Caring for Patients with Caring for Patients with COPD: Guidelines for COPD: Guidelines for

Diagnosis and ManagementDiagnosis and Management

M. Elizabeth Knauft, MD MSM. Elizabeth Knauft, MD MS

September 20, 2007September 20, 2007

GOLDGOLD Diagnosis and Classification of COPDDiagnosis and Classification of COPD 4 major components of COPD 4 major components of COPD

managementmanagement Assess and Monitor DiseaseAssess and Monitor Disease Reduce Risk FactorsReduce Risk Factors Manage Stable COPDManage Stable COPD Manage ExacerbationsManage Exacerbations

GOLDGOLD

1998: Global Initiative for Chronic 1998: Global Initiative for Chronic Obstructive Lung DiseaseObstructive Lung Disease

2001:2001: Global Strategy for the Diagnosis, Global Strategy for the Diagnosis, Management, and Prevention of COPDManagement, and Prevention of COPD

2006: Revision of above2006: Revision of above

Goals of GOLDGoals of GOLD

““To improve prevention and management of To improve prevention and management of COPD through a concerted worldwide effort COPD through a concerted worldwide effort of people involved in all facets of healthcare of people involved in all facets of healthcare and healthcare policy, and to encourage an and healthcare policy, and to encourage an expanded level of research interest in this expanded level of research interest in this highly prevalent disease.”highly prevalent disease.”

CaseCase

CC: DyspneaCC: Dyspnea HPI: 66 yo F with several years of progressive HPI: 66 yo F with several years of progressive

dyspnea, cough.dyspnea, cough. 60 pack year tobacco, active smoker (2ppd)60 pack year tobacco, active smoker (2ppd) PMH: DM IIPMH: DM II

Definition of COPDDefinition of COPD

Preventable and treatable disease with some Preventable and treatable disease with some significant extrapulmonary effects that may significant extrapulmonary effects that may contribute to the severity in individual patientscontribute to the severity in individual patients

Pulmonary component characterized by Pulmonary component characterized by airflow limitation that is not fully reversible.airflow limitation that is not fully reversible.

Airflow limitation progressive and associated Airflow limitation progressive and associated with abnormal inflammatory response of the with abnormal inflammatory response of the lung to noxious particles or gaseslung to noxious particles or gases

Spirometric Classification of COPD Spirometric Classification of COPD Severity Based on Post-Bronchodilator Severity Based on Post-Bronchodilator

FEV1FEV1

Stage I:Stage I:

MildMild

FEV1/FVC <70%FEV1/FVC <70%

FEV1 > 80% predictedFEV1 > 80% predicted

Stage II:Stage II:

ModerateModerate

FEV1/FVC <70%; 50%< FEV1<80% pred.FEV1/FVC <70%; 50%< FEV1<80% pred.

Stage III: Stage III: SevereSevere

FEV1/FVC <70%; 30%< FEV1<50% pred.FEV1/FVC <70%; 30%< FEV1<50% pred.

Stage IV:Stage IV:

Very SevereVery Severe

FEV1/FVC <70%FEV1/FVC <70%

FEV1<30%, or FEV1 < 50% pred. plus FEV1<30%, or FEV1 < 50% pred. plus presence of chronic respiratory failurepresence of chronic respiratory failure

Case Con’tCase Con’tSpirometrySpirometry

FEV1/FVC: 0.50FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% Postbronchodilator FEV1: 1.23L (63%

predicted)predicted)

Case Con’tCase Con’tSpirometrySpirometry

FEV1/FVC: 0.50FEV1/FVC: 0.50 Postbronchodilator FEV1: 1.23L (63% Postbronchodilator FEV1: 1.23L (63%

predicted)predicted)

Stage IIStage II

Mechanism of COPDMechanism of COPD

Proximal and peripheral airways, lung Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affectedparenchyma, pulmonary vasculature affected

Chronic inflammatory changes, amplified by Chronic inflammatory changes, amplified by oxidative stressoxidative stress

Burden of COPDBurden of COPD

Prevalence higher in Prevalence higher in smokers and ex-smokers than nonsmokerssmokers and ex-smokers than nonsmokers Patients over 40 than those under 40Patients over 40 than those under 40 Men than in womenMen than in women

MorbidityMorbidity MortalityMortality

66thth leading cause of death in 1990 (Global Burden leading cause of death in 1990 (Global Burden on Disease Study)on Disease Study)

