1. COPD All you wanted to know about COPD but were afraid to ask…

2. What to expect: Definition Epidemiology Risk Factors History/Physical Findings Diagnostic Studies Overview of Current Treatment Options Treatment of exacerbations

3. What is COPD? a disease state characterized by airflow limitation that is not fully reversible. Includes: Emphysema: – an anatomically defined condition characterized by destruction and enlargement of the lung alveoli. Chronic Bronchitis: – a clinically defined condition with chronic cough and phlegm; and small airways disease, a condition in which small bronchioles are narrowed.

4. Epidemiology: Currently 4th leading cause of Death in United States (also on the rise in Europe, Africa and Asia) With recent increase in female smoking, COPD now affects men and women equally, with early COPD patients now being predominately women. Non- caucasian ethnic groups are also catching up to caucasians in prevalence of COPD. Very Costly: Direct cost of COPD in 2002 were ~$18 billion.

5. Risk Factors SMOKING Airway hyper-responsiveness Occupational/Environmental Exposures – mining, textiles, ?second hand smoke Genetics – alpha-1-antitrypsin deficiency – There has been familial COPD clusters so other genetic factors likely play a role as well

6. Think about COPD if your patient has: Cough Sputum Production – Often first thing in the morning. Exertional Dyspnea – Activities involving significant arm work, particularly at or above shoulder level, are particularly difficult for patients with COPD. Conversely, activities that allow the patient to brace the arms and use accessory muscles of respiration are better tolerated. Any of those risk factors from the last slide

7. What do you see on exam? Most often nothing obvious, especially early in disease state-could be normal Often more helpful to rule out other diseases with similar symptoms (e.g heart failure) Classic Pink Puffer/Blue Bloater – Not very often.

9. Diagnosis COPD requires Spirometry for diagnosis and staging. – FEV1 – FVC – FEV1/FVC ratio: indicator of airway flow limitation FEV1/FVC < 70% predicted=limited airflow Cannot be fully reversed by bronchodilators

10. GOLD CRITERIA FOR COPD SEVERITY I:Mild COPD. FEV1/FVC < 70% FEV1 = 80% predicted with or without chronic symptoms (cough, sputum production) II:Moderate COPD. FEV1/FVC < 70%, FEV1 50-80% predicted with or without chronic symptoms (cough, sputum production) III: Severe COPD. FEV1/FVC < 70% FEV1 30-50% predicted with or without chronic symptoms (cough, sputum production) IV: Very Severe COPD. FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure **Notice how FEV1/FVC must be <70%

11. Differential Diagnosis Similar Symptoms: – Asthma – Heart Failure – Pneumonia – Even chronic sinusitis Similar PFT profile – Asthma – Cystic Fibrosis – Bronchiectasis – Some bronchiolitis

12. Treatment: What has SHOWN benefit? Smoking Cessation Oxygen Therapy mortality rate inversely proportional to #hours/day O2 is worn. Certain criteria, not everyone benefits immediately Lung Reduction Surgery in emphysema National Emphysema Treatment Trial – Mostly for upper lobe emphysema

13. Pharmacological Symptomatic Relief Bronchodilators-symptomatic Anticholinergics (Anti-ACh)-symptomatic AND acute FEV1 improvement – Tiotropium-reduces exacerbations Beta Agonists-short vs. long-acting – LABA as good as Anti-AChs-added together = improvement in symptoms and PFT profile Inhaled Corticosteroids-ongoing trials – Can help prevent further exacerbations

14. Non-pharmacological therapies: Flu Shot EVERY year PneumoVax Pulmonary Rehabilitation Lung Transplantation

15. Acute exacerbation change in the patient’s baseline dyspnea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management

16. ATS Guidelines for Hospitalization: The presence of high-risk comorbid conditions – pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure Inadequate response of symptoms to outpatient management Marked increase in dyspnea Inability to eat or sleep due to symptoms Worsening hypoxemia Worsening hypercapnia Changes in mental status Inability of the patient to care for her/himself (lack of home support) Uncertain diagnosis.

17. Treatment Bronchodilators Supplemental Oxygen – Either nasal cannula or Noninvasive Positive Pressure Ventilation if needed. Steroids (Yes- N Engl J Med 1999;340:1941-7) – If tolerated orals, Prednisone 30-40mg daily x 10d – Can’t do that? Equivalent IV dose.

18. Note on steroids: JAMA. 2010;303(23):2359-2367 Not ideal study: Cohort, composite end point Comparing Non-ICU level patients receiving IV vs. Oral steroids for acute COPD exacerbation. – IV dose: 120-800mg/day prednisone equivalent (yikes) – Oral dose: 20-80mg/day prednisone End point: Treatment failure – need for mechanical ventilation after hospital day#2 – readmission with in 30 days – inpatient mortality No worse outcome with low dose oral steroids compared to high dose IV form.

19. Treatment Antibiotics? If change in sputum (purulent, color change) in hospitalized patients Usually given if patient is admitted to ICU – Respiratory Fluoroquinolones – Amoxicillin/Clavulanate Initial Trial ( Ann Intern Med 1987;106:196-204)-showed modest benefit but did not control for use of steroids. Newer Trial ( Am J Respir Crit Care Med. 2010 Jan 15;181(2):150-7) compared 7 day course of doxycycline to placebo with all getting steroids, showed earlier clinical improvement (better at day 10) but no improvement in lung function or at day 30.

20. A few notes on Asthma Defined as: – Airway Inflammation – Airway hyperresponsiveness – Reversible-key difference from COPD Well defined “Step up/down” therapy algorithm for primary therapy. SMART trial showed increase in death related to LABA alone, so don’t do it. – This study has its own pro/cons-not in scope of this talk though.

21. ncbi.nlm.nih.gov

22. Exacerbations Check peak flow-compare to baseline values Albuterol MDI/nebs-as often as needed Steroids-usually oral, no recent trials like for COPD NO data showing antibiotics are of benefit unless the exacerbation is caused by pneumonia or other infection which would normally be treated with antibiotics.

23. References: ATS website: www.thoracic.orgwww.thoracic.org GOLD website:www.GOLDCOPD.com ACP medicine-COPD chapter. Lindenauer, P.K, et.al Association of Corticosteroid Dose and Route of Administration With Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease. JAMA. 2010;303(23):2359-2367 Anthonisen NR, Manfreda J, Warren CPW et al. Antibiotic therapy in exacerbations of COPD. Ann Intern Med 1987;106:196-204. Daniels, J.M.A, et.al Antibiotics in Addition to Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease Am J Respir Crit Care Med. 2010 Jan 15;181(2):150-7