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Patrick A. Laird, DNP, APRN, ACNP-BC, NEA-BC

COPD: THE WHO, WHAT, WHEN, AND WHY OF

MANAGEMENT

DISCLOSURES

• I have no actual or potential conflict of interest in relation to this presentation.

OBJECTIVES

• Review the pathophysiology of chronic obstructive pulmonary disease (COPD).

• Describe the role of pulmonary function tests (PFTs) in the diagnosis of COPD.

• Describe the comprehensive management of patients with a moderate to severe COPD exacerbation.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• Chronic Obstructive Pulmonary Disease (COPD) is the 4th

leading cause of death worldwide.

• COPD is expected to rise to the 3rd leading cause of death by 2020.

• In 2012, 6% of all deaths were attributed to COPD.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• 384 million COPD cases estimated in 2010.• Three million deaths annually.

• Predicted 4.5 million COPD related deaths by 2030

ECONOMIC BURDEN

• COPD exacerbations account for the majority of total economic burden

• Direct costs of COPD in US -- $32 billion• Indirect costs of COPD in US -- $20.4 billion

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https://www.cdc.gov/copd/infographics/copd-costs.html

https://www.cdc.gov/copd/infographics/copd-costs.html

DEFINITION

• COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

COPD ETIOLOGY,

PATHO-BIOLOGY

© 2019 Global Initiative for Chronic Obstructive Lung Disease

FACTORS INFLUENCING DISEASE PROGRESSION

• Smoking• Airway responsiveness

• Environmental exposure

• Age and gender

• Asthma

• Genetics• Chronic bronchitis

• Infections

• Socioeconomic status

COPD PATHOLOGY AND PATHOPHYSIOLOGY

• Pathology• Chronic inflammation

• Structural changes

• Pathophysiology• Airflow limitation and air trapping

• Gas exchange abnormalities

• Mucus hypersecretion

• Pulmonary hypertension

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"Emphysema" by Pulmonary Pathology is licensed under CC BY-SA 2.0

DIAGNOSIS

• COPD should be considered:• Dyspnea

• Chronic cough or sputum production

• History of exposure to risk factors

• Spirometry is required to make the diagnosis

ASSESSMENT AND

DIAGNOSIS

SYMPTOMS OF COPD

• Chronic and progressive dyspnea• Cough

• Sputum production

• Chest tightness

• Wheezing

SPIROMETRY

© 2019 Global Initiative for Chronic Obstructive Lung Disease C opyrights app ly

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POST-BRONCHODILATOR FEV1

Classification Severity FEv1

GOLD 1 Mild FEV1 ≥ 80% predicted

GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted

GOLD 3 Severe 30% ≤ FEV1 < 50% predicted

GOLD 4 Very Severe FEV1 < 30% predicted

© 2019 Global Initiative for Chronic Obstructive Lung Disease

DIFFERENTIAL DIAGNOSIS OF COPD

• Asthma

• Heart Failure

• Bronchiectasis

• Tuberculosis

• Obliterative Bronchiolitis• Diffuse Panbronchiolitis

"Anatomy (part 1)" by Alex Konahin is licensed under CC BY-NC-ND 4.0

RISK ASSESSMENT

• COPD Assessment Test (CATTM)• Chronic Respiratory Questionnaire (CCQ® )

• St George’s Respiratory Questionnaire (SGRQ)

• Chronic Respiratory Questionnaire (CRQ)

• Modified Medical Research Council (mMRC) questionnaire

COPD EXACERBATION

• Defined as an acute worsening of respiratory symptoms resulting in additional therapy

• Precipitated by several factors—respiratory tract infections most common

• Goal of therapy is to minimize impact of current exacerbation and prevent subsequent episodes

COPD EXACERBATION

• Classified as:• Mild (SABDs only)

• Moderate (SABDs plus antibiotics and/or oral corticosteroids)

• Severe (requires hospitalization or ED visits)

INDICATIONS FOR HOSPITALIZATION

• Severe symptoms• Acute respiratory failure

• New physical signs (cyanosis, peripheral edema)

• Failure to respond to initial management• Serious comorbidities (heart

failure, new arrhythmias)• Inadequate home support

"11831" by Proctor Archives is licensed under CC BY-NC-SA 2.0

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INDICATIONS FOR ICU ADMISSION

• Severe dyspnea not responsive to initial therapy• Changes in mental status

• Persistent or worsening hypoxemia (PaO2 < 40 mmHg)

• Severe or worsening respiratory acidosis (pH < 7.25)

• Need for invasive mechanical ventilation• Hemodynamically instability

MANAGEMENT OF NON-LIFE THREATENING EXACERBATIONS

• Severity of symptoms• Blood gases

• Chest x-ray

• Supplemental oxygen

• Bronchodilators• Consider oral steroids

MANAGEMENT OF NON-LIFE THREATENING EXACERBATIONS

• Consider antibiotics• Non-invasive ventilation if needed

• In ALL patients:

