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Pharmacology for COPD
GOLD Goals for COPD treatment
Disease Management should now be focusing on
 2 key areas
1. Reducing Symptoms
2. Reducing Risk.




                                        Adapted from GOLD 2013
GOLD 2013
                               Combined assessment of COPD
                             GOLD 4


                                                                                              ≥2


                             GOLD 3
                                      Less symptoms               More symptoms
SPIROMETRIC CLASSIFICATION




                                                                                                   EXACERBATION /YEAR
                                         High risk                  high risk




                             GOLD 2



                                                                                             <2
                                      Less symptoms               More symptoms
                             GOLD 1      Low risk                    low risk

                                            mMRC 01                    mMRC ≥2
                                             CAT <10   SYMPTOMS         CAT ≥10   Adapted from GOLD 2013
Pharmacological Treatment
      Patient         Recommended                           Alternative Choice                        Other possible treatments
                       First Choice
                                                                 LAMA
                         SAMA prn                                  or
          A                 or                                   LABA                                             Theophylline
                         SABA prn                                  or
                                                             SABA and SAMA
                             LAMA
                                                                                                          SABA and/or SAMA
          B                    or                            LAMA and LABA
                                                                                                             Theophylline
                             LABA

                         ICS + LABA                         LAMA and LABA
                                                                                                          SABA and/or SAMA
          C                   or                           LAMA + PDE4-inh.
                                                                                                             Theophylline
                            LAMA                           LABA + PDE4-inh.

                         ICS + LABA                  ICS + LABA and LAMA or
                                                                                                            Carbocysteine
                           And/ or                  ICS+LABA and PDE4-inh. or
          D                                                                                               SABA and/or SAMA
                           LAMA                         LAMA and LABA or
                                                                                                             Theophylline
                                                       LAMA and PDE4-inh.

(Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)
*Alternative medications can be used alone or in combination with other options in the First and Second columns       Adapted from GOLD 2013
Patient Type (A)
            Treatment Options

  1st Recommended choice :                                                                                                                <2
  • SABA Prn Or SAMA Prn                                                  GOLD 2




                                                                                                                                          EXACERBATION /YEAR
  Alternative Choice:
  • LABA Or LAMA
  Or                                                                      GOLD 1                        Less symptoms
  •SABA and SAMA                                                                                           Low risk

  Other Possible treatments *:                                                                                     mMRC 01
  • Theophylline                                                                                                    CAT <10




* Medications can be used alone or in combination with other options in the First recommended or alternative choices

                                                                                                                              Adapted from GOLD 2013
Short acting bronchodilators

Used as reliever medication
Types:

 ▫ Β2 agonists
    Salbutamol
 ▫ Anlicholinergics:
    Ipratroium
Potential Side Effects of COPD
therapy: β2 Agonists
Side effects include:
 ▫   Resting sinus tachycardia
 ▫   Ventricular arrhythmias (rare)
 ▫   Somatic tremor
 ▫   Hypokalemia
 ▫   Mild falls in PaO2
Potential Side Effects of COPD
Therapy: Anticholinergic Agents
Side effects are less common versus systemic
 agents (e.g., atropine)
 ▫ Dry mouth is most commonly reported adverse
   event (related to local deposition of agent)
 ▫ Possible worsening of glaucoma
 ▫ Occasional prostatic symptoms
Patient Type (B)
         Treatment Options

       1st Recommended choice :
                                                                                                                                            <2
       LABA or LAMA




                                                                                                                                             EXACERBATION /YEAR
                                                                            GOLD 2
       Alternative Choice:
       • LABA and LAMA                                                      GOLD 1
                                                                                                        More symptoms
       Other Possible treatments *:                                                                        low risk
       • SABA and/or SAMA
       • Theophylline
                                                                                                                       mMRC ≥2
                                                                                                                       CAT ≥10




* Medications can be used alone or in combination with other options in the First recommended or alternative choices

