COPD and Asthma Management. Allison Nykolaychuk,, RRT, FCSRT Education Coordinator Respiratory Therapy Zone 2, Horizon Health Network

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1 COPD and Asthma Management Allison Nykolaychuk,, RRT, FCSRT Education Coordinator Respiratory Therapy Zone 2, Horizon Health Network

2 What are we talking about?

3 Asthma Definition: Consider when symptoms are recurrent: Dyspnea,, chest tightness, wheezing, sputum production and cough often worse at night or early morning Often develop in conjunction with a stimuli and improve in response to bronchodilator and / or anti-inflammatory inflammatory therapy

4 Emphysema & Chronic Bronchitis

5 Emphysema Definition: Defined pathologically Presence of permanent enlargement of the airspaces distal to the terminal bronchioles Accompanied by destruction of the airway walls

6 Chronic Bronchitis Definition: Defined clinically Chronic productive cough for 3 months in each of 2 successive years Other causes of productive cough have been excluded

7 COPD Definition: Progressive Lung hyperinflation Systemic manifestations Increasing frequency and severity of exacerbations

8 Interrelations Chronic bronchitis Emphysema COPD Asthma Adapted from: ATS Statement Standards for the diagnosis and care of patients with chronic obstructive disease. Am J Respir and Crit Care Med 1995: 152: S78-S83 S83

9 Asthma vs COPD ASTHMA COPD Age of onset Usually <40 Usually >40 Smoking Hx Not causal Usually >10 pk-yr Sputum production Allergies Disease Course Spirometry Clinical Symptoms Infrequent Often Stable (with exacerbations) Often normalizes Intermittent & variable Often Infrequent Progressively worse with exacerbations May improve (never normal) Persistent

10 Asthma Worldwide prevalence of 7 10% In the US from 2001 through 2003: Average of 4210 deaths annually from asthma Average of 504,000 hospitalizations and 1.8 million ER visits People with current asthma had an average rate of ER visits of 8.8 / 100 persons

11 Clinical Assessment Asthma Pulmonary function testing: Reversible airway obstruction post bronchodilator Variable airflow obstruction over time or hyper-responsiveness responsiveness Methacholine or exercise may be helpful CXR not routine

12 Pulmonary Function measurement Spirometry showing reversible airway obstruction FEV1 / FVC & In FEV 1 post bronchodilator Peak Expiratory Flow Post bronchodilator OR Diurnal variation Positive Challenge Test Methacholine challenge OR Exercise challenge Children (6 y.o.. and older) Adults < lower limit (< ) & 12% 20% OR Not recommended < lower limit (< ) & 12% (min. of 200 ml) 60 L/min ( 20%)( OR >8% twice daily >20% multiple daily PC 20 <4 mg/ml ml (4 16 mg/ml ml is borderline; >16 mg/ml ml is negative) OR 10 15% decrease in FEV 1 post-exercise Modified from Canadian Thoracic Society Asthma Management Continuum 2010 Consensus Summary for children six years of age and over, and adults. Can Respir J 2010;17(1):

13

14 Environmental Control, Education and Written Action Plan An estimated ~25% of adult asthma cases are work related (perfumes, air fresheners) 10 15% may be caused by an occupational agent Avoidance of triggers Avoid tobacco smoke (may reduce person s s response to ICS) Respiratory infections

15 Environmental Control, Education and Written Action Plan Education regarding: Asthma Control Medications Guided self-management with written action plans COPD-actionplan_1.pdf

16 Relievers: Pharmacotherapy Fast acting bronchodilator Everyone Controllers: Inhaled corticosteroids (ICS) ICS with long acting beta agonist (LABA) Leukotriene receptor antagonist (LTRA) Prednisone Anti-immunoglobulin immunoglobulin E

17 Asthma in ER Initial assessment upon presentation should quickly evaluate the severity and need for urgent intervention Risk of life-threatening asthma Mild to moderate Severe Treatment: SABA +/- ipatropium bromide Systemic corticosteroids

18 COPD Major respiratory illness in Canada that is preventable and treatable Unfortunately COPD is under diagnosed Key messages from CTS (2008):

19 COPD Airflow limitation is usually progressive and associated with abnormal response to noxious particles or gases - primarily smoking Intrinsic factors include genes (á1- antitrypsin),, bronchial hyperreactivity and lung growth.

