MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Transcription

1 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE [2 nd Edition] QUCK REFERENCE FOR HEALTHCARE PROVDERS Ministry of Health Malaysia Academy of Medicine Malaysia Malaysian Thoracic Society

2 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Diagnosis and Assessment of COPD A diagnosis of COPD should be considered in any individual with symptoms of chronic cough, sputum production or dyspnoea and a history of exposure to risk factors for the disease, especially cigarette smoking. The diagnosis should be confirmed by spirometry showing a / FVC ratio of less than 70%. COPD severity should be assessed based on the severity of spirometric abnormality, symptoms, exercise capacity, complications and the presence of co-morbidities. Table 1: Classification of COPD Severity Based on Spirometric mpairment and Symptoms COPD stage Severity Classification by postbronchodilator spirometric values Classification by symptoms and disability Mild FEV 1/FVC < 0.70 FEV 1 > 80% predicted Shortness of breath when hurrying on the level or walking up a slight hill (MMRC 1) Moderate FEV 1/FVC < % < FEV 1 < 80% predicted Walks slower than people of the same age on the level because of breathlessness; or stops for breath after walking about 100 m or after a few minutes at own pace on the level (MMRC 2 to 3) Severe FEV 1/FVC < % < FEV 1 < 50% predicted Too breathless to leave the house or breathless when dressing or undressing (MMRC 4) V Very severe FEV 1/FVC < 0.70 FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Presence of chronic respiratory failure or clinical signs of right heart failure *Should there be disagreement between FEV 1 and symptoms, follow symptoms 2

3 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Managing Stable COPD Objectives of managing stable COPD: 1. Prevent disease progression 2. Relieve symptoms 3. mprove exercise tolerance 4. mprove lung function and general health 5. mprove quality of life 7. Prevent exacerbations 8. Prevent and treat complications 9. Reduce mortality. Figure 1: Algorithm for Managing Stable COPD Clinical features COPD severity Mild Moderate Severe Very severe For all patients: education, smoking cessation, avoidance of exposure, exercise, mantain ideal BM, vaccination, short-acting bronchodilator a as needed Pulmonary rehabilitation nfrequent symptoms SABA as needed SABA/SAAC combination as needed Persistent symptoms b LAAC or LABA LAAC and/or LABA f symptoms persist, add CS/LABA combination to LAAC or replace LABA with CS/LABA combination ± theophylline Frequent exacerbations c ( 1 per yr) Consider alternative cause d LAAC or CS/LABA combination or LAAC + CS/LABA combination ± theophylline Respiratory failure Consider alternative cause d LAAC + CS/LABA combination ± theophylline Long-term oxygen therapy Consider lung transplantation/lvrs Notes for Figure 1 (Please refer to the bottom of the next page) 3

4 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Figure 2: Algorithm for Managing Stable COPD in Resource-Limited Settings Clinical Clinical features feature COPD severity Mild Moderate Severe Very severe For all patients: education, smoking cessation, avoidance of exposure, exercise, maintain ideal BM, vaccination, short-acting bronchodilator a as needed Pulmonary rehabilitation nfrequent symptoms SABA as needed SABA/SAAC combination as needed Persistent symptoms b SABA/SAAC combination regularly SABA/SAAC combination regularly f symptoms persist, add theophylline and/or CS Frequent exacerbations c ( 1 per yr) Consider alternative cause d SABA/SAAC combination regularly + CS + theophylline (Consider referring to a tertiary centre to obtain long-acting bronchodilators) Respiratory failure Consider alternative cause d SABA/SAAC combination regularly + CS + theophylline Long-term oxygen therapy Consider lung transplantation/lvrs Notes: 1. SABA Short-acting β 2 agonist; SAAC Short-acting anticholinergic; LAAC Long-acting anticholinergic; LABA Long-acting β 2 agonist; CS nhaled corticosteroid; LVRS lung volume reduction surgery 2. CS dose per day should be at least 500 µg of fluticasone or 800 µg of budesonide a. All COPD patients, irrespective of disease severity, should be prescribed SABA or SABA/SAAC combination (Berodual /Combivent ) as needed. SABA has a more rapid onset of bronchodilatation than SAAC. b. Defined as need for rescue bronchodilators more than twice a week. c. Frequent exacerbation is defined as one or more episodes of COPD exacerbation requiring systemic corticosteroids ± antibiotics and/or hospitalisation over the past one year d. Consider alternative causes - it is less common for patients with mild COPD to have frequent exacerbations; similarly, respiratory failure is uncommon in patients with mild to moderate COPD severity. Hence, in such patients, an alternative cause should be explored even if the COPD diagnosis is firmly established. 4

5 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Table 2: Evidence-based nterventions in Stable COPD ntervention Outcome Level of evidence* Smoking cessation FEV 1 decline, mortality nfluenza vaccination COPD exacerbations, all-cause mortality (in patients aged 65 years during influenza season) -1 Pneumococcal vaccination community-acquired pneumonia -2 nhaled short-acting b 2 -agonists nhaled long-acting b 2 -agonists nhaled short-acting anticholinergic nhaled long-acting anticholinergic (tiotropium), dyspnoea, symptoms, QoL, COPD exacerbations, dyspnoea, symptoms, exercise tolerance, QoL, COPD exacerbations, mortality nhaled corticosteroids FEV 1, QoL, COPD exacerbations nhaled long-acting b 2 -agonist and inhaled corticosteroid combination [Seretide Accuhaler (salmeterol 50 µg/fluticasone 500 µg) twice daily, and Symbicort Turbuhaler (budesonide/formoterol 320/9 µg) twice daily], QoL, COPD exacerbations Oral theophylline Small FEV 1, symptoms -1 Long-term oxygen therapy Pulmonary rehabilitation Lung volume reduction surgery mortality (in patients with respiratory failure) dyspnoea, exercise capacity, QoL, anxiety and depression associated with COPD number of hospitalisations and days in hospital peripheral muscle strength FEV 1, exercise tolerance, QoL, mortality -1-2 * Refer to Table 4 : reduces, : increases or improves, QoL : quality of life 5

