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Caring for Patients with Caring for Patients with COPD: Guidelines for COPD: Guidelines for
Diagnosis and ManagementDiagnosis and Management
M. Elizabeth Knauft, MD MSM. Elizabeth Knauft, MD MS
September 20, 2007September 20, 2007
GOLDGOLD Diagnosis and Classification of COPDDiagnosis and Classification of COPD 4 major components of COPD 4 major components of COPD
managementmanagement Assess and Monitor DiseaseAssess and Monitor Disease Reduce Risk FactorsReduce Risk Factors Manage Stable COPDManage Stable COPD Manage ExacerbationsManage Exacerbations
GOLDGOLD
1998: Global Initiative for Chronic 1998: Global Initiative for Chronic Obstructive Lung DiseaseObstructive Lung Disease
2001:2001: Global Strategy for the Diagnosis, Global Strategy for the Diagnosis, Management, and Prevention of COPDManagement, and Prevention of COPD
2006: Revision of above2006: Revision of above
Goals of GOLDGoals of GOLD
““To improve prevention and management of To improve prevention and management of COPD through a concerted worldwide effort COPD through a concerted worldwide effort of people involved in all facets of healthcare of people involved in all facets of healthcare and healthcare policy, and to encourage an and healthcare policy, and to encourage an expanded level of research interest in this expanded level of research interest in this highly prevalent disease.”highly prevalent disease.”
CaseCase
CC: DyspneaCC: Dyspnea HPI: 66 yo F with several years of progressive HPI: 66 yo F with several years of progressive
dyspnea, cough.dyspnea, cough. 60 pack year tobacco, active smoker (2ppd)60 pack year tobacco, active smoker (2ppd) PMH: DM IIPMH: DM II
Definition of COPDDefinition of COPD
Preventable and treatable disease with some Preventable and treatable disease with some significant extrapulmonary effects that may significant extrapulmonary effects that may contribute to the severity in individual patientscontribute to the severity in individual patients
Pulmonary component characterized by Pulmonary component characterized by airflow limitation that is not fully reversible.airflow limitation that is not fully reversible.
Airflow limitation progressive and associated Airflow limitation progressive and associated with abnormal inflammatory response of the with abnormal inflammatory response of the lung to noxious particles or gaseslung to noxious particles or gases
Spirometric Classification of COPD Spirometric Classification of COPD Severity Based on Post-Bronchodilator Severity Based on Post-Bronchodilator
FEV1FEV1
Stage I:Stage I:
MildMild
FEV1/FVC <70%FEV1/FVC <70%
FEV1 > 80% predictedFEV1 > 80% predicted
Stage II:Stage II:
ModerateModerate
FEV1/FVC <70%; 50%< FEV1<80% pred.FEV1/FVC <70%; 50%< FEV1<80% pred.
Stage III: Stage III: SevereSevere
FEV1/FVC <70%; 30%< FEV1<50% pred.FEV1/FVC <70%; 30%< FEV1<50% pred.
Stage IV:Stage IV:
Very SevereVery Severe
FEV1/FVC <70%FEV1/FVC <70%
FEV1<30%, or FEV1 < 50% pred. plus FEV1<30%, or FEV1 < 50% pred. plus presence of chronic respiratory failurepresence of chronic respiratory failure
Case Con’tCase Con’tSpirometrySpirometry
FEV1/FVC: 0.50FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% Postbronchodilator FEV1: 1.23L (63%
predicted)predicted)
Case Con’tCase Con’tSpirometrySpirometry
FEV1/FVC: 0.50FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% Postbronchodilator FEV1: 1.23L (63%
predicted)predicted)
Stage IIStage II
Mechanism of COPDMechanism of COPD
Proximal and peripheral airways, lung Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affectedparenchyma, pulmonary vasculature affected
Chronic inflammatory changes, amplified by Chronic inflammatory changes, amplified by oxidative stressoxidative stress
Burden of COPDBurden of COPD
