Management of COPD -DR Tasleem Arif

COPD Management : 

COPD Management GOLD Guidelines Dr.Tasleem Arif Dept. of Chest Medicine SKIMS MC/H BEMINA SGR KMR

Goals : 

Goals Prevent disease progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality Prevent or minimize side effects from treatment Cessation of cigarette smoking

Components : 

Components Assess and monitor disease Reduce risk factors Manage stable COPD Manage acute exacerbations

Assess and Monitor Disease : 

Assess and Monitor Disease

Initial Visit : 

Initial Visit Pattern of symptom development Exposure to risk factors History of exacerbations or previous hospitalizations for respiratory disorder Past medical history Family history Social history Impact of disease on patient’s life Effect on family routines Feelings of depression or anxiety Social and family support available to the patient Possibilities for reducing risk factors, especially smoking cessation

Testing : 

Testing Spirometry Initially and yearly ABG Obtain if FEV1 < 40% predicted OR Clinical signs of respiratory or right heart failure Respiratory Failure Alpha-1 antitrypsin If patient <45 years old or strong family history of COPD

Follow-Up Visits : 

Follow-Up Visits Discuss new or worsening symptoms Perform spirometry if there is a substantial increase in symptoms OR if a complication occurs ABG Patients with an FEV1 <40% predicted Early signs of respiratory failure or CHF Monitor pharmacotherapy Dosages Adherence Inhaler technique Effectiveness of current regimen at controlling symptoms Side effects of treatment

Follow-up Visits : 

Follow-up Visits Monitor co-morbid conditions Bronchial carcinoma Tuberculosis Sleep apnea Left heart failure Obtain appropriate information through CXR, ECG whenever symptoms suggest one of these conditions

Reduce Risk Factors : 

Reduce Risk Factors

Risk Factors : 

Risk Factors Tobacco smoke Occupational dusts and chemicals Indoor and outdoor air pollutants

Smoking Cessation : 

Smoking Cessation The single MOST effective and cost-effective intervention to reduce the risk of developing COPD and to stop its progression Offer this at EVERY visit to the health care provider Brief 3 minute period of counseling Three types of counseling are esp. effective: Practical counseling Social support as part of the treatment Social support arranged outside of the treatment Several effective medications are available and at least one of these medications should be added to counseling if necessary and if there are no contraindications Nicotine gum, inhaler, nasal spray, trasndermal patch, sublingual tablet, lozenges Bupropion nortriptyline

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Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.

Smoking Prevention – What you can do as a provider: : 

Smoking Prevention – What you can do as a provider: Encourage comprehensive tobacco-control policies and programs Work with government officials to pass legislation to establish smoke-free schools, public facilities, and work environments Encourage patients to keep smoke-free homes Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.

Occupational Exposures : 

Occupational Exposures Primary prevention Eliminate or reduce exposures to various substances in the workplace Secondary prevention Surveillance and early detection

Indoor and Outdoor Air Pollution : 

Indoor and Outdoor Air Pollution Implement measures to reduce or avoid indoor air pollution from biomass fuel burned for cooking and heating in poorly ventilated dwellings Advise patients to monitor public announcements of air quality Avoid vigorous exercise outdoors or stay indoors during pollution episodes, depending on COPD severity

Manage Stable COPD : 

Manage Stable COPD

General Principles : 

General Principles Determine disease severity Implement step-wise treatment plan Educate the patient Improve skills Improve ability to cope with illness Improve health status Prescribe Treatment Pharmacologic Non-pharmacologic Rehabilitation Exercise training Nutrition counseling education Oxygen therapy Surgical interventions GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Patient Education : 

Patient Education Smoking cessation Basic information about COPD and pathophysiology of the disease General approach to therapy and specific aspects of medical treatment Self-management skills Strategies to help minimize dyspnea Advice about when to seek help Self-management and decision-making in exacerbations Advance directives and end-of-life issues

Medications : 

Medications Goals Prevent and control symptoms Reduce frequency and severity of exacerbations Improve health status Improve exercise tolerance No existing medications can modify the long-term decline in lung function Reduction of therapy once symptom control occurs is not normally possible COPD is progressive and over time will require progressive introduction of more treatments to attempt to limit the impact of these changes

Bronchodilators : 

Bronchodilators Central to symptom management Used in all stages of COPD severity Inhaled forms are preferred Can be prescribed as needed OR regularly to prevent or reduce symptoms Long-acting inhaled bronchodilators are more effective and convenient (but are more expensive) Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects All categories of bronchodilators have been show to increase exercise capacity without necessarily producing significant changes in FEV1

