Chronic Obstructive Pulmonary Disease (COPD) פרופ' רפאל ברויאר מכון הריאה ביה"ח האוניברסיטאי הדסה עין-כרם

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Relative Mortality, Leading Causes of Death in the US, 1980-2010 Proportion of 1980 Rate U.S. Centers for Disease Control (CDC)

Leading Causes of Death in the US, 2010 Heart disease 595,444 2 Cancer 573,855 3 Chronic lower respiratory disease (COPD) 137,789 4 Cerebrovascular disease (stroke) 129,180 5 Accidents 118,043 6 Alzheimer’s Disease 83,308 7 Diabetes 68,905 8 Nephritis, nephrotic syndrome, nephrosis 50,472 9 Influenza & pneumonia 50,003 10 Suicide 37,793 11 Septicemia 34,843 12 Chronic liver disease & cirrhosis 31,802 13 Essential hypertension & hypertensive renal disease 26,577 14 Parkinson’s disease 21,963 Pneumonitis due to solids & liquids 17,001 U.S. CDC, 2012

COPD Clinical presentation Pathophysiology Management strategy Treatment

אבחנה של COPD Airflow obstruction that is irreversible FEV1 / FVC < 70%

Chronic Obstructive Pulmonary Disease (COPD) גורמי סיכון: עישון - אקטיבי ופסיבי זיהום אוויר חשיפות תעסוקתיות לאבק/עשן גורמים גנטיים (חסר ב alpha-1-antitrypsin).

COPD ועישון עישון הוא הגורם העיקרי – אם אין עישון – יש לחשוב על אבחנה אחרת! בכלל האוכלוסיה – ככל שאדם עישן יותר "שנות קופסא" – FEV1 יורד. גם הסיכון למחלה תלוי ב”מינון” (שנות קופסה).

רמזים מרכזיים לאבחנה של COPD מאפיינים מרכזיים: גיל > 50 קוצר נשימה (דיספניאה) – פרוגרסיבי / קבוע. שיעול פרודוקטיבי כרוני. חשיפה לגורמי סיכון – בעיקר עישון

COPD: Traditional Classification Emphysema Phenotype The Pink Puffer Chronic Bronchitis Phenotype The Blue Bloater Irreversible airflow obstruction

COPD—Emphysema Phenotype The Pink Puffer

COPD – Emphysema Phenotype “An anatomical alteration of the lung characterized by an abnormal enlargement of the air spaces distal to the nonrespiratory bronchioles, accompanied by destructive changes of the alveolar walls."

Centriacinar Emphysema Emphysema Pathology Bullous Emphysema Centriacinar Emphysema

Emphysema Pathology Normal lung Emphysematous lung

COPD – Emphysema Phenotype Clinical Features סמפטומים: Dyspneaקוצר נשימה פרוגרסיבי. שיעול לא בולט. מיעוט (יחסי) בזיהומים ריאתיים. בדיקה גופנית: רזים, חולשת שרירים (asthenia). חזה חביתי, טכיפניאה. ללא כיחלון בולט ("ורודים"). ירידה דיפוזית בקולות הנשימה, אקספיריום מוארך. סרעפות נמוכות. קולות לב מרוחקים. אק"ג: ציר ימני, קומפלקסים קטנים.

COPD – Emphysema Phenotype תפקודי ריאה תמונה חסימתית אקספירטורית: FEV1 מופחת, FEV1 / FVC מופחת. למרבית החולים אין שיפור משמעותי עם מרחיבי סימפונות. היפראינפלציה ולכידת אוויר: TLC, RV ו-TLC / RV מוגברים. ירידה ביכולת הדיפוזיה של חמצן: DLCO מופחת. היפוקסמיה קלה עם Pco2 תקין.

Effect of Emphysema on Diffusion Capacity

Emphysema- CXR היפראינפלציה, חדירות יתר סרעפות שטוחות מרווח רטרוסטרנלי גדול

Emphysema- HRCT Normal Emphysema

COPD—Chronic Bronchitis Phenotype The Blue Bloater

COPD – Chronic Bronchitis Phenotype " A clinical disorder characterized by excessive mucus secretion... chronic or recurrent productive cough... on most days for a minimum of three months in the year for not less than two successive years."

COPD - Chronic Bronchitis Phenotype Clinical Features סמפטומים: שיעול יצרני כרוני, שפע ליחה "מוגלתית" זיהומים ריאתיים והתלקחויות תכופות. קוצר נשימה (מתגבר בהתלקחויות). בדיקה גופנית: עודף משקל. נטיה לכיחלון. אקספיריום מוארך עם צפצופים. סימנים של אי-ספיקת לב ימנית (Cor Pulmonale).

