copd: understanding the new guidelines
TRANSCRIPT
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COPD: UNDERSTANDING THE NEW
GUIDELINES
www.copdgold.com Isabel C. Mira-Avendano, MD
Pulmonary Staff
MAYO CLINIC-FLORIDA
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Worldwide medical problem.
In 2020, projected fif th in terms of burden of disease and
third in terms of mortality.
In 1998: GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG
DISEASE (GOLD).
In 2001: GOLD program released as a consensus report.
Revised in 2006 and now….
COPD: UNDERSTANDING THE GUIDELINES
INTRODUCTION
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MAIN REVIEW:
1. TREATMENT OBJECTIVES:
Immediate relieve and reduction of impact of symptoms
(short term impact of COPD).
Reduction of adverse events in the future (long term impact of
COPD).
2. CHANGE FROM “STAGE” TO “GRADE” OF COPD, based not only
in FEV1, but, other characteristics of each patient.
3. INDIVIDUALIZED SYMPTOM ASSESSMENT.
COPD: UNDERSTANDING THE GUIDELINES
INTRODUCTION
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exarcerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
INTRODUCTION
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exarcerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
INTRODUCTION
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Common and preventable disease.
Persistent air flow limitation, usually progressive and
associated with an enhanced chronic inflammatory response
in the airways and the lung to noxious particles and gases.
Mixture of small airway disease (bronchiolitis) plus
parenchymal destruction (emphysema).
COPD: UNDERSTANDING THE GUIDELINES
DEFINITION
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Prevalence, morbidity and mortality vary across countries and
among dif ferent groups and countries.
Mainly related with smoking, but, outdoor, occupational, and
indoor air pollution.
Higher prevalence smokers, older than 40 and men .
COPD among never smokers: 3 – 11%.
COPD: UNDERSTANDING THE GUIDELINES
PREVALENCE
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Other types of tobacco.
Passive exposure to cigarette smoking.
Smoking during pregnancy.
Occupational exposures.
Genetic (Alpha-1-AT).
Lung growth and development.
Socioeconomic status.
Chest 2005; 128: 1239
AJRCCM 2010; 182: 693
Chest 2011; 139: 752
COPD: UNDERSTANDING THE GUIDELINES
OTHER FACTORS RELATED
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The prevalence and burden of COPD are projected to increase
in the coming decades due to continued exposure to COPD
risk factors and the aging of the world’s population.
COPD will be the seventh leading DISABILITY ADJUSTED LIFE
YEAR (DALY) in 2030.
Proc Amer Thoracic Soc 2009: 6: 614
COPD: UNDERSTANDING THE GUIDELINES
BURDEN
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PATHOLOGY
Compromise of airways, lung parenchyma and pulmonary vasculature.
Chronic inflammation: persists after smoking cessation.
PATHOGENESIS
Oxidative stress.
Protease-Antiprotease imbalance
PATHOPHISIOLOGY
Airflow limitation/air trapping.
Gas exchange abnormalities.
Mucus hypersecretion.
COPD: UNDERSTANDING THE GUIDELINES PATHOLOGY, PATHOGENESIS,
PATHOPHYSIOLOGY
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exarcerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
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WHO?
Dyspnea, cough, sputum production in a patient with positive
exposures.
SPIROMETRY: FEV1/FVC < 0.70.
It is not necessary evaluate the degree of reversibility.
COPD: UNDERSTANDING THE GUIDELINES
DIAGNOSIS
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SYMPTOMS
Chronic cough.
Dyspnea.
Wheezing.
Development of airflow limitation.
COPD: UNDERSTANDING THE GUIDELINES
DIAGNOSIS
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MEDICAL HISTORY
Exposure to risk factors.
Past medical history.
Family history of COPD or other respiratory diseases.
Pattern of symptoms development.
Prior hospitalizations for respiratory disorders.
Presence of comorbidities.
Impact of the disease on the patient’s life.
COPD: UNDERSTANDING THE GUIDELINES
DIAGNOSIS
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GOALS OF THE ASSESSMENT ARE TO DETERMINE:
The impact in patient’s health status.
