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Presentation on theme: "Lobal Initiative for Chronic bstructive ung isease GOLDGOLD GOLDGOLD."— Presentation transcript:

1 lobal Initiative for Chronic bstructive ung isease GOLDGOLD GOLDGOLD

2 18/Oct/2005Dr. David P. Breen2 GOLD Website Address http://www.goldcopd.com

3 18/Oct/2005Dr. David P. Breen3 Facts About COPD n COPD is the 4 th leading cause of death in the United States (behind heart disease, cancer, and cerebrovascular disease). n In 2000, the WHO estimated 2.74 million deaths worldwide from COPD. n In 1990, COPD was ranked 12 th as a burden of disease; by 2020 it is projected to rank 5 th. n COPD is the 4 th leading cause of death in the United States (behind heart disease, cancer, and cerebrovascular disease). n In 2000, the WHO estimated 2.74 million deaths worldwide from COPD. n In 1990, COPD was ranked 12 th as a burden of disease; by 2020 it is projected to rank 5 th.

4 18/Oct/2005Dr. David P. Breen4 Leading Causes of Deaths U.S. 1998 All other causes of death 469,314 10. Chronic liver disease24,936 9. Nephritis26,295 8. Suicide29,264 7. Diabetes 64,574 6. Pneumonia and influenza93,207 5. Accidents94,828 4. Respiratory Diseases (COPD) 114,381 3. Cerebrovascular disease (stroke)158,060 2. Cancer 538,947 1. Cause of Death Number Heart Disease 724,269

5 18/Oct/2005Dr. David P. Breen5 Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 0 0 0.5 1.0 1.5 2.0 2.5 3.0 Proportion of 1965 Rate 1965 - 1998 –59% –64% –35% +163% –7% Coronary Heart Disease Coronary Heart Disease Stroke Other CVD COPD All Other Causes All Other Causes

6 18/Oct/2005Dr. David P. Breen6 Age-Adjusted Death Rates for COPD, U.S., 1960-1998 60 Deaths per 100,000 1960 1965 1970 2000 1975 1980 1985 1990 1995 50 40 30 20 10 0 0

7 18/Oct/2005Dr. David P. Breen7 Facts About COPD: U.S. n Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million. n The number of hospitalizations for COPD in 2000 was estimated to be 726,000. n Medical expenditures in 2002 were estimated to be $18.0 billion. n Between 1985 and 1995, the number of physician visits for COPD increased from 9.3 to16 million. n The number of hospitalizations for COPD in 2000 was estimated to be 726,000. n Medical expenditures in 2002 were estimated to be $18.0 billion.

8 18/Oct/2005Dr. David P. Breen8 Facts About COPD Cigarette smoking is the primary cause of COPD. In the US 47.2 million people (28% of men and 23% of women) smoke. The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate. Cigarette smoking is the primary cause of COPD. In the US 47.2 million people (28% of men and 23% of women) smoke. The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate.

9 18/Oct/2005Dr. David P. Breen9 Irish Figures Diseases of the Respiratory system are the cause of one in five deaths in Ireland today In 1999, Respiratory disease caused 7100 deaths: 3700 in men and 3400 in women 26% of respiratory deaths were due to COPD =1846 COPD-related deaths Clear social gradient: Respiratory mortality in the lowest occupational class was 200% higher than the highest occupational class Diseases of the Respiratory system are the cause of one in five deaths in Ireland today In 1999, Respiratory disease caused 7100 deaths: 3700 in men and 3400 in women 26% of respiratory deaths were due to COPD =1846 COPD-related deaths Clear social gradient: Respiratory mortality in the lowest occupational class was 200% higher than the highest occupational class Inhale survey

10 18/Oct/2005Dr. David P. Breen10 Clinically apparent disease Subclinical/ undiagnosed disease

11 18/Oct/2005Dr. David P. Breen11 COPD and Smoking 95% of COPD is caused by smoking 45% of young Irish adults are current smokers Prevalence of current smokers is higher in females (46.5% female v 44.2% male) 30% of school-leavers smoke 95% of COPD is caused by smoking 45% of young Irish adults are current smokers Prevalence of current smokers is higher in females (46.5% female v 44.2% male) 30% of school-leavers smoke ECRHS Group