                                                                                                                                 Adapted from GOLD 2013
Long-acting Bronchodilators in
COPD
Patients with dyspnea that is not relieved by the
 as-needed use of a short-acting bronchodilator
 should have a long acting Inhaled
 bronchodilator added to therapy
These agents include:
 ▫   Formoterol
 ▫   Indacaterol
 ▫   Tiotropium
 ▫   Salmeterol
LABAs in COPD guidelines
 British Thoracic Society suggest that long-acting bronchodilator
  therapy should always be considered when patients with COPD are
  symptomatic
 GOLD treatment recommendations for patients with stable COPD
  are characterized by a stepwise increase in therapy according to
  disease severity
 ATS/ERS COPD guidelines have indicated the importance of
  starting regular maintenance therapy based on the presence of
  persistent symptoms, regardless of the disease stage.
 The choice of agents may be based primarily on individual response,
  cost, side-effect profile and availability.


                                              International Journal of COPD 2008:3(4) 521–529
Patient Type (C)
         Treatment Options
 1st Recommended choice :
 LABA + ICS                                                                                                                      ≥2
 Or




                                                                                                                                   EXACERBATION /YEAR
 •LAMA                                                                   GOLD 4

 Alternative Choice:
 •LABA and LAMA                                                                                        Less symptoms
                                                                          GOLD 3
 •LAMA + PDE4-inh.                                                                                        High risk
 •LABA + PDE4-inh.
                                                                                                             mMRC 01
 Other Possible treatments *:                                                                                 CAT <10
 •SABA and/or SAMA
 •Theophylline

* Medications can be used alone or in combination with other options in the First recommended or alternative choices

                                                                                                                        Adapted from GOLD 2013
Patient Type (D)
               Treatment Options
    1st Recommended choice :
    • LABA + ICS
    And / or LAMA                                                                                                                        ≥2




                                                                                                                                          EXACERBATION /YEAR
    Alternative Choice:                                                   GOLD 4
    • LABA + ICS and LAMA or
    • LABA + ICS and PDE4-inh. or
    • LABA and LAMA or                                                                                  More symptoms
                                                                            GOLD 3                        high risk
    • LAMA and PDE4-inh. Or
    Other Possible treatments *:
    • Carbocysteine
                                                                                                                   mMRC ≥2
    • SABA and/or SAMA                                                                                             CAT ≥10
    • Theophylline



* Medications can be used alone or in combination with other options in the First recommended or alternative choices

