1. Management of stable chronic obstructive pulmonary disease (2) Seminar Training Primary Care Asthma + COPD 03- 2015 D.Anan Esmail

2. Pulmonary function studies Diagnosis of COPD Staging of COPD

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

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

5. 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

7. 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%

8. STAGING

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

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

11. 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

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

13. 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

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

15. ALL Category

16. reduce the Risk Factors for COPD

17. Annual influenza vaccination Pneumococcal vaccination

18. Regular physical activity (Pulmonary Rehabilitation)

19. Long-term oxygen therapy if chronic hypoxemia

20. Short-acting bronchodilator when needed

21. A Category Bronchodilator as needed

22. B Category regular treatment with a long-acting Bronchodilator

23. C+D Category First choice:

24. COPD is characterized by both airway and systemic inflammation

25. Inhaled glucocorticoids reduce this inflammation

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

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

28. inhaled glucocorticoids decrease exacerbations slow the progression of respiratory symptoms

29. inhaled glucocorticoids have little impact on lung function

30. 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

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

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

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

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

35. 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

36. lung function was better in the LAMA + LABA group

37. Rescue medication use did not differ significantly between the groups

38. exacerbations and mortality, were not assessed

39. 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

40. 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

41. 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

42. Major side effects of inhaled glucocorticoids

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

44. Dysphonia

45. Thrush

46. Oral Candidiasis

47. Skin Bruising

48. Osteoporosis

49. Adrenal Suppression

50. Cataracts

52. Local deposition of inhaled GC less common with dry powder devices

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

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

55. 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?

56. REFRACTORY DISEASE Limited benefit?

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

58. REFRACTORY DISEASE