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

2. Adolf Dasser

3. 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)

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

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

6. 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

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

8. 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

9. 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
<149
BMI
>21
<21

10. Relationship of BODE Score and 4-Year Mortality
0-2 %
3-4 %
5-6 %
>7 %

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

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

14. 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

15. 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

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

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

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

19. 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

20. 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

21. 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.

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

23. Anima Sana in Corpore Sano

24. 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

25. 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

26. Conquest