12 18/Oct/2005Dr. David P. Breen12 Smoking in Ireland Adults 43% in 1973 29% in 1994 27% now highest in lowest SE groups declining more slowly in women than men Children and teenagers 1/10 6th class pupils smoke regularly, 15% boys, 5% girls 1/2 6th class pupils have tried smoking smoking increases steadily in teens in both sexes 30-35% of 17 yo Dublin schoolchildren smoke regularly, equal in both sexes Adults 43% in 1973 29% in 1994 27% now highest in lowest SE groups declining more slowly in women than men Children and teenagers 1/10 6th class pupils smoke regularly, 15% boys, 5% girls 1/2 6th class pupils have tried smoking smoking increases steadily in teens in both sexes 30-35% of 17 yo Dublin schoolchildren smoke regularly, equal in both sexes

13 18/Oct/2005Dr. David P. Breen13 Lung Function decline

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15 lobal Initiative for Chronic bstructive ung isease GOLDGOLD GOLDGOLD

16 GOLD Workshop Report: Contents n Introduction n Definition and classification n Burden of COPD n Risk factors n Pathogenesis, pathology, and pathophysiology n Management n Future research n Introduction n Definition and classification n Burden of COPD n Risk factors n Pathogenesis, pathology, and pathophysiology n Management n Future research

17 18/Oct/2005Dr. David P. Breen17 Definition of COPD Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

18 Burden of COPD Key Points n The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. n Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women. n The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. n Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women.

19 Burden of COPD Key Points The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

20 Burden of COPD Key Points n The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions.

21 18/Oct/2005Dr. David P. Breen21 Direct and Indirect Costs of COPD, 2002 (US $ Billions) n Direct Medical Cost:$18.0 n Total Indirect Cost:$ 14.1 – Mortality related IDC 7.3 – Morbidity related IDC 6.8 n Total Cost $32.1 n Direct Medical Cost:$18.0 n Total Indirect Cost:$ 14.1 – Mortality related IDC 7.3 – Morbidity related IDC 6.8 n Total Cost $32.1 Source: NHLBI, NIH, DHHS

22 18/Oct/2005Dr. David P. Breen22 Risk Factors for COPD Host FactorsGenes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth ExposureTobacco smoke Occupational dusts and chemicals Infections Socioeconomic status Host FactorsGenes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth ExposureTobacco smoke Occupational dusts and chemicals Infections Socioeconomic status

23 18/Oct/2005Dr. David P. Breen23 Pathogenesis of COPD NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) COPD Genetic factors Respiratory infection Other

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27 18/Oct/2005Dr. David P. Breen27 Causes of Airflow Limitation n Irreversible Ô Fibrosis and narrowing of the airways Ô Loss of elastic recoil due to alveolar destruction Ô Destruction of alveolar support that maintains patency of small airways n Irreversible Ô Fibrosis and narrowing of the airways Ô Loss of elastic recoil due to alveolar destruction Ô Destruction of alveolar support that maintains patency of small airways

28 18/Oct/2005Dr. David P. Breen28 Causes of Airflow Limitation n Reversible Ô Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi Ô Smooth muscle contraction in peripheral and central airways Ô Dynamic hyperinflation during exercise n Reversible Ô Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi Ô Smooth muscle contraction in peripheral and central airways Ô Dynamic hyperinflation during exercise

29 18/Oct/2005Dr. David P. Breen29 Objectives of COPD Management n Prevent disease progression n Relieve symptoms n Improve exercise tolerance n Improve health status n Prevent and treat exacerbations n Prevent and treat complications n Reduce mortality n Minimize side effects from treatment n Prevent disease progression n Relieve symptoms n Improve exercise tolerance n Improve health status n Prevent and treat exacerbations n Prevent and treat complications n Reduce mortality n Minimize side effects from treatment

30 18/Oct/2005Dr. David P. Breen30 GOLD Workshop Report Four Components of COPD Management 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations

31 18/Oct/2005Dr. David P. Breen31 Assess and Monitor Disease: Key Points n Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.

