COPD

COPD

1. COPD By: Dr. Shima Ghavimi PGY-1

2. Overview What is COPD? How common is it? How can COPD be prevented ? How is COPD treated?

3. 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

4. 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

5. Primary Symptoms Chronic Bronchitis Chronic cough Shortness of breath Increased mucus Frequent clearing of throat Emphysema Chronic cough Shortness of breath Limited activity level

6. Risk Factors for COPD Socio-economic status © 2013 Global Initiative for Chronic Obstructive Lung Disease Genes Infections Aging Populations

7. COPD Comorbidities

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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 .

14. FEV 1 /FVC < 0.70 FEV 1 ≥ 80% predicted FEV 1 /FVC < 0.70 50% ≤ FEV 1 < 80% predicted FEV 1 /FVC < 0.70 30% ≤ FEV 1 < 50% predicted FEV 1 /FVC < 0.70 FEV 1 < 30% predicted or FEV 1 < 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: Mild II: Moderate IV: Very Severe Active reduction of risk factor(s); smoking cessation, flu vaccination Add short-acting bronchodilator (as needed) GOLD Guideline

15. Treatment option Bronchodilators – - Relaxes muscles around airways Steroids - Reduces inflammation Oxygen therapy - Helps with shortness of breath

16. 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.

17. 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 H ypkolemia .

18. 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.

19. 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

20. 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.

21. Medication for Prevention of Complications Annual flu vaccine -Reduces risk of flu and its complications Pneumonia vaccine -Reduces risk of common cause of pneumonia

22. 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

23. Managing Stable COPD Goals of Therapy -Relieve airflow obstruction -Improve exercise tolerance Reduce symptoms -Improve health status Reduced symptoms + Reduced risk = Successful disease management

24. 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