Severity of air flow limitation.
Risk for future events.
COPD: UNDERSTANDING THE GUIDELINES
ASSESSMENT
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To achieve these goals, COPD assessment must consider:
CURRENT LEVEL OF PATIENT’S SYMPTOMS.
SEVERITY OF AIRFLOW LIMITATION.
EXACERBATION RISK.
PRESENCE OF COMORBIDITIES.
COPD: UNDERSTANDING THE GUIDELINES
ASSESSMENT
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CURRENT LEVEL OF PATIENT’S SYMPTOMS
Modified British Medical Research Council ( mMRC)
questionnaire on breathlessness.
COPD Assessment Test (CAT)
COPD: UNDERSTANDING THE GUIDELINES
ASSESSMENT
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MODIFIED BRITISH MEDICAL RESEARCH
COUNCIL QUESTIONNAIRE OF DYSPNEA
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COPD ASSESSMENT TEST (CAT)
Eur Resp J 2009; 34: 648-54
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GOLD 1
GOLD 2
GOLD 3
GOLD 4
MILD
MODERATE
SEVERE
VERY SEVERE
FEV1 > 80%
predicted.
FEV1 50 – 80 %
predicted.
FEV1 30 – 50%
predicted.
FEV1 < 30%
predicted.
SEVERITY OF AIRFLOW LIMITATION
(BASED ON POST BD FEV1)
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EXACERBATION RISK
The best predictor for it: history of previous treated events.
TWO OR MORE EXACERBATIONS PER YEAR
COPD: UNDERSTANDING THE GUIDELINES
ASSESSMENT
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PRESENCE OF COMORBIDITIES
Cardiovascular disease.
Skeletal muscle dysfunction.
Metabolic syndrome.
Depression.
Lung cancer.
COPD: UNDERSTANDING THE GUIDELINES
ASSESSMENT
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UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
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LOW RISK, LESS SYMPTOMS
mMRC 0-1 or CAT < 10
GOLD 1 – 2
EXACERBATIONS < 2
UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
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UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
LOW RISK, MORE SYMPTOMS
mMRC > 2 or CAT > 10
GOLD 1 – 2
EXACERBATIONS < 2
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HIGH RISK, LESS SYMPTOMS
mMRC 0-1 or CAT < 10
GOLD 3 - 4
EXACERBATIONS > 2
UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
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HIGH RISK, MORE SYMPTOMS
mMRC > 2 or CAT > 10
GOLD 3 - 4
EXACERBATIONS > 2
UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
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ADDITIONAL INVESTIGATION
CXR / CHEST CT
LUNG VOLUMES / DLCO
PULSE OXIMETRY – ABG
EXERCISE OXIMETRY
ALPHA 1 AT LEVEL
UNDERSTANDING THE GUIDELINES
COMBINED COPD ASSESSMENT
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exacerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
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SMOKING CESSATION
Counseling (Evidence A).
Nicotine replacement.
Pharmacologic options.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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GOALS:
Reduce symptoms.
Reduce frequency and severity of exacerbations.
Improve health status and exercise tolerance.
IMPORTANT FACTS:
None of the medications modify the long term decline in lung
function.
Education about how to use it (inhaler, nebulizer) is very
important.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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BRONCHODILATORS
Effect in airway
smooth muscle tone.
Reduce dynamic
hyperinflation and
improve exercise
performance.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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B2-AGONISTS
Relax airway smooth muscle stimulating B2 adrenergic
receptors (cAMP)
SHORT ACTING B2 AGONISTS: used as needed or by schedule
improve FEV1 and symptoms (EVIDENCE B).
LONG ACTING B2 AGONISTS (Formoterol – Salmeterol –
Indacaterol): improve FEV1, lung volumes, dyspnea and
quality of life (EVIDENCE A).
Side effects: tachycardia, tremor.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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ANTICHOLINERGICS
Blockage of acetylcholine’s effect on muscarinic receptors.