Projected to be 3Projected to be 3rdrd leading cause by 2020 leading cause by 2020

Risk Factors for COPDRisk Factors for COPD

Cigarette smokeCigarette smoke Occupational dust and chemicalsOccupational dust and chemicals Environmental tobacco smokeEnvironmental tobacco smoke Indoor and outdoor pollutionIndoor and outdoor pollution

Management Goals for COPDManagement Goals for COPD

Relieve symptoms Relieve symptoms Prevent progression of diseasePrevent progression of disease Improve exercise toleranceImprove exercise tolerance Improve health statusImprove health status Prevent and treat complicationsPrevent and treat complications Prevent and treat exacerbationsPrevent and treat exacerbations Reduce mortalityReduce mortality

Four Major Components of COPD Four Major Components of COPD ManagementManagement

I: Assess and Monitor DiseaseI: Assess and Monitor Disease II: Reduce Risk FactorsII: Reduce Risk Factors III: Manage Stable COPDIII: Manage Stable COPD IV: Manage ExacerbationsIV: Manage Exacerbations

Assess and Monitor DiseaseAssess and Monitor Disease

DyspneaDyspnea Progressive, persistent, worse with exerciseProgressive, persistent, worse with exercise ““increased effort to breathe”, “air hunger”increased effort to breathe”, “air hunger”

Chronic coughChronic cough Intermittent, non-productiveIntermittent, non-productive

Chronic sputum production Chronic sputum production Any patternAny pattern

History of exposure to risk factorsHistory of exposure to risk factors Tobacco, occupational dust/chemicals, home cooking, Tobacco, occupational dust/chemicals, home cooking,

heating fuelsheating fuels

Assess and Monitor Disease-2Assess and Monitor Disease-2

Confirm diagnosis by spirometryConfirm diagnosis by spirometry Post bronchodilator FEV1/FVC < 0.70 Post bronchodilator FEV1/FVC < 0.70 Obtain ABG if FEV1 < 50% predicted or Obtain ABG if FEV1 < 50% predicted or

clinical signs right heart failureclinical signs right heart failure Alpha-1 antitrypsin level in young pts (<45 Alpha-1 antitrypsin level in young pts (<45

years)years) Identify comorbidities Identify comorbidities

Assess and Monitor Disease-3Assess and Monitor Disease-3

Differential DiagnosisDifferential Diagnosis AsthmaAsthma CHFCHF BronchiectesisBronchiectesis TuberculosisTuberculosis Obliterative BronchioloitsObliterative Bronchioloits Diffuse PanbronchiolitisDiffuse Panbronchiolitis

Reduce Risk FactorsReduce Risk Factors

Smoking Cessation!Smoking Cessation! Reduction of indoor and outdoor air pollutionReduction of indoor and outdoor air pollution

Manage Stable COPDManage Stable COPD

Individualize overall approach to address Individualize overall approach to address symptoms and improve quality of lifesymptoms and improve quality of life

Smoking cessationSmoking cessation Pharmacotherapy for COPD used to decrease Pharmacotherapy for COPD used to decrease

symptoms and/or complications symptoms and/or complications do NOT modify long-term decline in lung functiondo NOT modify long-term decline in lung function

Manage Stable COPD-2Manage Stable COPD-2BronchodilatorsBronchodilators

B-2 agonists, anticholinergics,methylxanthinesB-2 agonists, anticholinergics,methylxanthines Symptomatic management: prn or scheduledSymptomatic management: prn or scheduled Increase exercise capacity Increase exercise capacity Do not necessarily improve FEV1Do not necessarily improve FEV1 LABA more effective than SABALABA more effective than SABA Combination therapy more effective than increasing Combination therapy more effective than increasing

dose of single agentdose of single agent Long acting anticholinergic reduces rate of COPD Long acting anticholinergic reduces rate of COPD

exacerbations, improves effectiveness of pulmonary exacerbations, improves effectiveness of pulmonary rehabilitationrehabilitation

Manage Stable COPD-3Manage Stable COPD-3GlucocorticosteroidsGlucocorticosteroids

Inhaled corticosteroids (ICS) do not modify Inhaled corticosteroids (ICS) do not modify long term decline in FEV1long term decline in FEV1