COPD - Chronic Bronchitis Phenotype תפקודי ריאה תמונה חסימתית אקספירטורית: FEV1 מופחת, FEV1 / FVC מופחת ללא שיפור משמעותי עם מרחיבי סימפונות נפחי הריאה ויכולת דיפוזיה (DLCO) – תקינים

Chronic Bronchitis with Cor Pulmonale—CXR ללא ממצאים משמעותיים בריאות עצמן כלי דם ריאתיים מודגשים לב מוגדל

Cor Pulmonale Phenotype in COPD

COPD - Cor Pulmonale Phenotype שכיחות יותר של: היפוקסמיה קשה היפרקפניאה חמצת נשימתית כרונית.

Normal Chronic Bronchitis Emphysema

COPD Clinical presentation Pathophysiology Management strategy Treatment

Airway Obstruction Pathophysiology Destruction of peribronchial supporting tissue Plugging, inflammation & narrowing of airways

Findings in Human BAL Studies Smokers’ BAL contain 4-5 times more neutrophils than non-smokers Neutrophils in BAL fluid are the main source of elastase Cigarette smoke and neutrophils suppress anti-elastase activity Conclusion: Quantity and activity of elastase is increased in smokers

COPD - Pathophysiology HYPOTHESIS Anti-Elastase alpha-1-antitrypsin Elastase

COPD - Pathophysiology Barnes, Nat Rev 2008

COPD Clinical presentation Pathophysiology Management strategy Treatment

COPD Management Philosophy Relieve symptoms Improve exercise tolerance Improve health status AND Prevent disease progression Prevent & treat exacerbations Reduce mortality REDUCE SYMPTOMS REDUCE RISK

COPD Management To determine disease severity & guide therapy, assess: Symptoms Severity of airflow limitation Risk of exacerbation Presence of comorbidities Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

COPD Management Symptoms: clinical assessment, mMRC or CAT To determine disease severity & guide therapy, assess: Symptoms: clinical assessment, mMRC or CAT Severity of airflow limitation Risk of exacerbation Presence of comorbidities Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

COPD Assessment Tool—CAT Score > 10 considered symptomatic Symptom Assessment COPD Assessment Tool—CAT Score > 10 considered symptomatic

COPD Management Severity of airflow limitation (GOLD I-IV) To determine disease severity & guide therapy, assess: Symptoms (clinical assessment, mMRC or CAT) Severity of airflow limitation (GOLD I-IV) Risk of exacerbation Presence of comorbidities Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

(Post Bronchodilator FEV1) Grading COPD Severity STAGE CHARACTERISTICS (Post Bronchodilator FEV1) FEV1 / FVC < 70% I Mild FEV1 ≥ 80% predicted II Moderate 50% ≤ FEV1 ≤ 80% predicted III Severe 30% ≤ FEV1 ≤ 50% predicted IV Very Severe FEV1 ≤ 30% predicted

COPD Management Risk of exacerbation (frequency/year) To determine disease severity & guide therapy, assess: Symptoms (clinical assessment, mMRC or CAT) Severity of airflow limitation (GOLD I-IV) Risk of exacerbation (frequency/year) Presence of comorbidities Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

Definition of COPD Exacerbation Symptoms worsening beyond daily variations Cough / sputum / dyspnea Leads to change in medications Cause: Viral infection Bacterial infection Pollutants Diagnosis based on clinical presentation

Exacerbations—Critical Events in the Natural History of COPD Poor quality of life Accelerated loss of lung function Exacerbations  increased risk future exacerbations Increased risk of hospitalization All-cause 3-year mortality after hospitalization up to 49% (GOLD 2011)

Frequency of COPD Exacerbation & Survival Probability of survival Time (months) Prospective study, cohort 304 males, exacerbations requiring hospitalization, 5-year follow-up Soler-Cataluῆa, Thorax 2005

Hurst et al, ECLIPSE, NEJM 2010

Frequent Exacerbator Phenotype Pats with no exacerbation Pats with ≥2 exacerbations Year 1 Year 2 Year 3 Hurst et al, ECLIPSE, NEJM 2010

Treatment of COPD Exacerbations Treat early aggressively to minimize duration, prevent recurrence Short-acting inhaled bronchodilators (Ventalin, +/- Aerovent, as needed) Systemic corticosteroids Antibiotics Noninvasive ventilation 7 days

COPD: Antibiotic treatment Pathogens: Streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis Antibiotics: Cefuroxime, beta-lactam, macrolides, doxycycline