Bronchodilators : 

Bronchodilators Beta2-agonists Short-acting: albuterol Long-acting: salmeterol (Serevent™), formoterol (Foradil™) Anticholinergics Short acting: ipratropium bromide (Atrovent™) Long acting: tiotropium bromide (Spiriva™) Methylxanthines (Theophylline™) Combination bronchodilators Fenoterol/ipratropium (Duovent™) Salbutamol/ipratropium (Combivent™) GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Glucocorticosteroids : 

Glucocorticosteroids Use if FEV1 < 50% predicted and repeated exacerbations, e.g. three in the last three years Severe COPD and Very Severe COPD Does not modify the long-term decline in FEV1 BUT does reduce the frequency of excacerbations and improves health status The combination of a long-acting beta2-agonist and an inhaled glucocorticosteroid is more effective than the individual components Long-term treatment with oral glucocorticoids is NOT recommended

Inhaled Glucocorticoids : 

Inhaled Glucocorticoids Beclomethasone (Vanceril™) Budesonide (Pulmicort™) Fluticasone (Flovent™) Triamcinolone (Azmacort™)

Immunizations : 

Immunizations Vaccines Influenza yearly Reduces serious illness and death in COPD patients by approximately 50% Give once yearly: autumn OR twice yearly: autumn and winter Pneumovax Sufficient data to support its general use in COPD is lacking, but it is commonly used

Other Medications? : 

Other Medications? Alpha-1 Antitrypsin Augmentation Therapy Only if this deficiency is present in an individual should they undergo treatment Antibiotics Prophylactic use is NOT recommended Can be used in the treatment of infectious exacerbations of COPD Mucolytic agents Overall benefits are small, so currently not recommended for widespread use Types: Ambroxol Erdosteine (Erdostin, Mucotec) Carbocysteine (Mucodyne) Iodinated gylerol (Expigen)

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Antioxidant agents N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst) Have been shown to reduce the frequency of exacerbations and could have a role in the treatment of patients with recurrent exacerbations More studies are needed Immunoregulators Not recommended at this time No reproducible studies are available Antitussives Regular use is contraindicated in stable COPD since cough has a significant protective role Vasodilators Inhaled nitric oxide Can worsen gas exchange because of altered hypoxic regulation of ventilation-perfusion balance and is contraindicated in stable COPD

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Respiratory stimulants Doxapram (IV) Almitrine bismesylate Not recommended in stable COPD Narcotics Oral and parenteral opioids are effective for treating dyspnea in patients with advanced COPD Use this with caution; benefits may be limited to a few sensitive subjects nebulized opioids: insufficient evidence . Miscellaenous: Nedocromil Leukotriene modifiers Alternative healing methods None have been adequately studied in COPD patients at this time GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Stage 0: At Risk : 

Stage 0: At Risk Avoid risk factors Offer influenza vaccination

Stage I: Mild COPD : 

Stage I: Mild COPD Avoid risk factors Offer vaccination Use short-acting bronchodilators as needed

Stage II: Moderate COPD : 

Stage II: Moderate COPD Avoid risk factors Offer influenza vaccine Add short-acting bronchodilators when needed Add regular treatment with 1 or more long-acting bronchodilators Add rehabilitation

Stage III: Severe COPD : 

Stage III: Severe COPD Avoid risk factors Offer influenza vaccine Add short-acting bronchodilators when needed Add regular treatment with 1 or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticoids if repeated exacerbations

Stage IV: Very Severe COPD : 

Stage IV: Very Severe COPD Avoid risk factors Offer influenza vaccination Add short-acting bronchodilators as needed Add rehabilitation Add inhaled glucocorticoids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments

Non-Pharmacologic Therapy : 

Non-Pharmacologic Therapy

Rehabilitation : 

Rehabilitation COPD patients at all stages of severity benefit from exercise training programs Improves both exercise tolerance and symptoms of dyspnea and fatigue Goals Reduce symptoms Improve quality of life Increase physical and emotional participation in everyday activities Comprehensive program should include several types of health professionals: Exercise training Nutrition counseling Education Minimum effective length of time = 2 months Setting: inpatient OR outpatient OR home Baseline and outcome assessments of each participant should be made to quantify individual gains and target areas for improvement Measurement of spirometry before and after a bronchodilator drug Assessment of exercise capacity Assessment of inspiratory and expiratory muscle strength and lower limb strength

