COPD AND ASTHMA

Christopher Worsnop Department of Respiratory and Sleep Medicine

COPD DEFINITION
• Progressive airflow limitation that is not
fully reversible.

• Inflammation in the airways, lung
parenchyma and pulmonary vessels.

• Neutrophils, macrophages, CD 8 cells. • Proteinase - antiproteinase imbalance. • Oxidative stress.

COPD NAMES
• COPD = chronic obstructive pulmonary
disease

• COAD = chronic obstructive airways
disease

• 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 . .

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Respirology 2006. 11: 9 .

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 < 0.7 ⇒ airflow obstruction (this varies slightly with age) .

.→ a reduced FEV1 alone does not mean airflow obstruction → FEV1 is used for monitoring → Occasionally people with emphysema on HRCT have normal spirometry.

REVERSIBILITY WITH SPIROMETRY • An increase in FEV1 of > 12 % (and at least 200 ml) is likely to be due to the bronchodilator. • Reversibility does not predict symptomatic responses to bronchodilators. • If the FEV1 returns into the normal range. the diagnosis is likely to be asthma. .

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 .

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. Br 1977. .

not ready now) • Contemplation (40% .Stages of change • Pre Contemplation (40% of current smokers .ambivalent) • Preparation • Action • Maintenance .

Willpower alone .Self-help materials .Quit courses • Pharmacological .Current smoking cessation strategies • Non .Zyban .Doctor’s advice .Intensive counselling . .Nicotine replacement therapy .pharm.

short or long-acting → theophylline .rarely used now → combined bronchodilators .MEDICATIONS IN COPD • Other treatments are for control of symptoms → anticholinergics . tiotropium →β 2 agonists .ipratropium.

• Reversibility on spirometry does not predict long term symptomatic response. • Cease if no symptomatic benefit after a reasonable trial (6-12 weeks). • There are poor correlations between symptoms. . • FEV1 is not a good way to assess response to treatment. or unacceptable side effects. lung function and pathology.

Anticholinergics • Spiriva = tiotropium Atrovent = ipratropium • Long-acting more convenient. better exercise. and less dyspnoea. • Handihaler designed for COPD. . • Side effect = dry mouth in 14 %. less mortality. less exacerbations (NTT = 14).

β 2 agonists Ventolin. . more exercise. Foradile = eformoterol • • Short-acting for prn use. • Long-acting for regular use – less symptoms. better QOL • Less QOL with higher doses • Side effects = tremor. Airomir = salbutamol Bricanyl = terbutaline Serevent = salmeterol Oxis. tachycardia.

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 .

eczema.Why give a trial of ICS in COPD? • Any suggestion of asthma > history of asthma. . hayfever. allergy > some reversibility on spirometry • The patient is keen for more improvement in symptoms and exercise.

Combination treatment • Inhaled fluticasone and salmeterol (Seretide) • In moderate to severe COPD (FEV1 < 60 %) it has been shown to reduce exacerbations. improve QOL and FEV1.052 in the TORCH study. • A small reduction in mortality with p = 0. .

death. • Narrow therapeutic window. seizures. dysrhythmias. . • Significant side effects = nausea.Theophyllines • Benefits less well documented. • Drug interactions. • Monitor blood levels.

• It is not possible to predict those who will respond. • There is no evidence that long term prednisolone is of any benefit.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. • This does not predict those who will respond to ICS.

hospital admissions and exacerbations. .it does not prevent other URTI viruses. .reduces mortality. .VACCINES • Influenza vaccine .local side effects only. • Pneumococcal vaccine . .it is given twice 5 years apart. but it seems like a good idea. .no evidence about its use in COPD.it is given yearly.

8 weeks with twice weekly visits. • Two main components . • Variable cost to the patient. • A course is run over 6 . and education. but the exercise needs to be maintained at home. .improving fitness.PULMONARY REHABILITATION •There is good evidence that it improves symptoms in COPD. • Patients need to be well motivated. • Usually supervised by physiotherapists.

