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Christopher Worsnop Department of Respiratory and Sleep Medicine
• Progressive airflow limitation that is not
• Inflammation in the airways, lung
parenchyma and pulmonary vessels.
• Neutrophils, macrophages, CD 8 cells. • Proteinase - antiproteinase imbalance. • Oxidative stress.
• COPD = chronic obstructive pulmonary
• COAD = chronic obstructive airways
• COLD = chronic obstructive lung disease • CAL = chronic airflow limitation
They all mean the same thing.
Emphysema Asthma Airflow obstruction Intrinsic airways disease COPD .
. • any smoker → chronic cough → productive cough → dyspnoea .COPD DIAGNOSIS • Consider COPD in . .
Respirology 2006. 11: 9 .
7 ⇒ airflow obstruction (this varies slightly with age) .COPD DIAGNOSIS • Spirometry → is the best measure of airflow obstruction → FER = forced expiratory ratio → FER = FEV1/FVC or FEV1/VC using the larger of FVC or VC → FER < 0.
.→ a reduced FEV1 alone does not mean airflow obstruction → FEV1 is used for monitoring → Occasionally people with emphysema on HRCT have normal spirometry.
the diagnosis is likely to be asthma. • If the FEV1 returns into the normal range. • Reversibility does not predict symptomatic responses to bronchodilators. .REVERSIBILITY WITH SPIROMETRY • An increase in FEV1 of > 12 % (and at least 200 ml) is likely to be due to the bronchodilator.
MANAGEMENT OF COPD • STOP SMOKING • MEDICATIONS • VACCINATIONS • PULMNARY REHABILITATION .
COPDX Confirm the diagnosis and assess severity Optimize function Prevent deterioration Develop a support network and selfmanagement plan Exacerbations – manage appropriately .
STOP SMOKING .
. Br 1977.Stopping smoking slows the decline in lung function FEV1 (% of value at age 25) 100 Never smoked or not susceptible to smoke Smoked regularly and susceptible to its effects Disability 25 Death 0 25 50 75 Stopped at 65 75 Stopped at 45 50 Age (years) Adapted from: Fletcher et al.
Stages of change • Pre Contemplation (40% of current smokers .not ready now) • Contemplation (40% .ambivalent) • Preparation • Action • Maintenance .
.Intensive counselling .Current smoking cessation strategies • Non .Quit courses • Pharmacological .Doctor’s advice .Self-help materials .Nicotine replacement therapy .Zyban .pharm.Willpower alone .
tiotropium →β 2 agonists .short or long-acting → theophylline .MEDICATIONS IN COPD • Other treatments are for control of symptoms → anticholinergics .ipratropium.rarely used now → combined bronchodilators .
• There are poor correlations between symptoms. • FEV1 is not a good way to assess response to treatment. lung function and pathology.• Reversibility on spirometry does not predict long term symptomatic response. • Cease if no symptomatic benefit after a reasonable trial (6-12 weeks). or unacceptable side effects. .
• Handihaler designed for COPD. • Side effect = dry mouth in 14 %. less exacerbations (NTT = 14). and less dyspnoea. less mortality.Anticholinergics • Spiriva = tiotropium Atrovent = ipratropium • Long-acting more convenient. better exercise. .
β 2 agonists Ventolin. tachycardia. . more exercise. Foradile = eformoterol • • Short-acting for prn use. better QOL • Less QOL with higher doses • Side effects = tremor. Airomir = salbutamol Bricanyl = terbutaline Serevent = salmeterol Oxis. • Long-acting for regular use – less symptoms.
INHALED CORTICOSTEROIDS • Inhaled corticosteroids → the type of inflammation in COPD does not respond well to steroids. → Four major studies ⇒ indications are: > documented increase in FEV1 after 6 12 week trial > severe COPD (FEV1 < 50 %) with frequent exacerbations .
