central ohio pulmonary disease, inc. michael l. corriveau, md, facp, fccp
TRANSCRIPT
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Central Ohio Pulmonary Disease, Inc.
Michael L. Corriveau, MD, FACP, FCCP
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COPD2006
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Definition of COPD
“A disease state characterized by
airflow limitation that is not
fully reversible..”
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COPD
Normal
Damage +Cholinergic tone
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Epidemiology of COPD
12.5 million patients with chronic bronchitis
1.6 million patients with emphysema
8 million office visits and 1.5 million ER visits/year
$30 billion/year lost in healthcare/work loss
Fourth leading cause of death in the US
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COPD Mortality Rate Increasing
0
0.5
1.0
1.5
2.0
2.5
3.0
Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998
0 .0
0 .5
1 .0
1 .5
2 .0
2 .5
3 .0
1965 1965 -- 19981998 1965 1965 -- 19981998 1965 1965 -- 19981998 1965 - 1998 1965 1965 -- 19981998
––59%59% ––64%64% ––35%35% +163%+163% ––7%7%
CoronaryCoronaryHeartHeart
DiseaseDisease
StrokeStroke Other CVDOther CVD COPD All OtherAll OtherCausesCauses
www.goldcopd.com
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“You’ve come a long way,
baby.”
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COPD Patients
Stereotypical pictures of COPD patients
31
Blue BloaterBlue BloaterPink PufferPink Puffer
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Causes of COPD
Cigarette smoking
Alpha-1 antitrypsin deficiency
Industrial causes
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Alpha 1 Antitrypsin Deficiency
2 – 3% of patients with emphysema have AAT deficiency
40,000 – 60,000 Americans have AAT deficiency
Cigarette smoking increases the likelihood of symptomatic disease
Onset of symptoms earlier than non-AAT deficient patients(mean age at presentation = 46 years)
CXR often shows more prominent bullae in the bases
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Diagnosis of COPD
History (dyspnea, cough, wheezing)
Spirometry
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Value of Spirometry in COPD
Early, accurate diagnosis
More sensitive than peak flow or CXR
Document change in lung function over time
Having a “number” may benefit the patient
Helpful in stratifying the degree of disease
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Spirometry in COPD
Normal FEV1 > 80% of predicted value
Predicted value varies with age, height and sex
Normal FEV1% > 70%
Consider spirometry in past and present smokersover age 45, and patients with chroniccough, dyspnea or wheezing
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32
0
20
40
60
80
100
20 30 40 50 60 70 80 90
FEV1
(%)
Age (years)
Death
Disability
Symptoms Quit age 45
Age 55
Fletcher C, Peto R. Br Med J. 1977;1:1645-1648.
Smoking Cessation and Reduced Decline in FEV1
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Lung Volumes in Obstructive DiseaseLung Volumes in Obstructive Disease
VT
VT
NormalNormal COPDCOPD
RVRV
RVRV
TLCTLC
FRCFRC
ICIC
ICIC
TLCTLC
FRCFRC
Vo
lum
eV
olu
me
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Causes of Dyspnea in COPDnarrowed airways (bronchospasm, increased compliance
airway secretions, airway thickening, increased cholinergic tone)
hyperinflation
breathing athigh volumes
diaphragmflattening
DYSPNEA
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Dyspnea
Reduced activitycapacity
Deconditioning
Inactivity
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Smoking CessationSocietal Interventions
Restriction of minors’ access to tobacco products
Restriction of smoking in public places
Restriction on advertisements
Increasing prices through taxation
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Smoking CessationPhysician Interventions
Ask about tobacco use at every visit
Advise all smokers to quit
Assess smokers readiness to quit
Assist the patient in quitting
Arrange follow up visit
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Pulmonary Rehabilitation
“Pulmonary rehabilitation is a multidisciplinary servicefor patients with pulmonary disease and their families,provided by an interdisciplinary team of specialists,with the goal of achieving and maintaining theindividual’s maximum level of independence and functioningin the community.”
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Components of Pulmonary Rehabilitation
Education
Exercise
Psychosocial support
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Benefits of Pulmonary Rehabilitation
Improved activity capacity
Improved quality of life
Decrease in hospitalization
Return to work
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Short-Acting Bronchodilators: Albuterol
• Stimulates 2-receptors on airway smooth muscle
• Onset of effect: 1-3 minutes
• Duration of action: 4-6 hrs
• Reliever/rescue medication: PRN dosing 2:1 Selectivity
– Albuterol = 1,375:
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Long-Acting Bronchodilators: Salmeterol
• Stimulates 2-receptors on airway smooth muscle
• Onset of effect: 20-30 minutes
• Duration of action: 12+ hrs
• Maintenance medication: 1 inhalation b.i.d. 2:1 Selectivity
– Albuterol = 1,375:1
– Salmeterol = 85,000:1
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Formoterol
• Long-acting 2-agonist
• Dosage: 12 µg b.i.d. via dry-powder inhaler
• Onset of action: 1-3 minutes
• Duration of action: dose-dependent (12-hour duration with higher dose)
Bartow RA, Brogden RN. Drugs. 1998;55:303-322.
