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Defining COPD Georgina Grantham Community Respiratory Team Leader/ Respiratory Nurse Specialist

Defining COPD - STH COPD.pdf · 2018-10-18 · Defining COPD Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation

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Defining COPD

Georgina Grantham

Community Respiratory Team Leader/

Respiratory Nurse Specialist

Defining COPD

‘Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that

is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually

caused by significant exposure to noxious particles or gases’

Defining COPD

Chronic Obstructive

Pulmonary Disease

(COPD) is now the

preferred term for the

conditions in patients

with airflow limitation

previously diagnosed

as having chronic

bronchitis and

emphysema

NICE National Institute for Health and Care Excellence

Reference: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). June

2010. Available from www.nice.org.uk [Accessed November 2015]

Aetiology

COPD results from a gene-environment interaction

Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

Pathogenesis

COPD is characterised by an intense

inflammatory response by the airways

and alveoli to inhaled substances

such as tobacco smoke

Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930–6

Pathogenesis

6

Tobacco smoking produces lung inflammation in everyone yet only 20–30% of heavy smokers

develop COPD suggesting that the inflammatory response is exaggerated and amplified in

those with increased genetic predisposition or environmental risk factors

Reference: Hogg J. Airway Pathology Chapter 6. Asthma and COPD Basic Mechanisms and Clinical Management. Ed Barnes P. Academic Press 2008

Pathogenesis The inflammatory response …

… is characterised by increased numbers of

Neutrophils

Macrophages

T lymphocytes

in addition to increased concentrations of

Leukotrienes

Interleukins

TNF

Oxidative stress

TNF tumour necrosis factor

Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930–6

Pathological Changes

This chronic cycle of inflammatory injury and repair leads to

structural changes within the airway and alveoli

Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

Inflammation in Asthma v COPD

Although Asthma and COPD are both

associated with chronic inflammation of the

respiratory tract, there are differences in the

inflammatory cells involved in the two

diseases, which in turn account for differences

in symptoms and response to treatment

Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org.

Asthma COPD

Normal

Eosinophil

Inflammation

Neutrophil

Inflammation

Phenotypes

The term phenotype in the field of COPD is defined as:

“A single or combination of disease attributes that describe

differences between individuals with COPD”

The relative contributions of

chronic bronchitis and

emphysema vary from patient to

patient (NICE 2010)

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98; NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in

adults in primary and secondary care (partial update). June 2010

Phenotypes

What is the main pathology on the inside?

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Mainly Chronic Bronchitis?

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Mainly Emphysema?

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Phenotypes

Identifying the peculiarities of the different phenotypes of

COPD will allow us to implement a more personalized

treatment regime, in which the characteristics of the

patients, together with their severity will be key to

choosing the best treatment option

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Matching Pathology to Symptoms C

hro

nic

Bro

nchitis

Main symptom typically excessive phlegm production

Typically reports phlegm production worse in the mornings but reduces as the day goes on

Typically reports a history of frequent chest infections

‘Scooped’ out

appearance

on spirometry

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Matching Pathology to Symptoms E

mphysem

a Main symptom typically breathlessness

Typically does not report excessive phlegm production

Typically does not report a history of frequent chest infections

‘Steeple’

appearance on

spirometry

Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98

Multiple symptoms of COPD have a real impact on patient well-

being

SYMPTOMS1–4

Shortness of breath

Cough

Wheezing

Chest tightness

Sputum production

Worse in morning

Fatigue

Reference:

1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. [date last accessed

July 2017]2. O'Donnell DE. Eur Respir Rev. 2006;15:37–41; 3. Rennard S, et al. Eur Respir J. 2002;20:799–805; 4. Kessler R, et al. Eur Respir J. 2011;37:264–72; 5. Cleland JA, et al. Fam Pract.

2007;24:217–23

IMPACT ON WELL-BEING1–5

Activity/exercise limitation

Anxiety and depression

Apprehension about future events

Lack of confidence about steps to take action

Risk of increasing social isolation

Loss of independence

Assessment Tools

The MRC Breathlessness Score

Th

COPD Assessment Test (CAT)

The FEV1

• Severity According to FEV1 as a % of predicted

• > 80%

• Mild

• 50–80%

• Moderate

• 30–50%

• Severe

• < 30%

• Very severe

Number of Acute Exacerbations in Last 12/12

Management Goals

1. Reduce symptoms

2. Reduce frequency and severity of acute exacerbations

3. Improve health status and exercise tolerance

References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary secondary care (partial update). June 2010; Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner.

Smoking Cessation

Smoking cessation is the key intervention for all

COPD patients who continue to smoke

References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update) June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

Pulmonary Rehabilitation

All COPD patients appear to benefit from rehabilitation and

maintenance of physical activity, improving their exercise tolerance

and experiencing decreased dyspnoea and fatigue

Vaccination

Pneumococcal vaccination and an annual influenza vaccine

should be offered to all patients with COPD

References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

Aim of pharmacologic therapy in COPD

Reduce symptoms

Reduce frequency

and

severity

of

exacerbations

Improve health

status and

exercise tolerance

Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/

There are 2 main groups of medication that are used in the management of

COPD

Bronchodilators Corticosteroids

Pharmacology

29

References: Asthma and COPD: Basic Mechanisms and Clinical Management. 2nd Ed Peter Barnes Academic Press 2008; Lippincott’s Illustrated Reviews: Pharmacology 5th

edition, Harvey et al 2014; Basic and Clinical Pharmacology 12th edition Katzung et al 2012 LANGE basic; Sparrow J 2010 Pharmacological Management of COPD in The

Management of COPD in Primary and Secondary Care Ed Lynes M&K Update

Bronchodilators • Medications that increase the FEV1 or change other

spirometric variables, usually by altering airway smooth muscle tone, are termed bronchodilators, since the improvements in expiratory flow reflect widening of the airways

Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/

Bronchodilators • Bronchodilators improve emptying of the lungs, tend to

reduce dynamic hyperinflation at rest and during exercise and improve exercise performance

Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/

Short-acting

(SABA)

Long-acting

(LABA)

Salbutamol

Terbutaline

Formoterol

Indacaterol maleate

Olodaterol

Salmeterol

Short-acting

(SAMA)

Long-acting

(LAMA)

Ipratropium bromide Aclidinium bromide▼

Glycopyrronium bromide▼

Tiotropium bromide Umeclidinium bromide▼

Bronchodilators

Beta2 agonists

Anti-

muscarinics

Reference: MIMS. Available at www.mims.co.uk / [Accessed April 2017]

Inhaled corticosteroids

The effects of inhaled corticosteroids

on pulmonary and systemic

inflammation in patients with COPD

are controversial, and their role in the

management of stable COPD is

limited to specific indications

Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/

Inhaled corticosteroids

• Long-term treatment with inhaled corticosteroids is recommended for patients with severe and very severe COPD and frequent exacerbations that are not adequately controlled by long-acting bronchodilators

– Frequent exacerbations not adequately controlled by Long Acting Bronchodilators (≥2 per year) or

– ≥1 hospitalisation for exacerbation

Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/

Inhaled corticosteroids indications

• Increasing evidence suggests that patients with certain COPD phenotypes appear to benefit from ICS treatment including patients with:

• Asthma COPD Overlap Syndrome (ACOS)

• Frequent exacerbations

• Eosinophilia

Reference: Ernst P. et al. Eur Resp J. 2015;45:525–37

Questions?