32 18/Oct/2005Dr. David P. Breen32 Assess and Monitor Disease: Key Points n Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea.

33 18/Oct/2005Dr. David P. Breen33 Assess and Monitor Disease: Key Points n For the diagnosis and assessment of COPD, spirometry is the gold standard. n Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry. n For the diagnosis and assessment of COPD, spirometry is the gold standard. n Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry.

34 18/Oct/2005Dr. David P. Breen34 Assess and Monitor Disease: Key Points n Measurement of arterial blood gas tension should be considered in all patients with FEV 1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure.

35 18/Oct/2005Dr. David P. Breen35 SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY Diagnosis of COPD è è

36 18/Oct/2005Dr. David P. Breen36 Spirometry: Normal and COPD

37 18/Oct/2005Dr. David P. Breen37 Factors Determining Severity Of Chronic COPD Severity of symptoms Severity of airflow limitation Frequency and severity of exacerbations Presence of complications of COPD Presence of respiratory insufficiency Comorbidity General health status Number of medications needed to manage the disease Severity of symptoms Severity of airflow limitation Frequency and severity of exacerbations Presence of complications of COPD Presence of respiratory insufficiency Comorbidity General health status Number of medications needed to manage the disease

38 18/Oct/2005Dr. David P. Breen38 Classification by Severity Stage Characteristics 0: At risk Normal spirometry Chronic symptoms (cough, sputum) I: Mild FEV 1 /FVC < 70%; FEV 1 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV 1 /FVC < 70%; 50% FEV 1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) III: SevereFEV 1 /FVC < 70%; 30% FEV 1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) IV: Very SevereFEV 1 /FVC < 70%; FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Stage Characteristics 0: At risk Normal spirometry Chronic symptoms (cough, sputum) I: Mild FEV 1 /FVC < 70%; FEV 1 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV 1 /FVC < 70%; 50% FEV 1 < 80% predicted With or without chronic symptoms (cough, sputum, dyspnea) III: SevereFEV 1 /FVC < 70%; 30% FEV 1 < 50% predicted With or without chronic symptoms (cough, sputum, dyspnea) IV: Very SevereFEV 1 /FVC < 70%; FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure

39 18/Oct/2005Dr. David P. Breen39 GOLD Workshop Report Four Components of COPD Management 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations

40 Reduce Risk Factors Key Points Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD and stop its progression (Evidence A). Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD and stop its progression (Evidence A).

41 Reduce Risk Factors Key Points Brief tobacco dependence treatment is effective (Evidence A), and every tobacco user should be offered at least this treatment at every visit to a health care provider. Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A). Brief tobacco dependence treatment is effective (Evidence A), and every tobacco user should be offered at least this treatment at every visit to a health care provider. Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A).

42 Reduce Risk Factors Key Points Several effective pharmacotherapies for tobacco dependence are available (Evidence A), and at least one of these medications should be added to counseling if necessary, and in the absence of contraindications.

43 Reduce Risk Factors Key Points Progression of many occupationally- induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases (Evidence B).

44 Brief Strategies To Help The Patient Willing To Quit Smoking ASK Systematically identify all tobacco users at every visit. ADVISEStrongly urge all tobacco users to quit. ASSESS Determine willingness to make a quit attempt. ASSIST Aid the patient in quitting. ARRANGESchedule follow-up contact. ASK Systematically identify all tobacco users at every visit. ADVISEStrongly urge all tobacco users to quit. ASSESS Determine willingness to make a quit attempt. ASSIST Aid the patient in quitting. ARRANGESchedule follow-up contact.

45 18/Oct/2005Dr. David P. Breen45 GOLD Workshop Report Four Components of COPD Management 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations

46 18/Oct/2005Dr. David P. Breen46 Manage Stable COPD Key Points n The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment, depending on the severity of the disease. n For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A). n The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment, depending on the severity of the disease. n For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation (Evidence A).

47 18/Oct/2005Dr. David P. Breen47 Manage Stable COPD Key Points n None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A). Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.