                                                                                                                             Adapted from GOLD 2013
Impact of Exacerbations in COPD

            Patients with Frequent Exacerbations


                                                   Greater Airway
                                                    Inflammation
Fast Decline in lung
      function
                                      Higher Mortality
             Poorer Quality of Life
ECI COPD Course Lercture 2
Inhaled Corticosteroids
Inflammation plays central role in COPD &
 therapies aimed at halting or reversing
 inflammation are needed
Inhaled corticosteroids (ICS) decrease rate of
 exacerbation & may improve response to
 bronchodilators & decrease dyspnea in stable
 COPD
No studies show ICS reduce loss of lung function
Studies have not established a survival benefit
 when ICS is combined with long-acting B2 agonists
ECI COPD Course Lercture 2
Roflumilast Overview
 First oral COPD specific anti-inflammatory therapy for patients with
  severe COPD who have symptoms of chronic cough and sputum,
  history of frequent exncerbations. and on maintenance
  bronchodilat0r therapy
 A potent and selective Inhibitor of the PDE4 enzyme, that targets
  the chronic inflammation underlying COPD
 Indicated in EU for maintenance treatment of severe COPD
  associated with chronic bronchitis in adult patients with a history of
  frequent exacerbations, as add-on to bronchodilator treatment
 Significantly reduced exacerbations and improved lung function
  when added to maintenance therapy with bronchodilators, in
  patients with severe COPD, symptoms of chronic bronchitis, a
  history of frequent exacerbations
ECI COPD Course Lercture 2
Influenza Vaccination:
Risk for Any Exacerbation
Evaluation of results from randomized clinical trials
 indicates that inactivated influenza vaccine reduces
 exacerbations in COPD patients
The magnitude of this benefit is similar to that seen in
 large observational studies, and was due to a reduction
 in exacerbations occurring three or more weeks after
 vaccination, and due to influenza
There is a mild increase in transient local adverse effects
 with vaccination, but no evidence of an increase in early
 exacerbations.
ECI COPD Course Lercture 2
Selecting an Appropriate Aerosol Delivery
Device is Critical to Successfully Tx COPD
The number of different devices- each with
 different characteristics, requiring different
 inhalation techniques -can be confusing for the
 patient and the clinician.
Consider the unique features of the Inhaler In
 relation to the ventilatory nuances imposed by
 the disease.
Multiple devices are commonly used by patients
 with more severe disease, but can be confusing –
 leading to decreased adherence.
Pressurized Metered-dose
Inhalers (pMDIs)
Most commonly used handheld aerosol delivery device
Newer HFA-propellants provide an aerosol with lower
 forward jet velocity than the older CFC-propelled MDIs
Potential issues:
 ▫ Hand-breath coordination
 ▫ Taking a slow rather than rapid inhalation
 ▫ whether to inhale from residual volume or functional
    capacity
 ▫ Length of breath-hold at end-inspiration
 ▫ Priming and shaking before use
Dry Powder Inhalers(DPIs)
Breath-actuated- thus, eliminate many of the
 problems associated with coordinating pMDI
 actuation and inhalation
Potential issues:
 ▫ Need for higher inspiratory flow rate vs. pMDI
 ▫ Resistance can vary 10"fold depending on design
 ▫ Inhaler preparation and failure to hold device correctly
   may contribute to high error rates in some patients
Nebulizers
Alternate to pMDIs and DPIs for providing
 aerosol therapy, provided that the drug is
 available in liquid form
Most user-friendly of the inhaler devices
Frequently prescribed for patients with COPD
 ▫ Minimal coordination and effort is required
   during Inhalation compared to pMDIs and DPIs
 ▫ Aerosol is continuously produced
 ▫ Patient can sit comfortable, using tidal-volume
   breathing
Manage Stable COPD
Key Points
Regular treatment with inhaled
 glucocorticosteroids is appropriate for
 symptomatic COPD patients with an FEV1 <50%
 predicted (Stage lll: Severe COPD and Stage IV:
 Very Severe COPD) and repeated exacerbations
 e.g. 3 in the last three years (Evidence A).
This treatment has been shown to reduce the
 frequency of exacerbations and improve health
 status (Evidence A).
Manage Stable COPD
Key Points
Chronic treatment with systemic gluco-
 corticosteroids should be avoided because of an
 unfavorable benefit-to-risk ratio (Evidence A).
All COPD-patients benefit from exercise
 training programs, improving with respect to
 both exercise tolerance and symptoms of
 dyspnea and fatigue (Evidence A).
Bronchodilators in Stable COPD
Bronchodilator medications are central to
 symptom management in COPD
Inhaled therapy is preferred
The choice between beta-2 agonist,
 anticholinergic, theophylline, or combination
 therapy depends on availability and individual
 response in terms of symptom relief and side
 effects
ECI COPD Course Lercture 2
Life-Prolonging COPD Therapies
Supplemental oxygen

Smoking cessation

Surgery for selected patients: predominantly
 upper-lobe emphysema and low exercise
 capacity
ECI COPD Course Lercture 2
NOTT Study
Patients received continuous O2 or nocturnal
 O2
O2 dose adjusted for PaO2 of 60 - 80 mm Hg;
 increased by 1 L/min for exercise and sleep
ECI COPD Course Lercture 2
MRC study
Treatment group received O2 at least 15h/d
 (including sleeping hours) at 2 L/min; higher if
 needed to achieve PaO2 >60 mmHg
NOTT Study
One year mortality    Two-year mortality
 ▫ ARR: 8.7%            ▫ ARR: 18.4%
 ▫ RRR: 42.2%           ▫ RRR: 45.1%
 ▫ NNT: 11.5            ▫ NNT: 5.4

