COPD 08 - PowerPoint Presentation

COPD 2008COPD 2008

COL Oleh Hnatiuk, MD, FACP, FCCP

Program Director, PCCM Fellowship, NCC

Associate Professor of Medicine, USUHS

Staff, PCCMS, WRAMC

COPD 2008COPD 2008

COPD 2008COPD 2008

COPD 2008COPD 2008

Definition, Severity Classification & Mechanisms Burden of COPD Four Components of Management

– Assessment and Monitoring– Reducing Risk Factors– Managing Stable Disease– Managing Exacerbations

Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2007)

COPD 2008COPD 2008

The Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2007) available on the GOLD website www.goldcopd.org.

Reviewed 136 articles published b/w July 1, 2006 and June 30, 2007. Twenty-seven (27) papers were identified to have an impact on the GOLD report that was posted on the website in December 2006.

http://www.goldcopd.org/

COPD 2008COPD 2008QuestionQuestion

What is missing from this diagnosis of COPD?

“Chronic Obstructive Pulmonary Disease (COPD) is a __________ and _________ disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully__________. The airflow limitation is usually progressive and associated with an abnormal ____________responseof the lung to noxious particles or gases.”Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2007)

COPD 2008COPD 2008 DefinitionDefinition

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully __________. The airflow limitation is usually progressive and associated with an abnormal ____________responseof the lung to noxious particles or gases.



The phrase “preventable and treatable” incorporated following the ATS/ERS recommendations to recognize need to:– present a positive outlook for patients– encourage the health care community to take a more active

role in developing programs for COPD prevention– stimulate effective management programs to treat those with

the disease



Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal ____________ responseof the lung to noxious particles or gases.



There is responsiveness to a bronchodilator in 23% to 42% of all pts with COPD

In Lung Health Study, 59% of men and 85% of women with moderate disease had AHR

Asthmatics can develop airway remodeling and fixed airway obstruction (in up to 20%) over time

Population-based surveys have documented that chronic airflow limitation may occur in up to 10% of lifetime nonsmokers 40 years and older



Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory responseof the lung to noxious particles or gases.




COPD 2008 COPD 2008 Severity Classification Severity Classification

QuestionQuestion

The diagnosis and staging of COPD require what two spirometric measures?


COPD 2008COPD 2008 Severity Classification Severity Classification

FEV1/FVC

FEV1


COPD 2008COPD 2008 Severity ClassificationSeverity Classification

The diagnosis of COPD is confirmed when a post-bronchodilator FEV1/FVC < 0.7.


COPD 2008 COPD 2008 Severity Classification Severity Classification

QuestionQuestionWhat stage has been deleted from the 2007 GOLD Update? Based on the following PFTs, what stage is this patient’s COPD?

Pre-BD Post-BDFVC 3.65L (82%) 3.67L (83%)FEV1 1.05L (45%) 1.11L (51%)FEV1/FVC 0.29 0.30



Stage* Post BD FEV1/FVC FEV1 % Predicted

I: Mild FEV1/FVC < 0.7 FEV1 > 80%

II: Moderate FEV1/FVC < 0.7 50% < FEV1 < 80%

III: Severe FEV1/FVC < 0.7 30% < FEV1 < 50%

IV:Very Severe FEV1/FVC < 0.7 FEV1 < 30% (or)

< 50% plus chronic

respiratory failure**

* No longer contains Stage 0 (At Risk)**paO2 < 60 mm Hg at sea level or cor pulmonale (elevated JVP and pitting

ankle edema

Stage* Post BD FEV1/FVC FEV1 % Predicted

I: Mild FEV1/FVC < 0.7 FEV1 > 80%

II: Moderate FEV1/FVC < 0.7 50% < FEV1 < 80%

III: Severe FEV1/FVC < 0.7 30% < FEV1 < 50%

IV:Very Severe FEV1/FVC < 0.7 FEV1 < 30% (or)

< 50% plus chronic

respiratory failure**

* No longer contains Stage 0 (At Risk)**paO2 < 60 mm Hg at sea level or cor pulmonale (elevated JVP and pitting

ankle edema


Spirometric classification has proved useful in predicting health status, utilization of healthcare resources, research, development of exacerbations and mortality.