48 18/Oct/2005Dr. David P. Breen48 Manage Stable COPD Key Points n Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. n The principal bronchodilator treatments are beta 2 - agonists, anticholinergics, theophylline, and a combination of these drugs (Evidence A). n Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. n The principal bronchodilator treatments are beta 2 - agonists, anticholinergics, theophylline, and a combination of these drugs (Evidence A).

49 18/Oct/2005Dr. David P. Breen49 Bronchodilators in Stable COPD n Bronchodilator medications are central to symptom management in COPD. n Inhaled therapy is preferred. n 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. n Bronchodilator medications are central to symptom management in COPD. n Inhaled therapy is preferred. n 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.

50 18/Oct/2005Dr. David P. Breen50 Bronchodilators in Stable COPD n Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms. n Regular treatment with long-acting inhaled bronchodilators is more effective and convenient than treatment with short-acting bronchodilators, but more expensive. n Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. n Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms. n Regular treatment with long-acting inhaled bronchodilators is more effective and convenient than treatment with short-acting bronchodilators, but more expensive. n Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

51 18/Oct/2005Dr. David P. Breen51 Manage Stable COPD Key Points n Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV 1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A). n This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A). n Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV 1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e.g. 3 in the last three years (Evidence A). n This treatment has been shown to reduce the frequency of exacerbations and improve health status (Evidence A).

52 18/Oct/2005Dr. David P. Breen52 Manage Stable COPD Key Points n Chronic treatment with systemic glucocortico- steroids 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). n Chronic treatment with systemic glucocortico- steroids 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).

53 18/Oct/2005Dr. David P. Breen53 Manage Stable COPD Key Points n The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A).

54 18/Oct/2005Dr. David P. Breen54 Management of COPD by Severity of Disease Stage 0: At risk Stage I: Mild COPD Stage II: Moderate COPD Stage III: Severe COPD Stage IV: Very Severe COPD Stage 0: At risk Stage I: Mild COPD Stage II: Moderate COPD Stage III: Severe COPD Stage IV: Very Severe COPD

55 18/Oct/2005Dr. David P. Breen55 Management of COPD: All stages n Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure n Influenza vaccination n Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure n Influenza vaccination

56 18/Oct/2005Dr. David P. Breen56 Management of COPD Stage 0: At Risk Characteristics Recommended Treatment Chronic symptoms - cough - sputum No spirometric abnormalities

57 18/Oct/2005Dr. David P. Breen57 Management of COPD Stage I: Mild COPD Characteristics Recommended Treatment FEV 1 /FVC < 70 % FEV 1 > 80 % predicted With or without chronic symptoms Short-acting bronchodilator as needed

58 18/Oct/2005Dr. David P. Breen58 Management of COPD Stage II: Moderate COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% 50% < FEV 1 < 80% predicted With or without chronic symptoms Short-acting broncho- dilator as needed Regular treatment with one or more long-acting bronchodilators Rehabilitation

59 18/Oct/2005Dr. David P. Breen59 Management of COPD Stage III: Severe COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% 30% < FEV 1 < 50% predicted With or without chronic symptoms Short-acting broncho- dilator as needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocortico- steroids if repeated exacerbations Rehabilitation

60 18/Oct/2005Dr. David P. Breen60 Management of COPD Stage IV: Very Severe COPD Characteristics Recommended Treatment FEV 1 /FVC < 70% FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Short-acting bronchodilator as needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocorticosteroids if repeated exacerbations Treat complications Rehabilitation Long-term oxygen therapy if respiratory failure Consider surgical options

61 18/Oct/2005Dr. David P. Breen61 Old (2001) 0: At RiskI: Mild II: Moderate IIA IIB III: Severe New (2003) 0: At RiskI: MildII: ModerateIII: SevereIV: Very Severe Therapy at Each Stage of COPD Characteristics n Chronic Symptoms n Exposure to risk factors n Normal spirometry n FEV 1 /FVC < 70% n FEV 1 80% n With or without symptoms n FEV 1 /FVC < 70% n 50% < FEV 1 < 80% n With or without symptoms n FEV 1 /FVC < 70% n 30% < FEV 1 < 50% n With or without symptoms n FEV 1 /FVC < 70% n FEV 1 < 30% or FEV 1 < 50% predicted plus chronic respiratory failure Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long- acting bronchodilators Add rehabilitation Add i nhaled glucocorticosteroids if repeated exacerbations Add l ong-term oxygen if chronic respiratory failure Consider surgical treatments

