8/14/2019 ROUNTABLE COPD JAN 2012.ppt
1/71
DIAGNOSIS AND MANAGEMENT OF
CHRONIC OBSTRUCTIVE PULMONARYDISEASE : GOLD 2011
IDA BAGUS NGURAH RAI
21-01-2012
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
2/71
IV: Very SevereIII: SevereII: ModerateI: Mild
Therapy at Each Stage of COPD
FEV1/FVC < 70%
FEV1 > 80%predicted
FEV1/FVC < 70%
50% < FEV1 < 80%predicted
FEV1/FVC < 70%
30% < FEV1 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
4
3
2
1
mMRC>2
CAT >10
Symptoms(mMRC or CAT score))
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
26/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
mMRC>2
CAT >10
Symptoms(mMRC or CAT score))
If mMRC 0-1 or CAT < 10:
Less Symptoms (A or C)
If mMRC> 2 or CAT >10:
More Symptoms (B or D)
Assess symptoms first
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
27/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
Clas
sificationofAirflo
w
Limitation)
Risk
(E
xacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
4
3
2
1
mMRC>2
CAT >10
Symptoms(mMRC or CAT score))
If GOLD 1 or 2 and only
0 or 1 exacerbations per year:Low Risk (A or B)
If GOLD 3 or 4 or two ormore exacerbations per year:
High Risk (C or D)
Assess risk of exacerbations next
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
28/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
Clas
sificationofAirflo
w
Limitation)
Risk
(E
xacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)mMRC 0-1
CAT < 10
4
3
2
1
mMRC>2
CAT >10
Symptoms(mMRC or CAT score))
Patient is now in one offourcategories:
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk
Use combined assessment
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
29/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Risk
(GOLD
ClassificationofA
irflow
Limitation
)
Risk
(Exacerbation
history)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
4
3
2
1
mMRC>2
CAT >10
Symptoms(mMRC or CAT score))
Gl b l St t f Di i M t d
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
30/71
Patien
t
Characteristic Spirometric
Classification
Exacerbations
per year
mMRC CAT
ALow Risk
Less SymptomsGOLD 1-2 1 0-1 < 10
BLow Risk
More Symptoms GOLD 1-2 1 >2 10
CHigh Risk
Less SymptomsGOLD 3-4 >2 0-1 < 10
DHigh Risk
More SymptomsGOLD 3-4 >2 >2
10
Global Strategy for Diagnosis, Management andPrevention of COPD
Combined Assessment
of COPDWhen assessing risk, choose the highestrisk
according to GOLD grade or exacerbation history
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
31/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes
Lung cancerThese comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately.
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
32/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.
Lung Volumes and Diffusing Capacity:Help to characterizeseverity, but not essential to patient management.
Oximetry and Arterial Blood Gases:Pulse oximetry can be usedto evaluate a patients oxygen saturation and need for
supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening:Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD.
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
33/71
Exercise Testing:Objectively measured exercise impairment,assessed by a reduction in self-paced walking distance (suchas the 6 min walking test) or during incremental exercisetesting in a laboratory, is a powerful indicator of healthstatus impairment and predictor of prognosis.
Composite Scores:Several variables (FEV1, exercisetolerance assessed by walking distance or peak oxygen
consumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality.
Global Strategy for Diagnosis, Management and Prevention of COPD
Additional Investigations
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
34/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
Smoking cessation has the greatest capacity toinfluence the natural history of COPD. Health care
providers should encourage all patients who smoketoquit.
Pharmacotherapy and nicotine replacement reliablyincrease long-term smoking abstinence rates.
All COPD patients benefit from regular physicalactivity and should repeatedly be encouraged toremain active.
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
35/71
Appropriate pharmacologic therapy can reduce COPDsymptoms, reduce the frequency and severity of
exacerbations, and improve health status andexercise tolerance.
None of the existing medications for COPD has beenshown conclusively to modify the long-term declinein lung function.
Influenza and pneumococcal vaccination should beoffered depending on local guidelines.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
36/71
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
37/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
38/71
Bronchodilator medications are central to the
symptomatic management of COPD.
Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta2-agonists, anticholinergics, theophylline or combinationtherapy.
The choice of treatment depends on the availability of
medications and each patients individual response
in terms of symptom relief and side effects..
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
39/71
Long-acting inhaled bronchodilators are
convenient and more effective for symptom reliefthan short-acting bronchodilators.
Long-acting inhaled bronchodilators reduceexacerbations and related hospitalizations andimprove symptoms and healthstatus.