            MRC Study
Five-year mortality
  ▫ ARR: 21.5%
  ▫ RRR:32.2%                   ARR: Absolute Risk Reduction

  ▫ NNT: 4.65
                                RRR: Relative Risk Reduction
                                NNT: Number Needed to Treat
Indications for LTOT
 Based on randomized controlled               Based on Less Evidence
 clinical trials
  Continuous oxygen use                       Intermittent oxygen use
     ▫ Resting PaO2≤55 mm Hg                    ▫ Desaturation (Spo2≤ 88%)
     ▫ Resting PaO2 of 56-59 mm Hg with           with activity
       any one of the following:
                                                ▫ Desaturation (Spo2≤ 88%)
        Dependent Edema
                                                  at night
        P pulmonale on the
         electrocardiogram(P wave
         exceeding 3 mm in standard lead
         II, III or a VF)
        Polycythemia( hematocrit,> 56%)



Spo2 = oxygen saturation by pulse oximetry.
                                                     Stoller, Chest 2010;138:179
Oxygen Source: Cylinders
Not practical as primary system
Used as a backup for primary O2 system or for
 portability
Oxygen Concentrator
Oxygen from air (≈ 90-95%)
Most to 5 L/min; some to 10
 L/min
Simple; low maintenance
Electrically powered
Backup cylinder needed or
 portable concentrator
Less patient phobia than other
 systems
Conventional concentrators
 not portable
Transfilling Concentrators
Portable concentrators




• Maximum O2 produced and the dosing of the O2 differ by concentrator.
• If the patient increases the demand with a higher dose setting or
respiratory rate, either delivered dose. %O2, or both will decrease.
Liquid Oxygen
More efficient
Base unit
Portable unit (filled from base)
Higher flows available
Requires refilling
Backup cylinder needed
Patient phobia (thermal injury)
Oxygen Conserving Devices
Pulse dose (battery powered): fixed volume per
 breath; use standard cannula
 ▫ O2 on every breath or on alternate breaths
 ▫ Vary dose by peak flow or duration
Demand devices (pneumatically powered):
 deliver oxygen only during inhalation; use dual-
 lumen cannula
Reservoir cannula
Transtracheal oxygen
Oxygen Conserving Devices
Cylinders last longer
Fewer complications (drying, irritation, taste)
Cylinder devices: fit on any cylinder
Liquid devices: incorporated into device
Different devices produce different oxygenation
 and different devices may respond differently to
 varying conditions (exercise, sleep).
Prescription should be device specific
Reservoir Oxygen Cannula
Transtracheal Oxygen
Oxygen delivered directly into the
 trachea through a surgically implanted
 catheter
Advantages: inconspicuous; lack of
 nasal. ear, and facial irritation; remains
 in place during sleep and exercise
Complications: subcutaneous
 emphysema, bronchospasm, and
 paroxysmal coughing during placement;
 late complications include dislodged
 catheters, stomal infections, mucous
 balls (may be fatal)
Summary
O2 therapy for the patient with COPD is life-
 saving
O2 source can be cylinder, concentrator, or
 liquid
Portable O2 is important (necessary!)
O2 conserving devices extend the time patient
 can be away from fixed O2 source
Important for the clinician to appreciate
 differences between LTOT devices
ECI COPD Course Lercture 2

