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 ! ! !
POMA District VIII 29th Annual Winter Seminar
January 28-31, 2016
20