ICS appropriate for symptomatic, FEV1 < ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very 50% (Stage III: Severe and Stage IV: Very Severe) pts Severe) pts

Regular use of ICS reduces frequency of Regular use of ICS reduces frequency of exacerbationsexacerbations

Long term use systemic glucocorticosteroids is Long term use systemic glucocorticosteroids is NOT recommendedNOT recommended

Manage Stable COPD-4Manage Stable COPD-4

Influenza vaccineInfluenza vaccine Pneumococcal vacine (>65years; < 65 years Pneumococcal vacine (>65years; < 65 years

with FEV1 < 40 % predicted)with FEV1 < 40 % predicted)

Manage Stable COPD-5Manage Stable COPD-5Therapies NOT recommendedTherapies NOT recommended

No benefit from prophylactic antibiotic therapy No benefit from prophylactic antibiotic therapy Overall benefit from mucolytics is smallOverall benefit from mucolytics is small N-acetylcysteine: no reduction in exacerbationsN-acetylcysteine: no reduction in exacerbations Antitussives (cough has a protective role)Antitussives (cough has a protective role) Vasodilators (inhaled nitric oxide)Vasodilators (inhaled nitric oxide)

Manage Stable COPD-6Manage Stable COPD-6Non-Pharmacologic TreatmentsNon-Pharmacologic Treatments

Pulmonary rehabilitationPulmonary rehabilitation Goals: Reduce symptoms, improve quality of life, increase Goals: Reduce symptoms, improve quality of life, increase

physical and emotional participation in everyday activitiesphysical and emotional participation in everyday activities Supplemental oxygen Supplemental oxygen

Use > 15 h/day improves survival in patients with chronic Use > 15 h/day improves survival in patients with chronic respiratory failurerespiratory failure

PaO2<55, SaO2 <88%PaO2<55, SaO2 <88% PaO2 55-60, SaO2 = 88% and pulmonary hypertension, PaO2 55-60, SaO2 = 88% and pulmonary hypertension,

evidence of CHF, polycythemia (HCT > 55%)evidence of CHF, polycythemia (HCT > 55%)

Therapy at Each Stage of COPDTherapy at Each Stage of COPD

Stage I:Stage I:

MildMild

Reduction of risk factors; influenza vaccinationReduction of risk factors; influenza vaccination

Add short-acting bronchodilators prnAdd short-acting bronchodilators prn

Stage II:Stage II:

ModerateModerate

Add regular treatment with one or more long-Add regular treatment with one or more long-acting bronchodilators; add rehabilitationacting bronchodilators; add rehabilitation

Stage III:Stage III:

SevereSevere

Add inhaled glucocorticosteroids if repeated Add inhaled glucocorticosteroids if repeated exacerbationsexacerbations

Stage IV:Stage IV:

Very SevereVery Severe

Add long-term oxygen if chronic respiratory Add long-term oxygen if chronic respiratory failure; consider surgical treatmentsfailure; consider surgical treatments

Case Con’tCase Con’t

Short acting B2 agonistShort acting B2 agonist Long acting bronchodilator (B2 agonist or Long acting bronchodilator (B2 agonist or

anticholinergic)anticholinergic) Influenza vaccineInfluenza vaccine Pneumococcal vaccinePneumococcal vaccine Smoking cessationSmoking cessation

Manage ExacerbationsManage Exacerbations

Exacerbation:Exacerbation: “…“…an event in the natural course of the disease an event in the natural course of the disease

characterized by a change in the patient’s baseline characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a may warrant a change in regular medication in a patient with underlying COPD.”patient with underlying COPD.”

Infection of tracheobronchial tree and air pollution Infection of tracheobronchial tree and air pollution most common causesmost common causes

No cause identified in 1/3 exacerbationsNo cause identified in 1/3 exacerbations

Manage ExacerbationsManage Exacerbations

Increased SOB, wheeze, chest tightness, Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color increased cough and sputum, change in color or tenacity of sputumor tenacity of sputum

Assess severityAssess severity Dependent on pt’s baseline prior to exacerbationDependent on pt’s baseline prior to exacerbation ABGABG FEV1 not practicalFEV1 not practical CXRCXR Sputum cultureSputum culture

Manage ExacerbationsManage ExacerbationsHome managementHome management

Increase dose and/or frequency of short acting Increase dose and/or frequency of short acting bronchodilator therapybronchodilator therapy

