Copd Management

copd management.. chronic obstructive pulmonary disease

1. COPD: Management Pratap Sagar Tiwari , MD, Internal medicine

2. Making a diagnosis A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production and a history of exposure to risk factors of the disease. Spirometry is required to make the diagnosis in this clinical context; the presence of a post bronchodilator FEV1/FVC <0.70 confirms the presence of persistent airflow limitation and thus of COPD . FEV 1 :the volume of air forcefully expired during the 1st sec after taking a full breath Forced vital capacity ( FVC):the total volume of air expired with maximal force

3. Treatment line begins after assessment of severity of the condition Postbronchodilator FEV1/FVC <0.7 defines Airflow limitation Low risk High Risk 3 yr mortality =24%

4. Mmrc : Assess severity of breathlessness 0-1 = less breathlessness >2= more breathlessness

5. BODE INDEX Variable 1 2 3 FEV 1 O ≥ 65 50-64 36-49 ≤ 35 D ist walked in 6 min (m ) E ≥ 350 250-349 150-249 ≤ 149 MRC D yspnoea scale* 0-1 2 3 4 B ody mass index > 21 ≤ 21 BODE score 0-2 =mortality rate of around 10 % at 52 mnths , BODE score 7-10=mortality rate of around 80% at 52 mnths .

6. Management of COPD Chronic stable phase COPD COPD on Acute exacerbation

7. Chronic Stable phase COPD Only three interventions— smoking cessation, oxygen therapy in chronically hypoxemic patients, and lung volume reduction surgery in selected patients with emphysema—have been demonstrated to influence the natural history of patients with COPD. All other current therapies are directed at improving symptoms and decreasing the frequency and severity of exacerbations.

8. Pharmacotherapy Smoking cessation Bronchodilators

9. Smoking Cessation There are 4 principal pharmacologic approaches to the problem: Bupropion . Nicotine replacement therapy available as gum, transdermal patch, inhaler, and nasal spray; and Varenicline , a nicotinic acid receptor agonist/antagonist. Nortriptyline

10. Bronchodilators Anticholinergics B2 Agonists Inhaled bronchodilators   are the mainstay of COPD management Note: However no evidence that regular bronchodilator use slows deterioration of lung function. Anticholinergics have a greater bronchodilating effect than b2 agonists.

11. B Agonists Side effects: tremor and tachycardia SABA Inhaler /mdi For nebuliser DOA ( hr ) Salbutamol 100,200 mcg 5 mg/ml 4-6 Levalbuterol Albuterol Pirbuterol Terbutaline LABA Inhaler (mcg) Oral DOA ( hr ) Salmeterol 25-50 12 Formeterol Bambuterol Indacarterol 10-20 mg od

12. Anticholinergics Side effects: urinary retention, and dry mouth, tremor and tachycardia SAA Inhaler For nebuliser mg/ml DOA (HR) Ipratropium 20,40 MDI 0.25-0.5 6-8 Oxitropium 100 MDI 1.5 7-9 LAA Inhaler (mcg) Oral DOA ( hr ) Tiotropium 18 DPI 24

13. Steroids in Stable Copd Inhaled Glucocorticoids Oral Glucocorticoids In COPD, inhaled GCs are used as part of a combined regimen , but should NOT be used as sole therapy for COPD ( ie , without long-acting BDs ). Regular Rx improves symptoms, lung function and quality of life and reduce frequency of exacerbations in COPD with FEV1 <60% but however doesnot modify long term decline of FEV1 nor mortality .

14. Inhaled Glucocorticoids Their use has been A/W ↑ rates of oropharyngeal candidiasis & an ↑ rate of loss of bone density . A trial of inhaled GC should be considered in patients with frequent exacerbations, defined as ≥2/ yr , and in pts who demonstrate a significant amount of acute reversibility in response to inhaled BD.

15. Oral Glucocorticoids The chronic use of oral GCs for Rx of COPD is not recommended because of an unfavorable benefit/risk ratio. The chronic use of oral GCs is a/W significant side effects, including osteoporosis, weight gain, cataracts, glucose intolerance, & ↑ risk of infection .

16. Theophylline( methylxanthine ) Theophylline produces modest improvements in expiratory flow rates and vital capacity and a slight improvement in arterial o2 and Co2 levels in patients with moderate to severe COPD. Nausea is a common SE; tachycardia and tremor have also been reported. MX are less effective and less well tolerated than long acting inhaled bronchodilators and is not recommended if others r available & affordable. Addition of low dose slow release theophylline may be given along with long acting BDs.

17. Phosphodiesterase 4 inhibitors Once a day dosage :No direct bronchodilator activity but has shown to improve FEV1 in pts treated with salmeterol or tiotropium . Roflumilast ↓ moderate to severe exacerbations treated with CSs by 15-20 % in pts with ch bronchitis, severe and very severe COPD and a Hx of A/E . S/e: nausea, pain abodmen , diarrhea insomnia Note: Roflumilast & Theophylline shouldnot be given together.

18. Vaccination All Patients with COPD should receive the influenza vaccine annually. Polyvalent pneumococcal vaccine is also recommended, (in pt ≥65 yrs old or <65 + Fev1 <40 %)

19. Others Not recommended in stable copd by ATS, BTS, ETS,GOLD Mucokinetics and antioxidants (n- acetylcysteine ) Antitussive vasodilators like nitric oxide Drugs to treat pulmonary hypertension (ETA) Nedochromil (mast cell stabilizer) Monteleukast (leukotriene modifier) Antibiotics

20. Others Specific treatment in the form of IV a 1 AT augmentation therapy is available for individuals with severe a 1 AT deficiency. Eligibility for a 1 AT augmentation therapy requires a serum a 1 AT level <11 u M (approximately 50 mg/ dL ).