HOME OXYGEN THERAPY • Oxygen concentrator: 2 .PO2 on air at rest < 55 mmHg OR . AND . cor pulmonale. polycythaemia. i. • This oxygen improves mortality.no cigarettes for 3 months.e. and usually has no effect on symptoms. pulmonary hypertension.PO2 < 60 if evidence of hypoxic damage.when at his/her best and stable .4 l/min. via nasal prongs for > 16 hours/day IF . .

exercise is improved. • No cigarettes for 3 months. • The patient needs to be motivated to lug a cylinder around. . • SpO2 < 88 % with exercise AND .supplemental O2 prevents this desaturation AND .Portable home oxygen • This is designed to improve symptoms and increase exercise.

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 .

pneumonia • Heart failure. arrhythmia • Systemic infection. fever • Anaemia • Anxiety • Anything that increases metabolic rate .URTI.bacterial.ACUTE COPD EXACERBATION • The cause is often unknown • Respiratory infections . viral . bronchitis.

• CXR to look for pneumonia.increased dyspnoea .increased sputum production .sputum becoming discoloured • Antibiotics to cover Strep and Gram negatives have been shown to be useful if all three criteria are present. .Features of a COPD exacerbation • Anthonisen criteria: . and cover atypical bacteria if there is pneumonia.

do not give high doses of O2 too quickly .MANAGEMENT OF AN EXACERBATION • Supplemental O2 .aim to keep SpO2 > 90 %. and/or PaO2 > 60 mmHg . flow rate and patient’s inspiratory flow rate .consider the O2 concentration.

.  Reduced ventilatory drive.• 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. .

oral. but not great and must be balanced with side effects.some benefit. • Antibiotics .if there is evidence of infection • Physical activity .anticholinergics and β agonists • Corticosteroids .to prevent deconditioning • Non-invasive ventilation . intravenous . VPAP 2 .BiPAP.• Bronchodilators .inhaled.

mast cells. • Airway remodeling can occur and may lead to fixed airflow obstruction. • Chronic inflammation of the airways with bronchial hyper-responsiveness. CD 4 cells.ASTHMA DEFINITION • Variable airflow obstruction. . • Eosinophils.

15 % variation in FEV1 → > 20 % variation in peak flows • Variability with bronchodilator: → > 12 . histamine. .15 % increase in FEV1 → > 20 % increase in peak flows • Variability after challenge: → methacholine. exercise.ASTHMA DIAGNOSIS • Variability over time: → > 12 .

MANAGEMENT OF ASTHMA .

nationalasthma.au .www.org.

Goals of asthma management → reduce mortality → eliminate symptoms → maximize lung function → eliminate hyper-responsiveness → prevent airway remodeling .

• The diagnosis of asthma is based on: history physical examination supportive diagnostic testing.ASTHMA DIAGNOSIS • There is no ‘gold standard' for the diagnosis of asthma. including spirometry. .

mannitol . exercise.Establish the diagnosis • Variability over time: → > 12 .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. histamine.

Asthma severity • Classification as mild. but is of limited value in clinical practice. • Management needs to be individualized to achieve control. moderate or severe is useful for clinical trials and epidemiological studies. .

> What are the goals of treatment? > Is the patient’s asthma well controlled? .• The important questions are: > Does the patient really have asthma? > Is the asthma persistent and warrant ICS. or is it intermittent and ICS are not needed? Most adults will need ICS.

cough. 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 .Asthma Control • No or minimal symptoms .dyspnoea. wheeze.

Initiating treatment
• 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
Effect

Airway effects: ICS Systemic effects

1000

2000

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.

Foradile) • MDI/DPI usually preferable to nebulizers. Asmol) terbutaline .Asthma medications • Always check inhaler technique. Airomir. Epaq.Bricanyl long -acting β agonist with rapid onset . • Relievers: short acting β agonists - salbutamol (Ventolin.eformoterol (Oxis. .

