William P. Saliski Jr. DO Montgomery Pulmonary Consultants Management of COPD William P. Saliski Jr. DO Montgomery Pulmonary Consultants

Management of Stable COPD Pharmacotherapy Oxygen Smoking Cessation Vaccinations Rehabilitation Surgery Future Discussions

Assessing Severity Staging System (GOLD) Defines disease severity by FEV1 and ratio FEV1/FVC Used as a “guide” to manage patient therapy

General Approach Pharmacotherapy - prevent/decrease symptoms - reduce exacerbations - improve health status - improve exercise capacity

Short Acting Bronchodilators Beta agonists - albuterol, levabuteral, pirbuterol (SABA) Anticholinergics - ipratropium bromide

Short Acting Bronchodilators -Names Albuterol Sulfate - Provental HFA Ventolin HFA Proair HFA Levalbuterol - Xopenex Porbuterol - Maxair Ipatroprium Bromide – Atrovent Combu-Med - Combivent

Beta Agonist Therapy Dosing : 2 Puffs – as needed Side Effects : tremor, reflex tachycardia hypokalemia ( extreme use )

Anticholinergic Therapy Dosing – 2 puffs 4x/daily - 18 meq/puff -200 puffs/canister Side Effects - dry mouth, constipation ? Cardiovascular side effects

Combination Therapy (Combivent) Dosing – 2 puffs 4x/daily Combination therapy increased FEV1 more than either agent alone

Long Acting Bronchodilators (LABA) Salmeterol – Serevent Formoterol – Foradil Arfomoterol – Brovena (nebulizer use) Tiotropium – Spiriva Therapy in Gold II – IV

Beta Agonists (LABA) Dosing – both are dry powder used 2x/daily Side Effects – same as short acting agents - increase risk of death (Smart trial)

Anticholinergics (Long Acting) Dosing – dry powder 1x/daily Side Effects – dry mouth, headache constipation, glaucoma (worsening)

Comparison “Shopping” Foradil> Serevent Spiriva>Foradil>Serevent -Foradil has rapid onset, lasts longer -Spiriva affords better bronchodilation and better side effect profile

Bronchodilators Plus Inhaled Glucocorticosteroids (ICS) COPD characterized by airway and systemic inflammation Numerous ICS on the market No real difference in products ICS should not be used as sole therapy

Bronchodilator Plus ICS Advair Discus/Advair HFA (Fluticasone/Salmeterol)250 meq/50 mcg 2x/daily Symbicort 160/4.5 (Budesonide/Formeterol)2 puffs- 2x/daily Side Effects (ICS) oral candidiasis, pneumonia, adrenal suppression

Triple Inhaler Therapy Stage III-IV Gold LABA/ICS and tiotroprium bromide Decrease mortality, exacerbations, and hospitalizations

Theophylline Mechanism of action controversial Offers moderate bronchodilation Long acting extended release preps Narrow LD 50 Metabolized in liver Keep serum level 8 to 12 mcg/mL

Rarely Used Medications Systemic Glucocorticoids Mucoactive Agents Chronic Antibiotic Therapy

Supplemental Therapy Oxygen Secretion Clearance Smoking Cessation Vaccinations Rehabilitation Nutrition

Oxygen Therapy Long term oxygen therapy (LTOT) increases survival and improves quality of life Minimal adverse effects (humidify !) Close government regulation 2 billion dollars per year (Medicare)

LTOT Indications PaO2 ≤ 55 mm Hg or SaO2 ≤ 88 % Cor Pulmonale – PaO2 ≤ 59 mm Hg/SaO2 ≤ 89 % (Hct > 55 %, EKG - p pulmonale, CHF Desaturation with above numbers w/ exercise or at sleep

Prescribing Oxygen Obtain baseline ABG (does O2 Sat correlate?) (is patient hypercarbic?) Keep PaO2 60 to 65 mm Hg Keep SaO2≥92% Usually order 2L NC (continuous, exercise, sleep?)

Equipment Selection Keep your patient mobile Select lightest, most portable Think liquid O2 Oxygen conserving device Oxygen concentrator (bedroom)

Secretion Clearance Postural drainage Flutter valve therapy Hydration ?

Vaccinations COPD ≥ 65 yrs old Pneumococcal/polysaccharide vaccine COPD ≥ 65 yrs old COPD ≤ 65 yrs old w/ FEV1< 40% predicted Active tobacco use Give initial vaccine and 5 year booster Does not reduce mortality

Vaccinations given to all patients with COPD Influenza vaccination given to all patients with COPD Decrease risk of influenza significantly DOES NOT CAUSE THE FLU ! Timing ?

Smoking Cessation Clinician advice Nicotine replacement therapy Buproprion -(Zyban) 150 mg Varenicline – (Chantix) 1 mg Combination therapy- best outcome

Rehabilitation Low cost effective program Optimizes physical and social functioning Reduces hospitalization, LOS, ? Mortality Medically supervised

Rehabilitation Baptist Medical Center South Anita Jones 334.286.2859 Covered by Major Medical Insurances

Exercise Equipment

Nutrition 30% of patients with severe COPD are protein-calorie malnourished Increase mortality, decrease muscle function, decrease immunity Try high caloric dietary supplements Magestrol acetate (Megace)

What you don’t want to have