Management of Stable COPD

© 2016 Global Initiative for Chronic Obstructive Lung Disease Goals of Therapy : Reduce symptoms risk Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality © 2016 Global Initiative for Chronic Obstructive Lung Disease

Key points Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active.

Key points Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function. Influenza and pneumococcal vaccination should be offered depending on local guidelines.

Smoking Cessation: Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Even a brief (3-minute) period of counseling to urge a smoker to quit results in smoking quit rates of 5-10%. Nicotine replacement therapy (nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet) as well as pharmacotherapy with varenicline, bupropion, and nortriptyline reliably increases long-term smoking abstinence rates and are significantly more effective than placebo.

Risk Reduction: Encourage comprehensive tobacco-control policies with clear, consistent, and repeated nonsmoking messages. Emphasize primary prevention, best achieved by elimination or reduction of exposures in the workplace Reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings. Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors during pollution episodes.

© 2016 Global Initiative for Chronic Obstructive Lung Disease COPD Medications Beta2-agonists Short-acting beta2-agonists Long-acting beta2-agonists Anticholinergics Short-acting anticholinergics Long-acting anticholinergics Combination short-acting beta2-agonists + anticholinergic in one inhaler Combination long-acting beta2-agonist + anticholinergic in one inhaler Methylxanthines Inhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhaler Systemic corticosteroids Phosphodiesterase-4 inhibitors © 2016 Global Initiative for Chronic Obstructive Lung Disease

COPD Medications Key points: Long-acting formulations of beta2-agonists and anticholinergics are preferred over short-acting formulations. Based on efficacy and side effects, inhaled bronchodilators are preferred over oral bronchodilators. Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations. Long-term monotherapy with oral or inhaled corticosteroids is not recommended in COPD. The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV1 < 50% of predicted, chronic bronchitis, and frequent exacerbations.

Spirometric Classification Exacerbations per year Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Patient Characteristic Spirometric Classification Exacerbations per year CAT mMRC A Low Risk Less Symptoms GOLD 1-2 ≤ 1 < 10 0-1 B More Symptoms > 10 > 2 C High Risk GOLD 3-4 D © 2015 Global Initiative for Chronic Obstructive Lung Disease

Manage Stable COPD: Non-pharmacologic Patient Group Essential Recommended Depending on local guidelines A Smoking cessation (can include pharmacologic treatment) Physical activity Flu vaccination Pneumococcal vaccination B, C, D Pulmonary rehabilitation © 2015 Global Initiative for Chronic Obstructive Lung Disease

RecommendedFirst choice Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy Patient RecommendedFirst choice Alternative choice Other Possible Treatments A SAMA prn or SABA prn LAMA LABA SABA and SAMA Theophylline B LAMA and LABA SABA and/or SAMA C ICS + LABA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. D and/or ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or LAMA and PDE4-inh. Carbocysteine N-acetylcysteine

Group A : low risk, less symptoms GOLD stages 1-2 : FEV1 ≥ %50 0 - 1 Exacerbation in a year( not leading to hospital admission) CAT score < 10 First choice: SAMA ( Atrovent) or SABA ( Salbutamol) Prn Alternatives: LAMA(Tiotropium) or LABA(Salmeterol) or SABA+ SAMA Other possible treatment: Theophyline

Group B : low risk, more symptoms GOLD stages 1-2 : FEV1 ≥ %50 0 -1 Exacerbation in a year (not leading to hospital admission) CAT score ≥ 10 First choice: LAMA ( Tiotropium) or LABA ( Salmeterol, Formeterol) Alternatives: LAMA + LABA or Other possible treatment: Theophyline , SAMA and/or SABA

Group C : High risk, less symptoms GOLD stages 3-4 : FEV1 < %50 ≥ 1 Exacerbation in a year leading to hospital admission ≥ 2 Exacerbations in a year CAT score < 10 First choice: ICS ( seroflo, seretide, symbicort…) + LAMA or LABA Alternatives: LAMA + LABA or LAMA+ PDE4 inh or LABA + PDE4 inh Other possible treatment: Theophyline , SAMA and/or SABA