Tiotropium reduce exacerbations and hospitalizations
(EVIDENCE A).
Side effects: mouth dryness, prostatic symptoms.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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METHYLXANTHINES (THEOPHYLLINE).
No recommended if other therapies are affordable.
INHALED CORTICOSTEROIDS
Regular treatment with it improves symptoms, lung function
and quality of life and reduce frequency of exacerbations, in
patients with FEV1 <60% predicted (EVIDENCE A).
Side effects: oral candidiasis, voice change, skin bruising.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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COMBINED INHALED CORTICOSTEROIDS AND LONG ACTING
BRONCHODILATORS AND ANTICHOLINERGICS.
This combination is more effective than individual
components in improving lung function and frequency of
exacerbations in patients with moderate to severe COPD
(EVIDENCE B).
ORAL CORTICOSTEROIDS
No clear evidence of its benefit in stable COPD.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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PHOSPHODIESTERASE-4-INHIBITOR (ROFLUMILAST).
Reduce inflammation by inhibition of the breakdown on
intracellular cAMP.
Decrease exacerbations in patients with severe to very severe
COPD (EVIDENCE A).
Should be used in addition to long acting bronchodilators.
Side effects: nausea, diarrhea, sleep disturbance.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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OTHER PHARMACOLOGIC THERAPY:
Vaccination
Antibiotics: recommended only if evidence of infection.
Vasodilators in case of associated Pulmonary Hypertension.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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NO PHARMACOLOGIC THERAPY
PULMONARY REHABILITATION
Reduce symptoms and improve quality of life.
Six week-program.
O2 THERAPY
Long term administration increase survival in patients with
resting hypoxemia.
pO2 <55 mmHg or SO2 <88%
pO2 55-60 mmHg with SO2 88% if there is CHF, PH,
polycitemia.
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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LUNG VOLUME REDUCTION SURGERY (LVRS)
Improved survival in severe COPD with upper lobe emphysema
and low post rehabilitation exercise capacity.
Higher mortality than with medical management in severe
emphysema with FEV1 or DLCO < 20% predicted.
Ann Thorac Surg 2006; 82: 431-443
NEJM 2001; 345: 1075-83
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THERAPEUTIC OPTIONS
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LUNG TRANSPLANTATION
BODE INDEX 7 to 10
Resting hypercapnia
Pulmonary Hypertension
FEV1 / DLCO < 20% predicted
OTHERS
BULLECTOMY
PALLIATIVE CARE, END OF LIFE CARE, HOSPICE
COPD: UNDERSTANDING THE GUIDELINES
THERAPEUTIC OPTIONS
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exacerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
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REDUCE SYMPTOMS
Relieve symptoms
Improve exercise
tolerance
Improve health
status
REDUCE RISK
Prevent disease
progression
Prevent and treat
exacerbations
Reduce mortality
COPD: UNDERSTANDING THE GUIDELINES
GOALS OF THERAPY
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IDENTIFY AND
REDUCE EXPOSURE
TO RISK FACTORS
Smoking
Occupational
exposures
Indoor and outdoor
pollution
COPD: UNDERSTANDING THE GUIDELINES
MANAGEMENT OF STABLE COPD
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IMPORTANT FACTS:
Almost all evidence for the use of bronchodilators in COPD is
based on trials included patients GOLD 3 or 4.
FEV1 is a poor descriptor of disease status and for this reason
the treatment strategy for stable COPD should consider and
individual patient’s symptoms and risk for exacerbation.
Acute reversibil ity is not a reliable measurement and in general,
poor predictor of treatment’s benefit for FEV1 after one year.
Chest 2003: 123: 1441-9
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MANAGEMENT OF STABLE COPD
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COPD: UNDERSTANDING THE GUIDELINES
MANAGEMENT OF STABLE COPD
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1. 58 y/o woman. Productive cough. Mild SOB. FEV1 46%. Two hospitalizations in the prior year.
2. 62 y/o man. Dyspnea only with strong exercise. FEV1 52% predicted. No exacerbations.