62 18/Oct/2005Dr. David P. Breen62 GOLD Workshop Report Four Components of COPD Management 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations 1.Assess and monitor disease 2.Reduce risk factors 3.Manage stable COPD l Education l Pharmacologic l Non-pharmacologic 4.Manage exacerbations

63 18/Oct/2005Dr. David P. Breen63 Manage Exacerbations Key Points n Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. n The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B). n Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. n The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B).

64 18/Oct/2005Dr. David P. Breen64 Manage Exacerbations Key Points n Inhaled bronchodilators (beta 2 -agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocortico- steroids are effective for the treatment of COPD exacerbations (Evidence A).

65 18/Oct/2005Dr. David P. Breen65 Manage Exacerbations Key Points n Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, and/or fever) may benefit from antibiotic treatment (Evidence B).

66 18/Oct/2005Dr. David P. Breen66 Manage Exacerbations Key Points n Noninvasive intermittent positive pressure ventilation (NIPPV) in exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A).

67 18/Oct/2005Dr. David P. Breen67 Management of COPD n In selecting a treatment plan, the benefits and risks to the individual, and the direct and indirect costs to the individual, his or her family, and the community must be considered.

68 18/Oct/2005Dr. David P. Breen68 Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and dont know it. If you answer these questions, it will help you find out if you could have COPD. 1. Do you cough several times most days? Yes ___ No ___ 2. Do you bring up phlegm or mucus most days? Yes ___ No ___ 3. Do you get out of breath more easily than others your age? Yes ___ No ___ 4. Are you older than 40 years? Yes ___ No ___ 5. Are you a current smoker or an ex-smoker? Yes ___ No ___ If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better. Take time to think about your lungs……Learn about COPD ! Do you know what COPD is? This chronic lung disease is a major cause of illness, yet many people have it and dont know it. If you answer these questions, it will help you find out if you could have COPD. 1. Do you cough several times most days? Yes ___ No ___ 2. Do you bring up phlegm or mucus most days? Yes ___ No ___ 3. Do you get out of breath more easily than others your age? Yes ___ No ___ 4. Are you older than 40 years? Yes ___ No ___ 5. Are you a current smoker or an ex-smoker? Yes ___ No ___ If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better. Take time to think about your lungs……Learn about COPD ! Could it be COPD?

69 18/Oct/2005Dr. David P. Breen69 GOLD Website Address http://www.goldcopd.com

70 18/Oct/2005Dr. David P. Breen70

71 18/Oct/2005Dr. David P. Breen71 Spirometry is the GOLD Standard for the diagnosis of COPD

72 18/Oct/2005Dr. David P. Breen72 Smoking Cessation Pre-contemplator contemplation Action Relapse

73 18/Oct/2005Dr. David P. Breen73 n n

74 18/Oct/2005Dr. David P. Breen74 Pharmacological treatment n 1 st line treatment Ô Nicotine replacement l Nicotine polacrilex (gum) l Transdermal nicotine l Nicotine inhaler l Nicotine nasal spray l Nicotine lozenges l Combined modality Ô Bupropion n 2 nd line treatment Ô Clonidine Ô Nortripyline n 1 st line treatment Ô Nicotine replacement l Nicotine polacrilex (gum) l Transdermal nicotine l Nicotine inhaler l Nicotine nasal spray l Nicotine lozenges l Combined modality Ô Bupropion n 2 nd line treatment Ô Clonidine Ô Nortripyline

75 18/Oct/2005Dr. David P. Breen75 Management of Stable Disease n Smoking cessation n Pharmacological treatment n LTOT n Pulmonary rehabilitation n Surgery n Smoking cessation n Pharmacological treatment n LTOT n Pulmonary rehabilitation n Surgery