21. Oxygen (>15 hrs /day) Supplemental O 2 is the only pharmacologic therapy demonstrated to unequivocally decrease mortality rates in patients with COPD. PaO2 ≤ 7.3 kPa (55 mmhg ) or SaO2 <88 %, with or without hypercapnia confirmed twice over a 3 week period. PaO2 :7.3 - 8.0 kPa (55-60 mmhg ) or SaO2 of 88%, if there is evidence of pulmonary HTN, peripheral edema s/o CCF, or polycythemia (HCT>55%).

22. Lung Volume Reduction Surgery (LVRS ) Surgery to reduce the volume of lung in patients with emphysema was first introduced with minimal success in the 1950s and was reintroduced in the 1990s. Patients are excluded if they have significant pleural disease, a pulmonary artery systolic pressure >45 mmHg , extreme deconditioning, congestive heart failure , or other severe comorbid conditions. Patients with an FEV 1 <20% of predicted and either diffusely distributed emphysema on CT scan have an increased mortality rate after the procedure and thus are not candidates for LVRS. Patients with upper lobe–predominant emphysema and a low postrehabilitation exercise capacity are most likely to benefit from LVRS.

23. Lung Transplantation COPD is currently the second leading indication for lung transplantation. Current recommendations are that candidates for lung transplantation should be <65 years ; have severe disability despite maximal medical therapy ; and be free of comorbid conditions such as liver, renal, or cardiac disease.

24. Final: Steps in management Clinical diagnosis Spirometry Gold severity stage Drugs a/t stages

25. Stage Management All - Avoidance of risk factor(s) - Influenza vaccination - Pneumococcal vaccination Stage 1 Short-acting bronchodilator when needed Stage 2 Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Stage 3 Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations Stage 4 Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations Treatment of complications Long-term oxygen therapy if chronic respiratory failure Consider surgical treatments

26. References Global strategy for the diagnosis, management, and prevention of copd . Updated 2014 Harrison's Principles of Internal medicine .18th edition Davidson's Principles and practice of Medicine .21st edition. Uptodate version 20.3 Mercksmannual

27. COPD on AE The goal of treatment in COPD AE is minimize the impact of current exacerbation and to prevent the development of subsequent exacerbations. Signs of Severity

28. Exacerbation of COPD The Global Initiative for COPD(GOLD ), a report produced by the National Heart, Lung, and Blood Institute (NHLBI) and the WHO, defines an exacerbation of COPD as an acute increase in symptoms beyond normal day-to-day variation. This generally includes an acute increase in one or more of the following cardinal symptoms: Cough increases in frequency and severity Sputum production increases in volume and/or changes character Dyspnea increases

29. Common bacteria are ; Haemophilus influenzae Moraxella catarrhalis Streptococcus pneumoniae Pseudomonas aeruginosa Enterobacteriaceae Haemophilus parainfluenzae Staphylococcus aureus (Note: Despite the frequent implication of bacterial infection, chronic suppressive or "rotating" antibiotics are not beneficial in patients with COPD and is not recommended.) Most common cause is viral upper RTI

30. Criteria for hospitalization American Thoracic Society/European Respiratory Society (ATS/ERS) Inadequate response of symptoms to outpatient management Marked increase in dyspnea Inability to eat or sleep due to symptoms Worsening hypoxemia Worsening hypercapnia Changes in mental status Inability to care for oneself ( ie , lack of home support) Uncertain diagnosis High risk comorbidities including pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure In addition, there is general consensus that acute respiratory acidosis justifies hospitalization.

31. Bronchodilators Typically , patients are treated with an inhaled b-agonist, often with the addition of an anticholinergic agent . Patients are often treated initially with nebulized therapy , as such treatment is often easier to administer in older patients or to those in respiratory distress.

32. Antibiotics Inexpensive common oral antibiotics usually adequate .Broader spectrum if not responsive. Glucocorticoids Among patients admitted to the hospital, the use of glucocorticoids has been demonstrated to reduce the length of stay, hasten recovery, and reduce the chance of subsequent exacerbation or relapse for a period of up to 6 months. The GOLD guidelines recommend 30–40 mg of oral prednisolone or its equivalent for a period of 10–14 days.

33. Oxygen Target Pao2: 60-70 mmhg Nasal cannulae can provide flow rates up to 6 L /min with an associated FiO2 of approximately 40 % . Simple facemasks can provide an FiO2 up to 55 % using flow rates of 6 to 10 L per minute. Venturi masks can deliver an FiO2 of 24, 28, 31, 35, 40, or 60 percent. Non-rebreathing masks with a reservoir, one-way valves, and a tight face seal can deliver an inspired oxygen concentration up to 90 %.

34. Mechanical Ventilatory Support

35. Contraindications to NIPPV cardiovascular instability, impaired mental status or inability to cooperate, copious secretions or the inability to clear secretions, craniofacial abnormalities extreme obesity, or significant burns .

36. Invasive (conventional) mechanical ventilation

37. Causes of Chronic cough

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