Consider adding anticholinergic agentConsider adding anticholinergic agent Systemic glucocorticosteroidsSystemic glucocorticosteroids

Shorten recovery timeShorten recovery time Improve FEV1 and hypoxemiaImprove FEV1 and hypoxemia Consider (in addition to bronchodilators) if FEV1 < Consider (in addition to bronchodilators) if FEV1 <

50%50% 30-40 mg prednisone/d x 7-10 days30-40 mg prednisone/d x 7-10 days

Case Con’tCase Con’t

Increased dyspneaIncreased dyspnea Increase in sputum, now purulentIncrease in sputum, now purulent

Case Con’tCase Con’t

Increased dyspneaIncreased dyspnea Increase in sputum, now purulentIncrease in sputum, now purulent

Increase frequency of bronchodilators Increase frequency of bronchodilators (nebulized or inhaled)(nebulized or inhaled)

Consider oral glucocorticosteroidsConsider oral glucocorticosteroids

Manage ExacerbationsManage ExacerbationsHospital managementHospital management

Risk of death related to development of respiratory Risk of death related to development of respiratory acidosisacidosis

Indications for hospital assessment/admissionIndications for hospital assessment/admission Marked increase in intensity of symptomsMarked increase in intensity of symptoms Severe underlying COPDSevere underlying COPD New physical signs (cyanosis, peripheral edema)New physical signs (cyanosis, peripheral edema) Failure to respond to outpatient managementFailure to respond to outpatient management Significant comorbiditiesSignificant comorbidities Frequent exacerbationsFrequent exacerbations New arrythmiaNew arrythmia Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support

Manage ExacerbationsManage ExacerbationsHospital management-2Hospital management-2

Assess severity of symptoms- ABG, CXRAssess severity of symptoms- ABG, CXR OxygenOxygen BronchodilatorsBronchodilators

B-2 agonistB-2 agonist Add anticholinergic if no responseAdd anticholinergic if no response Role of methylzanthines is controversialRole of methylzanthines is controversial

Add oral or IV glucocorticosteroidsAdd oral or IV glucocorticosteroids

Manage ExacerbationsManage ExacerbationsHospital management-3Hospital management-3

Give antibiotics if:Give antibiotics if: Increased dyspnea, increased sputum volume, Increased dyspnea, increased sputum volume,

increased sputum purulenceincreased sputum purulence Two of the above three criteria are met, and Two of the above three criteria are met, and

one is presence of purulent sputumone is presence of purulent sputum Severe exacerbation requiring mechanical Severe exacerbation requiring mechanical

ventilation (invasive or noninvasive)ventilation (invasive or noninvasive) H. influenza, S. pneumoniae, M. catarrhalisH. influenza, S. pneumoniae, M. catarrhalis

Manage ExacerbationsManage ExacerbationsHospital management-4Hospital management-4

Ventilatory supportVentilatory support Noninvasive mechanical ventilation : 80% Noninvasive mechanical ventilation : 80%

success ratesuccess rate Moderate/severe dyspnea with use of accessory Moderate/severe dyspnea with use of accessory

muscles and paradoxical abdominal muscle motionmuscles and paradoxical abdominal muscle motion Moderate/severe respiratory acidosis (pH < 7.35, Moderate/severe respiratory acidosis (pH < 7.35,

paCO2 > 45)paCO2 > 45) Tachypnea (RR > 25 bpm)Tachypnea (RR > 25 bpm)

Manage ExacerbationsManage ExacerbationsDischarge CriteriaDischarge Criteria

Inhaled B2 agonist therapy is required no more Inhaled B2 agonist therapy is required no more than every 4 hoursthan every 4 hours

Pt able to walk across room (if previously Pt able to walk across room (if previously ambulatory)ambulatory)

Clinically stable for 12-24 hClinically stable for 12-24 h Stable ABG for 12-24 hStable ABG for 12-24 h Patient/caregiver understands proper Patient/caregiver understands proper

medication usemedication use Home care/follow-up arrangements madeHome care/follow-up arrangements made

SummarySummary

Diagnosis of COPD requires post-Diagnosis of COPD requires post-bronchodilator FEV1bronchodilator FEV1

Tobacco cessationTobacco cessation Layer treatment according to stage of COPDLayer treatment according to stage of COPD