76 18/Oct/2005Dr. David P. Breen76 Pharmacological therapy n Medications can reduce or abolish symptoms,increase exercise tolerance,reduce no and severity of symptoms and improve health status n No treatment alters the rate of decline of lung function n Inhaled route is preferable – smaller doses and therefore reduced side effects by inhalation n Combining agents have a greater effect on symptoms than single agents n Medications can reduce or abolish symptoms,increase exercise tolerance,reduce no and severity of symptoms and improve health status n No treatment alters the rate of decline of lung function n Inhaled route is preferable – smaller doses and therefore reduced side effects by inhalation n Combining agents have a greater effect on symptoms than single agents

77 18/Oct/2005Dr. David P. Breen77 General principles n Patients must be educated in the device n Choose right device for patient – MDI v DPI v Spacer device n Spacer good for delivery and reduce oral s/e n Compliance is variable – studies show at east 85% of patients take 70% of the prescribed doses - ? Reflect the constant symptoms n Education is essential for good adherence and proper use n Spirometry essential for diagnosis but not for monitoring n Patients must be educated in the device n Choose right device for patient – MDI v DPI v Spacer device n Spacer good for delivery and reduce oral s/e n Compliance is variable – studies show at east 85% of patients take 70% of the prescribed doses - ? Reflect the constant symptoms n Education is essential for good adherence and proper use n Spirometry essential for diagnosis but not for monitoring

78 18/Oct/2005Dr. David P. Breen78 Bronchodilators n Β 2 agonist n Anticholinergic agents n Methylxanthines Mode of action is smooth muscle relaxation – small changes in FEV but decreases in lung volumes resulting in better emptying and less hyperinflation n Β 2 agonist n Anticholinergic agents n Methylxanthines Mode of action is smooth muscle relaxation – small changes in FEV but decreases in lung volumes resulting in better emptying and less hyperinflation

79 18/Oct/2005Dr. David P. Breen79 Β 2 agonist n Inhaled (short, long acting), oral n Mode of action Ô Increase in c-amp within cells and promote smooth muscle relaxation Ô ?other non bronchodilator effects n S/E Ô Palpitations, PVC Ô Tremor Ô Sleep disturbance Ô Metabolic - hypokalaemia n Inhaled (short, long acting), oral n Mode of action Ô Increase in c-amp within cells and promote smooth muscle relaxation Ô ?other non bronchodilator effects n S/E Ô Palpitations, PVC Ô Tremor Ô Sleep disturbance Ô Metabolic - hypokalaemia

80 18/Oct/2005Dr. David P. Breen80 Anticholinergic drugs n Only available via inhaled route Ô Ipratropium Ô Oxitropium Ô Tiotropium n Inhibit muscarinic receptors n Tiotropium remains bound to receptors for up to 36 hours n Onset of bronchodilatation in 30 mins n S/E Ô Not associated with significant incidence of prostatism or cardiac S/E Ô Commonest – dry mouth(tiotropium), metallic taste (ipratropium), closed angle glaucoma n Only available via inhaled route Ô Ipratropium Ô Oxitropium Ô Tiotropium n Inhibit muscarinic receptors n Tiotropium remains bound to receptors for up to 36 hours n Onset of bronchodilatation in 30 mins n S/E Ô Not associated with significant incidence of prostatism or cardiac S/E Ô Commonest – dry mouth(tiotropium), metallic taste (ipratropium), closed angle glaucoma

81 18/Oct/2005Dr. David P. Breen81 Methylxanthines n Oral or I.V prn preparations n Non specific PDE inhibitors and increase c-amp n Bronchodilatation only occurs at high dose and narrow therapeutic/toxic window n Keep at level of 8-14 ug.dl n Can be bd or od drugs n S/E Ô Major – ventricular and atrial rhythm disturbance, convulsions Ô Minor – headache, nausea, vomiting, diarrhoea and heartburn n Oral or I.V prn preparations n Non specific PDE inhibitors and increase c-amp n Bronchodilatation only occurs at high dose and narrow therapeutic/toxic window n Keep at level of 8-14 ug.dl n Can be bd or od drugs n S/E Ô Major – ventricular and atrial rhythm disturbance, convulsions Ô Minor – headache, nausea, vomiting, diarrhoea and heartburn

