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COPD
Chronic BronchitisEmphysema
COPD
Chronic BronchitisEmphysema
PATHOLOGICAL
diagnosis
CLINICAL diagnosis
COPD
Chronic BronchitisEmphysema
PHYSIOLOGICAL
DIAGNOSIS:
Post-BD FEV1/FVC <0.7
Take Home Message
Not every smoker gets COPD
The diagnosis of COPD requires spirometry
Diagnostic Pathway
Diagnosis
Suspect the diagnosis
Case Find (Handheld spiro)
Diagnosis requires post-BD
Big change suggests asthma
Refer if unsure
What are we trying to achieve?
What are we trying to achieve?
Reduction is symptoms
Increase in exercise capacity
Reduction in exacerbations
Preservation of lung function
Take Home Message
The main reasons to optimise treatment are to reduce symptoms, improve exercise, and prevent exacerbations
Value in COPD Care
Value in COPD Care
London Respiratory “Value Pyramid”
Management Pathway
Management Pathway
Take Home Message
The cornerstone of COPD therapy is:
Smoking cessation
Pulmonary Rehabilitation
Influenza and Pneumococcal vaccination
Medicines Management
Responsible Respiratory Prescribing Group endorsed
Very comprehensive
(IMHO): too complex for daily use
GOLD Staging
mMRC ≥2
CAT≥10
mMRC 0-1
CAT<10SYMPTOMS
GOLD Staging
mMRC ≥2
CAT≥10
mMRC 0-1
CAT<10SYMPTOMS
RISK
Exacerbations
≥2*
1
0
GOLD Staging
mMRC ≥2
CAT≥10
mMRC 0-1
CAT<10SYMPTOMS
RISK
Exacerbations
≥2*
1
0
DC
A B A: Low Risk, Fewer Symptoms
B: Low Risk, More Symptoms
C: High Risk, Fewer Symptoms
D: High Risk, More Symptoms
2017 Assessment of COPD
C D
A B
4
3
2
1
RISK
GOLD
Stage
≥
2
1
0
RISK
Exacerbations
FEV1
<30%
30-50%
50-80%
>80%
GOLD A: smoking; vaccines; PR…
Group A
A bronchodilator
Continue, stop or
try alternative class
of bronchodilator
Evaluate
effect
GOLD 2017
GOLD B: smoking; vaccines; PR…
Group B
A long-acting bronchodilator
(LABA or LAMA)
LAMA + LABA
Persistent
symptoms
GOLD 2017
GOLD C: smoking; vaccines; PR…
Group C
LAMA
LAMA + LABA
Further
Exacerbation(s)
LABA + ICS
GOLD 2017
Preferred
GOLD D: smoking; vaccines; PR…Group D
LAMA + LABA
Further
Exacerbation(s)
Consider
macrolide
LAMA LABA + ICS
LAMA + LABA + ICS
Further
Exacerbation (s)
Persistent
symptoms/further
exacerbations
GOLD 2017
Consider roflumilast if
FEV1 <50% pred. and
patient has chronic
bronchitis
PharmacotherapyGroup D
LAMA + LABA
Consider
macrolide
LAMA LABA + ICS
LAMA + LABA + ICS
Further
Exacerbation (s)
Persistent
symptoms/further
exacerbations
GOLD 2017
Consider roflumilast if
FEV1 <50% pred. and
patient has chronic
bronchitis
PharmacotherapyGroup D
LAMA + LABA
Further
Exacerbation(s)
Consider
macrolide
LAMA LABA + ICS
LAMA + LABA + ICS
Further
Exacerbation (s)
Persistent
symptoms/further
exacerbations
GOLD 2017
Consider roflumilast if
FEV1 <50% pred. and
patient has chronic
bronchitis
Additional Considerations
Inhaler technique
New evidence in exacerbation prevention:
ICS-LABA=LAMA
LABA-LAMA>LAMA
LABA-LAMA>ICS-LABA
Steroid Withdrawal
Take Home Message
Pharmacotherapy in COPD is guided by symptoms and exacerbations rather than FEV1
We need to better target inhaled corticosteroids (unlike asthma where ICS go in early!)
COPD versus ASTHMA (and ACO)DIAGNOSE CHRONIC AIRWAYS DISEASE
Do symptoms suggest chronic airways disease?STEP 1
Yes No Consider other diseases first
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest ASTHMA COPD
Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days
Worse during the night or early
morning. Triggered by exercise,
emotions including laughter, dust or
exposure to allergens
Persistent despite treatment
Good and bad days but always daily
symptoms and exertional dyspnea
Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung functionRecord of variable airflow limitation
(spirometry or peak flow)Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function betweensymptoms Normal Abnormal
Previous doctor diagnosis of asthma
Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course No worsening of symptoms over time. Variation in symptoms either seasonally, or from year to year
May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks
Symptoms slowly worsening over time (progressive course over years)
Rapid-acting bronchodilator treatment provides only limited relief
Chest X-ray Normal Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of both
Could be ACOS
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or
COPD suggest that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
Markedreversible airflow limitation(pre-post bronchodilator) or otherproof of variable airflow limitation
STEP 3PERFORM
SPIROMETRY
FEV1/FVC < 0.7
post-BD
Asthma drugs
No LABAmonotherapy
STEP 4
INITIAL
TREATMENT*
COPD drugs
Asthma drugsNo LABA
monotherapy
ICS, and usually LABA
+/or LAMA
COPD drugs
*Consult GINA and GOLD documents for recommended treatments.
STEP 5
SPECIALISED
INVESTIGATIONS
or REFER IF:
• Persistent symptoms and/or exacerbations despite treatment.• Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and other causes of respiratory symptoms).• Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease).• Few features of either asthma or COPD.• Comorbidities present.• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.
Past history or family history
Multi-Morbidity
1/3 die from cardiovascular disease
1/4 die from cancer (principally lung cancer)
“What is the blood pressure?”
Summary
1: Not every smoker gets COPD
2: The diagnosis of COPD requires spirometry
3: The main reasons to optimise treatment are to reduce symptoms,
improve exercise, and prevent exacerbations.
4: The cornerstone of COPD therapy is:
Smoking cessation
Pulmonary Rehabilitation
Influenza and Pneumococcal vaccination
Summary
5: Pharmacotherapy in COPD is guided by symptoms and
exacerbations rather than FEV1
6: We need to better target inhaled corticosteroids (unlike asthma where
ICS go in early!)
7: Don’t forger co-morbidity
8: Discuss with the Community Team