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GOLD Website Address

GOLD Website Address. http://www.goldcopd.org. Which of the following have been shown to reduce mortality in COPD?. a) Long term inhaled corticosteroids in patients with FEV1 < 50 % b) Long term oxygen therapy for patients with baseline PaO2 < 55 mmHg, O2 sat < 88%

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GOLD Website Address

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  1. GOLD Website Address http://www.goldcopd.org

  2. Which of the following have been shown to reduce mortality in COPD? a) Long term inhaled corticosteroids in patients with FEV1 < 50 % b) Long term oxygen therapy for patients with baseline PaO2 < 55 mmHg, O2 sat < 88% c) Pulmonary rehabilitation for patients with moderate and severe disease d) Lung transplantation e) B and D

  3. Burden of COPD • Affects more than 5% of US population • Third leading cause of death in US • Twelfth leading cause of morbidity in US • Costs: Direct medical costs about $29.5 billion/yr Total costs about $49.9 billion in 2010

  4. Global Strategy for Diagnosis, Management and Prevention of COPD Definition of COPD • COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. • Exacerbations and comorbidities contribute to the overall severity in individual patients.

  5. Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD • Small Airways Disease • Airway inflammation • Airway fibrosis, luminal plugs • Increased airway resistance • Parenchymal Destruction • Loss of alveolar attachments • Decrease of elastic recoil AIRFLOW LIMITATION

  6. Air passage narrowed by plugged and swollen mucous membrane Chronic Bronchitis Bronchiole Presence of chronic productive cough for 3 months in each of two successive years in a patient in whom other causes of chronic cough have been excluded Mucus and pus impede action of respiratory cilia

  7. Inelastic collapsible bronchioles Enlarged air sacs due to destruction of alveolar walls (bullae) Walls of individual sacs torn (repair not possible) Destruction of the alveolar wall damages pulmonary capillaries by tearing, fibrosis, or thrombosis Emphysema Abnormal permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of their walls and without obvious fibrosis

  8. Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Genes Infections Socio-economic status Aging Populations

  9. Alpha-1-Antitrypsin Deficiency • Genetic deficiency of the protective anti-protease alpha-1-antitrypsin, predisposing to emphysema (destruction of alveolar walls) due to the unopposed action of neutrophil (and other) elastases. • Suspect in patients with: • COPD in a never smoker • COPD at a very young age • Strong family history of COPD • Emphysema more prominent in lung bases • COPD with unexplained liver disease • Diagnosis via serum level, genetic testing • Treat with alpha-1-antitrypsin replacement therapy. Intermittent IV infusion slows the rate of decline in lung function in those with airflow obstruction

  10. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS shortness of breath tobacco chronic cough occupation sputum indoor/outdoor pollution è SPIROMETRY: Required to establish diagnosis

  11. Spirometry: Obstructive Disease Normal 5 4 3 Volume, liters FEV1 = 1.8L FVC = 3.2L FEV1/FVC = 0.56 2 Obstructive 1 1 2 3 4 5 6 Time, seconds

  12. Pulmonary Function Tests in COPD 8 6 4 2 0 -2 -4 -6 Peak expiratory flow rate • Spirometry •  FEV1 •  FEV1/FVC •  FEF25-75% • Lung Volumes • May show • Normal – mild disease • Air trapping -  RV,  FRC, •  RV/TLC • Diffusing Capacity • Low in emphysema • Normal in chronic bronchitis Forced exhalation FEV1 (notch added by auto timer) Forced inhalation Normal COPD 1 2 3 4 Vital Capacity

  13. Global Strategy for Diagnosis, Management and Prevention of COPDAssessment of COPD • Assess symptoms • Assess degree of airflow limitation using spirometry • Assess risk of exacerbations • Assess comorbidities

  14. Symptom Assessment

  15. Chronic Obstructive Pulmonary Disease William P Sexauer, MD Division of Pulmonary and Critical Care Medicine Thomas Jefferson University

  16. Global Strategy for Diagnosis, Management and Prevention of COPDClassification of Severity of Airflow Limitation in COPD* 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

  17. Global Strategy for Diagnosis, Management and Prevention of COPDAssess Risk of Exacerbations To assessrisk of exacerbationsusehistory of exacerbations and spirometry: • Two or more exacerbationswithinthe last yearor an FEV1 < 50 % of predictedvalueareindicators of highrisk.

  18. Global Strategy for Diagnosis, Management and Prevention of COPDAssess COPD Comorbidities COPD patients are at increased risk for: • Cardiovasculardiseases • Osteoporosis • Respiratoryinfections • AnxietyandDepression • Diabetes • Lungcancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.