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ECI COPD Course Lercture 2

  • 2. GOLD Goals for COPD treatment Disease Management should now be focusing on 2 key areas 1. Reducing Symptoms 2. Reducing Risk. Adapted from GOLD 2013
  • 3. GOLD 2013 Combined assessment of COPD GOLD 4 ≥2 GOLD 3 Less symptoms More symptoms SPIROMETRIC CLASSIFICATION EXACERBATION /YEAR High risk high risk GOLD 2 <2 Less symptoms More symptoms GOLD 1 Low risk low risk mMRC 01 mMRC ≥2 CAT <10 SYMPTOMS CAT ≥10 Adapted from GOLD 2013
  • 4. Pharmacological Treatment Patient Recommended Alternative Choice Other possible treatments First Choice LAMA SAMA prn or A or LABA Theophylline SABA prn or SABA and SAMA LAMA SABA and/or SAMA B or LAMA and LABA Theophylline LABA ICS + LABA LAMA and LABA SABA and/or SAMA C or LAMA + PDE4-inh. Theophylline LAMA LABA + PDE4-inh. ICS + LABA ICS + LABA and LAMA or Carbocysteine And/ or ICS+LABA and PDE4-inh. or D SABA and/or SAMA LAMA LAMA and LABA or Theophylline LAMA and PDE4-inh. (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.) *Alternative medications can be used alone or in combination with other options in the First and Second columns Adapted from GOLD 2013
  • 5. Patient Type (A) Treatment Options 1st Recommended choice : <2 • SABA Prn Or SAMA Prn GOLD 2 EXACERBATION /YEAR Alternative Choice: • LABA Or LAMA Or GOLD 1 Less symptoms •SABA and SAMA Low risk Other Possible treatments *: mMRC 01 • Theophylline CAT <10 * Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 6. Short acting bronchodilators Used as reliever medication Types: ▫ Β2 agonists  Salbutamol ▫ Anlicholinergics:  Ipratroium
  • 7. Potential Side Effects of COPD therapy: β2 Agonists Side effects include: ▫ Resting sinus tachycardia ▫ Ventricular arrhythmias (rare) ▫ Somatic tremor ▫ Hypokalemia ▫ Mild falls in PaO2
  • 8. Potential Side Effects of COPD Therapy: Anticholinergic Agents Side effects are less common versus systemic agents (e.g., atropine) ▫ Dry mouth is most commonly reported adverse event (related to local deposition of agent) ▫ Possible worsening of glaucoma ▫ Occasional prostatic symptoms
  • 9. Patient Type (B) Treatment Options 1st Recommended choice : <2 LABA or LAMA EXACERBATION /YEAR GOLD 2 Alternative Choice: • LABA and LAMA GOLD 1 More symptoms Other Possible treatments *: low risk • SABA and/or SAMA • Theophylline mMRC ≥2 CAT ≥10 * Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 10. Long-acting Bronchodilators in COPD Patients with dyspnea that is not relieved by the as-needed use of a short-acting bronchodilator should have a long acting Inhaled bronchodilator added to therapy These agents include: ▫ Formoterol ▫ Indacaterol ▫ Tiotropium ▫ Salmeterol
  • 11. LABAs in COPD guidelines  British Thoracic Society suggest that long-acting bronchodilator therapy should always be considered when patients with COPD are symptomatic  GOLD treatment recommendations for patients with stable COPD are characterized by a stepwise increase in therapy according to disease severity  ATS/ERS COPD guidelines have indicated the importance of starting regular maintenance therapy based on the presence of persistent symptoms, regardless of the disease stage.  The choice of agents may be based primarily on individual response, cost, side-effect profile and availability. International Journal of COPD 2008:3(4) 521–529
  • 12. Patient Type (C) Treatment Options 1st Recommended choice : LABA + ICS ≥2 Or EXACERBATION /YEAR •LAMA GOLD 4 Alternative Choice: •LABA and LAMA Less symptoms GOLD 3 •LAMA + PDE4-inh. High risk •LABA + PDE4-inh. mMRC 01 Other Possible treatments *: CAT <10 •SABA and/or SAMA •Theophylline * Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 13. Patient Type (D) Treatment Options 1st Recommended choice : • LABA + ICS And / or LAMA ≥2 EXACERBATION /YEAR Alternative Choice: GOLD 4 • LABA + ICS and LAMA or • LABA + ICS and PDE4-inh. or • LABA and LAMA or More symptoms GOLD 3 high risk • LAMA and PDE4-inh. Or Other Possible treatments *: • Carbocysteine mMRC ≥2 • SABA and/or SAMA CAT ≥10 • Theophylline * Medications can be used alone or in combination with other options in the First recommended or alternative choices Adapted from GOLD 2013