200. 160 µ g) > pro drug with minimal oral side effects > once per day dosing > 50 % lung deposition . • Ciclesonide (Alvbeco MDI 80. 100 µ g. • Budesonide (Pulmicort Turbuhaler 400.]) • Beclomethasone (QVAR Autohaler 50. 250. 100 µ g MDI. Flixotide MDI 250. 200. 125.Inhaled corticosteroids • Fluticasone (Flixotide Accuhaler 500. 100 µ g) > double the lung deposition. 100 µ g. [nebs. 50) > double the potency of BDP/bud.

MDI 25 µ g) • Eformoterol (Oxis Turbuhaler 12 µ g. 100/50. 12/400). 250/50. • Tremor and tachycardia with big doses. Foradile Aerolizer 12 µ g) • Always used with ICS. MDI 250/25. & bud. . 6/200. • Symbicort can be used as i bd plus prn.Long acting β agonists • Salmeterol (Serevent Accuhaler 50 µ g. 125/25. & flut. • Consider a combination device: Seretide (salm. Accuhaler 500/50. Symbicort (eform. Turbuhaler 6/100. 50/25).

.useful in exercise-induced asthma.only on PBS for children . . .Leukotriene receptor antagonist • Montelukast (Singulair) . .useful for patients with throat side effects with ICS.one tablet per day.not as good as ICS.

• House dust mite can be reduced to acceptable levels. and ? benefit of overall asthma control. but measures are extreme.Avoiding triggers • In general. this is difficult. . • Obvious triggers on history should be avoided. • Some would consider allergy testing.

and may fabricate charts. • Use common sense and individualize the plan for the patient. . • 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. so requires review. • Check inhaler technique. • It is also variable. so patients should not under estimate their asthma: 1 .2 die per day from asthma in Australia • Does the patient really the dose of ICS? Think of “back titrating”. • It is unpredictable. .

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.

• Often a specific treatable cause is not found. • Viruses (rhinovirus) can produce exacerbations. but are not treatable or preventable. . or at least reduce its severity. • Predisposing factors are important to assess to try to reduce the chance of another exacerbation.

• Increase beta agonist use (+ ipratopium) • Increase steroids: > prednisolone (or IV steroids) .consider the side effect risk .careful review is needed .Treatment of exacerbations • Assess the need for hospital admission. • Possibly assess oxygen requirements.avoid complicated regimes .

logical if on submaximal ICS .Symbicort is designed for this as both drugs are at low doses .this also applies to Seretide. > Add an ICS to a combination inhaler .> Increase the puffs from a current inhaler .possibly cumbersome . except many patients seem to be already on large doses.

bronchiectasis. ILD? . Churg Strauss? ¥ Cardiac disease. vocal cord dysfunction.COPD. ABPA.asthma Difficult to control asthma ¥ Is it asthma? ¥ Is it something else .

medications. • Does he/she use his medication? • Does he/she use it properly? . work.smoking.• Lack of fitness? • Exacerbating factors … . GOR. triggers.

• Can patients take responsibility for their treatment? • Regular follow-up is needed. • Keep the treatment simple. • We need to be empathic. .Compliance • “Compliance” has been replaced by “acceptance” and “adherence”. • Patients need to understand the purpose of their treatment. • They are probably over-estimated.

collagen deposition in the bronchial wall. but this is unproven and controversial. • It may be preventable with early initiation of treatment. fibroblasts and myofibroblasts. • This can lead to irreversible airflow obstruction.Is there airway remodeling? • Thickening of the basement membrane. .

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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 .

2006 • www.copdx.au • www.nationalasthma.au • www. 343: 269-280.com.REFERENCES • www.org. Pulmonaryrehab. The COPDX plan. Burdon JGW. • Barnes PJ.ginasthma.com • ATS official statement on COPD. MJA 2003. 152: S77-S120. Town GI. 178: S1-S39. Chronic obstructive pulmonary disease. Frith PA. NEJM 2000.au • www.org. • National Asthma Council Asthma Management Handbook. • McKenzie DK.goldcopd. AM J Respir Crit Care Med 1995.com .

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