20 COPD Estimated 3 million deaths worldwide inh 2005 By 2010, expected to be the third leading global cause of death Stockley R.A., Progression of chronic obstructive pulmonary disease: impact of inflammation, comorbidities and therapeutic intervention. Current Medical Research and Opinions 2009; Vol 25:5,

21 Pathophysiology Increase in neutrophils,, macrophages, T-T lymphocytes (CD8+) Airway inflammation Airflow limitation and hyperinflation Mucociliary dysfunction, structural changes, systemic component

22 Clinical Assessment: COPD Spirometry Arterial Blood gases: Assessment of hypoxemia and/or hypercapnia Chest X-rays X to look for co-morbidities and to assist with the differential diagnosis

23 Clinical Assessment: COPD Targeted Spirometry Spirometry: (ex smokers >40) Do you cough regularly? Do you cough up phlegm regularly? Do even simple chores make you short of breath? Do you wheeze when you exert yourself, or at night? Do you get frequent colds that persist longer than those of people you know?

24 COPD Classification of Severity by FEV 1 Mild COPD stage Spirometry (post-bronchodilator) FEV 1 80% predicted, FEV 1 / FVC < 0.7 Moderate 50% FEV 1 < 80% predicted, FEV 1 / FVC < 0.7 Severe 30% FEV 1 < 50% predicted, FEV 1 / FVC < 0.7 Very Severe FEV 1 < 30% predicted, FEV 1 / FVC < 0.7 O Donnell DE, et al. Can Respir J 2007;14 (Suppl B):5B-32B.

25 CTS: Classify COPD Severity Using The MRC Dyspnea Scale none Grade 1 Breathless with strenuous exercise Mild Grade 2 Short of breath when hurrying on the level or walking up a slight hill Moderate Grade 3 Walks slower than people of the same age on the level or stops for breath while walking at own pace on the level Severe severe Grade 4 Stops for breath after walking 100 yards Grade 5 Too breathless to leave the house or breathless when dressing MRC = Medical Research Council CTS = Canadian Thoracic Society 1. Fletcher CM, et al. Br Med J 1959;1: O Donnell DE, et al. Can Respir J 2003;10(Suppl A):11A-33A.

26 Goals of Treatment Prevention of disease progress Decrease severity and frequency Improve exercise tolerance Prompt treatment of exacerbations Improved health status Decrease mortality

27 Treatment Education Smoking cessation Vaccinations Medications: Bronchodilators Steroids Antibiotics Pulmonary Rehabilitation

28 Education Disease process Medications, including how to administer How to improve life

29 Treatment

30 Effects of Smoking on FEV 1 100% Never smoked or not susceptible to smoke 75% FEV 1 50% Smoked regularly and susceptible to its effects Stopped at 45 Disability 25% Death Stopped at Fletcher, 1997 Age 100

31 Vaccinations Vaccinations can decrease exacerbations According to the ATS and CTS vaccinations against influenza can reduce illness and death in COPD by ~50% Vaccination against pneumococcal disease reduces bacteraemia

32 Optimal Pharmacotherapy in COPD Increasing Disability and Lung Function Impairment Mild Moderate Severe Infrequent AECOPD (< 1/year) Frequent AECOPD (> 1/year) SABD prn persistent disability LAAC + SABA prn or LABA + SABD prn LAAC or LABA+ SABA prn persistent disability LAAC + LABA + SABA prn persistent disability LAAC + ICS/LABA + SABA prn LAAC + ICS/LABA + SABA prn persistent disability LAAC + ICS/LABA + SABA prn +/- Theophylline

33 Bronchodilators Short acting bronchodilators improve pulmonary functions, dyspnea and exercise tolerance Long acting beta 2 agonists (LABA) have a more sustained effect than SABA Studies have shown Long acting anti- cholinergics (LAAC) combined with LABA may have additive effects.

34 Anticholinergics Ipatropium bromide: Onset 5 15 minutes Peak 1 2 hours, with effects lasting a total of 4 6 hours Tiotropium bromide monohydrate: Muscarinic receptor antagonist Effects lasting 24 hours Improvements in lung hyperinflation, exercise endurance, and exacerbations

35 Improvement in Trough FEV 1 Vincken et al, 2002

36 Inhaled Corticosteroids (ICS) ICS as a monotherapy is controversial as they do not have consistent effect on indices of airway inflammation, PF, symptoms, frequency or severity of exacerbation Studies have shown benefits from low dose combined therapy