Oxygen Therapy : 

Oxygen Therapy Stage IV - Severe COPD who have PaO2 at or below 55 mm Hg or SaO2 at or below 88% with or without hypercapnia OR PaO2 between 55-60 mm Hg or SaO2 88% IF pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (Hct > 55%) Based on awake PaO2 values GOAL Increase baseline PaO2 to at least 60 mm Hg at sea level and rest and/or produce SaO2 at least 90% Need to use at least 15 hours per day in patients with chronic respiratory failure to improve survival Can have a beneficial impact on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state

Surgical Treatment : 

Surgical Treatment Bullectomy Effective in reducing dyspnea and improving lung function in appropriately selected patient Lung volume reduction surgery Parts of the lung are resected to reduce hyperinflation Does not improve life expectancy Does improve exercise capacity in patients with predominantly upper lobe emphysema and a low post-rehabilitation exercise capacity May improve global health status in patients with heterogeneous emphysema High hospital costs; still experimental/palliative

Surgical Treatment : 

Surgical Treatment Lung transplantation Improves quality of life and functional capacity in appropriately selected patient Criteria for referral: FEV1 < 35% predicted PaO2 < 55-60 mm Hg PaCO2 > 50 mm Hg Secondary pulmonary hypertension All four criteria must be present

COPD Patients and Surgery : 

COPD Patients and Surgery Increased risk of post-operative pulmonary complications Risk of complications increases as the incision approaches the diaphragm Epidural and spinal anesthesia have a lower risk than general anesthesia Postpone surgery if the patient has a COPD exacerbation

Manage Exacerbations : 

Manage Exacerbations

General Points : 

General Points Most common causes of exacerbations are: Infection of the tracheobronchial tree Air pollution In 1/3 of severe exacerbations a cause cannot be identified Inhaled bronchodilators, theophylline, and systemic (preferably oral) glucocorticosteroids are effective treatments Patients with clinical signs of airway infection may benefit from antibiotic treatment Increased volume of sputum Change in color of sputum Fever Non-invasive intermittent positive pressure ventilation (NIPPV) in exacerbations is helpful: Improves blood gases and pH Reduces in-hospital mortality Decreases the need for invasive mechanical ventilation and intubation Decreases the length of hospital stay

Diagnosis and Assessment of Severity : 

Diagnosis and Assessment of Severity History Increased breathlessness Chest tightness Increased cough and sputum Change of color and/or tenacity of sputum Fever Non-specific: Malaise, insomnia, sleepiness, fatigue, depression, or confusion

Assessment of Severity : 

Assessment of Severity Lung Function Tests PEF < 100 L/min. or FEV1 < 1 L = severe exacerbation Arterial Blood Gas PaO2 < 60 mmHg and/or SaO2 < 90% with or without PaCO2 < 50 mmHg when breathing room air = respiratory failure Chest x-ray Look for complications Pneumonia Alternative diagnoses ECG Right ventricular hypertrophy Arrhythmias Ischemia Sputum Culture/sensitivity Comprehensive Metabolic Profile Assess for electrolyte disturbances, diabetes Albumin to assess nutrition

PLACE OF RX : 

PLACE OF RX Home? Hospital admission? Floor? ICU? GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Indications for Hospital Admission : 

Indications for Hospital Admission Marked increase in intensity of symptoms such as sudden development of resting dyspnea Severe background COPD Onset of new physical signs Cyanosis, peripheral edema Failure of exacerbation to respond to initial medical management Significant co-morbidities Newly occurring arrhythmias Diagnostic uncertainty Older age Insufficient home support

Indications for ICU Admission : 

Indications for ICU Admission Severe dyspnea that responds inadequately to initial emergency therapy Confusion, lethargy, coma Persistent or worsening hypoxemia (PaO2 < 40 mm Hg) and/or Severe/worsening hypercapnia (PaCO2 > 60 mm Hg) and/or Severe/worsening respiratory acidosis (pH < 7.25) despite supplemental oxygen and NIPPV NIPPV = non-invasive positive pressure ventilation

Management of Exacerbations : 

Management of Exacerbations Risk of dying from an exacerbation is closely related to: Development of respiratory acidosis Presence of significant co-morbidities Need for ventilatory support

Severe Exacerbation, Non Life Threatening : 

Severe Exacerbation, Non Life Threatening Assess severity of symptoms Obtain arterial blood gas and chest x-ray Administer controlled oxygen therapy Repeat ABG after 30 minutes Bronchodilators Glucocorticosteroids Consider antibiotics Consider non-invasive mechanical ventilation Monitor fluid balance and nutrition Consider subcutaneous heparin therapy Identify and treat associated conditions (CHF, arrhythmias)

