Caring for Patients with COPD: Guidelines for Diagnosis and Management M. Elizabeth Knauft, MD MS September 20, 2007

GOLD GOLD Diagnosis and Classification of COPD Diagnosis and Classification of COPD 4 major components of COPD management 4 major components of COPD management Assess and Monitor Disease Assess and Monitor Disease Reduce Risk Factors Reduce Risk Factors Manage Stable COPD Manage Stable COPD Manage Exacerbations Manage Exacerbations

GOLD 1998: Global Initiative for Chronic Obstructive Lung Disease 1998: Global Initiative for Chronic Obstructive Lung Disease 2001: Global Strategy for the Diagnosis, Management, and Prevention of COPD 2001: Global Strategy for the Diagnosis, Management, and Prevention of COPD 2006: Revision of above 2006: Revision of above

Goals of GOLD To improve prevention and management of COPD through a concerted worldwide effort of people involved in all facets of healthcare and healthcare policy, and to encourage an expanded level of research interest in this highly prevalent disease. To improve prevention and management of COPD through a concerted worldwide effort of people involved in all facets of healthcare and healthcare policy, and to encourage an expanded level of research interest in this highly prevalent disease.

Case CC: Dyspnea CC: Dyspnea HPI: 66 yo F with several years of progressive dyspnea, cough. HPI: 66 yo F with several years of progressive dyspnea, cough. 60 pack year tobacco, active smoker (2ppd) 60 pack year tobacco, active smoker (2ppd) PMH: DM II PMH: DM II

Definition of COPD Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients Pulmonary component characterized by airflow limitation that is not fully reversible. Pulmonary component characterized by airflow limitation that is not fully reversible. Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases

Spirometric Classification of COPD Severity Based on Post-Bronchodilator FEV1 Stage I: Mild FEV1/FVC <70% FEV1 > 80% predicted Stage II: Moderate FEV1/FVC <70%; 50%< FEV1<80% pred. Stage III: Severe FEV1/FVC <70%; 30%< FEV1<50% pred. Stage IV: Very Severe FEV1/FVC <70% FEV1<30%, or FEV1 < 50% pred. plus presence of chronic respiratory failure

Case Cont Spirometry FEV1/FVC: 0.50 FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% predicted) Postbronchodilator FEV1: 1.23L (63% predicted)

Case Cont Spirometry FEV1/FVC: 0.50 FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% predicted) Postbronchodilator FEV1: 1.23L (63% predicted) Stage II Stage II

Mechanism of COPD Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affected Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affected Chronic inflammatory changes, amplified by oxidative stress Chronic inflammatory changes, amplified by oxidative stress

Burden of COPD Prevalence higher in Prevalence higher in smokers and ex-smokers than nonsmokers smokers and ex-smokers than nonsmokers Patients over 40 than those under 40 Patients over 40 than those under 40 Men than in women Men than in women Morbidity Morbidity Mortality Mortality 6 th leading cause of death in 1990 (Global Burden on Disease Study) 6 th leading cause of death in 1990 (Global Burden on Disease Study) Projected to be 3 rd leading cause by 2020 Projected to be 3 rd leading cause by 2020

Risk Factors for COPD Cigarette smoke Cigarette smoke Occupational dust and chemicals Occupational dust and chemicals Environmental tobacco smoke Environmental tobacco smoke Indoor and outdoor pollution Indoor and outdoor pollution

Management Goals for COPD Relieve symptoms Relieve symptoms Prevent progression of disease Prevent progression of disease Improve exercise tolerance Improve exercise tolerance Improve health status Improve health status Prevent and treat complications Prevent and treat complications Prevent and treat exacerbations Prevent and treat exacerbations Reduce mortality Reduce mortality

Four Major Components of COPD Management I: Assess and Monitor Disease I: Assess and Monitor Disease II: Reduce Risk Factors II: Reduce Risk Factors III: Manage Stable COPD III: Manage Stable COPD IV: Manage Exacerbations IV: Manage Exacerbations

Assess and Monitor Disease Dyspnea Dyspnea Progressive, persistent, worse with exercise Progressive, persistent, worse with exercise increased effort to breathe, air hunger increased effort to breathe, air hunger Chronic cough Chronic cough Intermittent, non-productive Intermittent, non-productive Chronic sputum production Chronic sputum production Any pattern Any pattern History of exposure to risk factors History of exposure to risk factors Tobacco, occupational dust/chemicals, home cooking, heating fuels Tobacco, occupational dust/chemicals, home cooking, heating fuels