82 18/Oct/2005Dr. David P. Breen82 Levels increasedLevels decreased Respiratory acidosis CCF Liver cirrhosis Erthyromycin ciprofloxacin Cigarette smoke Anti-convulsant drugs rifampicin

83 18/Oct/2005Dr. David P. Breen83 Glucocorticoids n Inhalation Ô Beclomethasone Ô Budesonide Ô Triamcinolone Ô Fluticasone Ô Flunisolide n Oral Ô Not indicated in stable – excessive S/E profile n Inhalation Ô Beclomethasone Ô Budesonide Ô Triamcinolone Ô Fluticasone Ô Flunisolide n Oral Ô Not indicated in stable – excessive S/E profile

84 18/Oct/2005Dr. David P. Breen84 n Pharmacology Ô Effect transcription processes – slow action Ô High dose can be absorbed via the pulmonary circulation n S/E Ô Oral – osteoporosis, cataracts, peripheral myopathy Ô Topical/local S/E can be significant Ô Skin bruising n Clinical outcomes Ô If FEV<50% and a number of exacerbations/year rate of deterioration in health status can be reduced Ô 3 year prospective studies revealed no effect on rate of decline of FEV1 n Pharmacology Ô Effect transcription processes – slow action Ô High dose can be absorbed via the pulmonary circulation n S/E Ô Oral – osteoporosis, cataracts, peripheral myopathy Ô Topical/local S/E can be significant Ô Skin bruising n Clinical outcomes Ô If FEV<50% and a number of exacerbations/year rate of deterioration in health status can be reduced Ô 3 year prospective studies revealed no effect on rate of decline of FEV1

85 18/Oct/2005Dr. David P. Breen85 Combination therapy n Combination treatment is a convenient, safe and improves compliance n Initial data show a significant effect on pulmonary function and a reduction in symptoms n Largest effects in most severe – FEV<50% and a number of exacerbations n Combination treatment is a convenient, safe and improves compliance n Initial data show a significant effect on pulmonary function and a reduction in symptoms n Largest effects in most severe – FEV<50% and a number of exacerbations

86 18/Oct/2005Dr. David P. Breen86 Other agents n Mucolytic agents – carbocysteine, iodinated glycerol n Little evidence of any effect on lung function n Cochrane review – supports a role for reducing no of exacerbations in chronic bronchitis n N-acetylcysteine – at present prospective study ongoing n Mucolytic agents – carbocysteine, iodinated glycerol n Little evidence of any effect on lung function n Cochrane review – supports a role for reducing no of exacerbations in chronic bronchitis n N-acetylcysteine – at present prospective study ongoing

87 18/Oct/2005Dr. David P. Breen87 n Leukotreine receptor antagonist - No data to support role n Maintenance antibiotic –no data to suggest that these drugs are effective in modifying symptoms, exacerbations or lung function n Respiratory stimulants – oral peripheral chemoreceptor stimulant – improves V/Q matching and improves oxygenation – can result in peripheral neuropathy n Vaccination Ô Influenza – can reduce serious illness and death by 50% Ô Pneumococcal – reduces bacteraemia n Leukotreine receptor antagonist - No data to support role n Maintenance antibiotic –no data to suggest that these drugs are effective in modifying symptoms, exacerbations or lung function n Respiratory stimulants – oral peripheral chemoreceptor stimulant – improves V/Q matching and improves oxygenation – can result in peripheral neuropathy n Vaccination Ô Influenza – can reduce serious illness and death by 50% Ô Pneumococcal – reduces bacteraemia

88 18/Oct/2005Dr. David P. Breen88 Alpha1-antitrypsin deficiency n Augmentation therapy n Licensed for i.v. use twice a week n Expensive n No RCT showing benefit n Suggestio that rate of decline in those receiving drug is less than historical controls. n Augmentation therapy n Licensed for i.v. use twice a week n Expensive n No RCT showing benefit n Suggestio that rate of decline in those receiving drug is less than historical controls.

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