The ABCs of COPD
Transcription
The ABCs of COPD
“The ABCs of COPD” Stephen G. Basheda, D.O. ’S of COPD Anticholinergics POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 1 “The ABCs of COPD” Stephen G. Basheda, D.O. ANTICHOLINERGICS • SPIRIVA HANDIHALER/RESPIMAT • TUDORZA • INCRUISE ELLIPTA BETA - AGONISTS • SABAS (short-acting) • Albuterol • LABAS (long-acting) • Serevent/Foradil/Arcapta/Striverdi COMBINATION THERAPY POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 2 “The ABCs of COPD” Stephen G. Basheda, D.O. POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 3 “The ABCs of COPD” Stephen G. Basheda, D.O. POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 4 “The ABCs of COPD” Stephen G. Basheda, D.O. EXACERBATIONS • Change in symptoms over 2 to 3 days • Wheezing – steroids • Sputum change - antibiotics Summary • Significant burden associated with COPD and exacerbations – 672,000 hospitalizations1, 16.3 million office visits2 – 50%-75% of all COPD costs are for services associated with exacerbations3 • Exacerbations are a common occurrence – 77% of patients experienced at least 1 exacerbation in last 12 months4 – Patients of all severity levels experience exacerbations5 – The frequency of exacerbations per year increases with worsening COPD disease severity6 – History of exacerbations predicts future exacerbations7 – 68% of COPD exacerbations are unreported8 1. American Lung Association. Trends in chronic bronchitis and emphysema: morbidity and mortality. February 2010. www.lungusa.org. Accessed June 2, 2010. 2. National Institutes of Health, National Heart, Lung & Blood Institute. Morbidity and Mortality: 2009 chart book on cardiovascular, lung and blood diseases. www.nhlbi.nih.gov/resources/docs/cht-book.htm. Accessed September 13, 2010. 3. American Thoracic Society/European Respiratory Society. Standards for the diagnosis and management of patients with COPD [Internet]. Version 1.2. www.thoracic.org/go/copd. Accessed September 13, 2010. 4. O’Reilly J, et al. Prim Care Respir J. 2006;15:346-353. 5. Balcells E, et al. Resp Med. 2009;103:1293- 1302. 6. Miravitlles M, et al. Respir Med. 1999;93:173-179. 7. Groenewegen K, et al. Chest. 2008; 133;350-357. 8. Langsetmo L, et al. Am J Respir Crit Care Med. 2008;177:396-401. AD5516R0 POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 5 “The ABCs of COPD” Stephen G. Basheda, D.O. Summary • Frequent COPD exacerbations are associated with: – Higher rate of decline in lung function9,10 – Lower quality of life,8,11,12 • Across both moderate and severe patients11 • For both reported and unreported exacerbations8 – Prolonged and incomplete lung function recovery and symptom improvement following an exacerbation13 – Greater depression14 – Increased mortality15 • Guidelines recommend education on and prevention of exacerbations16,17 8. Langsetmo L, et al. Am J Respir Crit Care Med. 2008;177:396-401. 9. Donaldson GC, et al. Thorax. 2002;57:847-852. 10. Data on file, GlaxoSmithKline 11. Esteban, C., et al. Resp Med. 2009;103;1201-1208. 12. Seemungal T, et al. Am J Respir Crit Care Med. 1998;157:1418-1422. 13. Seemungal T, et al. Am J Respir Crit Care Med. 2000;161:1608-1613. 14. Quint, J.K., et al. Eur Respir J. 2008;32:53-60. 15. Soler-Cataluna JJ, et al. Thorax. 2005;60:925-931. 16. American Thoracic Society/European Respiratory Society. Standards for the diagnosis and management of patients with COPD [Internet]. Version 1.2. www.thoracic.org/go/copd. Accessed September 13, 2010. 17. