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Lifespa11 Cardiovasculru· l11slilule RJ1ode Island Hospital • The Miriam Hospital

Ne~vport HospitaJ

Delivering health with care!"

COPD Exacerbation and Prevention/Control of Infection

Center For Cardiac Fitness

Pulmonary Rehab Program

The Miriam Hospital

Outline

• Background COPD

• Acute Exacerbation of COPD

– Prevention of COPD Exacerbations • Tobacco Cessation

• Medications in COPD

• Prevention of Infection

– Hand Hygiene

– Vaccinations

What is COPD?

• COPD is a chronic respiratory disease characterized by airflow limitation

• Affects more than 5% of the population

– 13 million adults in the United States

• Third leading cause of death in the United States

• Smoking is by far the most important risk factor

Obstructive Lung Diseases

Asthma Emphysema

Chronic Bronchitis

Chronic Obstructive Pulmonary Disease

“COPD”

COPD: Chronic Bronchitis

Thickened airway wall

Increased Mucus Production

Alveoli with emphysema

Alveoli with emphysema

:w >Li

COPD: Emphysema

What is COPD?

• COPD is a chronic disease that is both preventable and treatable

• Airflow limitation is typically progressive and gets slowly worse over time

• Enhanced airway inflammation makes patients susceptible to “exacerbations” and infections – 1.5 million ER visits and 750,000 hospitalizations per

year

Acute Exacerbations of COPD and Prevention

COPD Exacerbation

• Acute worsening of respiratory symptoms occurring over a few days to weeks

• Possible symptoms include: – More breathless than usual – Less energy for daily activities – Increased or thicker phlegm – Change in color of phlegm – Increased use of rescue inhaler – Increased cough – Feeling of having a “chest cold” – Symptoms at night – Loss of appetite – Feeling that medications are no longer helping

TRIGGERS

Bacteria

EFFECTS

Pollutants

Syst mic Inflammation

Cardiovascular comorbidity

Greater airway inflammation

Bronchoconstriction, oedema, mucus

xpiratory flow limitation

Dynamic hyperinflation

Triggers of COPD Exacerbations

Wedzicha, JA, Seemungal T Lancet 2007

Poorer quality of life

Greater airway inflammation

Higher mortality

Faster decline in lung function

Frequent Exacerbators Associated With Many Worse Outcomes

Wedzicha, JA, Seemungal T Lancet 2007 370-786-796

Natural History of Lungs Never Smoker

or Non susceptible

FEV-1

(%)

Death

Disability

50%

100%

50 100 Time (yr)

Susceptible Smoker

Natural History of Lungs

••••••••••••••••••••••••••••••••••••••••••••••••

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~······················ • • ••••• • • ••••• •• • ••• •• • ••• •• • ••• •• •• ••• • ••• • •• •• •• •• •• .. ·•. •• •• •• •• ••• • •• • •• ~ . . ~ •• •• • •• •• • . ~ ................................ ... .............................. ...................... . ~ •• •• ♦ ~ •• ••

♦ ~

•♦ ••• ♦ • ♦ ••

Freq~ nt Exacerbators •• ••• ............................... ~, ..... . • ♦

• ♦ . ~ • ♦ • ♦ . ~

..................................................... c••······Y································· :• • • "

50%

Frequent Exacerbators Never Smoker

or Non susceptible

FEV-1

(%)

Death

Disability

50%

100%

50 100 Time (yr)

Exacerbations

Susceptible Smoker

Frequent Exacerbators

Reduction in Exacerbations

• Smoking Cessation

• Medication Compliance

• Early Treatment of Exacerbations

• Hand Hygiene and Vaccinations

Tobacco Cessation and Natural History of Lung Function

Never Smoker or

Non susceptible 100%

FEV-1

(%)

Death

Disability

50%

Tobacco Cessation

Age 45

Tobacco Cessation Age 65

Susceptible Smoker

50 100 Time (yr)

IN YOURSELF!

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other ~ 90,ettel TMn rnok• yOilr ~ dioiwl RememlMr

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Tobacco Cessation

• Self-help and group smoking cessation programs – Average 7 attempts to quit

• Nicotine replacement therapy – Chewing gum with better quit

rates than counseling alone. – Transdermal nicotine patches

• Long-term success rates range from 22-42%, vs 2-25%.

