Dr GH Kaye-Eddie Helen Joseph Hospital Pulmonology

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1 Dr GH Kaye-Eddie Helen Joseph Hospital Pulmonology

2 Introduction Definitions Impact of Exacerbations Assessment of COPD Management of COPD Management of Acute Exacerbations Prevention of Exacerbations

3 COPD is a major global health problem. Currently in the top 5 leading causes of death worldwide. Predicted to become the 4th most common cause by Predicted to become the 7th most common cause of chronic disability by Common cause of hospital admissions and time off work. Associated with significant economic burden.

4 COPD is a common preventable and treatable disease COPD is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.

5 An event characterized by a worsening of the patient s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication. Commonly caused by viral upper respiratory tract infections and infections of the tracheobronchial tree. Treatment aims to minimize the impact of the exacerbation and to prevent the development of subsequent exacerbations.

6 Impact of COPD Exacerbations Negative impact on quality of life Impact on symptoms and lung function Accelerated lung function decline EXACERBATIONS Increased Mortality Increased economic costs 2014 Global Initiative for Chronic Obstructive Lung Disease

7 More rapid decline in FEV1. Transient decline in lung functions from baseline. Increased concentrations of inflammatory markers in sputum. Neutrophils are attracted to the airway lumen during exacerbations, increased levels of neutrophils in sputum correlate with rapid decline in FEV1. Correlation between the number of previous exacerbations and extent of emphysema on HRCT. Percentage change in FEV1 with standard errors over 4 years. Donaldson G C et al. Thorax 2002;57:

8 Increased Dyspnoea. Reduced Exercise Capacity, decreased 6min walk distance. Accelerated loss of skeletal muscle, decreased BMI. Less time spent outdoors, greater likelihood of becoming housebound. Increased dependency; >50% of patients with require assistance with at least one ADL. Relationship between exacerbations frequency and quality of life parameters Anzueto et al. Proc Am Thorac Soc 2007; 4;

9 In hospital mortality rate of 11%. 180 day mortality rate of 33% 2 year mortality rate of 49%. Mortality increases with the frequency of exacerbations. Patients requiring hospital admission 4.3 times greater risk of death than those managed as outpatients. Mortality after COPD exacerbation Connors et al. Am J Respir Crit Care Med 1996; 154:

10 Estimated annual cost of COPD in the; European Union = 38.6 billion. United States = $ 29.5 billion. COPD Exacerbations account for > hospital admissions per year in the US. COPD Acute exacerbations account for the greatest proportion of the total COPD burden on the health care system. Estimated $ 18 billion.

11 Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities Global Strategy for Diagnosis, Management and Prevention of COPD Updated January Global Initiative for Chronic Obstructive Lung Disease

12 Chronic Cough Sputum Production Dyspnoea History of exposure to a risk factor for the disease; Cigarette Smoking Biomass Fuel Occupational Exposure Tuberculosis HIV

13 COPD Assessment Test (CAT): Modified British Medical Research Council (mmrc) Questionnaire PLEASE TICK IN THE BOX THAT APPLIES TO YOU (ONE BOX ONLY) mmrc Grade 0. I only get breathless with strenuous exercise. mmrc Grade 1. I get short of breath when hurrying on the level or walking up a slight hill. mmrc Grade 2. I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level. mmrc Grade 3. I stop for breath after walking about 100 meters or after a few minutes on the level. mmrc Grade 4. I am too breathless to leave the house or I am breathless when dressing or undressing.

14 In patients with FEV1/FVC < 0.70: GOLD 1: Mild GOLD 2: Moderate GOLD 3: Severe GOLD 4: Very Severe FEV1 > 80% predicted 50% < FEV1 < 80% predicted 30% < FEV1 < 50% predicted FEV1 < 30% predicted Based on Post-Bronchodilator FEV1

15 Patients with severe COPD have an annual exacerbation frequency of 3.43 per year compared to 2.68 per year for those with moderate COPD. Patients who suffer high numbers of exacerbations will continue to have frequent exacerbations. Patients in the GOLD 2 category (FEV % pred) have a significant number of exacerbations that can be reduced with pharmacotherapy.

16 To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year. An FEV1 < 50 % of predicted value are indicators of high risk. One or more hospitalizations for COPD exacerbation.

17 Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) Combined Assessment of COPD 4 3 (C) (D) 2 or > 1 leading to hospital admission 2 1 (A) (B) CAT < 10 CAT > 10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness 1 (not leading to hospital admission) Global Initiative for Chronic Obstructive Lung Disease

18 Assess symptoms first (C) (D) If CAT < 10 or mmrc 0-1: Less Symptoms/breathlessness (A or C) (A) (B) CAT < 10 CAT > 10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness If CAT > 10 or mmrc > 2: More Symptoms/breathlessness (B or D) 2014 Global Initiative for Chronic Obstructive Lung Disease

19 Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) Assess risk of exacerbations next (C) (A) (D) (B) CAT < 10 CAT > 10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness 2 or > 1 leading to hospital admission 1 (not leading to hospital admission) 0 If GOLD 3 or 4 or 2 exacerbations per year or > 1 leading to hospital admission: High Risk (C or D) If GOLD 1 or 2 and only 0 or 1 exacerbations per year (not leading to hospital admission): Low Risk (A or B) 2014 Global Initiative for Chronic Obstructive Lung Disease

