COPD and GOLD guidelines and management.pptx

COPD and GOLD guidelines and management.pptx

1. DIAGNOSIS AND MANAGEMENT OF COPD Dr. Nemani Sai Manasa 1st year PG

2. ROLE OF SPIROMETRY IN COPD DIAGNOSIS ASSESMENT OF SEVERITY OF AIRFLOW OBSTRUCTION (FOR PROGNOSIS) FOLLOW UP ASSESSEMENT THERAPEUTIC DECISIONS IDENTIFICATION OF RAPID DECLINE

3. INVESTIGATIONS SPIROMETRY THE EXPIRATORY VOLUME/ TIME TRACES SHOULD BE SMOOTH AND FREE FROM IRREGULARITIES THE PAUSE BETWEEN INSPIRATION AND EXPIRATION SHOULD BE LESS THAN ONE SECOND BOTH FVC AND FEV1 SHOULD BE THE LARGEST VALUE OBTAINED FROM ANY OF THREE TECHNICALLY SATISFACTORY CURVES AND SHOULD VARY BY NO MORE THAN 5% OR 150ML, WHICHEVER IS GREATER THE FEV1/FVC RATIO SHOULD BE TAKEN FROM THE TECHNICALLY ACCEPTABLE CURVE WITH THE LARGEST SUM OF FVC AND FEV1

4. BRONCHODILATION: POSSIBLE DOSAGE PROTOCOLS ARE 400MCG SHORT ACTING BETA AGONISTS, 160MCG SHORT ACTING ANTICHOLINERGIC, OR THE TWO COMBINED, FEV1 SHOULD BE MEASURED 10-15 MINUTES AFTER A SHORT ACTING BETA AGONIST IS GIVEN, OR 30-45 MINUTES AFTER SHORT ACTING ANTI CHOLINERGIC OR COMBINATION OF BOTH CLASSES OF DRUGS. SPIROMETRY MEASUREMENTS ARE EVALUATED BY CAMPARISON OF THE RESULTS WITH APPROPRIATE REFERENCE VALUES BASED ON AGE, HEIGHT AND SEX THE PRESENCE OF POST BRONCHODILATOR FEV1/FVC <0.7 CONFIRMS THE PRESENCE OF NON FULLY REVERSIBLE AIRFLOW OBSTRUCTION

5. INITIAL ASSESSMENT SEVERITY OF AIRFLOW OBSTRUCTION NATURE AND MAGNITUDE OF CURRENT SYMPTOMS PREVIOUS HISTORY OF MODERATE AND SEVERE EXACERBATIONS BLOOD EOSINOPHIL COUNT PRESENCE AND TYPE OF OTHER DISEASES (MULTIMORBIDITY)

6. GOLD GRADES

7. MODIFIED MRC DYSPNEA SCALE

8. CAT ASSESSEMENT CAT ASSESSEMENT QUESTIONNAIRE - WILL BE FILLED BY COPD PATIENTS SCORE RANGES FROM 0 TO 40 SCORE > 25 SEEN IN DIAGNOSED COPD PATIENTS

9. ADDITIONAL INVESTIGATIONS LUNG VOLUMES 1 COPD patients exhibit gas trapping - a rise in residual volume from early stages of the disease. 2 as airflow obstruction worsens, (static hyperinflation) - an increase in total lung capacity occurs, particularly during exercise (dynamic hyperinflation) these measurements help characterise the severity of COPD but are not essential to patient management DLCO (CARBON MONOXIDE DIFFUSING CAPACITY OF THE LUNGS) The single breath DLCO measurement evaluates the gas transfer properties of the respiratory system. it should be measured in any person with symptoms disproportionate to the degree of airflow obstruction since reduced dlco values < 60% predicted are associated with increased symptoms, decreased exercise capacity, worse health status

10. OXIMETRY AND ABG MEASUREMENT It is used to evaluate the patient’s need for supplemental oxygen therapy. ABG should be assessed in patients with o2 saturation <92%, as it provide information on pco2, and pH, which it needed to assession the need for non invasive ventilation. EXERCISE TESTING AND ASSESSMENT OF PHYSICAL ACTIVITY Tests such as 6 minute walking distance may reveal the extent of diability, risk of mortality, the need for intense rehabiliation Monitoring physical activity may be more relevant regarding prognosis. COMPOSITE SCORES: THE BODE (BODY MASS INDEX, OBSTRUCTIO, DYSPNEA AND EXERCISE) METHOD GIVES A COMPOSITE SCORE THAT IS A BETTER PREDICTOR OF SUBSEQUENT SURVIVAL THAN ANY SINGLE COMPONENT.

11. IMAGING CHEST X RAY: SIGNS OF LUNG INFLATION (FLATTENED DIAPHRAGM AND AN INCREASE IN VOLUME OF THE RETROSTRENAL AIR SPACE), HYPERLUCENCY OF THE LUNGS, AND RAPID TAPERING OF VASCULAR MARKINGS. IT IS NOT USEFUL IN ESTABLISHING THE DIAGNOSIS IN COPD, BUT IS IMPORTANT IN ESTABLISHING THE PRESENCE OF SIGNIFICANT CO MORBIDITES SUCH AS CONCOMITANT RESPIRATORY (PULMONARY FIBROSIS, BRIONCHIECTASIS, PLUERAL DISEASES), SKELETAL (KYPHOSCOLIOSIS) AND CARDIAC DISEASE (CARDIOMEGALY)