Prevalence higher in Prevalence higher in smokers and ex-smokers than nonsmokerssmokers and ex-smokers than nonsmokers Patients over 40 than those under 40Patients over 40 than those under 40 Men than in womenMen than in women
MorbidityMorbidity MortalityMortality
66thth leading cause of death in 1990 (Global Burden leading cause of death in 1990 (Global Burden on Disease Study)on Disease Study)
Projected to be 3Projected to be 3rdrd leading cause by 2020 leading cause by 2020
Risk Factors for COPDRisk Factors for COPD
Cigarette smokeCigarette smoke Occupational dust and chemicalsOccupational dust and chemicals Environmental tobacco smokeEnvironmental tobacco smoke Indoor and outdoor pollutionIndoor and outdoor pollution
Management Goals for COPDManagement Goals for COPD
Relieve symptoms Relieve symptoms Prevent progression of diseasePrevent progression of disease Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Prevent and treat complicationsPrevent and treat complications Prevent and treat exacerbationsPrevent and treat exacerbations Reduce mortalityReduce mortality
Four Major Components of COPD Four Major Components of COPD ManagementManagement
I: Assess and Monitor DiseaseI: Assess and Monitor Disease II: Reduce Risk FactorsII: Reduce Risk Factors III: Manage Stable COPDIII: Manage Stable COPD IV: Manage ExacerbationsIV: Manage Exacerbations
Assess and Monitor DiseaseAssess and Monitor Disease
DyspneaDyspnea Progressive, persistent, worse with exerciseProgressive, persistent, worse with exercise ““increased effort to breathe”, “air hunger”increased effort to breathe”, “air hunger”
Chronic coughChronic cough Intermittent, non-productiveIntermittent, non-productive
Chronic sputum production Chronic sputum production Any patternAny pattern
History of exposure to risk factorsHistory of exposure to risk factors Tobacco, occupational dust/chemicals, home cooking, Tobacco, occupational dust/chemicals, home cooking,
heating fuelsheating fuels
Assess and Monitor Disease-2Assess and Monitor Disease-2
Confirm diagnosis by spirometryConfirm diagnosis by spirometry Post bronchodilator FEV1/FVC < 0.70 Post bronchodilator FEV1/FVC < 0.70 Obtain ABG if FEV1 < 50% predicted or Obtain ABG if FEV1 < 50% predicted or
clinical signs right heart failureclinical signs right heart failure Alpha-1 antitrypsin level in young pts (<45 Alpha-1 antitrypsin level in young pts (<45
years)years) Identify comorbidities Identify comorbidities
Assess and Monitor Disease-3Assess and Monitor Disease-3
Differential DiagnosisDifferential Diagnosis AsthmaAsthma CHFCHF BronchiectesisBronchiectesis TuberculosisTuberculosis Obliterative BronchioloitsObliterative Bronchioloits Diffuse PanbronchiolitisDiffuse Panbronchiolitis
Reduce Risk FactorsReduce Risk Factors
Smoking Cessation!Smoking Cessation! Reduction of indoor and outdoor air pollutionReduction of indoor and outdoor air pollution
Manage Stable COPDManage Stable COPD
Individualize overall approach to address Individualize overall approach to address symptoms and improve quality of lifesymptoms and improve quality of life
Smoking cessationSmoking cessation Pharmacotherapy for COPD used to decrease Pharmacotherapy for COPD used to decrease
symptoms and/or complications symptoms and/or complications do NOT modify long-term decline in lung functiondo NOT modify long-term decline in lung function
Manage Stable COPD-2Manage Stable COPD-2BronchodilatorsBronchodilators
B-2 agonists, anticholinergics,methylxanthinesB-2 agonists, anticholinergics,methylxanthines Symptomatic management: prn or scheduledSymptomatic management: prn or scheduled Increase exercise capacity Increase exercise capacity Do not necessarily improve FEV1Do not necessarily improve FEV1 LABA more effective than SABALABA more effective than SABA Combination therapy more effective than increasing Combination therapy more effective than increasing