. allergy > some reversibility on spirometry • The patient is keen for more improvement in symptoms and exercise. eczema.Why give a trial of ICS in COPD? • Any suggestion of asthma > history of asthma. hayfever.
improve QOL and FEV1. • A small reduction in mortality with p = 0.Combination treatment • Inhaled fluticasone and salmeterol (Seretide) • In moderate to severe COPD (FEV1 < 60 %) it has been shown to reduce exacerbations. .052 in the TORCH study.
• Narrow therapeutic window. dysrhythmias. • Monitor blood levels. death. • Significant side effects = nausea.Theophyllines • Benefits less well documented. seizures. . • Drug interactions.
. • It is not possible to predict those who will respond. • This does not predict those who will respond to ICS.Oral corticosteroids • 5 – 10 % of patients will show an increase in FEV1 after a short course of prednisolone ½ mg/kg/day. but it does have significant side effects. • There is no evidence that long term prednisolone is of any benefit.
hospital admissions and exacerbations. but it seems like a good idea. . . .it is given twice 5 years apart.reduces mortality.it does not prevent other URTI viruses. • Pneumococcal vaccine . .no evidence about its use in COPD.VACCINES • Influenza vaccine . .local side effects only.it is given yearly.
improving fitness. but the exercise needs to be maintained at home. • Usually supervised by physiotherapists.PULMONARY REHABILITATION •There is good evidence that it improves symptoms in COPD. • Variable cost to the patient. . and education. • A course is run over 6 . • Patients need to be well motivated.8 weeks with twice weekly visits. • Two main components .
e. and usually has no effect on symptoms. • This oxygen improves mortality.PO2 on air at rest < 55 mmHg OR .PO2 < 60 if evidence of hypoxic damage.no cigarettes for 3 months.4 l/min.when at his/her best and stable . cor pulmonale. pulmonary hypertension. . via nasal prongs for > 16 hours/day IF .HOME OXYGEN THERAPY • Oxygen concentrator: 2 . i. AND . polycythaemia.
Portable home oxygen • This is designed to improve symptoms and increase exercise.supplemental O2 prevents this desaturation AND . • The patient needs to be motivated to lug a cylinder around.exercise is improved. . • No cigarettes for 3 months. • SpO2 < 88 % with exercise AND .
Lung Volume Reduction Surgery • Improves symptoms • Improves quality of life • Improves FEV1 • ? FEV1 after 5 years • ? symptomatic benefit after 2-4 years • Bullectomy is a separate issue • Consider lung transplantation .
000 .Problems with LVRS • Peri-operative morbidity & mortality • Local experience • Patients’ expectations • Long-term outlook is unknown • What is the best technique? • ? cost ~$20.
minimal benefit • Non-invasive ventilation – unproven • Self management plans – no proven benefit .Other treatments • Chronic antibiotics .no benefit • Mucolytics .
URTI. bronchitis. viral .ACUTE COPD EXACERBATION • The cause is often unknown • Respiratory infections . arrhythmia • Systemic infection.bacterial. pneumonia • Heart failure. fever • Anaemia • Anxiety • Anything that increases metabolic rate .
and cover atypical bacteria if there is pneumonia.increased dyspnoea . • CXR to look for pneumonia.Features of a COPD exacerbation • Anthonisen criteria: .sputum becoming discoloured • Antibiotics to cover Strep and Gram negatives have been shown to be useful if all three criteria are present.increased sputum production . .
and/or PaO2 > 60 mmHg .MANAGEMENT OF AN EXACERBATION • Supplemental O2 .do not give high doses of O2 too quickly . flow rate and patient’s inspiratory flow rate .aim to keep SpO2 > 90 %.consider the O2 concentration.
• A high dose of O2 in COPD with chronic hypercapnia may lead to a further rise in PCO2 due to : Haldane effect – O2 displacing CO2 from Hb. Worsening V/Q mismatch due to high PO2 in parts of the lung overcoming hypoxic vasoconstriction. . . Reduced ventilatory drive.