37 Oral Theophyllines Evidence is limited that theophyllines offer benefit. Very small therapeutic range

38 Roflumilast Reduces activity of several COPD-specific inflammatory cells (neutrophils( neutrophils,, macrophages and CD8+) and mediators (TNF-, MMP) 1 Reduces mucus hypersecretion and increases ciliary beat frequency 2,3 Reduces lung fibrotic remodeling and prevents emphysema 4,5 Reduces pulmonary vascular remodeling 4 1 Field S. Expert Opin. Investig. Drugs (2008) 17(5): Mataet al, Thorax. 2005; 60: Milara et al. Presented at ERS, Cortijo et al. Br J Pharm (2009), 156, Martorana et al. Am J Respir Crit Care Med. 2005;172:

39 Pre-Bronchodilator FEV 1 (time-course) 1.6 M2-127 salmeterol Mean change in prefev 1 [L] Weeks sal + placebo sal + roflumilast 500µg Roflumilast Placebo Fabbri LM, Calverley PMA et al. Lancet 2009;374:

40 Managing Dyspnea CTS Clinical Practice Guideline (2011) Recommendation 1: Do not routinely use anxiolytics or antidepressants Recommendation 2: Oral opioids for treatment of refractory dyspnea Recommendation 3a: Neuromuscular electrical muscle stimulation

41 Managing Dyspnea Recommendation 3b: Use of walking aids Recommendation 3c: Pursed-lip breathing Recommendation 4: Continuous oxygen therapy for patients with hypoxemia

42 Oxygen Therapy Long term oxygen therapy reverses hypoxaemia and prevents hypoxia and has been shown to increase life expectancy Goal to keep SpO 2 s s >90% (keep in mind the patient s s age as oxygenation status decreases as we age)

43 Oxygen Therapy A British Medical Research Council study compared hypoxaemic patients receiving 15 hours of oxygen per 24 hour period to those receiving no oxygen. Demonstrated oxygen was associated with a significant reduction in mortality. Mechanism is not fully understood but oxygen therapy has been accompanied by a small annual decline in PAPs.

44 Oxygen Therapy During sleep: Some patients may require oxygen only during sleep or may require more During exertion: Patients that are hypoxaemic during rest are generally hypoxaemic during exertion.

45 Carbon Dioxide Retention Oxygen leading to respiratory drive depression is overemphasized. Oxygen induced hypercapnia does occur but rarely.

46 Pulmonary Rehabilitation Maintain an active lifestyle Significantly improves dyspnea,, exercise endurance and quality of life If a formal program is not available, patients should be encouraged to undertake a home-based program

47 Survival And Frequency Of Exacerbations 1.0 Probability of surviving A p< B p=0.069 C p< Time (months) Group A = Patients with no acute exacerbations Group B = Patients with 1 2 acute exacerbations of COPD requiring hospital management Group C = Patients with > 3 acute exacerbations Soler-Cataluña JJ, et al. Thorax 2005;60:

48 Acute Exacerbations Sustained worsening of dyspnea,, cough or sputum production leading to an increase in medication usage. Triggers: At least half due to infectious CHF Exposure to allergens or irritants Pulmonary embolism

49 Acute Exacerbations Increase in medications: SABA, anticholinergic Oral or parental corticosteroids Antibiotics Re-evaluate evaluate care

50 Prevent Exacerbations Smoking cessation ICS / LABA LAAC Influenza vaccination Pulmonary rehabilitation Roflumilast

51 End of Life Very severe airflow limitation Poor functional status Poor nutritional status Pulmonary hypertension Recurrent severe acute exacerbations

52 Questions? Thank you.

53 References ATS Statement Standards for the diagnosis and care of patients with w chronic obstructive disease. Am J Respir and Crit Care Med 1995: 152: S78-S83 S83 Canadian Thoracic Society Asthma Management Continuum 2010 Consensus Summary for children six years of age and over, and adults. Can Respir J 2010;17(1): Fletcher CM, et al. Br Med J 1959;1: Marciniuk DD, et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J 2011;18(2):69-78 O Donnell DE, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 2008 update highlights for primary care. Can Respir J 2003;10(Suppl A):11A-33A. O Donnell DE, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 2008 update highlights for primary care. Can Respir J 2007;14 (Suppl B):5B-32B Soler-Cataluña JJ, et al. Thorax 2005;60:

54 References Stockley R.A., Progression of chronic obstructive pulmonary disease: impact of inflammation, comorbidities and therapeutic intervention. Current Medical Research and Opinions 2009; Vol 25:5, Vincken et al, Improved health outcomes in patients with COPD during 1 yr s treatment with tiotropium. Eur respir J 2002; 19: Vogelmeier C et al, Tiotropium versus Salmeterol for the Prevention of Exacerbations of COPD. N Engl J Med 2011;364:

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