  • 14. Impact of Exacerbations in COPD Patients with Frequent Exacerbations Greater Airway Inflammation Fast Decline in lung function Higher Mortality Poorer Quality of Life
  • 16. Inhaled Corticosteroids Inflammation plays central role in COPD & therapies aimed at halting or reversing inflammation are needed Inhaled corticosteroids (ICS) decrease rate of exacerbation & may improve response to bronchodilators & decrease dyspnea in stable COPD No studies show ICS reduce loss of lung function Studies have not established a survival benefit when ICS is combined with long-acting B2 agonists
  • 18. Roflumilast Overview  First oral COPD specific anti-inflammatory therapy for patients with severe COPD who have symptoms of chronic cough and sputum, history of frequent exncerbations. and on maintenance bronchodilat0r therapy  A potent and selective Inhibitor of the PDE4 enzyme, that targets the chronic inflammation underlying COPD  Indicated in EU for maintenance treatment of severe COPD associated with chronic bronchitis in adult patients with a history of frequent exacerbations, as add-on to bronchodilator treatment  Significantly reduced exacerbations and improved lung function when added to maintenance therapy with bronchodilators, in patients with severe COPD, symptoms of chronic bronchitis, a history of frequent exacerbations
  • 20. Influenza Vaccination: Risk for Any Exacerbation Evaluation of results from randomized clinical trials indicates that inactivated influenza vaccine reduces exacerbations in COPD patients The magnitude of this benefit is similar to that seen in large observational studies, and was due to a reduction in exacerbations occurring three or more weeks after vaccination, and due to influenza There is a mild increase in transient local adverse effects with vaccination, but no evidence of an increase in early exacerbations.
  • 22. Selecting an Appropriate Aerosol Delivery Device is Critical to Successfully Tx COPD The number of different devices- each with different characteristics, requiring different inhalation techniques -can be confusing for the patient and the clinician. Consider the unique features of the Inhaler In relation to the ventilatory nuances imposed by the disease. Multiple devices are commonly used by patients with more severe disease, but can be confusing – leading to decreased adherence.
  • 23. Pressurized Metered-dose Inhalers (pMDIs) Most commonly used handheld aerosol delivery device Newer HFA-propellants provide an aerosol with lower forward jet velocity than the older CFC-propelled MDIs Potential issues: ▫ Hand-breath coordination ▫ Taking a slow rather than rapid inhalation ▫ whether to inhale from residual volume or functional capacity ▫ Length of breath-hold at end-inspiration ▫ Priming and shaking before use
  • 24. Dry Powder Inhalers(DPIs) Breath-actuated- thus, eliminate many of the problems associated with coordinating pMDI actuation and inhalation Potential issues: ▫ Need for higher inspiratory flow rate vs. pMDI ▫ Resistance can vary 10"fold depending on design ▫ Inhaler preparation and failure to hold device correctly may contribute to high error rates in some patients
  • 25. Nebulizers Alternate to pMDIs and DPIs for providing aerosol therapy, provided that the drug is available in liquid form Most user-friendly of the inhaler devices Frequently prescribed for patients with COPD ▫ Minimal coordination and effort is required during Inhalation compared to pMDIs and DPIs ▫ Aerosol is continuously produced ▫ Patient can sit comfortable, using tidal-volume breathing
  • 26. Manage Stable COPD Key Points Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV1 <50% predicted (Stage lll: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A). This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A).