• Antibiotics .some benefit.BiPAP. intravenous .inhaled.• Bronchodilators . but not great and must be balanced with side effects. oral.to prevent deconditioning • Non-invasive ventilation . VPAP 2 .anticholinergics and β agonists • Corticosteroids .if there is evidence of infection • Physical activity .
. • Chronic inflammation of the airways with bronchial hyper-responsiveness. • Eosinophils. mast cells. CD 4 cells.ASTHMA DEFINITION • Variable airflow obstruction. • Airway remodeling can occur and may lead to fixed airflow obstruction.
ASTHMA DIAGNOSIS • Variability over time: → > 12 . .15 % increase in FEV1 → > 20 % increase in peak flows • Variability after challenge: → methacholine.15 % variation in FEV1 → > 20 % variation in peak flows • Variability with bronchodilator: → > 12 . histamine. exercise.
MANAGEMENT OF ASTHMA .
Goals of asthma management → reduce mortality → eliminate symptoms → maximize lung function → eliminate hyper-responsiveness → prevent airway remodeling .
.ASTHMA DIAGNOSIS • There is no ‘gold standard' for the diagnosis of asthma. • The diagnosis of asthma is based on: history physical examination supportive diagnostic testing. including spirometry.
15 % variation in FEV1 → > 20 % variation in peak flows • Variability with bronchodilator: → > 12 % (& > 200 ml) increase in FEV1 → > 20 % increase in peak flows • Variability after challenge: → methacholine. exercise. histamine. mannitol .Establish the diagnosis • Variability over time: → > 12 .
but is of limited value in clinical practice. .Asthma severity • Classification as mild. moderate or severe is useful for clinical trials and epidemiological studies. • Management needs to be individualized to achieve control.
• The important questions are: > Does the patient really have asthma? > Is the asthma persistent and warrant ICS. > What are the goals of treatment? > Is the patient’s asthma well controlled? . or is it intermittent and ICS are not needed? Most adults will need ICS.
wheeze. chest tightness • No nocturnal symptoms • Activities are not restricted • No or minimal use of relievers • No exacerbations • Peak flow variability < 20 % • Spirometry is normal. • ? bronchial hyper-reactivity .dyspnoea. cough.Asthma Control • No or minimal symptoms .
• Inhaled corticosteroids - ? start high
or low. Generally start with lower doses. • Start with a combination of ICS & LABA - Seretide or Symbicort – except maybe mild asthma. • Long term treatment for most adults ∴ consider long term systemic effects. • Local side effects - oral thrush, dysphonia.
Efficacy:safety ratio of inhaled steroids
Airway effects: ICS & LABA
Airway effects: ICS Systemic effects
Dose µ g (BDP/BUD)
Starting with a combination
• Many physicians now start treatment with a
combination. • Some GPs start with a combination, but some are reluctant because of the PBS indications. • There are several studies showing that starting treatment with Seretide provides quicker and better control of asthma. • There is an impression that the less medication changes, the better the compliance will be.
Bricanyl long -acting β agonist with rapid onset . Epaq.Asthma medications • Always check inhaler technique. Airomir. . • Relievers: short acting β agonists - salbutamol (Ventolin. Asmol) terbutaline .eformoterol (Oxis. Foradile) • MDI/DPI usually preferable to nebulizers.
160 µ g) > pro drug with minimal oral side effects > once per day dosing > 50 % lung deposition . [nebs.]) • Beclomethasone (QVAR Autohaler 50. • Budesonide (Pulmicort Turbuhaler 400. 200. 100 µ g. Flixotide MDI 250. 50) > double the potency of BDP/bud.Inhaled corticosteroids • Fluticasone (Flixotide Accuhaler 500. • Ciclesonide (Alvbeco MDI 80. 100 µ g. 100 µ g MDI. 100 µ g) > double the lung deposition. 200. 250. 125.