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Theophylline
Bronchodilation
Increase in central respiratory drive
Increased cardiac output
Increased muco-ciliary clearance
Increased fatigue threshold of the diaphragm
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Mucokinetic Agents
• Guiafenesin
• SSKI
• Mucomyst
• P & PD
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Advair now approved by the FDA for use inCOPD with chronic bronchitis
Package insert recommendation for initialand follow-up dexa scan
Package insert recommendation for periodiceye examinations
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Pre-ganglionic nervepre-synaptic
Parasympatheticganglion
Post-ganglionicnerve
ACh
Airway smooth muscle
Nicotinic transmission
M1 receptors (facilitate)
Pre-synapticM2 receptors (inhibitory)
Post-synapticM3 receptors (facilitate)
Cholinergic Cholinergic Transmission in the Airways Transmission in the Airways by by Acetylcholine Acetylcholine ((AChACh))
Neuromuscularjunction
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Tiotropium: Muscarinic Receptor Subtype Tiotropium: Muscarinic Receptor Subtype SelectivitySelectivity
Ipratropium 0.11 0.035 0.26
TiotropiumTiotropium 14.6014.60 3.6003.600 34.7034.70
Dissociation half-life (hours)M1 M2 M3
Disse B et al. Life Sci 1999;64 (6/7):457-464
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Van Noord JA. Thorax 2000;55:289–94
Tiotropium: Improvement in FEVTiotropium: Improvement in FEV11 Over 3 Over 3 Months (Months (vsvs Ipratropium)Ipratropium)
FE
V1
(L)
1.1
1.2
1.3
1.4
1.5
Time (minutes)
-60 -5 30 60 120 180
Day 1 Day 8 Day 92
240 300 360
Tiotropium (n=182)
Ipratropium (n=93)
p<0.05 on all test days peak and trough
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Medical Letter, May 24, 2004tiotropium
Improved lung function
Decrease symptoms of COPD
Increases quality of life
Decreases number of exacerbations
“an important advance in the treatment of COPD”
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GOLD Stages of COPD
NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated 2003).
Old 0: At Risk I: Mild II: ModerateIIA IIB
III: Severe
New 0: At Risk I. Mild II. Moderate III. Severe IV. Very severe
Characteristics •Chronic symptoms•Exposures to risk factors•Normal spirometry
•FEV1/FVC<70%
•FEV1>80%•With or without symptoms
•FEV1/FVC<70%
•50%>FEV1<80%•With or without symptoms
•FEV1/FVC<70%
•30%>FEV1<50%•With or without symptoms
•FEV1/FVC<70%
•FEV1<30% or presence of chronic respiratory failure or right heart failure
Avoidance of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting bronchodilatorsAdd rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long-term oxygen if chronic respiratory failureConsider surgical treatments
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LA Bronchodilators in COPD
CHEST 2004; 125:249-259
Drugs lung symptoms exercise decrease function tolerance exacerbations
Salmeterol ++ + - +/-
Formoterol ++ + - +
Tiotropium +++ ++ ? ++
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0
tiotropium+
SABA
add inhaled corticosteroid
salmeterol orformoterol +tiotropium
IV
III
II
I prn short-acting bronchodilator
tiotropium +salmeterol orformoterol
salmeterol orformoterol +
SABA
GOLD Stage
CHEST 2004; 125:249-259
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Choice of Long-Acting Bronchodilator in COPD
Efficacy
Compliance
Safety
Cost
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Alpha 1 Antitrypsin DeficiencyTreatment
NIH National Registry showed improved survival and decreasedrate of decline in patients receiving augmentation therapy
AAT levels increased
Trough levels maintained above minimal threshhold
Weekly infusions of 60 mg/kg
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Indications for O2 Therapy
PaO2 55 mmHg or less
PaO2 56 – 59 mmHg with complication, such as erythrocytosis or cor pulmonale
SaO2 88% or less
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Noninvasive Ventilation
Stable outpatient management
Acute exacerbation treated in hospitalincreases pHreduces PaCO2reduces breathlessness 1st 4 hours of Rxdecreases length of hospital stayreduces intubation rate
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Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
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Volume Reduction Surgery
A procedure in which 20-30% of the most diseasedportions of the lung are removed
Reduces lung hyperinflation
Dilates bronchi by increased traction forces
Places diaphragm at better mechanical advantage
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Volume Reduction SurgeryOutcomes
Improved dyspnea index scores
Improved elastic recoil of the lung
Decreased residual volume and FRC
Decreased PaCO2
Improved FEV1
Improved 6-minute walk distance
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Lung Transplantation
Over 1500 lung transplants/year in the United States
4000 candidates awaiting transplant in the US late 2003
Provides significant improvement in both health-relatedand overall quality of life
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Lung transplantationInclusion Criteria
Life expectancy less than 3 years
Failure of medical therapy
Age less than 60 years
No extrapulmonary organ failures
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Lung TransplantationExclusion Criteria
Coronary artery disease
Continuing substance abuse
Inadequate psychosocial support
Extreme cachexia or obesity
Recent malignancy (<3 years)
Long term, high dose corticosteroid use
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Useful Informational Web Sitesfor COPD
www.goldcopd.com
www.ats/copd.com
www.nlhep.org