  • 27. Manage Stable COPD Key Points Chronic treatment with systemic gluco- corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A). All COPD-patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).
  • 28. Bronchodilators in Stable COPD Bronchodilator medications are central to symptom management in COPD Inhaled therapy is preferred The choice between beta-2 agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects
  • 30. Life-Prolonging COPD Therapies Supplemental oxygen Smoking cessation Surgery for selected patients: predominantly upper-lobe emphysema and low exercise capacity
  • 32. NOTT Study Patients received continuous O2 or nocturnal O2 O2 dose adjusted for PaO2 of 60 - 80 mm Hg; increased by 1 L/min for exercise and sleep
  • 34. MRC study Treatment group received O2 at least 15h/d (including sleeping hours) at 2 L/min; higher if needed to achieve PaO2 >60 mmHg
  • 35. NOTT Study One year mortality Two-year mortality ▫ ARR: 8.7% ▫ ARR: 18.4% ▫ RRR: 42.2% ▫ RRR: 45.1% ▫ NNT: 11.5 ▫ NNT: 5.4 MRC Study Five-year mortality ▫ ARR: 21.5% ▫ RRR:32.2% ARR: Absolute Risk Reduction ▫ NNT: 4.65 RRR: Relative Risk Reduction NNT: Number Needed to Treat
  • 36. Indications for LTOT Based on randomized controlled Based on Less Evidence clinical trials  Continuous oxygen use  Intermittent oxygen use ▫ Resting PaO2≤55 mm Hg ▫ Desaturation (Spo2≤ 88%) ▫ Resting PaO2 of 56-59 mm Hg with with activity any one of the following: ▫ Desaturation (Spo2≤ 88%)  Dependent Edema at night  P pulmonale on the electrocardiogram(P wave exceeding 3 mm in standard lead II, III or a VF)  Polycythemia( hematocrit,> 56%) Spo2 = oxygen saturation by pulse oximetry. Stoller, Chest 2010;138:179
  • 37. Oxygen Source: Cylinders Not practical as primary system Used as a backup for primary O2 system or for portability
  • 38. Oxygen Concentrator Oxygen from air (≈ 90-95%) Most to 5 L/min; some to 10 L/min Simple; low maintenance Electrically powered Backup cylinder needed or portable concentrator Less patient phobia than other systems Conventional concentrators not portable
  • 40. Portable concentrators • Maximum O2 produced and the dosing of the O2 differ by concentrator. • If the patient increases the demand with a higher dose setting or respiratory rate, either delivered dose. %O2, or both will decrease.
  • 41. Liquid Oxygen More efficient Base unit Portable unit (filled from base) Higher flows available Requires refilling Backup cylinder needed Patient phobia (thermal injury)
  • 42. Oxygen Conserving Devices Pulse dose (battery powered): fixed volume per breath; use standard cannula ▫ O2 on every breath or on alternate breaths ▫ Vary dose by peak flow or duration Demand devices (pneumatically powered): deliver oxygen only during inhalation; use dual- lumen cannula Reservoir cannula Transtracheal oxygen
  • 43. Oxygen Conserving Devices Cylinders last longer Fewer complications (drying, irritation, taste) Cylinder devices: fit on any cylinder Liquid devices: incorporated into device Different devices produce different oxygenation and different devices may respond differently to varying conditions (exercise, sleep). Prescription should be device specific
  • 45. Transtracheal Oxygen Oxygen delivered directly into the trachea through a surgically implanted catheter Advantages: inconspicuous; lack of nasal. ear, and facial irritation; remains in place during sleep and exercise Complications: subcutaneous emphysema, bronchospasm, and paroxysmal coughing during placement; late complications include dislodged catheters, stomal infections, mucous balls (may be fatal)
  • 46. Summary O2 therapy for the patient with COPD is life- saving O2 source can be cylinder, concentrator, or liquid Portable O2 is important (necessary!) O2 conserving devices extend the time patient can be away from fixed O2 source Important for the clinician to appreciate differences between LTOT devices