The latest guidelines on the management of a COPD patient ( Stable COPD, patient with an exacerbation of COPD), latest modalities of treatment of a COPD patient
2. ROAD MAP
APPROACH TO A CASE OF COPD
2014 GUIDELINES OF COPD MANAGEMENT
A) Management of Stable COPD
B) Management of COPD exacerbations
NEWER THERAPIES
3. Approach
COPD SHOULD BE CONSIDERED
Over the age of 35 to 40
Shortness of breath with chronic cough and sputum
production,
Frequent winter colds
H/O exposure to risk factors for the disease.
STEPS
Assessment of symptoms
Assessment of degree of airflow obstruction by spirometry
and other investigations.
Assessment of risk of exacerbations
Assessment of comorbidities
4. Assessment of symptoms
COPD assessment test ( An 8 item measurement of
health status in COPD)
Clinical COPD Questionnaire ( Self administered
questionnaire to measure clinical control in patients
with COPD)
Modified British Medical Reasearch Questionnaire
6. OTHER INVESTIGATIONS
Chest X-ray: Seldom diagnostic but valuable to
exclude alternative diagnoses and establish presence
of significant comorbidities.
Lung Volumes and Diffusing Capacity: Help to
characterize severity, but no role in management.
Oximetry and Arterial Blood Gases: to evaluate
need for supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening:
Perform when COPD develops in patients of Caucasian
descent under 45 years or with a strong family history
of COPD.
8. Assessment of risk of exacerbations
To assess risk of exacerbations use history of
exacerbations and spirometry:
Two or more exacerbations within the last year or an
FEV1 < 50 % of predicted value are indicators of high
risk.
One or more hospitalizations for COPD exacerbation
should be considered
10. PATIENT CHARECTERSTIC SPIROMETRIC
CLASSIFICATION
EXACERBATION
PER YEAR
CAT mMRC
A
Low Risk
Less
Symptoms
GOLD 1-2 ≤ 1 < 10 0-1
B
Low Risk
More
Symptoms
GOLD 1-2 ≤ 1 > 10 > 2
C
High Risk
Less
Symptoms
GOLD 3-4 > 2 < 10 0-1
D
High Risk
More
Symptoms
GOLD 3-4 > 2 > 10 > 2
Combined assessment of COPD
12. A1 Antitrypsin deficiency
Alpha 1-antitrypsin deficiency (α1-antitrypsin deficiency, A1AD) is
a genetic disorder that causes defective production of (A1AT), leading
to decreased A1AT activity in the blood and lungs and deposition of
excessive abnormal A1AT protein in liver cells
Severe A1AT deficiency causes panacinar emphysema or COPD in
adult life in many people with the condition (especially if they are
exposed to cigarette smoke) along with various other conditions such
as
Cirrhosis, Asthma, Wegener’s Granulomatosis, Pancreatitis,
Gallstones, Bronchiectasis, Emphysema, Autoimmune hepatitis,
Cancer
13. The serum levels of some of the common genotypes are
PiMM: 100% (normal)
PiMS: 80% of normal serum level of A1AT
PiSS: 60% of normal serum level of A1AT
PiMZ: 60% of normal serum level of A1AT
PiSZ: 40% of normal serum level of A1AT
PiZZ: 10-15% (severe alpha 1-antitrypsin deficiency)
Treatment
Lung-affected A1AD patients may receive intravenous infusions of
alpha-1 antitrypsin, derived from donated human plasma. This
augmentation therapy is thought to arrest the course of the
disease and halt any further damage to the lungs.
17. Managing stable COPD:
Stop smoking
Encouraging patients with COPD to stop smoking is one
of the most important components of their management
All COPD patients still smoking, regardless of age,
should be encouraged to stop, and offered help to do so,
at every opportunity
Record a smoking history, including pack years smoked
Offer nicotine replacement therapy, varenicline or
bupropion (unless contraindicated) combined with a
support programme to optimise quit rates
18. Anti smoking therapy
Nicotine replacement therapy– Transdermal patches,
gums, sprays, lozenges, inhalers
Bupropion (Zyban) ( Anti depressant)
Nicotinic receptor partial agonist - Varenicline
(Chantix), Cystisine
Psychosocial approaches – Cognitive behavioral therapy
VACCINES
Influenza vaccines and Pneumococcal polysaccharide
vaccine is recommended for COPD patients
65 years or more
younger than age 65 with FEV1< 40% predicted
19. Pulmonary rehabitilation
It is divided into
Pharmacological
Non – pharmacological
Non pharmacological includes exercises, nutritional plan
Exercise is the cornerstone of pulmonary rehabilitation programs.
Although, exercise training does not directly improves lung function, it
causes improvement in physical condition. There are three basic types
of exercises to be considered. Aerobic exercise tends to improve the
body's ability to use oxygen by decreasing the heart rate and blood
pressure. Strengthening or resistance exercises can help build strength
in the respiratory muscles. Stretching and flexibility exercises like yoga
can enhance breathing coordination.
23. The phospodiesterase-4 inhibitor Roflumilast may be useful to
reduce exacerbations for patients with FEV1 < 50% of predicted,
chronic bronchitis, and frequent exacerbations
Theophylline –
Theophylline is less effective and less well tolerated than inhaled
long- acting bronchodilators and is not recommended if those
drugs are available and affordable.
There is evidence for a modest bronchodilator effect and some
symptomatic benefit in stable COPD. Addition of theophylline
to salmeterol produces a greater increase in FEV1 and a
decrease in breathlessness than salmeterol alone.
Low dose theophylline reduces exacerbations but does not
improve post-bronchodilator lung function.
