Chronic Obstructive Pulmonary Disease

1. Chronic Obstructive Pulmonary Disease

2. What is COPD?NICE Clinical Guideline 12, Feb 2004 • Disease characterised by airflow obstruction, which is usually progressive, not fully reversible, and does not change markedly over several months. • Airflow obstruction is due to a combination of airway and parenchymal damage and is associated with chronic inflammation, which differs from that seen in asthma.

3. So, what can we do for people with COPD? • Early diagnosis: contentious • NICE recommendation (smoker >35 years, presenting with symptoms) • Smoking cessation – most important • NICE recommendation • Pulmonary rehabilitation – important • Cochrane Review • NICE recommendation • Optimal drug management (including managing exacerbations) • See later

4. Diagnosis relies on clinical judgement based on a combination of: history physical examination confirmation of the presence of airflow obstruction using spirometry Symptoms NICE Clinical Guideline 12, Feb 2004

5. Assessment of severity of airflow obstructionNICE Clinical Guideline 12, Feb 2004

6. Stop smokingNICE Clinical Guideline 12, Feb 2004National Knowledge Week for COPD 2008. Available from:http://www.library.nhs.uk/respiratory/ViewResource.aspx?resID=278340&tabID=290&catID=5880 • Approximately 80% of COPD caused by smoking • Smoking cessation is the only intervention that reduces decline in FEV1 • Best way to reduce incidence of COPD is to reduce prevalence of smoking • campaigns aimed at smokers need to emphasise link between smoking and COPD • Encouraging patients with COPD to stop smoking is one of the most important components of their management • All COPD patients still smoking, regardless of age should be encouraged to stop, and offered help to do so, at every opportunity

7. Management of stable COPDNICE Clinical Guideline 12, Feb 2004 Breathlessness and exercise limitation

8. What about the role oflong-acting bronchodilatorsin COPD? NICE Clinical Guideline 12, Feb 2004

10. When should ICS be used?NICE Clinical Guideline 12, Feb 2004 Breathlessness and exercise limitation Frequent exacerbations

11. We need to weigh up the balance of risks and benefits of prescribing ICS in COPD Possible RISKS oral candidiasis hoarseness osteoporosis pneumonia BENEFITS ↓ exacerbations possibly better QoL Details are given on subsequent slides

12. The TORCH StudyCalverley PMA, et al. N Engl J Med 2007;356:775–89 Comparing combination with salmeterol alone over three years: NNT to prevent one moderate to severe exacerbation in one year is 8 (combination vs. salmeterol alone) NNH for one case of pneumonia in one year is 33 (combination vs. salmeterol alone)

13. Oral mucolytic agents and/or influenza vaccination NICE Clinical Guideline 12, Feb 2004

14. Oxygen therapyNICE Clinical Guideline 12, Feb 2004 The need for oxygen therapy should be assessed in: • all patients with severe airflow obstruction (FEV1 less than 30% predicted) • patients with cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, oxygen saturations less than or equal to 92% breathing air. Assessment should also be considered in patients with moderate airflow obstruction (FEV1 30–49% predicted).