COPD Management of Stable COPD Shyam Rao May 2014

Objectives Briefly review the GOLD classification of COPD Understand treatment options based on the GOLD classification of the disease Review non-pharmacologic treatment options

Case A 65-year-old woman is evaluated in a follow-up examination for dyspnea, chronic cough, and mucoid sputum; she was diagnosed with chronic obstructive pulmonary disease 3 years ago. The patient has a 40-pack-year history of cigarette smoking, but quit smoking 1 year ago. She is otherwise healthy, and her only medication is inhaled albuterol as needed. On physical examination, vital signs are normal. Breath sounds are decreased, but there is no edema or jugular venous distention. Spirometry shows an FEV 1 of 62% of predicted and an FEV1/FVC ratio of 65%. Chest radiograph shows mild hyperinflation. Which of the following is the most appropriate therapy for this patient? A-Add a long-acting β2-agonist B-Add an inhaled corticosteroid C-Add an oral corticosteroid D-Add theophylline and montelukast E-Continue current albuterol therapy

GOLD Global initiative for chronic obstructive lung disease Based on 3 different criteria Symptoms Severity of airflow limitation Risk of exacerbation

GOLD Criteria for Severity CategorySeverityFEV1 GOLD 1MildFEV1>80% predicted GOLD 2Moderate50%<FEV1<80% GOLD 3Severe30%<FEV1<80% GOLD 4Very SevereFEV1<30%

GOLD criteria assessment CategorySymptoms and CAT score Risk and number of exacerbations GOLD Stage Category ACAT<10, less symptomatic Low risk, 0-1 exacerbations GOLD stage I-II Category BCAT>10, more symptomatic Low risk, 0-1 exacerbations GOLD stage I-II Category CCAT<10, less symptomatic High risk, >2 exacerbations GOLD stage III-IV Category DCAT>10, more symptomatic High risk, >2 exacerbations GOLD stage III-IV

GOLD A and B CategoryTreatment GOLD A1) Short acting bronchodilator prn 2) Long acting bronchodilator or short acting beta agonist AND bronchodilator GOLD B1) Long acting bronchodilator (only one) 2) Long acting beta agonist AND long acting anticholinergic

GOLD C and D CategoryTreatment GOLD C1) LABA+glucocorticoid or long acting anticholinergic 2) LABA and long acting anticholinergic GOLD DLABA+glucocorticoid LABA+glucocorticoid and PDE4 inhibitor (for refractory disease) Triple therapy

Refractory Disease Theophylline: watch for toxicity levels but can be added on to category B, C, D as an additive treatment PDE4 inhibitor: decrease inflammation and improve airway smooth muscle relaxation

Non-pharmacologic Oxygen Smoking Cessation Secretion clearance Vaccines: pneumococcal and influenza Rehabilitation Surgery: Lung Volume Reduction Surgery and transplant

Lets go back to the case A 65-year-old woman is evaluated in a follow-up examination for dyspnea, chronic cough, and mucoid sputum; she was diagnosed with chronic obstructive pulmonary disease 3 years ago. The patient has a 40-pack-year history of cigarette smoking, but quit smoking 1 year ago. She is otherwise healthy, and her only medication is inhaled albuterol as needed. On physical examination, vital signs are normal. Breath sounds are decreased, but there is no edema or jugular venous distention. Spirometry shows an FEV 1 of 62% of predicted and an FEV1/FVC ratio of 65%. Chest radiograph shows mild hyperinflation. Which of the following is the most appropriate therapy for this patient? A-Add a long-acting β2-agonist B-Add an inhaled corticosteroid C-Add an oral corticosteroid D-Add theophylline and montelukast E-Continue current albuterol therapy

Summary GOLD criteria and categories were designed to provide specific treatment to patients not only based on airway involvement but also symptoms and risk of exacerbations Treatment should be based on the GOLD criteria and advanced based on the criteria Overall, general guidelines would be to start with short acting bronchodilators and expanding to long acting bronchodilators as the symptoms and severity of the disease worsen