24. Role of Antibiotics
Antibiotics should be given to patients with 3 cardinal
symptoms
A) Increased Dyspnoea
B) Increased sputum volume
C) Increased sputum prevalence
And people who are on mechanical ventilation
assistance
25. NEJM Aug 25th 2011
Adding Azithromycin, at a dose of 250 mg daily, for 1 year to
the usual treatment of patients who have an increased risk of
acute exacerbations of COPD
Advantages
1) Decreased the number of exacerbations per year
2) the incidence of colonization with selected respiratory
pathogens
3) Increased the quality of life
Disadvantages
1) Increased hearing loss in a small % of patients
2) Prolonged QTc
28. Advantages Of NIPPV
Decreases need for invasive ventilation and may be
associated with improved outcome.
CPAP alone can reduce work of breathing in COPD during
weaning and during sleep.
BiPAP weaning may be better than weaning on pressure
support via an ETT.
A lower rate of treatment failure ;lower mortality rate.
Greater improvements in the 1-hour
post-treatment pH and PaCO2 levels
29. Indication and Relative contraindication for NIPPV
Selection Criteria:
Moderate to severe dyspnea with the use of accessory muscles,
paradoxical breathing.
Moderate to severe acidosis PH 7.35 and/or PaCO2 > 45
mmHg
or PaO2/FiO2 < 200
RR > 25 breaths/min,accessory muscle
Exclusion Criteria:
Respiratory arrest. Cardiovascular instability.
Burns Extreme obesity.
Craniofacial trauma. APACHE score >29
High aspiration risk(. Cannot protect the airway )
30. Indications of IIPPV:
Hypoxemia that has not corrected with NIPPV
Exclusion criteria of NIPPV
Sever acidosis PH<7.25 and/or PaCO2 >60 mmHg
Impending respiratory arrest
Respiratory rate > 36 breaths/minute
Use of all accessory muscles
Thoracoabdominal paradox
Even minor mental state changes
Patient's subjective sense of exhaustion
Cardiovascular instability
31. Management of a COPD patient on ventilator
Use low tidal volumes to prevent stretching of the lung
parenchyma and VIL (Ventilator induced injury)
Another adverse effect of invasive mechanical ventilation in
COPD is the generation or aggravation of PEEPi
Auto (intrinsic) PEEP — Incomplete expiration prior to the initiation
of the next breath causes progressive air trapping . This
accumulation of air increases alveolar pressure at the end of
expiration, which is referred to as auto-PEEP.
Auto-PEEP develops commonly in high minute ventilation expiratory
flow limitation (obstructed airway) and expiratory resistance
(narrow airway).
Once auto-PEEP is identified, steps should be taken to stop or
reduce the pressure build-up. When auto-PEEP persists despite
management of its underlying cause, applied PEEP may be helpful if
the patient has an expiratory flow limitation (obstruction).
32. Applied (extrinsic) PEEP —
A small amount of applied PEEP (3 to 5 cmH2O) is used in most
mechanically ventilated patients to mitigate end-expiratory
alveolar collapse. A higher level of applied PEEP (>5 cmH2O) is
sometimes used to improve hypoxemia or reduce VILI in
patients with acute lung injury, acute respiratory distress
syndrome, or other types of hypoxemic respiratory failure.
Complications
Decrease in systemic venous return
Pulmonary baotrauma can be caused. Pulmonary barotrauma is
lung injury that results from the hyperinflation of alveoli past
the rupture point.
Raised ICP
Renal functions and electrolyte imbalances, due to decreased
venous return metabolism of certain drugs are altered and acid-
base balance is impeded
35. LVRS Lung Transplantation
Patient Factors Favoring LVRS over
Lung Transplantation
• Age > 65 yr
• Chronic medical conditions: Chronic
active viral hepatitis B, hepatitis C with
biopsy-proven histologic evidence of liver
disease, or HIV infection
• Organ system dysfunction precluding
appropriate immunosuppressive therapy:
renal insufficiency, liver dysfunction,
neuropathy, significant osteoporosis,
uncontrolled diabetes
• Refractory gastroesophageal reflux
disease
• Malignancy
• Inability to maintain long-term follow-up
• Psychiatric conditions
• Lack of social support
Patient Factors Favoring Lung
Transplantation over LVRS
• FEV1 ⩽ 20% predicted and either
homogeneous disease or DlCO ⩽
20% predicted
• Lack of emphysema on HRCT
• TLC < 100% predicted
• RV < 150% predicted
• PaCO2 > 60 mm Hg
• PaO2 < 45 mm Hg
• 6MWD ⩽ 140 m, < 3 min
unloaded pedaling on cycle
ergometer
• Pulmonary hypertension
• Clinically significant
bronchiectasis and/or recurrent
pulmonary infections
36. Newer modalities
A new study called the STASCOPE study funded by the National Heart
Lung and Blood Institute is being conducted to determine if
Simvastatin might reduce swelling in the lungs in patients with
COPD.
If it is found that Simvastatin reduces lung inflammation, there is a
possibility that the statin drug could also the limit the number or
severity of the exacerbations.
Beta Blockers may reduce mortality and exacerbations when added
to established inhaled stepwise therapy for COPD, independently of
CVD and cardiac drugs, and without adverse effects on pulmonary
function.
37. Asthma COPD Overlap Syndrome (ACOS)
A chapter on Asthma and COPD Overlap Syndrome (ACOS)
is in preparation by the Global Initiative for Chronic
Obstructive Lung Disease (GOLD).
major criteria for ACOS:
a physician diagnosis of asthma and COPD in the same
patient,
history or evidence of atopy, for example, hay fever, elevated
total IgE,
age 40 years or more,
smoking >10 pack-years, postbronchodilator FEV1 <80%
predicted and FEV1/FVC <70%.
A ≥15% increase in FEV1 or ≥12% and ≥200 ml increase in
FEV1 postbronchodilator treatment with albuterol would be
a minor criteria