Pulmonary Center of Excellence COPD Chi Lam, MD, FCCP May 25th, 2017

Adolf Dasser

Definition & Overview Common, Preventable, Treatable Persistent Respiratory Symptoms & Airflow Limitation Dyspnea, Cough, Sputum Risk Factors: Tobacco Smoking, Biomass Fuel Exposure, Air Pollution, Genetic, Abnormal Development, Accelerated Aging Exacerbations (Trilogy of Symptoms)

Dx & Assessment Trilogy of Symptoms ( Dyspnea, Cough, Sputum) Hx of Exposure to Risk Factors ( Tobacco, Pollution, Occupation ) Spirometry Co-morbidities

Toolbox for Assessment Spirometry ( < 70% FEV-1 / FVC ) mMRC GOLD ( 1, 2, 3, 4 ) CAT GOLD ( A, B, C, D ) BODE

m-MRC ( 0 - 4 ) 0 : Breathless with Strenuous Exercise 1 : Breathless Hurrying on the Level or Walking Slight Uphill 2 : Stop for Breath Walking on the Level at Own Pace or Slower than Cohort 3 : Stop After 100M or a Few Minutes on the Level 4 : House Bound, Breathless with ADL

GOLD ( 1 -4 ) FEV-1 / FVC 1 MILD >= 80% 2 MODERATE 50 - 80% 3 SEVERE 30 - 50% 4. VERY SEVERE <30%

CAT SYMPTOMS SEVERITY PHLEGM 0 - 5 Filled up COUGH Constant CHEST TIGHTNESS DYSPNEA ADLs Restricted OUT of HOME ACTIVITIES Homebound ENERGY LEVEL Depressed SLEEP Deprived

Values for Calculating the Four Components of the BODE Score Variable Score 1 2 3 FEV1, % predicted >65 50-65 35-49 <35 Dyspnea: MRC 4-point Scale 0-1 4 6MWD, m >350 250 - 349 150 - 249 <149 BMI >21 <21

Relationship of BODE Score and 4-Year Mortality 0-2 20 - 30% 3-4 50 - 60% 5-6 70 - 80% >7 80 - 90%

Comprehensive Interventions(1) Smoke Cessation E-cigarette ??? Pharmacologic Therapy Inhaler Technique Flu Vaccination Pneumococcal Vaccination

Comprehensive Intervention(2) O2 Therapy Non-invasive Ventilation Surgical Intervention Palliation Hospice

Pharmacotherapies Intervention Class Intervention Bronchodilators LABA + LAMA Corticosteroid-containing regimens LABA +LAMA +ICS Anti-inflammatory (non-steroid) Roflumilast Anti-infectives Long-Term macrocodes Mucoregulators Carbocysteine Various LVRS

SMOKE CESSATION Ask : Every Pt / Every Encounter & Document Advise : Strongly Urge All Users to Quit Access : Willingness / Desire, Action Now Assist : Pharmacotherapies, Social Support, Counseling, Replacement Arrange : Follow-up Contact

O2 Therapy Indication PaO2 <or= 55 mmHg ( 7.32 kPa ) or SaO2 <or= 88 %

Vaccination Influenza PPSV 23 ( < 65 years old ) PCV 13 & PPSV 23 ( >65 years old )

LVRS 6 - 10 Weeks of Pulmonary Rehab Upper Lobe Emphysema, Low Exercise Capacity FEV-1 < 20% DLCO < 20%

O2 Therapy Cor Pulmonale PaO2 <or= 59 mmHg (7.85 kPa) or SaO2 <or= 89% EKG evidence of Pulmonary Pulmonale Hematocrit > 55 % Clinical Evidence of Right Heart Failure

Benefits of Pulmonary Rehab Improve exercise capacity Reduces the perceived intensity of breathlessness Improve health-related quality of life Reduces the number of hospitalizations and days in the hospital Reduces anxiety and depression associated with COPD Strength and endurance training of the upper limbs improves arm function Benefits extend well beyond the immediate period of training Improve survival Respiratory muscle training is beneficial, especially when combined with general exercise training Improves recovery after hospitalization for an exacerbation Enhances the effect of long-acting bronchodilators

O2 Therapy Specific Situations PaO2 >or= 60mmHg or SaO2 >or= 90% with lung disease and other clinical needs. If the pt meets criteria at rest, O2 should also be Rx during sleep and exercise, and appropriately titrated. If the pt is normoxemic at rest but desaturates during exercise, O2 is generally Rx for use during exercise. For pts who desaturate (PaO2 <or= 55mmHg[7.32 kPa] during sleep, evaluate with sleep study.

Transplant BODE Index >= 7 FEV-1 < 15-20% 3+ Exacerbation ( year ) 1 Exacerbation with Respiratory Failure Pulmonary Hypertension ( Mild - Severe )

Anima Sana in Corpore Sano

LTAC PMV ( 3-4 weeks with trach ) Comprehensive Services with aggressive rehab strategies Therapist driven protocol Optimizing nutrition, PT, OT, Psychosocial Support Wean Success Rate : 34-60% 60-94% Survives to Discharge

Hospice Life Expectancy 6 Months or Less Dyspnea at rest, Refractory to Rx Reduced Function ( Bed - Chair Existence ) Fatigue / Cough ; Wt Decrease 10% / 6 Months FEV-1 < 30% ; Resting HR >100 Frequent ER / Hospitalization RV Failure SpO2 < 88% or pO2 <55 or pCO2 >55 Declining FEV-1 >40cc / year

Conquest