Combining bronchodilators of differentpharmacological classes may improve efficacy anddecrease the risk of side effects compared toincreasing the dose of a single bronchodilator.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
40/71
Regular treatment with inhaled corticosteroids (ICS)
improves symptoms, lung function and quality of lifeand reduces frequency of exacerbations for COPD
patients with an FEV1
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
41/71
An inhaled corticosteroid combined with a long-acting
beta2-agonist is more effective than the individualcomponents in improving lung function and health
status and reducing exacerbations in moderate to verysevere COPD.
Combination therapy is associated with an increased riskof pneumonia.
Addition of a long-acting beta2-agonist/inhaledglucorticosteroid combination to an anticholinergic(tiotropium) appears to provide additional benefits.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: CombinationTherapy
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
42/71
Chronic treatment with systemic
corticosteroids should be avoided because ofan unfavorable benefit-to-risk ratio.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: SystemicCorticosteroids
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
43/71
In patients with severe and very severeCOPD (GOLD 3 and 4) and a history ofexacerbations and chronic bronchitis, thephospodiesterase-4 inhibitor (PDE-4),roflumilast, reduces exacerbations treated
with oral glucocorticosteroids.
Therapeutic Options:Phosphodiesterase-4 Inhibitors
Gl b l St t f Di i M t d P ti f COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
44/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Theophylline
Theophylline is less effective and less well tolerated thaninhaled long-acting bronchodilators and is notrecommended if those drugs are available and affordable.
There is evidence for a modest bronchodilator effect andsome symptomatic benefit compared with placebo in stableCOPD. Addition of theophylline to salmeterol produces agreater increase in FEV1and breathlessness than
salmeterol alone.
Low dose theophylline reduces exacerbations but does notimprove post-bronchodilator lung function.
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
45/71
Influenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1< 40%predicted.
The use of antibiotics, other than for treating infectiousexacerbations of COPD and other bacterial infections, iscurrently not indicated.
Therapeutic Options: OtherPharmacologic Treatments
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
46/71
Alpha-1 antitrypsin augmentation therapy:notrecommended for patients with COPD that is unrelatedto the genetic deficiency.
Mucolytics:Patients with viscous sputum may benefitfrom mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators:Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associated
with COPD is not recommended.
Therapeutic Options: OtherPharmacologic Treatments
l b l f d f
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
47/71
All COPD patients benefit from exercise trainingprograms with improvements in exercise toleranceand symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitationprogram is 6 weeks, the longer the programcontinues, the more effective the results.
If exercise training is maintained at home thepatient's health status remains above pre-rehabilitation levels.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
Gl b l S f Di i M d P i f COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
48/71
Oxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increase
survival in patients with severe, resting hypoxemia.
Ventilatory Support:Combination of noninvasiveventilation (NIV) with long-term oxygen therapy may
be of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Other Treatments
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
49/71
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
50/71
Identification and reduction of exposure to risk factors
are important steps in prevention and treatment.
Individualized assessment of symptoms, airflow
limitation, and future risk of exacerbations should beincorporated into the management strategy.
All COPD patients benefit from rehabilitation andmaintenance of physical activity.
Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.
gy g g
Manage Stable COPD: Key Points
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
51/71
Long-acting formulations of beta2-agonists
and anticholinergicsare preferred over short-acting formulations. Based on efficacy and
side effects, inhaled bronchodilators arepreferred over oral bronchodilators.
Long-term treatment with inhaled
corticosteroids added to long-actingbronchodilators is recommended for patientswith high risk of exacerbations.
Manage Stable COPD: Key Points
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
52/71
Long-term monotherapy with oral or inhaled
corticosteroids is not recommended inCOPD.
The phospodiesterase-4 inhibitor roflumilastmay be useful to reduce exacerbations forpatients with FEV1 < 50% of predicted,
chronic bronchitis, and frequentexacerbations.
Manage Stable COPD: Key Points
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
53/71
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
Reduce
symptoms
Reducerisk
Manage Stable COPD: Goals of Therapy
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
54/71
Avoidance of risk factors
- smoking cessation- reduction of indoor pollution
- reduction of occupational exposure Influenza vaccination
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: All COPD Patients
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
55/71
gy g , g
Manage Stable COPD: Non-pharmacologic
Patient Essential Recommended Depending on local
guidelines
A
Smoking cessation (can
include pharmacologic
treatment)
Physical activity
Flu vaccination
Pneumococcal
vaccination
B, C, D
Smoking cessation (caninclude pharmacologic
treatment)
Pulmonary rehabilitation
Physical activity
Flu vaccination
Pneumococcal
vaccination
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
56/71
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: PharmacologicTherapy
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
57/71
Exa
cerbationsp
eryear
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC>2
CAT >10
GOLD 3
GOLD 2
GOLD 1
SAMAprn
orSABA prn
LABA
orLAMA
ICS + LABA
or
LAMA
Manage Stable COPD: PharmacologicTherapy
FIRST CHOICE
A B
DC
ICS + LABA
or
LAMA
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: PharmacologicTherapy
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
58/71
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC> 2
CAT > 10
GOLD 3
GOLD 2
GOLD 1
LAMA or
LABA orSABA and SAMA
LAMA and LABA ICS and LAMA orICS + LABA and LAMA or
ICS + LABA and PDE4-inh or
LAMA and LABA orLAMA and PDE4-inh.
