4 COPD DEFINITIONProgressive airflow obstruction that is not fully reversible.Most COPD is due to cigarette smokingSaetta et al AJRCCM 2001; 163: 1304Hogg et al NEJM 2004; 350: 2645Lancet 2009; 374:
5 BURDEN OF COPD IN NEW ZEALAND 7,716 people with COPD hospitalised in 2011/12.An average of 1.5 times per person.30 day readmission rate of 17.9%.Average length stay of 4.2 days.Average cost per hospitalised patient was about $7,700.COPD contributed to $54 million in hospitalisation costs (20.3% of total respiratory hospitalisation costs).National Health Committee report, New Zealand, December 2013.
7 Exacerbations per year 4321CD> 21GOLD STAGEbased on FEV1RISKExacerbations per yearRISKABSYMPTOMSmMRC mMRC 2-4CAT < CAT > 10
8 ACUTE COPD EXACERBATION The cause is often unknownRespiratory infections –bacterial, viral,- URTI, bronchitis, pneumoniaHeart failure, arrhythmiaSystemic infection, feverAnaemiaAnxietyAnything that increases metabolic rateERJ 2007; 29: 1224
9 COPD exacerbations30 % bacterial, 23 % viral, 25 % both, 22 % other ERJ 2007; 29: 1224.Various studies show a wide range of organisms, but few atypical bacteria (Legionella, Chlamydia, Mycoplasma).Antibiotics recommended if type I Anthonisen, or type II with purulent sputum, or NIV.
10 CLASSIFICATION OF COPD EXACERBATION A = AIRWAY VIRAL INFECTIONB = BACTERIAL INFECTION (including pneumonia)C = CO-INFECTION D = DEPRESSION/ANXIETYE = EMBOLISM (pulmonary)F = FAILURE (cardiac or lung integrity)G = GENERAL ENVIRONMENTX = NO SPECIFIC CAUSE IDENTIFIEDMartin MacDonald et al Respirology 2011; 16: 264
11 Features of a COPD exacerbation Anthonisen criteria:- increased dyspnoea- increased sputum productionsputum becoming discolouredAntibiotics to cover Strep and Gram negatives have been shown to be useful if all three criteria are present.CXR to look for pneumonia, and cover atypical bacteria if there is pneumonia.
13 Death after a COPD exacerbation 40 % mortality in the 12 months after a hospital admission for a COPD exacerbation. AJRCCM 1996; 154: 959Predictors of mortality:older age, lung cancer, BMI < 20, CV disease, past hospital admissions,needing supplemental O2 on discharge,use of accessory muscles. ERJ 2013: 42; 946.
16 Smoking cessation in Lung Health Study 72 ml fall over 2 years in those who ceased smoking300 ml over 2 years in those who kept smoking.JAMA 1994; 272: 1497
17 Current medical management of COPD in New Zealand LONG ACTING BETA AGONIST (LABA)Salmeterol (Serevent) is indicated for long-lasting (12 hour) bronchodilation in adults with reversible airways obstruction due to COPD.Should not be used in asthma without ICS.
18 LONG ACTING MUSCARINIC ANTAGONIST (LAMA) Tiotropium (Spiriva) is indicated for the long term once daily maintenance treatment of bronchospasm and dyspnoea associated with COPD, including chronic bronchitis and emphysema.Special Authority Criteria
20 TIME TO FIRST EXACERBATION p = 0.028TIME TO FIRSTHOSPITALISATIONp = 0.055Ann Intern Med 2005; 143:
21 Spiriva Placebo p Exacerbation 27.9 % 32.3 % 0.036 Hospitalization 7.0 % %No. of exacerbationsper patient per yearExacerbation daysAntibiotic daysOral steroid daysNo. of hospitalizationsHospitalization daysAnn Intern Med 2005; 143:
22 p < 0.008 p < 0.048 Eur Respir J 2002; 19: 209. Spiriva Atrovent
23 ICS/LABAFluticasone / salmeterol (Seretide) is indicated for the symptomatic treatment of patients with moderate to severe COPD (pre-bronchodilator FEV1<60% predicted normal), who have significant symptoms despite bronchodilator therapy.
24 Effects of ICS/LABA combination therapy on inflammatory markers Percentage change from baseline for lung biopsy endpoints: median treatment differencesStudy population: 140 current and past smokers with moderate to severe COPD
25 Reducing exacerbations with ICS/LABA in severe COPD Kardos et al 2007
26 Seretide reduces the rate of exacerbations requiring systemic corticosteroids over 3 years (TORCH) -0.050.150.350.550.750.951.15placeboSalFPSFC43% (p<0.001)0.800.640.520.46Exacerbation ratep-valueTreatment effectSFC vs placebo43%<0.001SFC vs sal29%<0.001SFC vs FP13%0.02Calverley PMA et al New Eng J Med 2007; 356:
27 TORCH: different stages of COPD Adapted from Jenkins C, et al. Respiratory Research 2009; 10: 59.
28 Budesonide / eformoterol (Symbicort) is indicated in the regular treatment of adult patients with moderate to severe COPD [FEV1 ≤50% of predicted normal], with frequent symptoms despite beta2-agonist use and a history of exacerbations.SYMBICORT should not be used for the initiation of bronchodilator therapy in COPD
29 BUD/FORM vs. each components or placebo NSNS**BUD/FORM vs PlaceboBUD/FORM vs BUDBUD/FORM vs FORMBUD vs PlaceboFORM vs Placebo*NS*NSNS = Not SignificantAdapted from Szafranski W, et al. Eur Respir J 2003; 21:
30 Symbicort plus Spiriva versus placebo plus Spiriva Number of severe exacerbationsdecreased by 62%Adapted from Welte T, et al. AJRCCM 2009; 180: 741.
31 Pneumonia and ICS in COPD Double the pneumonia risk with fluticasone (9 % vs 5% over 2 years), but no increase in mortality.No difference in de novo pneumonia.The difference is only seen in those with worsening COPD prior to the pneumonia.Calverley et al INSPIRE study CHEST 2011; 139:505.Not seen with Symbicort Turbuhaler, but seen with the Rapihaler. Sharafkhaneh A, et al. Respir Med2012;106:257–68.
32 Newly COPD drugs in New Zealand (but not yet reimbursed) BREO ELLIPTA (ICS/LABA)– Fluticasone fuorate/VilanterolSymptomatic treatment of patients with COPD with FEV1 < 70 % and past exacerbations.
33 ANORO ELLIPTA (LABA/LAMA) Umeclidinium/Vilanterol Once daily bronchodilator to relieve symptoms in COPD patients.
35 PULMONARY REHABILITATION There is good evidence that it improves symptoms in COPD reduces hospitalizations and length of stay.Patients need to be well motivated.Two main components - improving fitness, and education.A course is run over weeks with twice weekly visits.The exercise needs to be maintained at home.Cochrane database 2006; Lancet 1996; 348: 1115.
36 VACCINESInfluenza vaccine - reduces mortality, hospital admissions and exacerbations.- it does not prevent other URTI viruses.- local side effects only.- it is given yearly NEJM 1994; 331: 778
37 Pneumococcal vaccine - Little evidence about its use in COPD, but it seems like a good idea. - older than NEJM 2003; 348: 1747- less than 65 with major comorbidity- less than 65 and FEV1 < 40 % 276- it is given twice 5 years apart in COPD.