Impact of COPD Exacerbations Accelerated lung function decline Impact on symptoms & quality of life Increased mortality Exacerbations Increased economic costs Treat early aggressively to minimize duration, prevent recurrence

COPD Management Presence of comorbidities To determine disease severity & guide therapy, assess: Symptoms (clinical assessment, mMRC or CAT) Severity of airflow limitation (GOLD I-IV) Risk of exacerbation (frequency / year) Presence of comorbidities Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

Systemic Manifestations & Comorbidities Cardiovascular disease Pulmonary hypertension Ischemic heart disease Congestive heart failure Stroke Lung cancer Diabetes, metabolic syn Osteoporosis Skeletal muscle dysfunction Depression

COPD—Independent Risk Factor for Cardiovascular Morbidity Percent with Condition

Higher Rates of Hospitalization Due To Comorbidities Reproduced with permission of Chest, from “Comorbidity and Mortality in COPD Related Hospitalizations in the United States, 1979 to 2001,” Holguin F et al, Vol 128, pp 2005-2011, Copyright © 2005.

Higher Mortality Rates Due to Cormorbidities IHD = ischemic heart disease CHF = congestive heart failure RF = respiratory failure PVD = pulmonary vascular disease TM = thoracic malignancy Speaker notes A recent evaluation of the USA National Hospital Discharge Survey analyzed more than 47 million hospital discharges for COPD (8.5% of all hospitalisations) that occurred in the USA from 1979 to 2001. The prevalence and in-hospital mortality of many conditions were greater in hospital discharges with any mention of COPD versus those that did not mention COPD. A hospital diagnosis of COPD was associated with a higher rate of age-adjusted, in-hospital mortality for pneumonia, hypertension, heart failure, respiratory failure, and thoracic malignancies. In contrast, a hospital diagnosis of COPD was not associated with a greater prevalence of hospitalisation or in-hospital mortality for acute and chronic renal failure, HIV, gastrointestinal hemorrhage, and cerebrovascular disease. References Holguin F, Folch E, Redd SC, Mannino DM. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest. 2005;128:2005-2011. Holguin et al Chest 2005

Comorbidity in COPD Traditional View Current Debate Airflow obstruction & emphysema affect gas exchange  systemic implications Current Debate Is airways compromise the central disease process? OR Is it one manifestation of a “systemic” inflammatory state with multiple organ compromise?

COPD Clinical presentation Pathophysiology Management strategy Treatment

COPD Risk Assessment C D B A ≥2 Risk of Exacerbation 1 GOLD IV GOLD III GOLD II GOLD I Severity of Obstruction Risk of Exacerbation ≥2 1 Frequency of Exacerbations C D A B Increasing Symptoms (mMRC or CAT score) mMRC 0-1 CAT < 10 mMRC > 2 CAT > 10 Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011

COPD Treatment Smoking Cessation Short-Term ↓ cough, sputum ↑ lung function Long-Term ↑ survival ↑ QOL ↓ lung function ↓cormorbidities

COPD Risk and Smoking Cessation Smoked regularly and susceptible to effects of smoke Never smoked or not susceptible to smoke Stopped smoking at 45 (mild COPD) Stopped smoking at 65 (severe COPD) Disability Death 25 50 75 100 Age (years) FEV1 (% of value at age 25) Speaker Notes The set of curves on this slide shows the risks for death and disability for smoking and nonsmoking men. The slide shows the effects that smoking, and stopping smoking, can have on FEV1 in a man who is liable to develop COPD if he smokes. Reference Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ. 1977;1:1645-1648. Fletcher CM, Peto R. BMJ. 1977;1:1645-1648

COPD Treatment ↓ exacerbation frequency Influenza, Pneumococcal Immunization Short-Term Long-Term ↓ exacerbation frequency

COPD Treatment Short-Term Long-Term Bronchodilators: Long-acting Beta2 Agonist or Anti Cholinergic ↓ airflow obstruction ↓ hyperinflation ↑ exercise endurance ↑ tremors, dry mouth ↑ Quality of life ↓ exacerbations Combination: Inhaled Corticosteroid & Long-acting Beta2 Agonist ↓ dyspnea ↑ exercise tolerance ↑ possibly survival ↑ risk of pneumonia