dose of single agentdose of single agent Long acting anticholinergic reduces rate of COPD Long acting anticholinergic reduces rate of COPD
exacerbations, improves effectiveness of pulmonary exacerbations, improves effectiveness of pulmonary rehabilitationrehabilitation
Manage Stable COPD-3Manage Stable COPD-3GlucocorticosteroidsGlucocorticosteroids
Inhaled corticosteroids (ICS) do not modify Inhaled corticosteroids (ICS) do not modify long term decline in FEV1long term decline in FEV1
ICS appropriate for symptomatic, FEV1 < ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very 50% (Stage III: Severe and Stage IV: Very Severe) pts Severe) pts
Regular use of ICS reduces frequency of Regular use of ICS reduces frequency of exacerbationsexacerbations
Long term use systemic glucocorticosteroids is Long term use systemic glucocorticosteroids is NOT recommendedNOT recommended
Manage Stable COPD-4Manage Stable COPD-4
Influenza vaccineInfluenza vaccine Pneumococcal vacine (>65years; < 65 years Pneumococcal vacine (>65years; < 65 years
with FEV1 < 40 % predicted)with FEV1 < 40 % predicted)
Manage Stable COPD-5Manage Stable COPD-5Therapies NOT recommendedTherapies NOT recommended
No benefit from prophylactic antibiotic therapy No benefit from prophylactic antibiotic therapy Overall benefit from mucolytics is smallOverall benefit from mucolytics is small N-acetylcysteine: no reduction in exacerbationsN-acetylcysteine: no reduction in exacerbations Antitussives (cough has a protective role)Antitussives (cough has a protective role) Vasodilators (inhaled nitric oxide)Vasodilators (inhaled nitric oxide)
Manage Stable COPD-6Manage Stable COPD-6Non-Pharmacologic TreatmentsNon-Pharmacologic Treatments
Pulmonary rehabilitationPulmonary rehabilitation Goals: Reduce symptoms, improve quality of life, increase Goals: Reduce symptoms, improve quality of life, increase
physical and emotional participation in everyday activitiesphysical and emotional participation in everyday activities Supplemental oxygen Supplemental oxygen
Use > 15 h/day improves survival in patients with chronic Use > 15 h/day improves survival in patients with chronic respiratory failurerespiratory failure
PaO2<55, SaO2 <88%PaO2<55, SaO2 <88% PaO2 55-60, SaO2 = 88% and pulmonary hypertension, PaO2 55-60, SaO2 = 88% and pulmonary hypertension,
evidence of CHF, polycythemia (HCT > 55%)evidence of CHF, polycythemia (HCT > 55%)
Therapy at Each Stage of COPDTherapy at Each Stage of COPD
Stage I:Stage I:
MildMild
Reduction of risk factors; influenza vaccinationReduction of risk factors; influenza vaccination
Add short-acting bronchodilators prnAdd short-acting bronchodilators prn
Stage II:Stage II:
ModerateModerate
Add regular treatment with one or more long-Add regular treatment with one or more long-acting bronchodilators; add rehabilitationacting bronchodilators; add rehabilitation
Stage III:Stage III:
SevereSevere
Add inhaled glucocorticosteroids if repeated Add inhaled glucocorticosteroids if repeated exacerbationsexacerbations
Stage IV:Stage IV:
Very SevereVery Severe
Add long-term oxygen if chronic respiratory Add long-term oxygen if chronic respiratory failure; consider surgical treatmentsfailure; consider surgical treatments
Case Con’tCase Con’t
Short acting B2 agonistShort acting B2 agonist Long acting bronchodilator (B2 agonist or Long acting bronchodilator (B2 agonist or
anticholinergic)anticholinergic) Influenza vaccineInfluenza vaccine Pneumococcal vaccinePneumococcal vaccine Smoking cessationSmoking cessation
Manage ExacerbationsManage Exacerbations
Exacerbation:Exacerbation: “…“…an event in the natural course of the disease an event in the natural course of the disease
characterized by a change in the patient’s baseline characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a may warrant a change in regular medication in a patient with underlying COPD.”patient with underlying COPD.”
