1 / 37

Caring for Patients with COPD: Guidelines for Diagnosis and Management

Caring for Patients with COPD: Guidelines for Diagnosis and Management. M. Elizabeth Knauft, MD MS September 20, 2007. GOLD Diagnosis and Classification of COPD 4 major components of COPD management Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Manage Exacerbations.

Patman
Download Presentation

Caring for Patients with COPD: Guidelines for Diagnosis and Management

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Caring for Patients with COPD: Guidelines for Diagnosis and Management M. Elizabeth Knauft, MD MS September 20, 2007

  2. GOLD • Diagnosis and Classification of COPD • 4 major components of COPD management • Assess and Monitor Disease • Reduce Risk Factors • Manage Stable COPD • Manage Exacerbations

  3. GOLD • 1998: Global Initiative for Chronic Obstructive Lung Disease • 2001: Global Strategy for the Diagnosis, Management, and Prevention of COPD • 2006: Revision of above

  4. Goals of GOLD • “To improve prevention and management of COPD through a concerted worldwide effort of people involved in all facets of healthcare and healthcare policy, and to encourage an expanded level of research interest in this highly prevalent disease.”

  5. Case • CC: Dyspnea • HPI: 66 yo F with several years of progressive dyspnea, cough. • 60 pack year tobacco, active smoker (2ppd) • PMH: DM II

  6. Definition of COPD • Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients • Pulmonary component characterized by airflow limitation that is not fully reversible. • Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases

  7. Spirometric Classification of COPD Severity Based on Post-Bronchodilator FEV1

  8. Case Con’tSpirometry • FEV1/FVC: 0.50 • Postbronchodilator FEV1: 1.23L (63% predicted)

  9. Case Con’tSpirometry • FEV1/FVC: 0.50 • Postbronchodilator FEV1: 1.23L (63% predicted) • Stage II

  10. Mechanism of COPD • Proximal and peripheral airways, lung parenchyma, pulmonary vasculature affected • Chronic inflammatory changes, amplified by oxidative stress

  11. Burden of COPD • Prevalence higher in • smokers and ex-smokers than nonsmokers • Patients over 40 than those under 40 • Men than in women • Morbidity • Mortality • 6th leading cause of death in 1990 (Global Burden on Disease Study) • Projected to be 3rd leading cause by 2020

  12. Risk Factors for COPD • Cigarette smoke • Occupational dust and chemicals • Environmental tobacco smoke • Indoor and outdoor pollution

  13. Management Goals for COPD • Relieve symptoms • Prevent progression of disease • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality

  14. Four Major Components of COPD Management • I: Assess and Monitor Disease • II: Reduce Risk Factors • III: Manage Stable COPD • IV: Manage Exacerbations

  15. Assess and Monitor Disease • Dyspnea • Progressive, persistent, worse with exercise • “increased effort to breathe”, “air hunger” • Chronic cough • Intermittent, non-productive • Chronic sputum production • Any pattern • History of exposure to risk factors • Tobacco, occupational dust/chemicals, home cooking, heating fuels

  16. Assess and Monitor Disease-2 • Confirm diagnosis by spirometry • Post bronchodilator FEV1/FVC < 0.70 • Obtain ABG if FEV1 < 50% predicted or clinical signs right heart failure • Alpha-1 antitrypsin level in young pts (<45 years) • Identify comorbidities

  17. Assess and Monitor Disease-3 • Differential Diagnosis • Asthma • CHF • Bronchiectesis • Tuberculosis • Obliterative Bronchioloits • Diffuse Panbronchiolitis

  18. Reduce Risk Factors • Smoking Cessation! • Reduction of indoor and outdoor air pollution

  19. Manage Stable COPD • Individualize overall approach to address symptoms and improve quality of life • Smoking cessation • Pharmacotherapy for COPD used to decrease symptoms and/or complications • do NOT modify long-term decline in lung function

  20. Manage Stable COPD-2Bronchodilators • B-2 agonists, anticholinergics,methylxanthines • Symptomatic management: prn or scheduled • Increase exercise capacity • Do not necessarily improve FEV1 • LABA more effective than SABA • Combination therapy more effective than increasing dose of single agent • Long acting anticholinergic reduces rate of COPD exacerbations, improves effectiveness of pulmonary rehabilitation