COPD 2008COPD 2008 Assessment and MonitoringAssessment and Monitoring

QuestionQuestion

True or False: Oral glucocorticosteroid reversibility testing predicts disease progression in COPD.



QuestionQuestion

False: Neither bronchodilator nor oral glucocorticosteroid reversibility testing predicts disease progression, whether judged by decline in FEV1, deterioration of health status, or frequency of exacerbations



QuestionQuestion True or False: Measurement of arterial blood gas tension (or SaO2) should be considered only in patients with FEV1 < 65% predicted?



False: In advanced COPD, measurement of arterial blood gases while the patient is breathing air is important. This test should be performed in stable patients with FEV1 < 50% predicted or with clinical signs suggestive of respiratory failure or right heart failure.


COPD 2008 COPD 2008 Assessment and MonitoringAssessment and Monitoring

QuestionQuestion

When is an alpha-1 antitrypsin level recommended in a patient with COPD?



QuestionQuestion

In patients of Caucasian descent who develop COPD at a young age (< 45 years) or who have a strong family history of the disease, it may be valuable to identify coexisting alpha-1antitrypsin deficiency. This could lead to family screening or appropriate



QuestionQuestion

The Public Health Service recommends a five-step program (the five A’s) for smoking cessation intervention. After ASK, ADVISE, ASSESS, and ASSIST, what is the last step in the GOLD guidelines?



•ASK Systematically identify all tobacco users at every visit

•ADVISE Strongly urge all tobacco users to quit

•ASSESS Determine willingness to make a quit attempt.

•ASSIST Aid the patient in quitting•ARRANGE Schedule follow-up contact


COPD 2008COPD 2008 Managing Stable DiseaseManaging Stable Disease

QuestionQuestion

True or False: Influenza vaccine and pneumococcal polysaccharide vaccine are recommended for all COPD patients.



False: In COPD patients, influenza vaccines canreduce serious illness. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 yearsand older and for COPD patients younger than age 65 with an FEV1 < 40% predicted


COPD 2008 COPD 2008 Managing Stable DiseaseManaging Stable Disease

NutritionNutritionNutritional support had no significant effect on anthropometric measures, lung function or exercise capacity in patients with stable COPD. Although some quality of life indices gave significant findings, these results were from a single small unblinded study and restricted to certain domains of health status measurements. More work in this particular area is needed to establish whether supplementation can lead to subjective benefits in quality of life.

Cochrane Database, 2007

COPD 2008 COPD 2008 Managing Stable DiseaseManaging Stable DiseasePulmonary Pulmonary RehabilitationRehabilitation

Rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances patients’ sense of control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.



MucolyticsMucolyticsIn participants with chronic bronchitis or COPD, treatment with mucolytics was associated with a small reduction in acute exacerbations and a reduction in total number of days of disability. Benefit may be greater in individuals who have frequent or prolonged exacerbations, or those who are repeatedly admitted to hospital with exacerbations with COPD. They should be considered for use, through the winter months at least, in patients with moderate or severe COPD in whom inhaled corticosteroids (ICS) are not prescribed.



Nocturnal NIPPVNocturnal NIPPVNocturnal NIPPV for at least three months in hypercapnic patients with stable COPD had no consistent clinically or statistically significant effect on lung function, gas exchange, respiratory muscle strength, sleep efficiency or exercise tolerance. However, the small sample sizes of these studies precludes a definite conclusion regarding the effects of NIPPV in COPD.



QuestionQuestion

In addition to quitting smoking, the only other intervention that has ever been shown to improve mortality in COPD is long-term oxygen therapy. How long (per day) does oxygen have to be worn to achieve this effect?



Oxygen TherapyOxygen Therapy

The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival. It can also have a beneficial effect on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state.





Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55 mm Hg (8.0 kPa)). Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night.




PaO2 < 55 mm Hg, or SaO2 < 88 %, at rest, breathing room air.