Symptom- and Risk-Based Treatment Paradigm few symptoms, high risk of exacerbations 1: Combination inhaled corticosteroid/long-acting beta2 agonist or long-acting anticholinergic 2: Combination 2 long-acting bronchodilators or combination inhaled corticosteroid / long-acting anticholinergic many symptoms, high risk of exacerbations 2: Combination inhaled corticosteroid/long-acting beta2 agonist, long-acting anticholinergic 3: May add phosphodiesterase-4 inhibitor or short-acting bronchodilator and theophylline or carbocysteine few symptoms, low risk of exacerbations 1: Short-acting bronchodilator 2: Combination of short-acting bronchodilators / introduce long-acting bronchodilator more symptoms, low risk of exacerbations 1: Long-acting bronchodilators recommended 2: Combination of long-acting bronchodilators in patients with severe breathlessness C D Increasing Airways Obstruction Increasing Exacerbations A B Increasing Symptoms Global Initiative for COPD (GOLD) 2011

COPD Treatment Short-Term Long-Term Oxygen Therapy ↑ exercise endurance ↑ survival

Oxygen Therapy Improves Survival "The more hours, the better!" Lancet 2003 362:1053-1061

Indications for Oxygen Therapy PaO2 <55 mm Hg or SaO2 ≤88% Milder hypoxemia - In the presence of cor pulmonale or hematocrit >55% Normoxemic at rest but desaturation during exercise or sleep

Oxygen Therapy Aim: PaO2 60-70mm Hg or SatO2 >88% Nasal masks 1-2L/min Venturi masks 24%, 28%, 35% Monitor SatO2, PaCO2 and pH If hypoxemia persists or CO2 retention worsens: optimize bronchodilators, consider using assisted noninvasive ventilation

Noninvasive Ventilation If hypoxemia persists or CO2 retention worsens: Optimize bronchodilators and consider using assisted noninvasive ventilation

COPD Treatment Short-Term Long-Term Pulmonary Rehabilitation ↓ dynamic hyperinflation ↓ functional dyspnea ↑ exercise endurance ↑ QOL ↑ possibly survival

Pulmonary Rehabilitation Goals: Reduce symptoms, improve quality of life, and increase participation in daily activities Program includes: Exercise training (tolerance and muscle strength) Nutrition counseling Education

Pulmonary Rehabilitation Components: Exercise training (bicycle ergometry/treadmill & upper limb exercises) Education Nutrition counseling Smoking cessation 8-12 week duration Beneficial in a wide range of disability

Benefits of Pulmonary Rehabilitation in COPD Improves exercise capacity Improves recovery from exacerbation Improves QOL Reduces perceived intensity of breathlessness Reduces hospitalizations, days in hospital Reduces anxiety & depression Benefits beyond immediate training period May improve survival

Acute reversibility of airways obstruction in response to bronchodilator is a poor predictor of benefit to FEV1 after 1 year SF BUILD THIS SLIDE UP

Exercise Tolerance & Survival in COPD 365 patients, 2 centers, 1994-2005 Smoking history >10 years FEV1/FVC < 0.70 171 deaths (47%, 43±24 mo), respiratory failure (majority), cardiovascular disease (9%), lung cancer (18%), other causes (23%) Nonsurvivors older, more severe airflow limitation, lower mean exercise capacity 6MWD best predictor of all-cause mortality Cote & Celli et al, Chest 2007

Exercise Capacity & Survival in COPD F/U (months) Survival probability 1.0 0.8 0.6 0.4 0.2 0 12 24 36 48 60 72 84 96 >350 m <350 m Exercise tolerance predicts survival in COPD Cote & Celli et al, Chest 2007

COPD Phenotypes Emphysema-hyperinflation Dyspnea, exercise intolerance, hyperinflation Chronic bronchitis Cough & sputum 3 mos/yr, 2 yr Frequent exacerbator ≥ 2 exacerbations / year Cor pulmonale COPD w bronchiectasis HRCT diagnosis, airways colonization? Mixed asthma-COPD Increased reversibility of obstruction COPD-eosinophilia Comorbidities & systemic inflammation ↑ biomarkers (C-reactive protein, serum alymoid A, IL-6, IL-8, tumor necrosis factor α, leukocytes) α1 antitrypson

Phenotype-Specific COPD Treatment Benefit Roflumilast Frequent exacerbator (≥ 2 / yr) ↓ exacerbations ↑ quality of life ↑ lung function Azithromycin Frequent exacerbator (≥ 2 / yr) ↑ QOL Chronic antibiotic COPD with bronchiectasis ↓ eradicate colonizing microorganisms ↓ chronic inflammation Inhaled corticosteroids COPD-eosinophilia and Mixed asthma-COPD

COPD Treatment Treatment Phenotype Benefit Lung Volume Reduction Surgery / Bronchoscopy Predominantly upper lobe emphysema ↑ exercise capacity Lung Transplantation With failure of medical treatment, select patients ↓ exacerbations ↑ quality of life ↑ lung function

