Management of stable chronic obstructive pulmonary disease (2) Seminar Training Primary Care Asthma + COPD D.Anan Esmail

Pulmonary function studies Diagnosis of COPD Staging of COPD

Diagnosis Of COPD SPIROMETRY SYMPTOMS Cough Sputum Dyspnea RISK FACTORS Tobacco Occupation

Spirometry: post-bronchodilator FEV1/FVC <0.7 confirms the presence of airflow limitation that is not fully reversible Diagnosis Of COPD

Pharmacologic intervention is offered according to disease severity and the patient’s tolerance for specific drugs pulmonary function testing can be helpful by staging the disease Once the diagnosis of COPD is established

GOLD 1 FEV1/FVC ˂ 70%, FEV1 ≥ 80% GOLD 2 FEV1/FVC ˂ 70%, FEV1 ˂ 80% GOLD 3 FEV1/FVC ˂ 70%, FEV1 ˂ 50% GOLD 4 FEV1/FVC ˂ 70%, FEV1 ˂ 30%

STAGING

High risk less symptoms High risk more symptoms Low risk more symptoms Low risk less symptoms AB CD

Low Risk FEV 1 /FVC ratio <0.7 And FEV 1 ≥50% (GOLD I, II) 0 or 1 exacerbations in the past year

High Risk FEV 1 /FVC ratio <0.7 And FEV 1 <50 % (GOLD III, IV) ≥2 exacerbations per year or one hospitalization for an exacerbation

Less Symptomatic Mild or infrequent symptoms breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill

More Symptomatic Moderate to severe symptoms patient walk slower than others of same age due to breathlessness stop to catch breath when walking on level ground at own pace

High risk less symptoms High risk more symptoms Low risk more symptoms Low risk less symptoms AB CD

ALL Category

reduce the Risk Factors for COPD

Annual influenza vaccination Pneumococcal vaccination

Regular physical activity (Pulmonary Rehabilitation)

Long-term oxygen therapy if chronic hypoxemia

Short-acting bronchodilator when needed

A Category Bronchodilator as needed

B Category regular treatment with a long-acting Bronchodilator

C+D Category First choice:

COPD is characterized by both airway and systemic inflammation

Inhaled glucocorticoids reduce this inflammation

COPD inhaled glucocorticoids should NOT be used as sole therapy (without long-acting bronchodilators)

COPD inhaled glucocorticoids used as part of a combined regimen fluticasone-salmeterol budesonide-formoterol mometasone-formoterol

inhaled glucocorticoids decrease exacerbations slow the progression of respiratory symptoms

inhaled glucocorticoids have little impact on lung function

inhaled glucocorticoids have little impact on mortality The risk of death in the combination group did not differ from that in the LABA alone Group

C+D Category First choice: long-acting anticholinergic alone

Combination therapy ICS+LABA improves outcomes (mortality, lung function, health status, rate of exacerbations) compared to long-acting anticholinergics alone

Combination therapy ICS+LABA Pneumonia was substantially more frequent compared to long-acting anticholinergics alone

C+D Category Second choice: combination long-acting beta agonist and long- acting anticholinergic

question that whether it would preferable to add a second long- acting bronchodilator or an inhaled glucocorticoid in patients whose disease in not well- controlled with a single long-acting bronchodilator

lung function was better in the LAMA + LABA group

Rescue medication use did not differ significantly between the groups

exacerbations and mortality, were not assessed

These data are insufficient to change in the current guidelines the first step is initiation of a longacting bronchodilator alone rather than the combination of a long-acting beta agonist plus an inhaled glucocorticoid

if there are signs of asthmatic component to the COPD Inhaled glucocorticoid therapy may be warranted earlier at the same time that the long-acting inhaled bronchodilator is initiated

if there are signs of asthmatic component to the COPD Inhaled glucocorticoids are continued in patients whose symptoms, frequency of exacerbations, and/or lung function improve within one month

Major side effects of inhaled glucocorticoids

Inhaled glucocorticoids fewer and less severe adverse effects compared to orally-administered glucocorticoids

Dysphonia

Thrush

Oral Candidiasis

Skin Bruising

Osteoporosis

Adrenal Suppression

Cataracts

Local deposition of inhaled GC less common with dry powder devices

Local deposition of inhaled GC avoided by use of a large volume spacer with MDIs

Local deposition of inhaled GC avoided by rinsing the mouth after each administration with all devices

Confirm diagnosis of COPD Category A Category B Category C+D Alternative combination (LAMA/LABA+LAMA) LABA + ICS LABD q.i.d SA-BD as needed Limited benefit?

REFRACTORY DISEASE Limited benefit?

REFRACTORY DISEASE patients continue to have symptoms or repeated exacerbations of COPD despite therapy with long-acting inhaled bronchodilator plus an inhaled glucocorticoid

REFRACTORY DISEASE