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

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

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

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

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

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

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

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

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

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

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

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

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

15. 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

16. 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

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

21. 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

22. Rarely Used Medications
Systemic Glucocorticoids
Mucoactive Agents
Chronic Antibiotic Therapy

23. Supplemental Therapy Oxygen Secretion Clearance Smoking Cessation
Vaccinations
Rehabilitation
Nutrition

24. 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)

25. 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

26. 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?)

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

28. Secretion Clearance Postural drainage Flutter valve therapy
Hydration ?

29. 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

30. 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 ?

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

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

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

35. Exercise Equipment

36. 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)

37. What you don’t want to have