20 Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) Combined Assessment of COPD 4 3 (C) (D) 2 or > 1 leading to hospital admission 2 1 (A) (B) CAT < 10 CAT > 10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness 1 (not leading to hospital admission) Global Initiative for Chronic Obstructive Lung Disease

21 2014 Global Initiative for Chronic Obstructive Lung Disease

22 COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer Bronchiectasis These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately Global Initiative for Chronic Obstructive Lung Disease

23 Reduce Symptoms; Relieve dyspnoea Improve exercise tolerance Improve health status Reduce Risk; Prevent disease progression Prevent and treat exacerbations Reduce mortality

24 Avoidance of Risk Factors; Encourage all patients who smoke to quit! Smoking cessation slows the decline of FEV1and improves mortality Pharmacotherapy and nicotine replacement increase success Reduce indoor pollution Reduce occupational exposures All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active Influenza and Pneumococcal Vaccination

25 2014 Global Initiative for Chronic Obstructive Lung Disease

26 Bronchodilator medications are the mainstay of symptom relief in COPD. The choice of bronchodilator depends on the availability of medications and each patient s individual response in terms of symptom relief and side effects. Long-acting inhaled bronchodilators are convenient and more effective for symptom relief. Long-acting inhaled bronchodilators reduce exacerbations and related hospitalizations and improve symptoms and health status. Combining bronchodilators of different pharmacological classes may improve efficacy.

27 ICS improve symptoms, lung function and quality of life and reduces frequency of exacerbations in patients with an FEV1 < 60% predicted. Monotherapy with ICS is not recommended. ICS therapy is associated with an increased risk of pneumonia. Withdrawal of ICS therapy may lead to exacerbations in some patients.

28 ICS + LABA combinations are more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD. Combination therapy is associated with an increased risk of pneumonia. Combining ICS + LABA with a LAMA (tiotropium) appears to provide additional benefits.

29 Low dose theophylline reduces exacerbations but does not improve post-bronchodilator lung function. Theophylline is less well tolerated than inhaled bronchodilators. Roflumilast reduces exacerbations in patients with severe and very severe COPD (FEV1 < 50% pred), chronic bronchitis and a history of exacerbations and. Chronic treatment with systemic corticosteroids should be avoided because of an unfavourable benefit-to-risk ratio.

30 The use of antibiotics, other than for treating infectious exacerbations of COPD and other bacterial infections, is currently not indicated. Patients with viscous sputum may benefit from mucolytics; overall benefits are very small. Antitussives are not recommended.

31 Patients with chronic respiratory failure; PaO2 < 55mmHg Room Air O2 Saturations < 88% > 15 hours per day Increases survival in patients with severe, resting hypoxemia. Combination of NIV with LTDO2 therapy may be beneficial in patients with pronounced daytime hypercapnia.

32 Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) Management of COPD 4 3 (C) (D) 2 or > 1 leading to hospital admission 2 1 (A) (B) CAT < 10 CAT > 10 Symptoms mmrc 0 1 mmrc > 2 Breathlessness 1 (not leading to hospital admission) Global Initiative for Chronic Obstructive Lung Disease

33 Exacerbations per year GOLD 4 GOLD 3 C ICS + LABA or LAMA ICS + LABA and/or LAMA D 2 or > 1 leading to hospital admission GOLD 2 GOLD 1 A SAMA prn or SABA prn LABA or LAMA B 1 (not leading to hospital admission) 0 CAT < 10 mmrc 0-1 CAT > 10 mmrc > Global Initiative for Chronic Obstructive Lung Disease

34

35 Oxygen; Titrate to improve hypoxemia, target sats of 88-92%. Bronchodilators; Short-acting inhaled bronchodilators are preferred SABA ± SAMA Systemic corticosteroids; Shorten recovery time Improve lung function (FEV1) and arterial hypoxemia (PaO2) Reduce the risk of early relapse, treatment failure, and length of hospital stay mg prednisone per day for 5-10 days.

36 Antibiotics should be given to patients with; Three cardinal symptoms- increased dyspnoea increased sputum volume increased sputum purulence Patients who require mechanical ventilation.

37 Non-invasive ventilation (NIV); Improves respiratory acidosis Decreases respiratory rate Decreases severity of dyspnoea Decreases complications Decreases length of hospital stay Decreases mortality and needs for intubation

38 To Intubate or not?? Age Acute physiology score (APACHE) Body mass index Functional status before the exacerbation PaO2/FiO2 ratio (<300) Use of LTDO2 Serum albumin Cardiac comorbid conditions

39 Smoking Cessation Adherence; Inhaler technique Use of appropriate medications; Long Acting Bronchodilators Inhaled Corticosteroids PDE4 Inhibitors or theophylline Vaccination; Influenza vaccines reduces serious illness Pneumococcal polysaccharide vaccine for COPD patients > 65 years or younger patients with an FEV1 < 40% predicted Maintain physical activity; Early Pulmonary Rehabilitation after hospital admissions Address Depression, anxiety and social problems

40 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Connors et al. Outcomes following acute exacerbation of severe chronic obstructive lung disease: the SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Am J Respir Crit Care Med 1996;154: Anzueto. Impact of exacerbations on COPD Eur Respir Rev 2010; 19: Anzueto et al. Exacerbations of Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc. 2007; 4: Roche et al. Predictors of outcomes in COPD exacerbation cases presenting to the emergency department. Eur Respir J. 2008; 32: Donaldson et al. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002; 57:

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