3. 74 y/o man. Dyspnea at rest. FEV1 25% predicted. Three exacerbations.
4. 70 y/o woman. Dyspnea with minimal activity. Not at rest. FEV1 63% predicted. No history of exacerbations
C
A
D
B
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MANAGEMENT OF STABLE COPD
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PATIENT GROUP FIRST CHOICE ALTERNATIVE OTHER
A
B
C
D
SABA or SA
Anticholinergic prn
LABA or LA
Anticholinergic
ICS and LABA or LA
anticholinergic
ICS and LABA or LA
anticholinergic
LABA or LA
Anticholinergic or
combination of both.
Combination of
LABA and LA
anticholinergic
LA anticholinergic
and LABA
ICS, LABA, and LA
anticholinergic or
ICS, LABA and PDH-
4 inhibitor or LA
anticholinergic and
PDH-4 inhibitor.
Theophylline
SABA and/or SA
anticholinergic
and/or Theophylline.
PDH-4 inhibitor
and/or SABA and/or
SA anticholinergic
and/or Theophylline.
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NONPHARMACOLOGIC TREATMENT
COPD: UNDERSTANDING THE GUIDELINES
MANAGEMENT OF STABLE COPD
PATIENT
GROUP
ESSENTIAL RECOMMENDED OTHERS
A
B-D
Smoking cessation
Smoking cessation
Pulmonary
Rehabilitation
Physical Activity
Physical Activity
Vaccination
Vaccination
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Routine follow up is essential in COPD.
Evaluate:
SYMPTOMS. CAT questionnaire every 2 -3 months.
SMOKING STATUS.
LUNG FUNCTION: Spirometry every year.
PHARMACOTHERAPY AND OTHER MEDICAL THERAPY.
EXACERBATION HISTORY.
COMORBIDITIES.
COPD: UNDERSTANDING THE GUIDELINES
MONITORING AND FOLLOW UP
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exarcerbations.
SECTION SIX: Comorbidities and COPD.
COPD: UNDERSTANDING THE GUIDELINES
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Acute event characterized by a worsening of the patient’s
respiratory symptoms, which leads to a change in medication.
Negatively affect quality of life.
Accelerate the rate of decline of lung function.
Associated with increased mortality.
COPD: UNDERSTANDING THE GUIDELINES
MANAGEMENT OF EXACERBATIONS
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Main reason, viral infections.
In up to one third of cases, etiology can not be identified.
It is very important rule out other pathologies which can
mimic or aggravate the exacerbation (heart failure, PE,
Pneumonia).
Diagnosis is based on clinical symptoms: worsening dyspnea,
cough, sputum production.
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MANAGEMENT OF EXACERBATIONS
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ASSESSMENT
Pulse Oximetry.
Chest Radiographs.
ECG.
CBC.
Sputum sample.
General Blood tests.
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MANAGEMENT OF EXACERBATIONS
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TREATMENT OPTIONS
GOALS:
Minimize the impact of the current exacerbation and prevent
the development of subsequent exacerbations.
Eighty percent of the cases are treated in the outpatient
setting.
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MANAGEMENT OF EXACERBATIONS
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POTENTIAL INDICATIONS FOR HOSPITAL ASSESSEMET OR
ADMISSION
Marked increase in intensity of symptoms.
Severe underlying COPD.
Onset of new physical signs (cyanosis, peripheral edema).
Failure to respond to initial therapy.
Presence of serious comorbidities.
Frequent exacerbations.
Older age.
Insufficient home support.
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MANAGEMENT OF EXACERBATIONS
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PHARMACOLOGIC TREATMENT
SHORT ACTING BRONCHODILATORS / ANTICHOLINERGICS.
CORTICOSTEROIDS
Shorten recovery and improve arterial hypoxemia. EVIDENCE A.
Prednisone 40 mgm daily for five days. EVIDENCE B.