  21. Manage Stable COPD-3Glucocorticosteroids • Inhaled corticosteroids (ICS) do not modify long term decline in FEV1 • ICS appropriate for symptomatic, FEV1 < 50% (Stage III: Severe and Stage IV: Very Severe) pts • Regular use of ICS reduces frequency of exacerbations • Long term use systemic glucocorticosteroids is NOT recommended

  22. Manage Stable COPD-4 • Influenza vaccine • Pneumococcal vacine (>65years; < 65 years with FEV1 < 40 % predicted)

  23. Manage Stable COPD-5Therapies NOT recommended • No benefit from prophylactic antibiotic therapy • Overall benefit from mucolytics is small • N-acetylcysteine: no reduction in exacerbations • Antitussives (cough has a protective role) • Vasodilators (inhaled nitric oxide)

  24. Manage Stable COPD-6Non-Pharmacologic Treatments • Pulmonary rehabilitation • Goals: Reduce symptoms, improve quality of life, increase physical and emotional participation in everyday activities • Supplemental oxygen • Use > 15 h/day improves survival in patients with chronic respiratory failure • PaO2<55, SaO2 <88% • PaO2 55-60, SaO2 = 88% and pulmonary hypertension, evidence of CHF, polycythemia (HCT > 55%)

  25. Therapy at Each Stage of COPD

  26. Case Con’t • Short acting B2 agonist • Long acting bronchodilator (B2 agonist or anticholinergic) • Influenza vaccine • Pneumococcal vaccine • Smoking cessation

  27. Manage Exacerbations • Exacerbation: • “…an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” • Infection of tracheobronchial tree and air pollution most common causes • No cause identified in 1/3 exacerbations

  28. Manage Exacerbations • Increased SOB, wheeze, chest tightness, increased cough and sputum, change in color or tenacity of sputum • Assess severity • Dependent on pt’s baseline prior to exacerbation • ABG • FEV1 not practical • CXR • Sputum culture

  29. Manage ExacerbationsHome management • Increase dose and/or frequency of short acting bronchodilator therapy • Consider adding anticholinergic agent • Systemic glucocorticosteroids • Shorten recovery time • Improve FEV1 and hypoxemia • Consider (in addition to bronchodilators) if FEV1 < 50% • 30-40 mg prednisone/d x 7-10 days

  30. Case Con’t • Increased dyspnea • Increase in sputum, now purulent

  31. Case Con’t • Increased dyspnea • Increase in sputum, now purulent • Increase frequency of bronchodilators (nebulized or inhaled) • Consider oral glucocorticosteroids

  32. Manage ExacerbationsHospital management • Risk of death related to development of respiratory acidosis • Indications for hospital assessment/admission • Marked increase in intensity of symptoms • Severe underlying COPD • New physical signs (cyanosis, peripheral edema) • Failure to respond to outpatient management • Significant comorbidities • Frequent exacerbations • New arrythmia • Diagnostic uncertainty • Older age • Insufficient home support

  33. Manage ExacerbationsHospital management-2 • Assess severity of symptoms- ABG, CXR • Oxygen • Bronchodilators • B-2 agonist • Add anticholinergic if no response • Role of methylzanthines is controversial • Add oral or IV glucocorticosteroids

  34. Manage ExacerbationsHospital management-3 Give antibiotics if: • Increased dyspnea, increased sputum volume, increased sputum purulence • Two of the above three criteria are met, and one is presence of purulent sputum • Severe exacerbation requiring mechanical ventilation (invasive or noninvasive) • H. influenza, S. pneumoniae, M. catarrhalis

  35. Manage ExacerbationsHospital management-4 • Ventilatory support • Noninvasive mechanical ventilation : 80% success rate • Moderate/severe dyspnea with use of accessory muscles and paradoxical abdominal muscle motion • Moderate/severe respiratory acidosis (pH < 7.35, paCO2 > 45) • Tachypnea (RR > 25 bpm)

  36. Manage ExacerbationsDischarge Criteria • Inhaled B2 agonist therapy is required no more than every 4 hours • Pt able to walk across room (if previously ambulatory) • Clinically stable for 12-24 h • Stable ABG for 12-24 h • Patient/caregiver understands proper medication use • Home care/follow-up arrangements made

  37. Summary • Diagnosis of COPD requires post-bronchodilator FEV1 • Tobacco cessation • Layer treatment according to stage of COPD

More Related