COPDBy: Dr. Shima Ghavimi

PGY-1

Overview

What is COPD?

How common is it?

How can COPD be prevented ?

How is COPD treated?

What is COPD ? A set of lung diseases that limit air flow

and is not fully reversible. COPD patients report they are “in so

need” for air Usually progressive and is associated with

inflammation of the lungs Potentially preventable with proper

precautions and avoidance of precipitating factors

Symptomatic treatment is available

2 Major Causes of COPD Chronic Bronchitis is characterized by

Chronic inflammation and excess mucus production

Presence of chronic productive cough

Emphysema is characterized by Damage to the small, sac-like units of the

lung that deliver oxygen into the lung and remove the carbon dioxide

Chronic cough*Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2014

Primary Symptoms

Chronic Bronchitis Chronic cough Shortness of breath Increased mucus Frequent clearing of throat

Emphysema Chronic cough Shortness of breath Limited activity level

Risk Factors for COPD

Socio-economic status

© 2013 Global Initiative for Chronic Obstructive Lung Disease

Genes

Infections

Aging Populations

COPD Comorbidities

How common is COPD ?

12.7 million U.S. adults (aged 18 and over) were estimated to have COPD.*

24 million other adults have evidence of troubled breathing, indicating COPD is under diagnosed by up to 60%*

*COPD Fact Sheet. Aug, 2014. www/lungusa.org

COPD-A Major Cause of Hospitalization & Death

COPD is the:

Fourth leading cause of death

Leading cause of hospitalizations in the U.S. in 2013

How Can COPD be Prevented ?

Stop Smoking- Smokers are 90% more likely to

develop COPD

Avoid or protect yourself from exposures to- Second-hand smoke - Also avoid substances such as chemical vapors, fumes, dusts, and exhaust fumes that irritate our lungs

Opportunities for Improvement

Currently, care outcomes less than optimal

Unplanned re-admissions are costly-30 day re-admits largely preventable

COPD evidence-based care exist for both in-patient (exacerbation) and out-patient (Sx control)

- Use of evidence-based care is low

Stable phase COPD

Only 3 interventions have been demonstrated to influence the natural history of patients with COPD:

Smoking cessations O2 therapy in chronically hypoxemic

patients Lung volume reduction surgery in

selected patients with emphysema

There is currently suggestive, but not definitive, evidence that the use of inhaled glucocorticoids may alter the mortality rate (but not lung function).

All the other current therapies are directed at improving symptoms and decreasing the frequency and severity of exacerabations.

• FEV1/FVC < 0.70• FEV1 ≥ 80% predicted

• FEV1/FVC < 0.70• 50% ≤ FEV1 < 80%

predicted

• FEV1/FVC < 0.70• 30% ≤ FEV1 < 50%

predicted

• FEV1/FVC < 0.70• FEV1 < 30% predicted

or FEV1 < 50% predicted plus respiratory failure or signs of right heart failure

Add regular treatment with long-acting bronchodilators; Begin Pulmonary Rehabilitation

Add inhaled glucocorticosteroids if repeated acute exacerbations

Add LTOT for chronic hypoxemia.Consider surgical options

III: Severe

I: MildII: Moderate

IV: Very Severe

Active reduction of risk factor(s); smoking cessation, flu vaccinationAdd short-acting bronchodilator (as needed)

GOLD Guideline

Treatment option

Bronchodilators – - Relaxes muscles around airways

Steroids - Reduces inflammation

Oxygen therapy - Helps with shortness of breath

Treatments Cont.

Most commonly prescribed short acting Bronchodilators are:

- Anti-Cholenergic: Ipratropium bromide- Beta-2 agonist: Albuterol,

Metaproterenol- 2-4 puffs every 6 hours

- Ipratropium Bromide is preferred as the first line agent: b/c of it’s longer duration of action and absence of sympathomimetic SE.

Treatments Cont.

Short acting Beta-2 agonist – are less expensive and more rapid action of onset. and at maximal doses they have bronchodilator action equivalent to ipratropium.

- But they may cause Tachacardia, Tremors and Hypkolemia.

Treatment cont,

Oral glucocorticoid-chronic use of oral glucocorticoid is not recommended

Theophylline: produces modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial O2 and CO2

N/V is a common S/E. But tachycardia and tremor have been reported.

Other agents: N—acetyl cysteine has been used in

patients with COPD for both its mucolytic and antioxidant properties. But prospective trial failed to find any benefit with respect to decline in lung function or prevention of exacerbations.

a1AT for individual with severe deficiency

(a1AT less than 50mg/dl), but not recommended for patients with severe

1AT but normal pulmonary function and a normal chest CT scan. And if the patient is eligible to get this treatment prior to that they need to be vaccinated for Hep B.

Medication for Prevention of Complications

Annual flu vaccine -Reduces risk of flu and its complications

Pneumonia vaccine-Reduces risk of common cause of pneumonia

Under Treatment of COPD COPD - an expensive, chronic condition- Incidence is increasing- Financial liability is escalating

Diagnostic spirometry is woefully under-used

Use of evidence-based treatment guidelines is low

Failure to control symptoms a precursor to exacerbations

COPD hospital re-admissions are largely preventable

Chronic disease management strategies a necessity

Managing Stable COPD Goals of Therapy

-Relieve airflow obstruction

-Improve exercise tolerance Reduce symptoms

-Improve health status

Reduced symptoms + Reduced risk = Successful disease management

Resources & References American Lung Association. Chronic obstructive pulmonary disease (COPD) Fact Sheet, 2014 www.lungusa.org

National Heart, Lung, and Blood Institute, NIH. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease Executive Summary, Updated 2014

National Heart, Lung, and Blood Institute, NIH. COPD-Key points and How is COPD treated? August, 2014 http://www.nhlbi.nih.gov/health