Lancet 1999; 354: 456-460
AJRCCM 1996; 154: 407-412
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MANAGEMENT OF EXACERBATIONS
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ANTIBIOTICS
Indicated if increased dyspnea, sputum production and
purulence. EVIDENCE B.
If two of three of above symptoms are present. EVIDENCE C .
In case of need for Mechanical ventilation. EVIDENCE B .
Cochrane Databas Systemic Review 2006: CD004403
Chest 2008; 133: 756-766
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MANAGEMENT OF EXACERBATIONS
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OTHERS
O2 THERAPY
VENTILATORY SUPPORT
INDICATIONS FOR ICU ADMISSION:
Severe dyspnea, which does not improve with initial therapy.
Mental status changes.
Worsening hypoxemia and/or acidosis (ph<7.25), despite
NIMV.
Hemodynamic instability.
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MANAGEMENT OF EXACERBATIONS
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INDICATIONS FOR NO INVASIVE MV SUPPORT
Respiratory Acidosis.
Severe dyspnea with signs of respiratory muscle fatigue,
increase work of breathing or both.
INDICATIONS FOR INVASIVE MV SUPPORT
No tolerance to NIMV.
Respiratory or cardiac arrest.
Massive aspiration.
Inability to remove secretions.
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MANAGEMENT OF EXACERBATIONS
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HOSPITAL DISCHARGE AND FOLLOW UP
Able to use Long Acting Bronchodilators.
Need for Short acting Bronchodilators no more frequently
than every 4 hours.
Able to sleep and eat without interruption because of
dyspnea.
Able to walk across the room.
Patient stable during the prior 12 – 24 hours.
Stable ABG in the prior 12 – 24 hours.
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MANAGEMENT OF EXACERBATIONS
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PREVENTION OF COPD EXARCERBATIONS
Smoking cessation.
Vaccination.
Use of Long acting Bronchodilators with or without inhaled
corticosteroids.
Phosphodiesterase 4 inhibitors.
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MANAGEMENT OF EXACERBATIONS
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SUMMARY OF NEW RECOMMENDATIONS
SECTION ONE: Definition and overview of COPD.
SECTION TWO: Diagnosis and Assessment of COPD.
SECTION THREE: Therapeutic options in COPD.
SECTION FOUR: Management of Stable COPD.
SECTION FIVE: Management of Exarcerbations.
SECTION SIX: Comorbidities and COPD.
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Comorbidities may have a significant impact on prognosis.
Differential diagnosis may be dif ficult.
More common: cardiovascular disease.
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COMORBIDITIES AND COPD
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CARDIOVASCULAR DISEASES
Ischemic heart disease
Its prevalence is increased among COPD patients.
Treatment should be based in current guidelines.
Selective B1-blockers.
Heart Failure
Thirty percent of patients with COPD have heart failure.
FEV1 is strong predictor of mortality in heart failure.
Treatment according with heart failure guidelines.
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COMORBIDITIES AND COPD
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CARDIOVASCULAR DISEASES
ATRIAL FIBRILLATION
Following current guidelines.
Selective B-1 blockers.
HYPERTENSION
The more common comorbidity associated with COPD.
Regular treatment should be offered.
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COMORBIDITIES AND COPD
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OTHERS
OSTEOPOROSIS
LUNG CANCER
ANXIETY AND DEPRESSION
COPD: UNDERSTANDING THE GUIDELINES
COMORBIDITIES AND COPD
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COPD is a common and preventable disease.
It is an important cause of morbidity and mortality worldwide.
Diagnosis is based on CLINICAL SYMPTOMS plus evidence of
obstruction in Spirometry (FEV1/FVC < 0.70).
NEW CLASSIFICATION IS BASED ON PATIENT’S
CHARACTERISTICAS: FOUR DIFFERENTS GRADES.
Treatment is adapted to the grade of COPD (PERSONALIZED
EACH CASE).
It is necessary to have a good follow up
Comorbidities must be recognized and treated.
COPD: UNDERSTANDING THE GUIDELINES
CONCLUSIONS
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COPD: UNDERSTANDING THE GUIDELINES
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