• Prescription Medications – Bupropion (Wellbutrin)

• 1 year quit rates 23% vs. 12% with placebo

– Varenicline (Chantix) • 1 year quit rates 23% vs. 9% with

placebo

Medications for COPD

• Short acting bronchodilators

– Albuterol, ipratropium, combivent

• Also referred to as “rescue inhalers”

• All have been shown to improve symptoms and quality of life

• None have been shown to decrease the rate of exacerbations

• No added benefit to taking short acting bronchodilators “regularly” versus “as needed”

lllO(: ... , ,., ,,

Atrovent• HFA (lpratroplum bromide, HFA)

1Inhalation Aerosol 12.9a,,ms

• 200 mec,rt"d ,nh.11tk>ns

11.i'\ Boeh ringer \,1IU1v lnge lheim

FOROIVII. INHAl.ATIONWITH PRO\/'ENTIL• ttrAACTUATORONLY

Rx only

200 METERED INHALATIONS

COnlbiVent• (lpratroplum bromide and albuterol sulfate)

Inhalation Aerosol 14.7grams . 200 metered actuations

60----· ··---V.,,tolln' HFA __ , -­.... ,. .......

--.. ~ ---Nt>I WI. S/1

Short acting bronchodilators (rescue inhalers)

ProAir Proventil Ventolin

Atrovent Combivent

Nebulizers

• The same medications that come in rescue inhalers are sometimes prescribed in nebulized form

• Albuterol, ipratropium, duonebs

• Most patients have similar improvement in lung function with inhalers vs nebulizers

• Some patients have a better response with neublizers

Medications for COPD

• Long acting bronchodilators

– Spiriva (tiotropium), Serevent (salmeterol), Foradil (formotorol)

• Maintenance Inhalers

– Improve lung function

– Improve quality of life

– Reduce exacerbations

Spiriva• HandiHaler'" (!lotropfum bromide fnhalatlon powder)

foalil'- (', "OSAR 11 > --- ----.---

Long Acting Bronchodilators

Spiriva

Foradil

Serevent

Medications for COPD

• Combination long acting bronchodilator with inhaled corticosteroids

– Advair, Symbicort, Dulera

• Reduces exacerbations compared to either agent alone

• Improves lung function

• Improves quality of life

• Can increase rate of pneumonia

Oulera

,,. :': l

Oult _ra

.. -.. __ _ ::.:. .. ------~

•

Combination long acting bronchodilators and inhaled

corticosteroids

Advair

Dulera

Symbicort

00

> w .... 50 C:

g>,, C: ., .r; 0 u= r:: E ., -., -50 ~ -0 2 "' -100 ::, 'c <

-150 0 24

No. of Patients Placebo 1524 1248 Salmeterol 1521 1317 Fluticasone 1534 1346 Combination therapy 1533 1375

48

1128 1218 1230 1281

72

Weeks

96

1049 979 1127 1054 1157 1078 1180 1139

120

906 1012 1006 1073

156

819 934 908 975

Combination therapy

Fluticasone Salmeterol

Placebo

Medications improve lung function

Medication Conclusions

• Medications help to prevent hospital admission and keep patients healthy

• Common Problems:

– feel no effect from medications

– cost a lot of money

Avoid the urge to stop Medications

Hand Hygiene and Vaccinations

Triggers for COPD Exacerbations

5-10% 10-25%

30%

40-50%

Viral

Bacterial

Atypical bacteria

Air pollution

■ ■ ■ ■

Majority of COPD exacerbations are triggered by infection

How are germs spread?

• Germs are released into the air when you sneeze or cough

long do particles stay in the air? hair dead skin soot

-3•5~.

-15HC.

-45ue.

-30-60min.

-1-2 hr

-2-10 hr

-8 · >24 hr

The approximate time it tak s for t hese partic les t o s ttle on meter (39 ') in undisturbed air.

Cover with Your Sleeve!!

Prevent the Spread

• To prevent the spread of infection – Turn away from other people before sneezing or

coughing

– Sneeze or cough into your sleeve making sure to completely cover your mouth and nose

– If you have to cough or sneeze into your hands try to use a tissue. Throw away tissue immediately after use.

– Always wash your hands after coughing or sneezing

Your Mother Does Know Best

G~rmFa.rm

.