12. Chest X Ray Hyper inflation reduced bronchodilator vascular markings intercoastal spaces are mildly enlarged flattening of the diaphragm in lateral view of CXR, retrosternal space > 2.5cm, increased AP diameter - suggestive of over inflated lungs narrow mediastinum emphysematous bullae seen -sub pleural, thin walled, cyst like apperance

13. CHEST CT It is useful in quantification of the airway abnormality It is considered in patients who has symptoms out of proportion to disease severity on lung function testing, FEV1 less than 45% predicted with significant hyperinflation and gas trapping if present It is useful in emphysema patients to quantitative analysis for emphysema extent, location and fissure integrity is also being performed to assist with endobronchial valve therapy and lung volume reduction surgery (LVRS). According to recommendations in general population, Annual CT. Scan is recommended for lung cancer screening in patients with COPD due to smoking.

14. CHEST CT emphysematous bullae is seen centrilobular emphysematous bullae- typical distribution alpha 1 anti trypsin deficiency mediated emphysema has panlobular emphysema

15. ECG CHANGES IN COPD MULTI FOCAL ATRIAL TACHYCARDIA: It is characterised by the presence of atrial complexes from different foci in the atria these changes mostly occur due to enhanced automaticity. Multiple independent automatic foci are present in the atria, resulting in varying P wave configuration. presence of >= 3 consecutive P waves of different morphologies with an isoelectric baseline P wave with rate >100bpm, varying PR and RR interval

16. MANAGEMENT OF COPD PATIENTS GROUP A SHORT OR LONG ACTING BRONCHODILATOR CAN BE GIVEN GROUP B TREATMENT SHOULD BE INITATED WITH LABA+LAMA COMBINATION. THESE PATIENTS ARE MORE LIKELY TO HAVE CO MORBIDITIES THAT MAY ADD TO THEIR SYMPTOMATOLOGY GROUP E LABA+LAMA+ ICS HAS BEEN SHOWN TO BE SUPERIOR TO LABA+ICS CONSIDER LABA+LAMA+ICS IN THESE PATIENTS IF BLOOD EOSINOPHIL COUNT IS MORE THAN OR EQUAL TO 300 CELLS/MICROLITER

17. COPD EXACERBATION INITIALLY CONFIRM THE DIAGNOSIS AND QUANTIFY THE SEVERITY OF THE EPISODE. MILD: Dyspnea visual analogue scale < 5, RR<24 breaths/min, HR< 95bpm, RESTING SaO2 >= 92% breathing ambient air, CRP <10mg/L MODERATE: Dyspnea visual analogue scale >=5, RR>= 24 breaths/min, HR >=95bpm, resting SaO2 <92%, CRP > 10mg/L SEVERE: Dyspnea, RR, HR, SaO2, CRP same as moderate, ABG shows new onset/ worsening hypercapnia and acidosis (PaCO2 > 45mmhg and pg < 7.35)

18. Management of exacerbation Short acting inhaled beta agonist, with or with out short acting anti cholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalisation duration. Duration of therapy should not normally be more than 5 days antibiotics, can shorten the recovery time, reduce the risk of early relapse, treatment, failure, and hospitalisation duration. Duration of antibiotic course should normally be 5 days. It is indicated in patients having increase in DYSPNEA, sputum purulence and sputum volume. The choice of antibiotics is based on local bacterial resistance pattern. usually, initial empirical treatment is an amino penicillin with clavulanic acid, macrolide, tetracycline. methylxanthines are not recommended due to increased side effects non invasive mechanical ventilation should be the first mode of ventilation used in Copd patients with acute respiratory failure, it improves gas exchange and reduce work of breathing.

19. Non pharmacological therapy Smoking cessation Pulmonary rehabilitation Long term oxygen therapy Nutritional support SURGICAL INTERVENTIONS FOR COPD Bullectomy Lung coils Lung volume reduction surgery Endobronchial valve placement

20. Endobronchial valve placement

21. COPD and Co morbidities Cardiovascular diseases: Heart failure: it may accompany acute COPD, occurring as heart failure with acute pulmonary edema It is seen in 40% of mechanically ventilated COPD patients hypercapnic respiratory failure have evidence of left ventricular dysfunction. Ischemic heart disease: 90 days after, acute COPD exacerbations there is an increased risk of cardiovascular events like death, MI, stroke, unstable angina, transient ischemic attack. arrythmias: bronchodilators (especially short acting beta blockers) are potential pro arrhythmic agents. Peripheral vascular disease: COPD patients with PAD has worse functional capacity and worse health status compared with those without PAD.

22. bronchectasis obstructive sleep apnea and insomnia periodontitis and dental hygiene osteoporosis gastro esophageal reflux disease (GERD) secondary polycythemia anemia anxiety and depression. Lung cancer.

23. Vaccination Influenza vaccination can reduce serious illness such a LRTI requiring hospitalisation and death in people with COPD. Has decreased risk of ischemic heart disease when they were vaccinated Pneumococcal conjugate vaccine (PCV 20) or (PCV 15), followed by pneumococcal polysaccharide vaccine (PPSV23) for people with COPD. It has shown to reduce the incidence of community acquired pneumonia and exacerbation for people with COPD. RSV vaccine for individuals over 60 years with chronic heart or lung disease dTaP/ dTPa vaccination to protect against pertussis( whooping cough) for people with COPD that were not vaccinated in adolescence and zoster vaccine to protect against shingles for people with COPD over 50 years

24. THANK YOU.