Turbuhaler 6/100. Accuhaler 500/50. • Tremor and tachycardia with big doses. • Symbicort can be used as i bd plus prn. 100/50.Long acting β agonists • Salmeterol (Serevent Accuhaler 50 µ g. Symbicort (eform. 50/25). MDI 250/25. & bud. Foradile Aerolizer 12 µ g) • Always used with ICS. MDI 25 µ g) • Eformoterol (Oxis Turbuhaler 12 µ g. & flut. 125/25. 6/200. 250/50. 12/400). . • Consider a combination device: Seretide (salm.
.only on PBS for children .useful for patients with throat side effects with ICS.useful in exercise-induced asthma.Leukotriene receptor antagonist • Montelukast (Singulair) .not as good as ICS. .one tablet per day. . .
and ? benefit of overall asthma control. this is difficult. but measures are extreme. • House dust mite can be reduced to acceptable levels. • Obvious triggers on history should be avoided. . • Some would consider allergy testing.Avoiding triggers • In general.
• Use common sense and individualize the plan for the patient. and may fabricate charts. • Patients tend not to use peak flow meters.Asthma management plans • Good evidence that they reduce mortality and morbidity. • Don’t make them too complicated. .
Education and review • Asthma is a chronic condition in adults. • It is also variable. so patients should not under estimate their asthma: 1 . • It is unpredictable. so requires review. .2 die per day from asthma in Australia • Does the patient really the dose of ICS? Think of “back titrating”. • Check inhaler technique.
pulmonary oedema. PTX > allergen exposure > smoking > poor medication use > underestimation of asthma and symptoms > poorly managed asthma .ASTHMA EXACERBATIONS • Think about a treatable cause and predisposing factors: > pneumonia. PE.
• Predisposing factors are important to assess to try to reduce the chance of another exacerbation. • Viruses (rhinovirus) can produce exacerbations. but are not treatable or preventable. or at least reduce its severity.• Often a specific treatable cause is not found. .
consider the side effect risk .avoid complicated regimes . • Possibly assess oxygen requirements.Treatment of exacerbations • Assess the need for hospital admission.careful review is needed . • Increase beta agonist use (+ ipratopium) • Increase steroids: > prednisolone (or IV steroids) .
this also applies to Seretide.possibly cumbersome .logical if on submaximal ICS .Symbicort is designed for this as both drugs are at low doses . > Add an ICS to a combination inhaler .> Increase the puffs from a current inhaler . except many patients seem to be already on large doses.
COPD. ABPA. Churg Strauss? ¥ Cardiac disease. bronchiectasis. ILD? . vocal cord dysfunction.asthma Difficult to control asthma ¥ Is it asthma? ¥ Is it something else .
triggers.• Lack of fitness? • Exacerbating factors … . medications. work.smoking. GOR. • Does he/she use his medication? • Does he/she use it properly? .
• Patients need to understand the purpose of their treatment.Compliance • “Compliance” has been replaced by “acceptance” and “adherence”. • We need to be empathic. • Keep the treatment simple. . • Can patients take responsibility for their treatment? • Regular follow-up is needed. • They are probably over-estimated.
collagen deposition in the bronchial wall. but this is unproven and controversial.Is there airway remodeling? • Thickening of the basement membrane. • It may be preventable with early initiation of treatment. fibroblasts and myofibroblasts. . • This can lead to irreversible airflow obstruction.
COPD ? Asthma COPD & asthma .
COPD & ASTHMA SUMMARY COPD Not variable Neutrophils ASTHMA Variable Eosinophils DISEASE CONTROL Stop smoking ICS & avoid triggers AIM OF TREATMENT Symptom control Reduce mortality Prevent fixed obstruction .
Frith PA. MJA 2003. Burdon JGW. NEJM 2000. Pulmonaryrehab.REFERENCES • www. • McKenzie DK.au • www. Chronic obstructive pulmonary disease.org. 152: S77-S120. 2006 • www. • National Asthma Council Asthma Management Handbook. Town GI.ginasthma. The COPDX plan.nationalasthma. 343: 269-280.copdx.com.au • www.com . 178: S1-S39.au • www.goldcopd. • Barnes PJ.com • ATS official statement on COPD. AM J Respir Crit Care Med 1995.org.
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