Assess and Monitor Disease-2 Confirm diagnosis by spirometry Confirm diagnosis by spirometry Post bronchodilator FEV1/FVC < 0.70 Post bronchodilator FEV1/FVC < 0.70 Obtain ABG if FEV1 < 50% predicted or clinical signs right heart failure Obtain ABG if FEV1 < 50% predicted or clinical signs right heart failure Alpha-1 antitrypsin level in young pts (<45 years) Alpha-1 antitrypsin level in young pts (<45 years) Identify comorbidities Identify comorbidities

Assess and Monitor Disease-3 Differential Diagnosis Differential Diagnosis Asthma Asthma CHF CHF Bronchiectesis Bronchiectesis Tuberculosis Tuberculosis Obliterative Bronchioloits Obliterative Bronchioloits Diffuse Panbronchiolitis Diffuse Panbronchiolitis

Reduce Risk Factors Smoking Cessation! Smoking Cessation! Reduction of indoor and outdoor air pollution Reduction of indoor and outdoor air pollution

Manage Stable COPD Individualize overall approach to address symptoms and improve quality of life Individualize overall approach to address symptoms and improve quality of life Smoking cessation Smoking cessation Pharmacotherapy for COPD used to decrease symptoms and/or complications Pharmacotherapy for COPD used to decrease symptoms and/or complications do NOT modify long-term decline in lung function do NOT modify long-term decline in lung function

Manage Stable COPD-2 Bronchodilators B-2 agonists, anticholinergics,methylxanthines B-2 agonists, anticholinergics,methylxanthines Symptomatic management: prn or scheduled Symptomatic management: prn or scheduled Increase exercise capacity Increase exercise capacity Do not necessarily improve FEV1 Do not necessarily improve FEV1 LABA more effective than SABA LABA more effective than SABA Combination therapy more effective than increasing dose of single agent Combination therapy more effective than increasing dose of single agent Long acting anticholinergic reduces rate of COPD exacerbations, improves effectiveness of pulmonary rehabilitation Long acting anticholinergic reduces rate of COPD exacerbations, improves effectiveness of pulmonary rehabilitation

Manage Stable COPD-3 Glucocorticosteroids Inhaled corticosteroids (ICS) do not modify long term decline in FEV1 Inhaled corticosteroids (ICS) do not modify long term decline in FEV1 ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very Severe) pts ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very Severe) pts Regular use of ICS reduces frequency of exacerbations Regular use of ICS reduces frequency of exacerbations Long term use systemic glucocorticosteroids is NOT recommended Long term use systemic glucocorticosteroids is NOT recommended

Manage Stable COPD-4 Influenza vaccine Influenza vaccine Pneumococcal vacine (>65years; 65years; < 65 years with FEV1 < 40 % predicted)

Manage Stable COPD-5 Therapies NOT recommended No benefit from prophylactic antibiotic therapy No benefit from prophylactic antibiotic therapy Overall benefit from mucolytics is small Overall benefit from mucolytics is small N-acetylcysteine: no reduction in exacerbations N-acetylcysteine: no reduction in exacerbations Antitussives (cough has a protective role) Antitussives (cough has a protective role) Vasodilators (inhaled nitric oxide) Vasodilators (inhaled nitric oxide)

Manage Stable COPD-6 Non-Pharmacologic Treatments Pulmonary rehabilitation Pulmonary rehabilitation Goals: Reduce symptoms, improve quality of life, increase physical and emotional participation in everyday activities Goals: Reduce symptoms, improve quality of life, increase physical and emotional participation in everyday activities Supplemental oxygen Supplemental oxygen Use > 15 h/day improves survival in patients with chronic respiratory failure Use > 15 h/day improves survival in patients with chronic respiratory failure PaO2<55, SaO2 <88% PaO2<55, SaO2 <88% PaO , SaO2 = 88% and pulmonary hypertension, evidence of CHF, polycythemia (HCT > 55%) PaO , SaO2 = 88% and pulmonary hypertension, evidence of CHF, polycythemia (HCT > 55%)

Therapy at Each Stage of COPD Stage I: Mild Reduction of risk factors; influenza vaccination Add short-acting bronchodilators prn Stage II: Moderate Add regular treatment with one or more long- acting bronchodilators; add rehabilitation Stage III: Severe Add inhaled glucocorticosteroids if repeated exacerbations Stage IV: Very Severe Add long-term oxygen if chronic respiratory failure; consider surgical treatments

Case Cont Short acting B2 agonist Short acting B2 agonist Long acting bronchodilator (B2 agonist or anticholinergic) Long acting bronchodilator (B2 agonist or anticholinergic) Influenza vaccine Influenza vaccine Pneumococcal vaccine Pneumococcal vaccine Smoking cessation Smoking cessation