Group D : High risk, more symptoms GOLD stages 3-4 : FEV1 < %50 ≥ 1 Exacerbation in a year leading to hospital admission ≥ 2 Exacerbations in a year CAT score ≥ 10 First choice: ICS ( seroflo, seretide, symbicort…) + LAMA and/or LABA Alternatives: ICS+ LAMA + LABA or ICS+ LABA+ PDE4 inh or LAMA + PDE4 inh or LAMA +LABA Other possible treatment: Theophyline , SAMA and/or SABA, ACC, Carbocystein

Manage Exacerbation of COPD

Key points: The most common causes of COPD exacerbations are viral upper respiratory tract infections and infection of the tracheobronchial tree. Diagnosis relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms that is beyond normal day-to-day variation. The goal of treatment is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations.

Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation. Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. COPD exacerbations can often be prevented.

Consequences Of COPD Exacerbations Negative impact on quality of life Impact on symptoms and lung function EXACERBATIONS Accelerated lung function decline Increased economic costs Increased Mortality © 2016 Global Initiative for Chronic Obstructive Lung Disease

Assessments: Arterial blood gas measurements (in hospital): PaO2 < 60mmhg with or without PaCO2 > 50mmhg when breathing room air indicates respiratory failure. Chest radiographs: useful to exclude alternative diagnoses. ECG: may aid in the diagnosis of coexisting cardiac problems. Whole blood count: identify polycythemia, anemia or bleeding. Purulent sputum during an exacerbation: indication to begin empirical antibiotic treatment. Biochemical tests: detect electrolyte disturbances, diabetes, and poor nutrition. Spirometric tests: not recommended during an exacerbation.

Treatment options: Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%.   Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended . Nebulized magnesium as an adjuvent to salbutamol treatment in the setting of acute exacerbations of COPD has no effect on FEV1.

Antibiotics should be given to patients with: Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. Who require mechanical ventilation. Non-invasive ventilation( NIV) : Improves respiratory acidosis, decreases respiratory rate, severity of dyspnea, complications and length of hospital stay. Decreases mortality and needs for intubation.

Indications for Hospital Admission Marked increase in intensity of symptoms Severe underlying COPD Onset of new physical signs Failure of an exacerbation to respond to initial medical management Presence of serious comorbidities Frequent exacerbations Older age Insufficient home support

COPD case

A 65 year old male comes to the Emergency department because of shortness of breath. He notes that over the last 2-3 years he has had gradual worsening of his ability to exert himself without feeling out of breath, and it has been acutely worse for the past week, including a worsening productive cough. On questioning, he reveals that he coughs almost every morning as well, and this has been going on for even longer, perhaps 4-5 years. The cough is now productive of yellowish-brownish sputum. He denies chest pain, fevers, chills or night sweats. He has no history of lower extremity edema. The rest of his review of systems is negative. He is 40Pack/year smoker. No history of other medical problems

On exam, his BP is 144/88 mmHg, HR is 98, respiratory rate is 28 breaths per minute. His temp is 37.2. Oxygen saturation is documented as 93% on 4 L. You find him sitting up in the bed, leaning forward and his lips are bluish. There is no cervical lymphadenopathy, JVD or carotid bruits. Chest exam shows mild intercostal retractions seen around the anterolateral costal margins. Wheezes and rhonchi are present bilaterally, without crackles. Heart exam is unremarkable, though the heart sounds are distant. Lower extremities show no cyanosis, clubbing or edema.

