Marilyn Borkgren-Okonek, APN, CCNS, RN, MS Suburban Lung Associates, S.C. Elk Grove Village, IL www.goldcopd.com GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD Global Strategy for Diagnosis, Management and Prevention of COPD 2015 COPD Comorbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Type II Diabetes Lung cancer Bronchiectasis These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. 44
COPD Comorbidities: Cardiovascular Conditions Coronary artery disease / Ischemic heart disease (blocked coronary arteries, angina ) Heart failure (congestive heart failure / CHF; right sided heart failure / cor pulmonale ) Atrial fibrillation (irregular heart rhythm) Hypertension (high blood pressure) Pulmonary Hypertension Coronary Artery Disease in COPD Smoking history is the key shared risk factor for both COPD and CAD Symptoms: chest pain/ pressure, arm/jaw pain, fatigue, shortness of breath Chronic inflammation associated with COPD (especially during exacerbations) promotes atherosclerosis Diagnosis: image enhanced stress testing ( chemical stress testing), CT angiography, cardiac catheterization Other diagnostic tests: lipid profile (cholesterol, HDL/LDL, triglycerides, apolipoproteins), CRP / hs CRP (C-reactive protein) Treatment: Lifestyle modifications, medications (cardioselective Beta Blocker medications, statins, blood thinners etc.) Left sided heart failure: Congestive Heart Failure (CHF) Inadequate pumping action of the heart (systolic, diastolic) Blood backs up into the lungs, causing shortness of breath especially during activity or when lying flat Other symptoms include: fatigue and loss of appetite Right sided heart failure: (Cor Pulmonale when associated with lung disease) Swelling in the feet and ankles Shortness of breath 5 million in United States with heart failure; 20-30% of patients with CHF also have COPD Diagnostic tests: echocardiogram, ECG, chest X-ray, lab tests 45
Discussing coronary artery disease and heart failure with your doctor or nurse: Could my symptoms represent a heart condition? What are my risk factors? What tests do you recommend? Are the medications safe given my COPD and lung medications? What are my dietary guidelines or restrictions? What are my exercise / activity guidelines? When do I seek medical attention? If you have COPD (especially if you also have heart disease Get emergency help if you experience any of these danger signs: It is hard to talk. It is hard to walk. Lips or fingernails turn gray or bluish. Your heartbeat or pulse is very fast or irregular. Your medicine does not help for very long or it does not help at all. Breathing is still fast and hard. You experience chest pain, chest pressure, arm pain, dizziness, marked weakness. Adapted from GOLD Patient Guide 2015 46
Pulmonary Hypertension in COPD Elevated pressure in the arteries leading from the right side of the heart through the lungs May be suspected by ECG, echocardiogram, chest X-ray or chest CT scan findings; diagnosis confirmed by right heart catheterization Classification: World Health Organization Group 3 Prevalence in COPD unknown Reduces exercise capacity Treatment: Maintain adequate oxygen levels at rest, during activity, and during sleep (O2 saturation > 90%) +/- other specific pulmonary HTN medications Osteoporosis in COPD Why the risk in COPD? Tobacco use, reduced activity, corticosteroid medications (especially daily Prednisone > 5 mg for longer than 3 months), low vitamin D levels (other possible metabolic mechanisms / inflammation) Diagnosis by DXA scan (dual-energy X-ray absorptiometry) hip and spine Prevention: weight bearing activity, smoking cessation, Calcium intake 1000-1500 mg/day + vitamin D 800-1000 IU daily in divided doses Treatment: T score on DXA below -2.5; routine osteoporosis medications (bisposphonates) 47
Respiratory Infections Acute Bronchitis Cough, dry to productive Sputum clear to colored Shortness of breath mild to moderate Wheezing Chest X-ray often normal Resolves within 2-3 weeks Pneumonia Cough, usually productive Sputum clear, colored or bloody Shortness of breath mild to severe Fever Fatigue Abnormal chest X-ray Duration may exceed 3 weeks Pneumonia Treatment of Respiratory Infections GOLD Guidelines recommend antibiotic treatment for acute bronchitis for 3 cardinal symptoms: increased shortness of breath, increased volume of sputum, purulence (discoloration) of sputum In MOST cases of acute bronchitis and communityacquired pneumonia, the exact causative bug is not known Bronchitis is usually viral or bacterial Pneumonia is usually bacterial or viral, but can also be caused by fungus or parasite 48
Depression and Anxiety in COPD Present in > 30-40% of persons with COPD Quality of life: emotional functioning, social-role functioning, activities of daily living (ADL), and recreational pastimes Why so common? sleep disruption, change in appetite, reduced energy and activity, role changes, frequent symptoms, fear C.O.P.D. Information Line at 1-866-316-COPD (2673) www.copdfoundation.org Talk to your family Talk to your doctor or nurse Exercise regularly Find what you enjoy Join a support group Eat a balanced diet Practice relaxation and breathing techniques Maintain participation in faith group PULMONARY REHABILITATION Stay Active = Stay Positive Stay Healthy 49
From GOLD Update 2015 Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease.. Exacerbations and comorbidities contribute to the overall severity in individual patients. GOALS OF MANAGEMENT OF STABLE COPD Reduce symptoms Relieve shortness of breath, cough, wheezing Improve exercise tolerance Improve health status Reduce risk Prevent disease progression Prevent and treat exacerbations Reduce mortality 50