PaO2 < 55 mm Hg, or SaO2 < 88 %, during sleep for a patient who demonstrates an PaO2 > 56 mm Hg, or SaO2 > 89 percent, while awake.

PaO2 < 55 mm Hg or SaO2 < 88%, during exercise for a patient who demonstrates an PaO2 > 56 mm Hg, or SaO2 > 89 percent during the day, while at rest.


Oxygen TherapyOxygen Therapy PaO2 is 56-59 mm Hg or whose SaO2 = 89%, if

there is evidence of: – Dependent edema suggesting congestive heart

failure; – Pulmonary hypertension or cor pulmonale,

determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF); or

– Erythrocythemia with a hematocrit greater than 56 percent.


QuestionQuestion

True or False: None of the existing medications for COPD have been shown to modify the long-term decline in lung function that is the hallmarkof this disease. Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.



True



Short-Acting Beta Agonists Short-Acting Beta Agonists (SABA)(SABA)

Until further data are available, the strategy of providing a short-acting beta-2 agonist on a PRN basis, and then either continuing with the short-acting beta-2 agonist regularly or conducting an “n of 1” trial of regular beta-2 agonist or regular anticholinergic to determine the treatment that gives the best relief of symptoms (and continuing with it), would seem cost effective.



SABA vs. LABASABA vs. LABA

There is little difference between regular long term use of IpB alone and salmeterol if the aim is to improve COPD symptoms and exercise tolerance. However, salmeterol was more effective in improving lung function variables. In terms of post-bronchodilator lung function, combination therapy conferred modest benefits and a significant improvement in HRQL, and reduced supplemental short-acting beta-agonist requirement, although this effect was not consistent. Additional studies are needed.



LABALABA

This review shows that the treatment of patients with COPD with salmeterol 50 mcg produces modest increases in lung function.

There were varying effects for other important outcomes such as health related quality of life or reduction in symptoms. However,

there was a consistent reduction in exacerbations which may help people with COPD who suffer frequent deterioration of symptoms prompting healthcare utilization. The strength of evidence for the use of salmeterol 100 mcg, formoterol 12 mcg, 18 mcg, 24 mcg was insufficient to provide clear indications for practice.



LABALABA

Tiotropium reduced COPD exacerbations and related hospitalizations compared to placebo and ipratropium. It also improved health related quality-of-life and symptom scores among patients with moderate and severe disease, and may have slowed decline in. Additional long-term studies are required to evaluate its effect on mortality and change in FEV1 to clarify its role in comparison to, or in combination with, long-acting ß2-agonists and to assess its effectiveness in mild and very severe COPD.



TheophyllineTheophylline

Theophylline has a modest effect on FEV1 and FVC and slightly improves arterial blood gas tensions in moderate to severe COPD. These benefits were seen in participants receiving a variety of different concomitant therapies. Improvement in exercise performance depended on the method of testing. There was a very low dropout rate in the studies that could be included in this review, which suggests that recruited participants may have been known by the investigators to be theophylline tolerant. This may limit the generalizability of these studies.



Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms

and exacerbations. The principal bronchodilator treatments are beta-agonists,

anticholinergics, and methylxanthines used singly or in combination.

Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators




Wise R, Tashkin D. AJM 2007;120:S4


ICSICS

Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients.

There was no statistically significant effect on mortality in COPD patients.

Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible

ICS slowed the rate of decline in quality of life, as measured by the St George’s Respiratory Questionnaire



ICS (cont.)ICS (cont.)

Response to ICS was not predicted by oral steroid response, bronchodilator reversibility or bronchial hyper-responsiveness in COPD patients. There was an increased risk of oropharyngeal candidiasis and hoarseness.

The few long term studies that measured bone effects generally showed no major effect on fractures and bone mineral density over 3 years.



LABA +ICS vs. PlaceboLABA +ICS vs. Placebo Fluticasone/salmeterol and budesonide/formoterol both reduced the rate of

exacerbations. The clinical impact of this effect depends on the frequency of exacerbations experienced by patients. The patients included in these trials had on average 1-2 exacerbations per year which means that treatment with combination therapy would lead to a reduction of one exacerbation every two to four years in these individuals.

