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Chronic Obstructive Pulmonary Disease Dr Ashley Davies March 2014

Chronic Obstructive Pulmonary Disease Dr Ashley Davies March 2014. COPD. Sources of information. Bradford and Airedale COPD Guideline. NICE COPD Guideline 2010. NICE smoking cessation services guideline 2013. RCGP Essential Knowledge Updates 7 & 10. GP Update Handbook Spring 2014.

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Chronic Obstructive Pulmonary Disease Dr Ashley Davies March 2014

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  1. Chronic Obstructive Pulmonary DiseaseDr Ashley DaviesMarch 2014

  2. COPD

  3. Sources of information • Bradford and Airedale COPD Guideline. • NICE COPD Guideline 2010. • NICE smoking cessation services guideline 2013. • RCGP Essential Knowledge Updates 7 & 10. • GP Update Handbook Spring 2014

  4. COPD In Numbers • 900,000 on GP register in UK. • 2 million missing cases. • 30,000 deaths per year in UK. • Rate of death from respiratory cause in UK 2x Europe. • 1.4 million GP consultations (4x that for angina). • 1 million bed days per year. • 1 in 8 admissions. • COPD set to become the 3rd leading cause of death worldwide by 2020 after heart disease and stroke.

  5. Think of the diagnosis! • Over 35 yrs • Smoker or ex smoker • Exertional breathlessness • Chronic cough • Regular sputum production • Frequent winter bronchitis • Wheeze • And have no features of asthma

  6. COPD-diagnosis • Airflow limitation • Progressive • Not fully reversible • Does not change markedly over months • IT ISN’T “SMOKER’S ASTHMA”

  7. COPD Diagnosis • History • Examination • Spirometry

  8. Spirometry

  9. Spirometry & COPD • Post-bronchodilator • FEV1/FVC <0.7 • FEV1 < 80% • (FEV1 response > 400ml or 20% pefr variation= asthma)

  10. Other investigations • CXR (lung cancer) • FBC (polycythaemia) • BMI • Spo2 ( LTOT) • ECG/Echo (heart disease/cor pulmonale) • Alpha1- antitrypsin • Sputum culture

  11. Stop them Smoking! • Smoking cessation is the only therapy shown to reduce mortality(apart from LTOT).

  12. Smoking Cessation • 50% smokers develop airflow limitation. • 20% smokers will develop significant COPD. • Stopping smoking is the ONLY intervention (excluding LTOT) shown to reduce MORTALITY. • Stopping smoking REDUCES DECLINE in FEV1 • Stopping smoking REDUCES SYMPTOMS

  13. Stopping smokingslows decline in lung function Never smoked or not susceptible to smoke 100 75 50 25 0 Smoked regularly and susceptible to its effects Stopped at 45 FEV1 (% of value at age 25) Disability Stopped at 65 Death 25 50 75 Age (years) Adapted from: Fletcher et al,Br Med J 1977.

  14. Smoking Cessation • LUNG HEALTH STUDY 2000 showed significant smaller decline FEV1 in smoking intervention group compared to control group. American Journal of Respiratory and Critical care Medicine.2000;161 (2) 381-390. • Kanner et al, showed significant reduction in cough, chronic phlegm production, wheezing and shortness of breath. Am J Med 1999; 106:410-416. • ECLIPSE study followed 2000 people over 3 years.Smoking cessation reduces decline in lung function (to about half that of smokers).NEJM 2011; 365:1184.

  15. Journal of Royal Society Medicine: review of evidence for effective smoking cessation in COPD 2011 • RCT showed Bupropion + counselling 27% vs 8% placebo, long term abstinence. • Nurse led smoking cessation+ NRT better than nurse led cessation alone. • Annual spirometry+ brief intervention+ GP letter showed higher quit rate @ 3 years in COPD smokers.

  16. Cochrane Review of COPD 2003 • 1 year abstinence rates • Behavioural intervention + pharmacological 34% • Placebo 9% • RR=3.81

  17. Which smoking cessation therapy?NICE guidelines • Offer NRT/varenicline/bupropion + brief intervention/counselling.NICE 2013. • Patient preference is important. • NRT can be given to 12-17 yr olds, pregnant or breast feeding women, cardiovascular disease; and more than one NRT can be used concurrently. • Don’t offer pharmacotherapies again within 6 months failure. • “the evidence demonstrates….varenicline was superior to NRT and bupropion in achieving continuous abstinence”.NICE technology appraisal guidance 2013.

  18. Don’t forget Immunisations! • Annual influenza • Pneumoccoccal

  19. Evidence for Influenza Vaccination • Nichols et al, Ann. Intern Med 1999; 130(5): 397-403 • Cohort of N= 1898 elderly people with chronic lung disease. • Followed over 3 ‘flu seasons. • 52% reduction in hospitalisation for pneumonia and influenza. • 70% reduction in risk for death.

  20. Evidence for Pneumococcal vaccination • Nichol et al, Arch Intern Med. 1999; 159(20): 2437-2442 • Cohort of N= 1989 eldelry people with chronic lung disease. • 43% reduction in hospitalisations for pneumonia and influenza. • 29% reduction in risk for death from all causes. • ALSO RCGP Evidence Knowledge Summary 7: combined vaccination reduces risk of COPD patients being hospitalised for pneumonia by 63% and reduces risk of death by 81%.