• Assess fluid balance

• VTE prophylaxis

• Manage associated conditions

IN D IC AT IO N S F O R N O N IN VA S IV E M E C H A N IC A L

V EN T ILAT IO N

• For patients with one of the following:• Respiratory acidosis (PaCO2 ≥

45 mmHg and arterial pH ≤ 7.35

• Severe dyspnea with respiratory muscle fatigue

• Increased work of breathing

• Persistent hypoxemia despite the use of supplemental O2

IN D IC AT IO N S F O R IN VA S IV EM E C H A N IC A L V E N T ILAT IO N

• Inability to tolerate NIV• Failure of NIV

• Respiratory or cardiac arrest

• Decreased level of consciousness

• Agitation

• Persistent vomiting or aspiration

• Severe hemodynamic instability

• Severe supraventricular or ventricular arrhythmias

• Life-threatening hypoxia

PHARMACOLOGIC TREATMENT

• Three classes of medications commonly used in exacerbations

• Bronchodilators

• Corticosteroids

• Antibiotics

"Assorted Medications" by NIAID is licensed under CC BY 2.0

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OUTPATIENT MANAGEMENT

• Need for antibiotics• Assess symptoms

• Determine severity of exacerbation

• Risk factors for resistant pathogens (penicillin-resistant Streptococcus pneumoniae, beta-latamase-resistant Haemophilusinfluenzae

OUTPATIENT MANAGEMENT

• Uncomplicated COPD exacerbation• Treat with:• Macrolide OR

• Second- or third-gerneration cephalosporin OR

• Doxycycline OR

• Trimethoprim-sulfamethoxazole

OUTPATIENT MANAGEMENT

• No increased risk for Pseudomonas:• Amoxicillin-clavulanate OR

• Fluroquinolone

• Increased risk for Pseudomonas:

• Obtain sputum culture and gram stain

• Ciprofloxacin

INPATIENT MANAGEMENT

• No increased risk for Pseudomonas:• Levofloxacin OR

• Moxifloxacin OR

• Ceftriaxone OR

• Cefotaxime

• Increased risk for Pseudomonas:

• Levofloxacin OR

• Cefepime OR

• Ceftazidime OR

• Piperacillin-tazobactam

INTERVENTIONS TO REDUCE COPD EXACERBATION FREQUENCY

Intervention Class Intervention

Bronchodilators LABAsLAMAsLABA + LAMA

Corticosteroid-containing Regimens LABA + ICSLABA + LAMA + ICS

Anti-inflammatory Roflumilast

Anti-infectives VaccinesMacrolides

Mucoregulators N-acetylcysteineCarbocysteine

Others Smoking CessationPulmonary RehabLung Volume Reduction

1 – 4 WEEK FOLLOW-UP

• Assess ability to cope to environment• Understanding of treatment regimen

• Inhaler techniques

• Need for long-term oxygen

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1 – 4 WEEK FOLLOW-UP

• Capacity to do physical activity (including activities of daily living)• Document symptoms (CAT or mMRC)

• Status of comorbid conditions

12 - 16 WEEK FOLLOW-UP

• Same as 1 – 4 week follow-up with addition of the following

• Measure spirometry (FEV1)

"Espirometria" by infosalut is licensed under CC BY-NC-SA

2.0

DRUG COSTS

https://www.needymeds.org/drp.taf?filename=copd.htm

CONTACT INFORMATION

• Patrick A. Laird, DNP, APRN, ACNP-BC, NEA-BC• Patrick.A.Laird@uth.tmc.edu

• 713-500-2088

REFERENCES

• Division of Population Health | CDC. (2019, June 28). Retrieved August 7, 2019, from https://www.cdc.gov/nccdphp/dph/index.html

• Eisner, M. D., Anthonisen, N., Coultas, D., Kuenzli, N., Perez-Padilla, R., Postma, D., … Committee on Nonsmoking COPD, Environmental and Occupational Health Assembly. (2010). An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 182(5), 693–718. https://doi.org/10.1164/rccm.200811-1757ST

• GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. (n.d.). Retrieved from https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf

• Hopkinson, N. S., Molyneux, A., Pink, J., Harrisingh, M. C., & Guideline Committee (GC). (2019). Chronic obstructive pulmonary disease: Diagnosis and management: summary of updated NICE guidance. BMJ (Clinical Research Ed.), 366, l4486. https://doi.org/10.1136/bmj.l4486

• McCormack, M. (n.d.). Overview of pulmonary function testing in adults—UpToDate. Retrieved August 2, 2019, from https://www.uptodate.com/contents/overview-of-pulmonary-function-testing-in-adults?search=pulmonary%20function%20tests%20adult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

• Press, V. G., Au, D. H., Bourbeau, J., Dransfield, M. T., Gershon, A. S., Krishnan, J. A., … Feemster, L. C. (2019). Reducing Chronic Obstructive Pulmonary Disease Hospital Readmissions. An Official American Thoracic Society Workshop Report. Annals of the American Thoracic Society, 16(2), 161–170. https://doi.org/10.1513/AnnalsATS.201811-755WS

• Singh, D., Agusti, A., Anzueto, A., Barnes, P. J., Bourbeau, J., Celli, B. R., … Vogelmeier, C. (2019). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: The GOLD science committee report 2019. The European Respiratory Journal, 53(5). https://doi.org/10.1183/13993003.00164-2019

• Wedzicha, J. A., Calverley, P. M. A., Albert, R. K., Anzueto, A., Criner, G. J., Hurst, J. R., … Krishnan, J. A. (2017). Prevention of COPD exacerbations: A European Respiratory Society/American Thoracic Society guideline. The European Respiratory Journal, 50(3). https://doi.org/10.1183/13993003.02265-2016