THERAPY & MANAGEMENT

ASTHMA & COPD

Dr. Mike IredaleOctober 2010

www.brit-thoracic.org.uk

www.asthma.org.uk

ASTHMA

“a chronic inflammatory disorder of the airways….in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.”

ACUTE ASTHMA

Assessment - able to complete sentences ? - peak expiratory flow rate - respiratory rate - pulse - oxygen saturation - arterial blood gases

ACUTE ASTHMA - Treatment

Oxygen - high flow / concentration

Nebulised (high dose) B2-agonist - salbutamol - terbutaline

ACUTE ASTHMA - Treatment (2)

Steroids - prednisolone (40-50 mg daily) - hydrocortisone (100mg qds)

no need to taper dose continue inhaled steroid

ACUTE ASTHMA - Treatment (3)

Ipratropium Bromide - nebulised 500mcg qds

- acute severe asthma - life-threatening asthma - poor initial response to nebulised B2-agonist - only for initial phase of treatment

ACUTE ASTHMA - Treatment (4)

Intravenous Magnesium Sulphate - 1.2 - 2g IV infusion over 20 min (single dose)

consider if: life-threatening or near fatal asthma acute severe asthma with poor initial response after consultation with senior medical staff

ACUTE ASTHMA - Treatment (5)

Intravenous Infusions

Aminophylline - 0.5 mg / kg / hr - omit bolus if on oral aminohylline / theophylline - check levels

B2-agonist - limited evidence - ventilated patients

ACUTE ASTHMA - Treatment (6)

Antibiotics

Routine prescription of antibiotics is NOT

indicated for acute asthma.

ACUTE ASTHMA

ITU Referral: - deteriorating peak flow - persisting / worsening hypoxia - hypercapnea - falling pH on ABG - exhaustion / feeble respiration - drowsiness, confusion, coma, cardiac arrest

ACUTE ASTHMA

Discharge: - on discharge medication for 24 hours - PEF >75% best/predicted + <25% variability - oral + inhaled steroid + bronchodilator - inhaler technique checked - PEF meter + action plan - follow up: GP 2 days, chest clinic 4 weeks

Questions ?

CHRONIC ASTHMA

Treatment Goals: - minimal symptoms during day & night - minimal need for reliever medication - no exacerbations - no limitation of physical activity - normal lung function

(FEV1 / PEF > 80% predicted or best)

CHRONIC ASTHMA

Non-Pharmacology

- smoking cessation (active / passive) - allergen avoidance - complementary / alternative medicine - weight reduction in obese - gastro-oesophageal reflux - immunotherapy

CHRONIC ASTHMA

Pharmacology

- step-wise approach - start at level appropriate to severity - step-down when control is good

- compliance, inhaler technique, trigger factors

CHRONIC ASTHMA

STEP 1: Mild Intermittent Asthma

inhaled short-acting B2-agonist - as required - reliever therapy

CHRONIC ASTHMA

STEP 2: Introduction of Regular Preventer Therapy

inhaled steroid is first choice - 400-800 mcg BDP (beclomethasone) equivalent

CHRONIC ASTHMA Inhaled Steroids:

- beclomethasone (BDP) - budesonide

- fluticasone - mometasone - ciclesonide

- large volume spacer in doses >1500 mcg BDP

CHRONIC ASTHMA

STEP 3: Add-on therapy

long-acting B2-agonist - salmeterol - formoterol

- good response - continue no response - stop

CHRONIC ASTHMA

STEP 3: Add-on therapy (2)

if control remains inadequate: - increase inhaled steroid to 800 mcg / day

CHRONIC ASTHMA

STEP 3: Add-on therapy (3)

if control remains inadequate trial of:

- leukotriene receptor antagonists - theophylline

CHRONIC ASTHMA STEP 4: Poor control on moderate dose

inhaled steroid + add-on therapy: Addition of 4th drug

- increase inhaled steroid to 2000 mcg / day - leukotriene receptor antagonists - theophylline - slow-release oral B2-agonist

CHRONIC ASTHMA

STEP 5: Continuous or Frequent use of Oral Steroid

- side-effects

- steroid sparing medication - inhaled steroid most effective - immunosuppressants

CHRONIC ASTHMA

Step Down

- patients often left over treated

- regular review - aim to maintain at lowest dose inhaled steroid that keeps asthma controlled

Questions ?