LAMA and LABA
Manage Stable COPD: PharmacologicTherapy
SECOND CHOICE
A
DC
B
Exa
cerbationsperyear
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: PharmacologicTherapy
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
59/71
> 2
1
0
mMRC 0-1
CAT < 10
GOLD 4
mMRC> 2
CAT >10
GOLD 3
GOLD 2
GOLD 1
Theophylline
PDE4-inh.SABA and/or SAMA
Theophylline
CarbocysteineSABA and/or SAMA
Theophylline
SABA and/or SAMA
Theophylline
Manage Stable COPD: PharmacologicTherapy
ALTERNATIVE CHOICES
A
DC
B
Exa
cerbationsperyear
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
60/71
An exacerbation of COPD is:
an acute event characterized by a
worsening of the patients respiratorysymptoms that is beyond normal day-to-day variations and leads to a
change in medication.
gy g , g
Manage Exacerbations
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
61/71
The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.
Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.
The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.
gy g , g
Manage Exacerbations: Key Points
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
62/71
Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an
exacerbation. Systemic corticosteroids and antibiotics can shorten
recovery time, improve lung function (FEV1) andarterial hypoxemia (PaO
2),and reduce the risk of
early relapse, treatment failure, and length ofhospital stay.
COPD exacerbations can often be prevented.
g g g
ManageExacerbations: Key Points
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
63/71
Arterialblood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa when breathing room airindicates respiratory failure.
Chestradiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole bloodcount: identify polycythemia, anemiaor bleeding.
Purulent sputum during an exacerbation: indication to begin
empirical antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes,and poor nutrition.
Spirometric tests:not recommended during an exacerbation.
G oba St ategy o ag os s, a age e t a d e e t o o CO
Manage Exacerbations: Assessments
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
64/71
Oxygen:titrate to improve the patients hypoxemia with a
target saturation of 88-92%.
Bronchodilators:Short-acting inhaled beta2-agonists with or
without short-acting anticholinergics are preferred.
Systemic Corticosteroids: Shorten recovery time, improve lung
function (FEV1) and arterial hypoxemia (PaO2), and reduce
the risk of early relapse, treatment failure, and length ofhospital stay. A dose of 30-40 mg prednisolone per day for
10-14 days is recommended.
gy g , g
Manage Exacerbations:Treatment Options
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
65/71
Antibiotics should be given to patients with:
Three cardinal symptoms: increased
dyspnea, increased sputum volume, andincreased sputum purulence.
Who require mechanical ventilation.
gy g , g
ManageExacerbations:Treatment Options
Global Strategy for Diagnosis, Management and Prevention of COPD
ManageExacerbations:
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
66/71
Noninvasive ventilation (NIV):
Improves respiratory acidosis, reduces
respiratory rate, severity of dyspnea,complications and length of hospital stay.
decreases mortality and needs forintubation.
GOLD Revision 2011
ManageExacerbations:TreatmentOptions
Global Strategy for Diagnosis, Management and Prevention of COPD
ManageExacerbations:Indications for
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
67/71
Marked increase in intensity of symptoms
Severe underlying COPD
Onset of new physical signs
Failure of an exacerbation to respond to initialmedical management
Presence of serious comorbidities
Frequent exacerbations
Older age
Insufficient home support
ManageExacerbations:Indications for
Hospital Admission
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
68/71
COPD often coexists with other diseases
(comorbidities) that may have a significant
impact on prognosis. In general, presence of
comorbidities should not alter COPD treatment
and comorbidities should be treated as if the
patient did not have COPD.
Manage Comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
69/71
Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation,
and hypertension) is a major comorbidity inCOPD and probably both the most frequent
and most important disease coexisting with
COPD. Cardioselective beta-blockers are notcontraindicated in COPD.
ManageComorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
70/71
Osteoporosis andanxiety/depression:often under-diagnosed and associated with poor health status andprognosis.
Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.
Serious infections: respiratory infectionsare especially
frequent.Metabolic syndrome and manifest diabetes: morefrequent in COPD and the latter is likely to impact on
prognosis.
ManageComorbidities
8/14/2019 ROUNTABLE COPD JAN 2012.ppt
71/71
WORLD COPD DAY
November 14, 2012
Raising COPD Awareness Worldwide
Top Related