Q. What is the most likely diagnosis? COPD with acute exacerbation

Q. What should your target O2 saturation be for this patient? Target oxygen saturation should be 90-92%. Hypercapnia can accompany the aggressive use of supplemental oxygen. This O2 target can help maximize hemoglobin saturation, and lessen the likelihood of hypercapnia from ventilation/perfusion mismatches. Placing patients with chronic COPD and acute respiratory failure on 100% O2 has been shown to increased Pa Co2 by 23+,- 5 mmhg

Q. If this patient also had a history of heart failure, what test might be helpful to exclude CHF as playing a role in the patients dyspnea? B-type natriuretic peptide (BNP) can be used to help distinguish heart failure from other causes of dyspnea

Optimal Cut Point (pg/mL) RULE-IN Cut Points Optimal Cut Point (pg/mL) Sensitivity (%) Specificity (%) PPV (%) NPV (%) All Patients 900 90 85 76 94 <50 years old 450 93 95 67 99 ≥ 50 years olf 91 80 77 92 RULE-OUT Cut Point   300 68 62

Chest X.ray showed mild hyperinflation without any obvious infiltrate EKG revealed mild sinus tachycardia On emergent cardiac echocardiography : EF=50% , mild RV dilation, 2+TR Hct= 59% , Electrolytes were in normal ranges. Q. What are the mainstays of treatment of acute COPD Exacerbations in this patient?

Bronchodilators: the mainstay of therapy for acute exacerbations Bronchodilators: the mainstay of therapy for acute exacerbations. Data indicate similar efficacy with nebulizer or MDI, but MDI requires patients to be more alert, and nebs still recommended by many experts. Short acting beta agonist ± Short acting anti cholinergic combination nebulizer = Daulin Systemic corticosteroids: Reduce 30 day treatment failure rate (23% vs 33%), 90 day treatment failure rate (37-48%) and length of hospital stay (8 vs 10 days), while improving lung function. * 40mg/day for 5 days

Antibiotics Mucolytics Antibiotics are recommended for acute exacerbations of COPD that are characterized by “increased volume and purulence of secretions.” They decrease mortality and treatment failure rates, while accelerating improvement of peak expiratory flow rates Mucolytics The use of mucolytic agents, chest physiotherapy, intermittent positive pressure breathing and directed coughing have not been shown to be effective

What is your recommended order? Injection of a sedative drug The internal medicine resident is called by the emergency ward nurse that admitted patient with COPD looks worse, and is now somnolent and confused. What is your recommended order? Injection of a sedative drug Increased the inhaled O2 Injection of another dose of corticosteroide re- assessing of a new ABG

ABG revealed an increase of 25mmHg in Pa CO2, PH = 7.12 What do you prefer to do? Non invasive ventilation or Intubation and using of mechanical ventilation

Benefits of positive pressure-ventilation are lower rates of intubation, lower in-hospital mortality rates and shorter hospital stays. Patients with *respiratory arrest, *medical instability (hypotensive shock, cardiac ischemia), *an inability to protect their airway, *excessive secretions, *agitation or *uncooperativeness (or those with *a facial structure that precludes proper mask fitting) are likely to need intubation.

Q. In which stage he is? A, B, C or D The patient was discharged after 5 days with administration of Atrovent MDI prn and Theophyline 100mg bid. 8 months later a spirometry exam was done in stable situation and it showed FEV1 = 58% and FEV1/FVC = 60%. He has not experienced another admission due to exacerbation during a one year of follow-up. He complained of a large amount of sputum, daytime coughing and difficult sleeping due to respiratory problem. Q. In which stage he is? A, B, C or D

Stage B

Q. What is your recommended treatment right now? Increased the dose of Atrovent LAMA( Tiotropium Bromide) should be added ICS should be added SABA(salbutamol) added to Atrovent

Manage Stable COPD: Pharmacologic Therapy RECOMMENDED FIRST CHOICE 2 or more or > 1 leading to hospital admission 1 (not leading to hospital admission) GOLD 4 ICS + LABA or LAMA ICS + LABA and/or LAMA GOLD 3 Exacerbations per year A B GOLD 2 SAMA prn or SABA prn LABA or LAMA GOLD 1 CAT < 10 mMRC 0-1 CAT > 10 mMRC > 2 © 2015 Global Initiative for Chronic Obstructive Lung Disease