COPD

..is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy.

COPD - Treatment

SMOKING CESSATION

..is the single most important way of affecting outcome in patients at all stages of COPD

COPD - Treatment (2) Bronchodilators (BD)

- stepwise approach - stop therapy if ineffective

short acting as needed (B2-agonist or AC)

combination short acting BD

long-acting BD (B2-agonist or AC)

COPD - Treatment (2)

Bronchodilators - Mod/severe COPD: consider -

combination long-acting BD + inhaled steroid

theophylline

COPD - Treatment (3)

Frequent exacerbations:

optimise BD therapy with one or more long-acting BD (B2-agonist or AC)

inhaled steroid - if FEV1 < 50% + 2 exacerbations in last year

COPD - Treatment (4)

Other measures:- nutrition- vaccination- pulmonary rehabilitation- breathlessness treatment- surgery- mucolytic therapy- depression

COPD - Treatment (5)

Long Term Oxygen Therapy (LTOT):

- improved survival (25% - 41% 5 yr) - less secondary polycythaemia - prevents progression of pulmonary hypertension - better neuropsychological health

COPD - Treatment (5)

Long Term Oxygen Therapy (LTOT):

- FEV1 < 1.5 l - paO2 < 7.3 kPa, on 2 occasions 3 weeks apart - at least 15 hrs each day - no benefit if continue to smoke

Questions ?

COPD - Acute Exacerbation

Presentation: Important symptoms include

- increased sputum purulence - increased sputum volume - increased dyspnoea - increased wheeze - chest tightness - fluid retention

COPD - Acute Exacerbation

Treatment: Bronchodilators

- nebulised in hospital + regular - B2-agonist / anticholinergic

- acute response does not imply long-term benefit

- iv aminophylline if severe and not responding

COPD - Acute Exacerbation

Treatment: Antibiotic

if 2 or more of - increased breathlessness - increased sputum volume - development of purulent sputum

COPD - Acute Exacerbation

Treatment: Antibiotic

commonest bacterial causes - Haemophilus influenzae - Streptococcus pneumoniae

amoxycillin first choice for most patients

COPD - Acute Exacerbation

Treatment: Steroid - common practice but value unclear

Justified if: - already on oral steroid - previous documented response - first presentation of airways obstruction - AFO fails to respond to increase bronchodilator

COPD - Acute Exacerbation

Treatment:

Diuretic - peripheral oedema - raised JVP

Anticoagulant - prophylactic clexane for acute on chronic respiratory failure

COPD - Acute Exacerbation

Treatment: OXYGEN

? resp. failure - oxygen saturation - pO2 < 8 kPa, SaO2 < 92%

? type of resp failure - ABG - type 1: normal or low pCO2

- type 2: raised pCO2

COPD - Acute Exacerbation

Treatment: OXYGEN

type 1 - high concentration oxygen

- monitor with SaO2 unless patient deteriorates

- aim to keep SaO2 >94-98 %

COPD - Acute Exacerbation

Treatment: OXYGEN type 2 - controlled oxygen therapy

- 24 % FiO2 , repeat ABG after 60 min

- if pO2 > 8 kPa + pCO2 & pH ISQ - no change - if pO2 < 8 kPa + pCO2 & pH ISQ - increase to 28% - if pCO2 increases & pH falls - alternative strategy

COPD - Acute Exacerbation

Alternative strategies for COPD & respiratory failure:

- non-invasive ventilation (NIV)(pH < 7.35, pCO2 > 6)

- intubation and ventilation

(- iv doxapram)

Questions ?

www.brit-thoracic.org.uk

www.asthma.org.uk