There is an overall reduction in mortality, but this outcome is dominated by the results of TORCH and further studies on budesonide/formoterol are required. The three year number needed to treat to prevent one extra death is 36 (95% CI 21 to 258), using a baseline risk of 15.2% from the placebo arm of TORCH.

Both treatments led to statistically significant improvement in health status measurements, although the clinical importance of the differences observed is open to interpretation.



LABA +ICS vs. LABALABA +ICS vs. LABA

The exacerbation rates with combined inhalers were reduced in comparison to long-acting beta-agonists alone

There was no significant difference in mortality between combined inhalers and long-acting beta-agonists alone.

Pneumonia occurred more commonly with combined inhalers (OR 1.62; 95% CI 1.35 to 1.94).

There was no significant difference in terms of hospitalizations, although the two studies contributing data to this outcome may have

been drawn from differing populations. Combination was more effective than LABA in improving quality of life

measured by the St George Respiratory Questionnaire, and the Chronic Respiratory Questionnaire



LABA+ICS vs. ICSLABA+ICS vs. ICS

Exacerbation rates were significantly reduced with combination therapies

Data from one large study suggest that there is no significant difference in the rate of hospitalizations.

Mortality was also lower with combined treatment. Quality of life, lung function and withdrawals due to lack of

efficacy favored combination treatment. No significant differences were found between FPS and BDP in

the primary outcomes, but the confidence intervals for the BDP results were wide as smaller numbers of patients have been studied.



The addition of regular treatment with inhaled glucocorticosteroids to bronchodilator treatmentis appropriate for symptomatic COPD patientswith an FEV1 < 50% predicted (Stage III: SevereCOPD and Stage IV: Very Severe COPD) andrepeated exacerbations .



QuestionQuestion

True or False: Chronic treatment with systemic steroids is appropriate in some patients for control of symptoms.



FALSE:

Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio.



SurgerySurgery

Patients with FEV1/DLco < 20% of predicted AND homogeneous (diffuse) distribution of emphysema are at high risk for death after surgery and are unlikely to benefit from lung volume reduction surgery (LVRS).

NETT. NEJM 2001;345:1075-83.


SurgerySurgery

Post-hoc subgroup analyses showed that patients with predominantly upper-lobe emphysema who had low exercise capacity (<40W) who underwent LVRS had significant improvements in survival (risk ratio 0.47; p=0.005) and functional outcomes as compared with medical therapy.

The cost-effectiveness ratio for this group was more favorable than the entire cohort ($98,000 per quality-adjusted life year at 3 years c/w $8,000-$64,000 for CABG, $130,000-220,000 for lung transplant, $65,000 for heart transplant and $47,000 for AICD in survivors of cardiac arrest with low EF).

NETT. NEJM 2003;348:2092-102.


SurgerySurgery

The evidence summarized in this review is drawn from one large study, and several smaller trials. The findings from the large study indicated that in patients who survive up to three months post-surgery, there were significantly better health status and lung function outcomes in favor of surgery compared with usual medical care. Patients identified post hoc as being of high risk of death from surgery were those with particularly impaired lung function and poor diffusing capacity and/or homogenous emphysema. Further research should address the effect of this intervention on exacerbations and rate of decline in lung function and health status.



SurgerySurgery Guidelines for Referral

BODE index exceeding 5 Guidelines for Transplantation Patients with a BODE index of 7 to 10

or at least 1 of the following: History of hospitalization for exacerbation associated

with acute hypercapnia (PCO2 exceeding 50 mm Hg) Pulmonary hypertension or cor pulmonale, or both,

despite oxygen therapy. FEV1 of less than 20% and either DLCO of less than

20% or homogenous distribution of emphysema.

ISHLT Guidelines. JHeartLungTrans.2006;25:745


Surgery Surgery QuestionQuestion

What is BODE an acronym for?

COPD 2008 COPD 2008 Managing Stable DiseaseManaging Stable Disease SurgerySurgery

Celli B, et al. NEJM. 2004;350:1005

COPD 2008 COPD 2008 The EndThe End

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COPD 08 - PowerPoint Presentation