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 01 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 01
• 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
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 01
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
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
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