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease – Updated 2009. www.goldcopd.org. Accessed September 13, 2010. AD5516R0 FEV1 POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 6 “The ABCs of COPD” Stephen G. Basheda, D.O. www.goldcopd.com POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 7 “The ABCs of COPD” Stephen G. Basheda, D.O. HYPOXEMIC DRIVE “ suppression ” ventilatory response • • • minute ventilation. . . NO CHANGE increase dead space ventilation Haldane effect AJRCCM 155:609.1997 ARRD 122:747.1980 HYPOXEMIA. . . . . . . oxygen HYPERCARBIA. . . . . ventilatory support POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 8 “The ABCs of COPD” Stephen G. Basheda, D.O. ICD - 10 POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 9 “The ABCs of COPD” Stephen G. Basheda, D.O. POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 10 “The ABCs of COPD” Stephen G. Basheda, D.O. JUST DO IT Smoking Cessation • Chantix – 40 to 50% success • Nicotine replacement therapy – 20 to 25% success rate • Pat on the back – less than 5% success KCAL - NUTRITION • • • • • COPD - weight loss increased resting energy expenditure reduced calorie intake systemic inflammation tissue hypoxia medications Pulmonary “ Cachexia ” • • Definition BMI < 20 kg / m 2 IBW < 90 % • • • Treatment increase kcal ? anabolic steroids ? growth hormone POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 11 “The ABCs of COPD” Stephen G. Basheda, D.O. LUNG CANCER - SCREENING Chest CT Scanning • Age 55 to 74 • Smoking history – one pack-a-day for 30 years • Active smoker or quit within the past 15 years MORTALITY POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 12 “The ABCs of COPD” Stephen G. Basheda, D.O. NON – INVASIVE POSITIVE PRESSURE VENTILATION • • • • • • • Indications acute respiratory acidosis hypoxemia Exclusions respiratory arrest hemodynamic instability uncooperative / unresponsive patient craniofacial trauma / surgery aspiration risk / secretions OXYGEN • PaO2 < 55 mm Hg • SaO2 < 88 % • PaO2 55 – 60 mmHg with : cor pulmonale / edema erythrocytosis Decreased mortality ! ! ! PERI-OPERATIVE PULMONARY ISSUES • • • • • Patient – related risk factors smoking general health status age obesity COPD / asthma POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 13 “The ABCs of COPD” Stephen G. Basheda, D.O. PERI-OP ( cont ) Procedure – related factors surgical site thorax/upper abdomen ( 10 – 40 % ) • surgical time > 3 hours • anesthesia risks ? general > spinal • PREOPERATIVE ASSESSMENT • • • • History and physical Pulmonary function tests Arterial blood gases Chest radiograph • Risk reduction lung expansion exercises post-op pain control NEJM 340: 937. 1999 QUALITY ISSUES POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 14 “The ABCs of COPD” Stephen G. Basheda, D.O. REHABILITATION - PULMONARY • • • • • • Physical therapy / exercise training Occupational therapy Smoking cessation Respiratory therapy / education Behavior modification / mental health nutrition POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 15 “The ABCs of COPD” Stephen G. Basheda, D.O. REHABILITATION OUTCOMES • • • • Increase exercise / oxygen uptake Decrease dyspnea index Increase quality of life ? Mortality / hospitalizations SPIROMETRY POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 16 “The ABCs of COPD” Stephen G. Basheda, D.O. THEOPHYLLINES • Benefits bronchodilator respiratory stimulant diuretic diaphragm function pulmonary vasodilator anti-inflammatory • Risks side effects drug interactions POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 17 “The ABCs of COPD” Stephen G. Basheda, D.O. UPPER AIRWAY OBSTRUCTION • Extrathoracic variable • Intrathoracic variable • Fixed Diagnosis flow – volume loop CT scanning bronchoscopy VACCINES • Pneumococcal – Pneumovax – Prevnar 13 • Influenza POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 18 “The ABCs of COPD” Stephen G. Basheda, D.O. WATER - HYDRATION • Pulmonary toilet – flutter valve • Mucolytics • Fluids X - RAYS POMA District VIII 29th Annual Winter Seminar January 28-31, 2016 19 “The ABCs of COPD” Stephen G. Basheda, D.O. YA – HOO ! ! ! 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