness, confusion, coma, cardiac arrest

12. ACUTE ASTHMA • Discharge: • - on discharge medication for 24 hours • - PEF >75% best/predicted + <25% variability • - oral + inhaled steroid + bronchodilator • - inhaler technique checked • - PEF meter + action plan • - follow up: GP 2 days, chest clinic 4 weeks

13. Questions ?

14. CHRONIC ASTHMA • Treatment Goals: • - minimal symptoms during day & night • - minimal need for reliever medication • - no exacerbations • - no limitation of physical activity • - normal lung function • (FEV1 / PEF > 80% predicted or best)

15. CHRONIC ASTHMA • Non-Pharmacology • - smoking cessation (active / passive) • - allergen avoidance • - complementary / alternative medicine • - weight reduction in obese • - gastro-oesophageal reflux • - immunotherapy

16. CHRONIC ASTHMA • Pharmacology • - step-wise approach • - start at level appropriate to severity • - step-down when control is good • - compliance, inhaler technique, trigger factors

17. CHRONIC ASTHMA • STEP 1: Mild Intermittent Asthma • inhaled short-acting B2-agonist • - as required • - reliever therapy

18. CHRONIC ASTHMA • STEP 2: Introduction of Regular Preventer Therapy • inhaled steroid is first choice • - 400-800 mcg BDP (beclomethasone) equivalent

19. CHRONIC ASTHMA • Inhaled Steroids: • - beclomethasone (BDP) • - budesonide • - fluticasone • - mometasone • - ciclesonide • - large volume spacer in doses >1500 mcg BDP

20. CHRONIC ASTHMA • STEP 3: Add-on therapy • long-acting B2-agonist • - salmeterol • - formoterol • - good response - continue • no response - stop

21. CHRONIC ASTHMA • STEP 3: Add-on therapy (2) • if control remains inadequate: • - increase inhaled steroid to 800 mcg / day

22. CHRONIC ASTHMA • STEP 3: Add-on therapy (3) • if control remains inadequate trial of: • - leukotriene receptor antagonists • - theophylline

23. CHRONIC ASTHMA • STEP 4: Poor control on moderate dose inhaled steroid + add-on therapy: Addition of 4th drug • - increase inhaled steroid to 2000 mcg / day • - leukotriene receptor antagonists • - theophylline • - slow-release oral B2-agonist

24. CHRONIC ASTHMA • STEP 5: Continuous or Frequent use of Oral Steroid • - side-effects • - steroid sparing medication • - inhaled steroid most effective • - immunosuppressants

25. CHRONIC ASTHMA • Step Down • - patients often left over treated • - regular review • - aim to maintain at lowest dose inhaled • steroid that keeps asthma controlled

26. Questions ?

27. COPD • ..is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy.

28. COPD - Treatment • SMOKING CESSATION • ..is the single most important way of affecting outcome in patients at all stages of COPD

29. COPD - Treatment (2) • Bronchodilators (BD) • - stepwise approach • - stop therapy if ineffective • short acting as needed (B2-agonist or AC) • combination short acting BD • long-acting BD (B2-agonist or AC)

30. COPD - Treatment (2) • Bronchodilators - Mod/severe COPD: consider - • combination long-acting BD + inhaled steroid • theophylline

31. COPD - Treatment (3) • Frequent exacerbations: • optimise BD therapy with one or more long-acting BD (B2-agonist or AC) • inhaled steroid - if FEV1 < 50% + 2 exacerbations in last year

32. COPD - Treatment (4) Other measures: - nutrition - vaccination - pulmonary rehabilitation - breathlessness treatment - surgery - mucolytic therapy - depression

33. COPD - Treatment (5) • Long Term Oxygen Therapy (LTOT): • - improved survival (25% - 41% 5 yr) • - less secondary polycythaemia • - prevents progression of pulmonary • hypertension • - better neuropsychological health

34. COPD - Treatment (5) • Long Term Oxygen Therapy (LTOT): • - FEV1 < 1.5 l • - paO2 < 7.3 kPa, on 2 occasions 3 weeks apart • - at least 15 hrs each day • - no benefit if continue to smoke

35. Questions ?

36. COPD - Acute Exacerbation • Presentation: Important symptoms include • - increased sputum purulence • - increased sputum volume • - increased dyspnoea • - increased wheeze • - chest tightness • - fluid retention

37. COPD - Acute Exacerbation • Treatment: Bronchodilators • - nebulised in hospital + regular • - B2-agonist / anticholinergic • - acute response does not imply long-term benefit • - iv aminophylline if severe and not • responding

38. COPD - Acute Exacerbation • Treatment: Antibiotic • if 2 or more of • - increased breathlessness • - increased sputum volume • - development of purulent sputum

39. COPD - Acute Exacerbation • Treatment: Antibiotic • commonest bacterial causes • - Haemophilus influenzae • - Streptococcus pneumoniae • amoxycillin first choice for most patients

40. COPD - Acute Exacerbation • Treatment: Steroid • - common practice but value unclear • Justified if: • - already on oral steroid • - previous documented response • - first presentation of airways obstruction • - AFO fails to respond to increase bronchodilator

41. COPD - Acute Exacerbation • Treatment: • Diuretic • - peripheral oedema • - raised JVP • Anticoagulant • - prophylactic clexane for acute on chronic • respiratory failure

42. COPD - Acute Exacerbation • Treatment: OXYGEN • ? resp. failure - oxygen saturation • - pO2 < 8 kPa, SaO2 < 92% • ? type of resp failure - ABG • - type 1: normal or low pCO2 • - type 2: raised pCO2

43. COPD - Acute Exacerbation • Treatment: OXYGEN • type 1 - high concentration oxygen • - monitor with SaO2 unless patient deteriorates • - aim to keep SaO2 >94-98 %

44. COPD - Acute Exacerbation • Treatment: OXYGEN • type 2 - controlled oxygen therapy • - 24 % FiO2 , repeat ABG after 60 min • - if pO2 > 8 kPa + pCO2 & pH ISQ - no change • - if pO2 < 8 kPa + pCO2 & pH ISQ - increase to 28% • - if pCO2 increases & pH falls - alternative strategy

45. COPD - Acute Exacerbation Alternative strategies for COPD & respiratory failure: - non-invasive ventilation (NIV) (pH < 7.35, pCO2 > 6) - intubation and ventilation (- iv doxapram)

46. Questions ?

47. www.brit-thoracic.org.ukwww.asthma.org.uk