Scr-....b'e!m! www.1st-in-handwashing.com

Best Protection Is To Clean Your Hands

• 1 in 3 people leaving the restroom fail to wash their hands

• MD’s in the hospital traveling from patient to patient – 70-80% compliance w/ hand

hygiene

– Feel free to complain

Washing with Soap and Water

• Adjust water to desired temperature

• Moisten hands with soap and water

• Wash well under running water for a minimum of 15-20 seconds, using a rotary motion and friction

• Rinse hands well under running water

• Turn off faucet with paper towel and discard

• Dry hands with a clean paper towel and discard

Use Alcohol Based Hand Gels

• For routine hand cleaning only if your hands are not visibly soiled

• After contact with another persons intact skin – i.e. shaking hands

• After contact with inanimate objects – i.e. telephone, door knob

Vaccinations

Influenza and pneumococcal vaccinations are recommended for all patients with

chronic lung disease!

General Concepts

• Inject either live weakened form or part of the bacteria/virus

• Body forms antibodies against the component of the vaccine

• Antibodies subsequently fight infection if you are exposed

• Myth – Neither flu or pneumococcal

vaccine can give you the disease

• Neither guarantee that you will not get the disease

Community Acquired Pneumonia

Community Acquired Pneumonia

• Pneumonia No. 1 cause of infection-related mortality

– 3rd Most frequent hospital diagnosis in patient >65 years

– 1.3 million cases/yr in US in 2005

Cassiere et al Diss. Mon 1998 44:613-75 Niedeman et al. Annals Int Med 2009; s2-18 Niedermen et al Clin Ther 1998;20: 820

700 [ru

600 Cu Pneumonia and

-Jl.

\ Infl uenza

L Q) 500 Tuberculosis Q_

0

8 0 400 35 0 ~ 30

~ 25

300 20 Q) ~ 15 cu 0: - 10 >- ,200 5 ."t::;

Cu 0 t 1Q70 1900 1900 0 ~ ~

1100

0 ..l_,---------,------.--, _ ____:~!!!!!!!'!!!!!;!!!!!!, !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!~. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!._J

11900 19'20 1940 11960 19',8.0

JAMA. 1999,:2'81 :,61 -,6,6

Pneumonia Associated Mortality Rates

1918

1946 Mass Production of Penicillin

Flu Epidemic

Sanitation/Hygiene

Mortality rates for pneumonia have not improved since penicillin

200,000

en 150,000 Ill en ~

15 _g 100,000

e :> z

50,000

50

65-69 70-74 75-79 80-84 85-89 >90

Age (Years)

50

40 ~ 'O

30 &" 3 0

20 irr = q --10 ~

0

Am J Resp lr Cr1t Care Med Vol 165 . pp 766--772, 2002

Incidence and Mortality Increase with Age

Incidence (Squares)

Mortality (Triangles)

Morality:7.8% 15.4%

Pneumonia is the most common cause of infectious death in

people age >65

Pneumococcal Vaccination

• Streptococcus Pneumoniae: “Pneumococcus” – Common inhabitant of mouth

– Most common cause of bacterial pneumonia- acquired in the community

• 500,000 Cases per Year

– Responsible for >40,000 deaths/yr

• Vaccine Recommendations: – Age 2-64 w chronic disease

– All patients >65

• Vaccine does not prevent all cases of pneumococcal pneumonia but decreases the severity of disease – I.e. less likely to die from it

• Vaccine does not prevent other types of bacterial pneumonia

1

Pneumococcal Vaccination Algorithm

Has the Person Been Vaccinated before?

Yes No or Unsure

Was the Person > age 65 At the time of vaccination?

Vaccination Indicated

Yes Yes

Vaccination Not Indicated No >5 Years Elapsed Since

Vaccine

www.CDC.gov

Flu Vaccine

A Weeklw Jnfl■enza S■rveillance Report Prepared by the Influenza Division

12

1 .

2007

Pneumonia and Influenza Mortality for 122 U.S. Cities

Seasonal Baseline

2008

Week Ending 1/14/2012

2009 2010

4~--------------------------

.. ~···· ............ . c_,.,.. .. .. •••~•--••-

2011

20 30 40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40 50 10 20 30 40

Weeks

Yearly peak Weeks 5-15

pld Envelope Neuraminldasc (Siaflda~c)

During Flu Season

Vaccination: • May not prevent the

“Flu” – Decreases severity of

disease • Less hospitalization, less

loss of work, lower mortality

Important For People at RISK

Conclusions

• COPD is a common progressive disease • Acute exacerbations present significant short and

long term risk to patient • Medications can help to prevent acute exacerbations

of COPD • Tobacco cessation is the only therapy known to slow

the decline of lung function in COPD • Washing your hands is important • The flu and pneumonia vaccines play an important

role in keeping you healthy

Comments/Questions