Manage Exacerbations Exacerbation: Exacerbation: …an event in the natural course of the disease characterized by a change in the patients baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD. …an event in the natural course of the disease characterized by a change in the patients baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD. Infection of tracheobronchial tree and air pollution most common causes Infection of tracheobronchial tree and air pollution most common causes No cause identified in 1/3 exacerbations No cause identified in 1/3 exacerbations

Manage Exacerbations Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color or tenacity of sputum Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color or tenacity of sputum Assess severity Assess severity Dependent on pts baseline prior to exacerbation Dependent on pts baseline prior to exacerbation ABG ABG FEV1 not practical FEV1 not practical CXR CXR Sputum culture Sputum culture

Manage Exacerbations Home management Increase dose and/or frequency of short acting bronchodilator therapy Increase dose and/or frequency of short acting bronchodilator therapy Consider adding anticholinergic agent Consider adding anticholinergic agent Systemic glucocorticosteroids Systemic glucocorticosteroids Shorten recovery time Shorten recovery time Improve FEV1 and hypoxemia Improve FEV1 and hypoxemia Consider (in addition to bronchodilators) if FEV1 < 50% Consider (in addition to bronchodilators) if FEV1 < 50% mg prednisone/d x 7-10 days mg prednisone/d x 7-10 days

Case Cont Increased dyspnea Increased dyspnea Increase in sputum, now purulent Increase in sputum, now purulent

Case Cont Increased dyspnea Increased dyspnea Increase in sputum, now purulent Increase in sputum, now purulent Increase frequency of bronchodilators (nebulized or inhaled) Increase frequency of bronchodilators (nebulized or inhaled) Consider oral glucocorticosteroids Consider oral glucocorticosteroids

Manage Exacerbations Hospital management Risk of death related to development of respiratory acidosis Risk of death related to development of respiratory acidosis Indications for hospital assessment/admission Indications for hospital assessment/admission Marked increase in intensity of symptoms Marked increase in intensity of symptoms Severe underlying COPD Severe underlying COPD New physical signs (cyanosis, peripheral edema) New physical signs (cyanosis, peripheral edema) Failure to respond to outpatient management Failure to respond to outpatient management Significant comorbidities Significant comorbidities Frequent exacerbations Frequent exacerbations New arrythmia New arrythmia Diagnostic uncertainty Diagnostic uncertainty Older age Older age Insufficient home support Insufficient home support

Manage Exacerbations Hospital management-2 Assess severity of symptoms- ABG, CXR Assess severity of symptoms- ABG, CXR Oxygen Oxygen Bronchodilators Bronchodilators B-2 agonist B-2 agonist Add anticholinergic if no response Add anticholinergic if no response Role of methylzanthines is controversial Role of methylzanthines is controversial Add oral or IV glucocorticosteroids Add oral or IV glucocorticosteroids

Manage Exacerbations Hospital management-3 Give antibiotics if: Increased dyspnea, increased sputum volume, increased sputum purulence Increased dyspnea, increased sputum volume, increased sputum purulence Two of the above three criteria are met, and one is presence of purulent sputum Two of the above three criteria are met, and one is presence of purulent sputum Severe exacerbation requiring mechanical ventilation (invasive or noninvasive) Severe exacerbation requiring mechanical ventilation (invasive or noninvasive) H. influenza, S. pneumoniae, M. catarrhalis H. influenza, S. pneumoniae, M. catarrhalis

Manage Exacerbations Hospital management-4 Ventilatory support Ventilatory support Noninvasive mechanical ventilation : 80% success rate Noninvasive mechanical ventilation : 80% success rate Moderate/severe dyspnea with use of accessory muscles and paradoxical abdominal muscle motion Moderate/severe dyspnea with use of accessory muscles and paradoxical abdominal muscle motion Moderate/severe respiratory acidosis (pH 45) Moderate/severe respiratory acidosis (pH 45) Tachypnea (RR > 25 bpm) Tachypnea (RR > 25 bpm)

Manage Exacerbations Discharge Criteria Inhaled B2 agonist therapy is required no more than every 4 hours Inhaled B2 agonist therapy is required no more than every 4 hours Pt able to walk across room (if previously ambulatory) Pt able to walk across room (if previously ambulatory) Clinically stable for h Clinically stable for h Stable ABG for h Stable ABG for h Patient/caregiver understands proper medication use Patient/caregiver understands proper medication use Home care/follow-up arrangements made Home care/follow-up arrangements made

Summary Diagnosis of COPD requires post- bronchodilator FEV1 Diagnosis of COPD requires post- bronchodilator FEV1 Tobacco cessation Tobacco cessation Layer treatment according to stage of COPD Layer treatment according to stage of COPD