  19. Global Strategy for Diagnosis, Management and Prevention of COPDCombinedAssessment of COPD 4 (C) (D) > 2 3 Risk (Exacerbation history) Risk (GOLD Classification of Airflow Limitation) 2 (B) 1 (A) 1 0 mMRC 0-1 CAT < 10 mMRC > 2 CAT >10 Symptoms (mMRC or CAT score))

  20. Global Strategy for Diagnosis, Management and Prevention of COPDCombinedAssessment of COPD When assessing risk, choose the highest risk according to GOLD grade or exacerbation history

  21. The term “BODE” refers to which of the following: a) a term used in discussing prognosis with patients and families b) a composite scoring system that describes prognosis in patients with COPD c) a world class skier with an ego and atitude to match his considerable talent d) all of the above

  22. BODE Index Celli BR et al., NEJM 2004; 350:1005-12

  23. BODE Index  Score of 0 to 2 Score of 3 to 4 Score of 5 to 6 Score of 7 to 10 Celli BR et al., NEJM 2004; 350:1005-12

  24. Preventive/General Measures • Smoking cessation: counseling pharmacologic aids - Avoid environmental/occupational exposures • Vaccinations: influenza, pneumococcal • Encourage physical activity

  25. COPD Risk & Smoking Cessation 100 Never smoked or not susceptible to smoke 75 Smoked regularly and susceptible to effects of smoke Stopped smoking at 45 (mild COPD) FEV1 (% of value at age 25) 50 Disability Stopped smoking at 65 (severe COPD) 25 Death 0 25 50 75 Age (years) Adapted from Fletcher C et al. Br Med J. 1977;1:1645–1648.

  26. Global Strategy for Diagnosis, Management and Prevention of COPDTherapeutic Options: COPD Medications

  27. Global Strategy for Diagnosis, Management and Prevention of COPDManage Stable COPD: PharmacologicTherapy(Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)

  28. TORCH Study 6112 COPD patients (FEV1 < 60%) randomized to salmeterol/fluticasone (50/500), salmeterol, fluticasone, or placebo followed for 3 years. Primary outcome was all cause mortality. Results: 1. No signif difference in mortality between groups (S/F vs placebo, p=0.052) 2. All components reduced exacerbations compared to placebo 3. S/F and fluticasone improved HRQL vs placebo 4. All components improved lung function vs placebo 5. Both fluticasone groups had higher pneumonia rates than placebo NEJM 2007 356;8:775-789

  29. COPD Interventions Shown to Reduce Mortality • Smoking cessation for patients with early disease • Home oxygen therapy for persistent baseline hypoxemia • Lung Volume Reduction Surgery for very selected patients (upper lobe predominant emphysema, low exercise capacity after rehab)

  30. “UPLIFT” Study 5993 COPD patients (FEV1 < 70%) randomized to tiotropium once daily vs placebo and followed for 4 years. LABA and ICS not excluded. Primary outcome measure was rate of decline in FEV1. Results: • No signif difference in rate of FEV1 decline between groups • Tiotropium improved: Pulmonary function – p < 0.001 HRQL (St George’s) – p < 0.001 Exacerbations – p < 0.001 Incidence of respiratory failure – p < 0.05 NEJM 2008 359;15:1543-54

  31. TiotropiumvsSalmeterol NEJM 2011 364;12:1093-103

  32. Azithromycin in COPD NEJM 365;8:689-698 8/25/11

  33. Pharmacologic Interventions shown to reduce COPD Exacerbations • Inhaled LA beta-agonists • Inhaled LA anticholinergics • Inhaled corticosteroids for patients with FEV1 < 50% • Azithromycin • Phosphodiesterase-4 inhibitor - roflumilast In select subgroup: chronic bronchitis phenotype FEV1 < 50% Frequent exacerbations

  34. Other Therapies Oxygen: Long term (home) oxygen if baseline PO2  55 mmHg, O2 Sat  88% As needed during acute exacerbations Non-invasive ventilation (NIV): 1. During acute or acute-on-chronic hypercapneic respiratory failure – avoid intubation 2. Part-time use (nocturnal) for chronic hypercapneic respiratory failure

  35. Benefits of Pulmonary Rehabilitation *From Joint ACCP/AACVPR Evidence-Based Guidelines on Pulmonary Rehabilitation, 2007 Definition of Rating Scale: 1- Strong; 2 – Weak. A – High; Finding consistently supported by well-designed RCT’s; B – Moderate; Based on findings from RCT’s with inconsistent results or methodologic limitations; C – Low; Supported by observational studies

  36. Surgical Options for COPD Lung Volume Reduction Surgery for Emphysema 1. Age < 75 2. Ex-smoker > 6 months 3. FEV1 < 45% pred; RV > 150% pred 4. Dyspnea despite max medical therapy, incl Pulmonary Rehab 5. *Emphysema with upper lobe predominance 6. *Low exercise capacity post-rehab (F < 25W, M < 40W) Bullectomy 1. Giant Bulla > 30% of hemithorax 2. Severe and/or progressive dyspnea despite maximal medical therapy 3. PFT evidence of air-trapping (RV > 150 % pred.) 4. CT evidence of compression of surrounding normal lung parenchyma

  37. Lung Transplantation - COPD now the #2 indication for lung transplant in US -REFERRAL CRITERIA: BODE index of 7-10 or at least one of the following: a. FEV1 < 20% and either DLCO < 20% or homogenous distribution of emphysema b. Pulmonary hypertension/corpulmonale despite O2 therapy c. History of hospitalization for exacerbation with acute hypercapnia (PCO2 > 50 mm Hg) Kotloff, Thabut AJRCCM 184:159-171 7/15/11

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