COPD – Conclusions COPD: underdiagnosed; high & rising mortality Dyspnea, chronic cough, +/- sputum, risk factors  consider COPD Diagnosis by spirometry: FEV1 / FVC < 70% Treatment of stable COPD: consider symptoms, severity of obstruction, frequency of exacerbations Manage exacerbations: bronchodilators, corticosteroids, +/- antibiotics

COPD – Conclusions High rates of comorbidities Rehabilitation: a standard of care to break the cycle of dyspnea, fear, anxiety, increasing inactivity A heterogeneous disease: the future is phenotype-specific treatment

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Emphysema Asthma Bronchitis Other Airways Obstruction

Differential Diagnosis: COPD and Asthma Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation ASTHMA Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation 83

COPD – Differential Diagnosis History Asthma Emphysema Chronic Bronchitis +/- + Smoking Common (usually nocturnal) May be absent Main complaint Productive Cough Episodic Dyspnea ++ - Exacerbations Common Allergy

COPD - Differential Diagnosis Physical Examination Asthma Emphysema Chronic Bronchitis Rare + +/- Barrel Chest Prolonged Expiration In severe exacerbation Typical Decreased Breathing Sounds -/+/++ Wheezing ++ Cyanosis - In advanced disease Weight Loss

COPD - Differential Diagnosis PFT Asthma Emphysema Chronic Bronchitis Pulmonary Function Component  Normal/ FEV1   /No change FEV1 after Bronchodilator Normal/  Residual Volume (RV) Normal Total Lung Capacity (TLC) Diffusion Capacity (DLCO)

COPD - Differential Diagnosis Complications Asthma Emphysema Chronic Bronchitis During exacerbation Common Hypoxemia Rare In advanced disease Erythrocytosis In severe exacerbation End-stage disease Hypercarbia Cor-pulmonale

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Bronchiectasis - Definition מצב בו דלקות וזיהומים גורמים נזק לדרכי האוויר, כך שאלו הופכים למעוותים ריר מצטבר בדרכי האוויר וקיים קושי לסלקו בשל פגיעה במנגנוני סילוק ההפרשות של דרכי האוויר התוצאה – זיהומים חוזרים וקשים

Bronchiectasis - Pathology

Bronchiectasis - Etiology Recurrent bronchial infections Airway obstruction (localized) caused by foreign body, benign tumor Post-infectious (measles, pertussis, S. aureus, TB) Immune deficiency- hypoglobulinemia, leukocyte dysfunction Cystic fibrosis Ciliary dyskinesia (Kartagener's syndrome) Allergic bronchopulmonary aspergillosis

Bronchiectasis - Clinical Features Chronic productive cough Coarse crackles, clubbing Hemoptysis Obstructive lung disease Respiratory failure

Bronchiectasis - Diagnosis Chest x-ray Bronchography High-resolution CT

Bronchiectasis Chest x-ray

Bronchiectasis Bronchography

Bronchiectasis High-resolution CT BETTER CT AVAIL IN PAT TZ Z844321

Bronchiectasis - Treatment Antibiotics (p. aeruginosa, s. aureus) Vaccinations Physiotherapy Bronchodilators Surgery for localized disease

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Bronchiolitis Obliterans - Definition תהליך הצטלקות כרוני של דרכי האוויר הקטנות של הריאה. בעקבות כך - הרס פרוגרסיבי של דרכי אוויר אלו המביאה להתפתחות מחלת ריאות חסימתית. מדובר בהתהליך בלתי הפיך בעיקרו.

Bronchiolitis Obliterans - Etiology Inhalation of toxic fumes (smoke) Connective tissue disease (RA) Post BMT, lung & heart-lung transplant Drugs (eg., gold, penicillamine) Consequent to respiratory infections (adenovirus, mycoplasma) Cryptogenic

Cryptogenic Bronchiolitis Obliterans Clinical Features Onset: months to years Dyspnea and cough with minimal sputum production Normal breathing sounds, occasionally rhonchi CXR= normal or hyperinflation, CT= mosaic attenuation, ground-glass pattern

Bronchiolitis Obliterans Inspiratory & Expiratory HRCT מוזאיקה (אוויר כלוא) זכוכית חול

Obstructive Pulmonary Disease Chronic obstructive pulmonary disease (COPD) Asthma Bronchiectasis Cystic fibrosis Bronchiolitis obliterans Alpha-1-antitrypsin deficiency

Alpha-1-Antitrypsin Deficiency 5% מחולי אמפיזמה רמות האנזים בחולים קטנות מ-35% הגנוטיפ התקין מכונה PiMM והפגום PiZZ הביטויים הקליניים: אמפיזמה שחמת והפטומה. טיפול – תחליף האנזים (Zymera)