Management of COPD Exacerbations : 

Management of COPD Exacerbations Controlled oxygen therapy Administer enough to maintain PaO2 > 60 mmHG or SaO2 > 90% Monitor patient closely for CO2 retention or acidosis Bronchodilators (inhaled) Increase doses or frequency Combine ß2 agonists and anticholinergics Use spacers or air-driven nebulizers Consider adding IV methylxanthine (aminophylline) if needed

Management of COPD Exacerbations : 

Management of COPD Exacerbations Glucocorticosteroids (oral or IV) Recommended as an addition to bronchodilator therapy If baseline FEV1 < 50% predicted 30-40 mg oral prednisolone x 7-10 days OR nebulized budesonide (Pulmicort™) Antibiotics IF breathlessness and cough are increased AND sputum is purulent and increased in volume Choice of antibiotics should reflect local antibiotic sensitivity for the following microbes: S. pneumoniae H. influenzae M. catarrhalis

Management of COPD Exacerbations : 

Management of COPD Exacerbations Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing > 25 mL sputum per day OR with lobar atelectasis.

Management of COPD Exacerbations : 

Management of COPD Exacerbations Ventilatory Support Decrease mortality and morbidity Relieve symptoms Used most commonly in Stage IV, Very Severe COPD Forms: Non-invasive using negative or positive pressure devices invasive/mechanical with oro- or naso-tracheal tube OR tracheostomy

NIPPV : 

NIPPV Success rates of 80-85% Increases pH, reduces PaCO2, reduces severity of breathlessness Decreases length of hospital stay Decreases mortality/intubation rate

NIPPV (C-PAP, Bi-PAP) : 

NIPPV (C-PAP, Bi-PAP) Selection criteria Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion Moderate to severe acidosis (pH < 7.35) and hypercapnia (PaCO2 > 45 mmHg) Respiratory frequency > 25 breaths/minute

NIPPV : 

NIPPV Exclusion criteria Respiratory arrest Cardiovascular instability Hypotension Arrhythmias Myocardial infarction Somnolence, impaired mental status, lack of cooperation High aspiration risk – viscous/copius secretions Recent facial or gastroesophageal surgery Cranio-facial trauma, fixed nasopharyngeal abnormalities Extreme obesity

Indications for Invasive Mechanical Ventilation : 

Indications for Invasive Mechanical Ventilation Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Respiratory rate > 35 breaths/minute Life-threatening hypoxemia: PaO2 < 40 mm Hg Severe acidosis (pH < 7.25) and hypercapnia (PaCO2 > 60 mm Hg) Respiratory arrest Somnolence, impaired mental status Cardiovascular complications Hypotension/shock/heart failure Other complications Metabolic abnormalities/sepsis/pneumonia/pulmonary embolism/barotrauma/massive pleural effusion NIPPV failure

Use of Invasive Ventilation in End-Stage COPD : 

Use of Invasive Ventilation in End-Stage COPD Hazards: Ventilator-acquired pneumonia Increased prevalence of multi-resistant organisms Barotrauma Failure to wean to spontaneous ventilation Mortality among COPD patients with respiratory failure is no greater than mortality among patients ventilated for non-COPD reasons

Discharge Criteria : 

Discharge Criteria Inhaled Beta2-agonist use is at most every 4 hours Patient is able to walk across the room Patient is able to eat and sleep without frequent awakening Patient has been clinically stable for 12-24 hours ABGs are stable for 12-24 hours Patient/home caregiver fully understands correct use of medications Follow-up and home care arrangements have been completed Patient, family, and physician are confident that patient can manage successfully

Follow-Up Assessment after Hospital Discharge : 

Follow-Up Assessment after Hospital Discharge 4-6 weeks after discharge Assess: Ability to cope in usual environment Inhaler technique Understanding of recommended treatment regimen Measure FEV1 Determine need for long-term oxygen therapy and/or home nebulizer (for patients with very severe COPD, Stage IV)

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THANK YOU

REFERENCES : 

REFERENCES National Heart, Lung, and Blood Institute Data Fact Sheet for Chronic Obstructive Pulmonary Disease GOLD (Global Initiative for Chronic Obstructive Lung Disease) Executive Summary, April 2001 GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. Updated July 2005. www.goldcopd.org – Accessed August 21, 2006. Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October 2000.