  21. Pulmonary Rehabilitation! • ‘The magnitude of the effects of pulmonary rehabilitation on exercise capacity, dyspnoea and health related quality of life are significantly greater than the effects of bronchodilator drugs’. • NICE COPD Guidance 2010

  22. Pulmonary rehabilitation • Pulmonary rehabilitation is a multidisciplinary programme of care for patients with COPD and is individually tailored to optimise a patient’s physical and social performance1 • Identify patients who will benefit from pulmonary rehabilitation, usually MRC dyspnoea scale grade 3 or above1 1. NICE guideline No. 12. Thorax 2004.

  23. What is Pulmonary Rehabilitation? • Physio/OT/nurse/Dr/dietitician team • Patient education- lung health,disease, exacerbations, use of inhalers, coping with breathlessness. • Exercise training and guidance on activities. • Pyschosocial support-coping with isolation, panic. • Nutritional advice.

  24. Evidence for Pulmonary Rehabilitation • Ries AL et al Chest,1997;112(5): 1363-1396.Statistically significant improvement in quality of life, functional exercise capacity and maximal exercise capacity. • Significantly reduced breathlessness. Thorax 2001;56(11): 827-834. • Reduced hospitalisation? Conflicting evidence.NICE 2010. • Griffiths TLD Lancet 2000; 355(9201):362-368.Increased GP consultations but reduced home visits. • No change in FEV1.Smith K et al meta-analysis Am rev Respir Dis 1992;145(3): 533-539. • Benefit appears to wane with time.Limited evidence of benefit from attending more than one programme.NICE 2010

  25. SABA or SAMA?

  26. Evidence of harm from SAMA? • NICE recommends either SABA or SAMA (but not both). • AGH guidelines and GP Update guidelines recommend SABA. • SAMA’s associated with increased risk of CV events, SABAs are not. US Cohort of 82,000 veterans, Chest 2010; 137:13. • Meta-analysis suggested NNH 174/year to cause 1 MI. JAMA 2008;300: 1439. • Why?Increased sympathetic drive.

  27. SABA first!

  28. Do Llamas kill?

  29. So do LAMAs also cause MI? • UPLIFT trial: the big RCT of tiotropium vs placebo showed no increased risk of cardiovascular events. In fact it showed REDUCTION in CV events. • Massive cohort study in Ontario. N= 200,000. Showed that starting either a LABA or a LAMA increased the risk of cardiovascular events but the absolute risk was very small. The risk of LAMAs was no higher than those on LABAs.

  30. UPLIFT trial, NEJM Oct 2008 • 4 yr trial tiotropium in COPD • 5993 patients, patients continued all other inhalers. • Clinically significant slowing of rate of decline FEV1?(6ml/yr). • Non significant trend to reducing mortality. • 14% reduction risk of exacerbations.

  31. POET-COPD trial, NEJM 2011 • 7000 patients tiotropium vs salmeterol • All other inhalers continued. • Tiotropium increased time to first exacerbation, and time to first severe exacerbation (slightly- 1 fewer exacerbation over 10 yrs) • Discontinuation rates & adverse events same in both groups. • Cardiovascular events and all cause mortality similar both groups. • Benefits tiotropium regardless of severity or whether using inhaled steroids.

  32. Add tiotropium next!

  33. Which one?

  34. Handihaler vs Respimat • Tiotropium available in 2 devices. • MHRA advice(currently being reviewed): don’t give Respimat to those with known arrhythmias. • Large meta-analysis BMJ 2011;342:3215 suggested increased risk death from Respimat.NNH 124/yr all cause mortality. i.e. 124 people using respimat for 1 year, one extra death (but -massive confidence intervals). • New RCT suggested no difference in mortality NEJM 2013: 369:1491. But beware- it’s a non-inferiority trial.

  35. Bad!Bad!Bad!

  36. Add in LABA +/- Inhaled Steroid • Inhaled steroids only for severe disease, FEV1<50% • Inhaled steroids ONLY in combination with other inhalers. • Symbicort 400/12 and Seretide 500 Accuhaler are the only two licenced for COPD.

  37. Inhaled Steroids and COPD • No evidence of benefit in mild/moderate COPD. • Cochrane review 2013 demonstrated no evidence for using beclometasone. • Increased risk fractures, NNH 80/3yr to cause a fracture. Meta-analysis Thorax 2011;66:699. • Increased risk pneumonia, fluticasone seems to have a higher risk than budesonide. PATHOS trial, BMJ 2013: 346: 3306 • ICS do not reduce rate of decline in FEV1 • Long term ICS use has no impact on mortality.Cochrane 2007, issue 3 ; and JAMA 2008;300:2407

  38. Benefits of ICS in COPD • Some evidence for improved quality of life (Dr Hosker) • Evidence for reduction in exacerbations. TORCH trial NEJM 2007;356:775. Also Meta-analysis JAMA 2008;300:1439.

  39. Consider long term oxygen! • FEV1<30% • Cyanosis • Polycythaemia • Peripheral oedema • Raised JVP • Spo2 <92% breathing air

  40. LTOT • Treatment of HYPOXAEMIA not breathlessness. • Improves survival,reduces incidence polycythaemia, reduces progression to pulmonary hypertension. • Remember 5 yr survival rate if PaO2 falls <8KPa is <50%. • 2 RCT show increased survival benefit if used 15 hrs/day.Survival rate increases if used for 20hrs/day.

  41. Mucolytics • NICE: poor quality evidence for reducing excerbations. • No reduction in mortality • Consider if chronic cough • Discontinue if no symptomatic improvement. • Remember the maintenance dose!

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