1. Examining Emphysema and Chronic Bronchitis
COPD IN LONG TERM CARE
Examining Emphysema and Chronic Bronchitis

2. Objectives Understand the diagnostic criteria for COPD
Understand the relevance of COPD exacerbations
Understand the features that predict a poor prognosis in COPD
Understand the treatment of COPD

3. COPD in Canada: Epidemiology and Costs

4. Key Message Keynotes to the speaker:
Partially reversible hyperinflation was added to the definition because it is the best correlate of dyspnea and exercise limitation, and it is more responsive to treatment than FEV1
Exacerbations and systemic manifestations are of key importance as the disease progress; not only do co-morbidities increase risk of certain causes of mortality, they also increase all-cause mortality.

5. Causes of COPD

6. Comorbidities Associated with COPD

7. Malnutrition in COPD
COPD PHENOTYPES

8. Pathophysiology of COPD
Mucous gland hyperplasia
Normal terminal bronchioles & alveoli
Profuse exudate in lumen
Distended bronchioles communicating with each other
Inflammatory infiltrate
Destruction of bronchioles & capillary bed
Note: Expiratory flow limitation is the pathophysiological hallmark of COPD. (Canadian Respiratory Journal, September 2007 v14 Supp B Pg. 6B)
Loss of epithelium
Image Source: netterimages.com/image/list.htm?s=emphysema&Submit.x=51&Submit.y=6

9. Evidence-based Physical Examination of COPD

10. Key Message Keynotes to the speaker:
A post-bronchodilator FEV1/FVC (forced vital capacity) less than 0.70 is required for COPD to be diagnosed.
Misdiagnosis of COPD may prevent COPD patients from receiving therapy that could reduce symptom and future risk while causing others to receive unnecessary treatment

11. Classification by Impairment of Lung Function

12. Identify Patients with Possible COPD

13. Clinical Course o COPD

14. Assessing Disability in COPD

15. Smoking Cessation

16. Smoking Cessation

17. AECOPD: Definition

18. AECOPD Severity: Mortality
Key points:
Relationship between severity of AECOPD and mortality.
Cox proportional hazards model using predictors for mortality in COPD including age, BMI, FEV1, co-morbidity score, ABG results, use LTOT, and smoking history

19. AECOPD Severity: Mortality
Key points:
Relationship between AECOPD frequency and mortality
Cox proportional hazards model using predictors for mortality in COPD including age, BMI, FEV1, co-morbidity score, ABG results, use LTOT, and smoking history

20. Consequences of AECOOPD

21. Survival In COPD Severity of disease FEV1 and Dsypnea MRC
Smoking Status
Frequency and Severity of Exacerbations
Exercise Tolerance
BMI

22. Management of Symptomatic, Mild COPD

23. Vaccinations

24. AECOPD: Prevention Strategies

25. Oxygen Therapy in COPD

26. Comprehensive Management of COPD

27. Optimal Pharmacotherapy

28. Key Message Keynotes to the speaker:
A recent Canadian study (CAGE study Can Respir J accepted for publication) has shown that a minority of COPD patients receives currently recommended pharmacologic treatment (34%)
Under use of efficacious therapies in moderate to severe patients has been demonstrated in the CAGE study as was ICS overuse in mild disease

29. Optimal Pharmacotherapy of Moderate to Severe COPD
Tiotropium bromide = Spiriva; Salmeterol – Serevent; Formoterol = Symbicort; Salbutamol = ventolin;

30. Optimal Pharmacotherapy of Moderate to Severe COPD
DAXAS

31. Key Message

32. End of Life Care in COPD

33. Overall Causes of Death in COPD Patients
This slide illustrates what the overall causes of death were in the TORCH study, based on the primary cause of death in the Efficacy population assigned by the Clinical Endpoint Committee
Note that slightly different proportions have been published in the CEC manuscript (McGarvey et al2) – cardiovascular 26%, respiratory 35%, cancer 21%, Other 10%, Unknown 8%) which are based on all the deaths adjudicated (911) rather than the 875 deaths in the Efficacy population
References
Calverley PMA, Anderson JA, Celli B. for the TORCH investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. NEJM 2007; 356(8):
McGarvey LP, John M, Anderson JA, Zvarich M, Wise RA. Ascertainment of cause-specific mortality in COPD – operations of the TORCH Clinical Endpoint Committee. Thorax 2007 (in press)

34. End of Life Care Relief of Dyspnea Treatment of AECOPD
Supplemental Oxygen
Narcotics
Advanced Directive

35. CTS Recommendations for the Management of COPD

36. Acknowledgemnts
Dr. John Bertley - slides
CTS guidelines