Infection of tracheobronchial tree and air pollution Infection of tracheobronchial tree and air pollution most common causesmost common causes
No cause identified in 1/3 exacerbationsNo cause identified in 1/3 exacerbations
Manage ExacerbationsManage Exacerbations
Increased SOB, wheeze, chest tightness, Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color increased cough and sputum, change in color or tenacity of sputumor tenacity of sputum
Assess severityAssess severity Dependent on pt’s baseline prior to exacerbationDependent on pt’s baseline prior to exacerbation ABGABG FEV1 not practicalFEV1 not practical CXRCXR Sputum cultureSputum culture
Manage ExacerbationsManage ExacerbationsHome managementHome management
Increase dose and/or frequency of short acting Increase dose and/or frequency of short acting bronchodilator therapybronchodilator therapy
Consider adding anticholinergic agentConsider adding anticholinergic agent Systemic glucocorticosteroidsSystemic glucocorticosteroids
Shorten recovery timeShorten recovery time Improve FEV1 and hypoxemiaImprove FEV1 and hypoxemia Consider (in addition to bronchodilators) if FEV1 < Consider (in addition to bronchodilators) if FEV1 <
50%50% 30-40 mg prednisone/d x 7-10 days30-40 mg prednisone/d x 7-10 days
Case Con’tCase Con’t
Increased dyspneaIncreased dyspnea Increase in sputum, now purulentIncrease in sputum, now purulent
Case Con’tCase Con’t
Increased dyspneaIncreased dyspnea Increase in sputum, now purulentIncrease in sputum, now purulent
Increase frequency of bronchodilators Increase frequency of bronchodilators (nebulized or inhaled)(nebulized or inhaled)
Consider oral glucocorticosteroidsConsider oral glucocorticosteroids
Manage ExacerbationsManage ExacerbationsHospital managementHospital management
Risk of death related to development of respiratory Risk of death related to development of respiratory acidosisacidosis
Indications for hospital assessment/admissionIndications for hospital assessment/admission Marked increase in intensity of symptomsMarked increase in intensity of symptoms Severe underlying COPDSevere underlying COPD New physical signs (cyanosis, peripheral edema)New physical signs (cyanosis, peripheral edema) Failure to respond to outpatient managementFailure to respond to outpatient management Significant comorbiditiesSignificant comorbidities Frequent exacerbationsFrequent exacerbations New arrythmiaNew arrythmia Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
Manage ExacerbationsManage ExacerbationsHospital management-2Hospital management-2
Assess severity of symptoms- ABG, CXRAssess severity of symptoms- ABG, CXR OxygenOxygen BronchodilatorsBronchodilators
B-2 agonistB-2 agonist Add anticholinergic if no responseAdd anticholinergic if no response Role of methylzanthines is controversialRole of methylzanthines is controversial
Add oral or IV glucocorticosteroidsAdd oral or IV glucocorticosteroids
Manage ExacerbationsManage ExacerbationsHospital management-3Hospital management-3
Give antibiotics if:Give antibiotics if: Increased dyspnea, increased sputum volume, Increased dyspnea, increased sputum volume,
increased sputum purulenceincreased sputum purulence Two of the above three criteria are met, and Two of the above three criteria are met, and
one is presence of purulent sputumone is presence of purulent sputum Severe exacerbation requiring mechanical Severe exacerbation requiring mechanical
ventilation (invasive or noninvasive)ventilation (invasive or noninvasive) H. influenza, S. pneumoniae, M. catarrhalisH. influenza, S. pneumoniae, M. catarrhalis
Manage ExacerbationsManage ExacerbationsHospital management-4Hospital management-4
Ventilatory supportVentilatory support Noninvasive mechanical ventilation : 80% Noninvasive mechanical ventilation : 80%
success ratesuccess rate Moderate/severe dyspnea with use of accessory Moderate/severe dyspnea with use of accessory
muscles and paradoxical abdominal muscle motionmuscles and paradoxical abdominal muscle motion Moderate/severe respiratory acidosis (pH < 7.35, Moderate/severe respiratory acidosis (pH < 7.35,
paCO2 > 45)paCO2 > 45) Tachypnea (RR > 25 bpm)Tachypnea (RR > 25 bpm)
Manage ExacerbationsManage ExacerbationsDischarge CriteriaDischarge Criteria
Inhaled B2 agonist therapy is required no more Inhaled B2 agonist therapy is required no more than every 4 hoursthan every 4 hours
Pt able to walk across room (if previously Pt able to walk across room (if previously ambulatory)ambulatory)
Clinically stable for 12-24 hClinically stable for 12-24 h Stable ABG for 12-24 hStable ABG for 12-24 h Patient/caregiver understands proper Patient/caregiver understands proper
medication usemedication use Home care/follow-up arrangements madeHome care/follow-up arrangements made
SummarySummary
Diagnosis of COPD requires post-Diagnosis of COPD requires post-bronchodilator FEV1bronchodilator FEV1
Tobacco cessationTobacco cessation Layer treatment according to stage of COPDLayer treatment according to stage of COPD