6 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Managing Acute Exacerbations of COPD Objectives of managing exacerbations of COPD: Relieve symptoms and airflow obstruction Maintain adequate oxygenation Treat any co-morbid conditions that may contribute to the respiratory deterioration Treat any precipitating factor such as infection Table 3: Evidence-based nterventions in Acute Exacerbations of COPD Level of ntervention Outcome evidence* nhaled short-acting β 2 -agonists FEV 1, dyspnoea nhaled short-acting anticholinergic FEV 1, dyspnoea ntravenous aminophylline FEV 1, dyspnoea -1 Systemic corticosteroids FEV 1, shorten recovery time, hypoxaemia Antibiotics short-term mortality, treatment failure, sputum purulence (in patients with purulent sputum and increased dyspnoea or increased -1 sputum volume, and in patients requiring ventilatory support) Supplemental oxygen hypoxaemia Non-invasive ventilation intubation, mortality, length of hospital stay (in acute respiratory failure) * Refer to Table 4 : reduces, : increases or improves Table 4: US / Canadian Preventive Services Task Force Level of Evidence Scale Evidence obtained from at least one properly randomized controlled trial - 1 Evidence obtained from well-designed controlled trials without randomization - 2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group - 3 Evidence obtained from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence Opinions of respected authorities, based on clinical experience; descriptive studies and case reports; or reports of expert committees 6

7 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Figure 3: Algorithm for Managing Acute Exacerbations of COPD: Home Management Patient with AECOPD Obtain relevant history: Underlying COPD severity (if known), co-morbidities, present treatment regimen Any indication for hospital assessment or admission? None Hospital assessment or admission indicated nhaled short-acting bronchodilator (SABA + SAAC) from pmd via a spacer device or nebuliser depending on severity Good response to initial treatment Failure to improve Discharge with follow-up Check inhaler technique Arrange appropriate investigations if this is a new presentation Refer to specialist if necessary ndications for hospital assessment or admission: Marked increase in intensity of symptoms such as sudden development of dyspnoea Underlying severe COPD Development of new physical signs e.g., cyanosis, peripheral oedema Haemodynamic instability Reduced alertness Failure of exacerbation to respond to initial medical management Significant co-morbidities Newly occurring cardiac arrhythmias Older age nsufficient home support Administer initial treatment: nhaled short-acting bronchodilators (SABA + SAAC) from pmd via a spacer device or nebuliser Oral prednisolone (or intravenous hydrocortisone if patient unable to swallow or vomits) Start initial dose of antibiotics (if appropriate) Supplemental oxygen therapy (preferably via Venturi mask) if SpO 2 < 90%, aim for SpO % Home Management ncrease dose and frequency of inhaled short-acting bronchodilator (SABA + SAAC) from pmd Oral prednisolone mg daily for 7-14 days (if there is significant dyspnoea or baseline FEV 1 < 50% predicted) Oral antibiotics if patient has 2 out of 3 cardinal symptoms (ie, purulent sputum, increased sputum volume, increased dyspnoea) Refer to nearest hospital or patient s usual hospital 7

8 MANAGEMENT OF CHRONC OBSTRUCTVE PULMONARY DSEASE QUCK REFERENCE FOR HEALTH CARE PROVDERS Figure 4: Algorithm for Managing Acute Exacerbations of COPD: Hospital Management Patient with AECOPD Obtain relevant history: Current symptoms, recent treatment from other doctors, COPD severity, previous episodes (AECOPD/hospital admission/cu admission/invasive or non-invasive ventilation) Examine for danger signs: Respiratory distress, tachyarrhythmia, cyanosis, heart failure, exhaustion. Arrange appropriate investigations: ABG (note the FiO 2 ), FBC, BUSECr, LFT, blood glucose, CXR, ECG, sputum C&S Administer initial treatment: Controlled oxygen therapy if SpO 2 < 90%, aim for SpO % nhaled short-acting bronchodilators (SABA + SAAC) from pmd via a spacer device or nebuliser Oral prednisolone (intravenous hydrocortisone if patient unable to swallow or vomits) Start antibiotics if patient has 2 out of 3 cardinal symptoms (i.e, purulent sputum, increased sputum volume, increased dyspnoea) Good response Failure to improve Discharge with follow-up Check inhaler technique Refer to specialist if this is a new presentation Home Management ncrease dose and frequency of inhaled short-acting bronchodilator (SABA + SAAC) from pmd Oral prednisolone mg daily for 7-14 days Ensure adequate supply of oral antibiotics if started ndications for hospital admission: Marked increase in intensity of symptoms such as sudden development of dyspnoea Underlying severe COPD Development of new physical signs e.g., cyanosis, peripheral oedema Haemodynamic instability Reduced alertness Failure of exacerbation to respond to initial medical management Significant co-morbidities Newly occurring cardiac arrhythmias Older age nsufficient home support No indication for hospital admission Admit to hospital Hospital Management Controlled supplemental oxygen therapy to maintain PaO 2 > 8 kpa or SpO 2 > 90% without worsening hypercapnia or precipitating acidosis nhaled short-acting bronchodilators from pmd via a spacer device or nebuliser Consider intravenous aminophylline if inadequate response to inhaled short-acting bronchodilators Systemic corticosteroids for 7-14 days Antibiotics (if appropriate) Monitor fluid balance and nutrition Consider subcutaneous heparin Closely monitor condition of the patient Consider invasive or non-invasive ventilation 8