CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD), BRONCHIAL ASTHMA

Transcription

1 CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD), BRONCHIAL ASTHMA GOLD GINA

2 Chronic Obstructive Pulmonary Disease (COPD) COPD is currently the fourth leading cause of death in the world.1 COPD is projected to be the 3rd leading cause of death by More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population. 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study Lancet 2012; 380(9859): Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to PLoS Med 2006; 3(11): e Global Initiative for Chronic Obstructive Lung Disease

3 Economic and Social Burden Economic burden of COPD COPD is associated with significant economic burden. COPD exacerbations account for the greatest proportion of the total COPD burden. European Union: Direct costs of respiratory disease ~6% of the total healthcare budget COPD accounting for 56% (38.6 billion Euros) of the cost of respiratory disease. USA: Direct costs of COPD are $32 billion Indirect costs $20.4 billion Global Initiative for Chronic Obstructive Lung Disease

4 COPD Definition Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

5 Factors that influence disease progression Genetic factors Age and gender Lung growth and development Exposure to particles Socioeconomic status Asthma & airway hyper-reactivity Chronic bronchitis Infections 2017 Global Initiative for Chronic Obstructive Lung Disease

6 Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Genes Infections Socio-economic status Aging Populations 2015 Global Initiative for Chronic Obstructive Lung Disease

7 Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK

8 Clinical forms of COPD Pink puffer Blue bloater

9 Medical History Patient s exposure to risk factors Past medical history Family history of COPD or other chronic respiratory disease. Pattern of symptom development History of exacerbations or previous hospitalizations for respiratory disorder Presence of comorbidities Impact of disease on patient s life Social and family support available to the patient. Possibilities for reducing risk factors, especially smoking cessation Global Initiative for Chronic Obstructive Lung Disease

10 Diagnosis and Initial Assessment 2017 Global Initiative for Chronic Obstructive Lung Disease

11 Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities 2015 Global Initiative for Chronic Obstructive Lung Disease

12 Symptoms of COPD The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production that can be variable from day-to-day. Dyspnea: Progressive, persistent and characteristically worse with exercise. Chronic cough: May be intermittent and may be unproductive. Chronic sputum production: COPD patients commonly cough up sputum Global Initiative for Chronic Obstructive Lung Disease

13 Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry COPD Assessment Test (CAT) Assess risk of exacerbations Assess comorbidities or Clinical COPD Questionnaire (CCQ) or mmrc Breathlessness scale 2015 Global Initiative for Chronic Obstructive Lung Disease

14 2017 Global Initiative for Chronic Obstructive Lung Disease

15 Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1 > 80% predicted GOLD 2: Moderate predicted 50% < FEV1 < 80% GOLD 3: Severe predicted 30% < FEV1 < 50% 2015 Global Initiative for Chronic Obstructive Lung Disease

16 Spirometry 2017 Global Initiative for Chronic Obstructive Lung Disease

17 Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk. One or more hospitalizations for COPD exacerbation should be considered high risk Global Initiative for Chronic Obstructive Lung Disease

18 Assessment of Exacerbation Risk COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. Classified as: Mild (treated with SABDs only) Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure. Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS) Global Initiative for Chronic Obstructive Lung Disease

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20 Differential Diagnosis

21 Prevention & Maintenance Therapy (1) Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present. Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient s response, preference and ability to use various drug delivery devices. Inhaler technique needs to be assessed regularly Global Initiative for Chronic Obstructive Lung Disease

22 Prevention & Maintenance Therapy (2) Influenza vaccination decreases the incidence of lower respiratory tract infections. Pneumococcal vaccination decreases lower respiratory tract infections. Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities. In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival. In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient s need for supplemental oxygen Global Initiative for Chronic Obstructive Lung Disease

23 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy Patient(Medications Recommended Alternative choice Other Possible in each box are mentioned in alphabetical order, and therefore First choice not necessarily in order of preference.) Treatments A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Theophylline B LAMA or LABA LAMA and LABA SABA and/or SAMA Theophylline ICS + LABA or LAMA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. SABA and/or SAMA Theophylline ICS + LABA and/or LAMA ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or LAMA and LABA or LAMA and PDE4-inh. Carbocysteine N-acetylcysteine SABA and/or SAMA Theophylline C D

24 Treatment of Stable COPD Model for the initiation, and then subsequent escalation and/or deescalation of pharmacologic management of COPD according to the individualized assessment of symptoms and exacerbation risk (GOLD 2017)

25 Treatment of Stable COPD 2017 Global Initiative for Chronic Obstructive Lung Disease

26 Pharmacologic Therapy 2017 Global Initiative for Chronic Obstructive Lung Disease

27 Pharmacologic Therapy 2017 Global Initiative for Chronic Obstructive Lung Disease

28 Non-Pharmacologic Treatment Education and self-management Physical activity Pulmonary rehabilitation programs Exercise training Self-management education End of life and palliative care Nutritional support Vaccination Oxygen therapy 2017 Global Initiative for Chronic Obstructive Lung Disease

29 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Nonpharmacologic Patient Group Essential A Smoking cessation (can include pharmacologic treatment) B, C, D Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilitation Recommended Depending on local guidelines Physical activity Flu vaccination Pneumococcal vaccination Physical activity Flu vaccination Pneumococcal vaccination 2015 Global Initiative for Chronic Obstructive Lung Disease

30 Non-Pharmacologic Treatment Oxygen therapy Long-term oxygen therapy is indicated for stable patients who have: PaO2 at or below 7.3 kpa (55 mmhg) or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or PaO2 between 7.3 kpa (55 mmhg) and 8.0 kpa (60 mmhg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%) Global Initiative for Chronic Obstructive Lung Disease

31 Non-Pharmacologic Treatment 2017 Global Initiative for Chronic Obstructive Lung Disease

32 Management of Exacerbations COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. They are classified as: Mild (treated with short acting bronchodilators only, SABDs) Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure Global Initiative for Chronic Obstructive Lung Disease

33 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options Oxygen: titrate to improve the patient s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Nebulized magnesium as an adjuvent to salbutamol treatment in the setting of acute exacerbations of COPD has no effect on FEV Global Initiative for Chronic Obstructive Lung Disease

34 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options Antibiotics should be given to patients with: Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. Who require mechanical ventilation Global Initiative for Chronic Obstructive Lung Disease

35 Management of Exacerbations Classification of hospitalized patients Acute respiratory failure life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased compared with baseline or elevated > 60 mmhg or the presence of acidosis (ph < 7.25) Global Initiative for Chronic Obstructive Lung Disease

36 Management of Exacerbations 2017 Global Initiative for Chronic Obstructive Lung Disease

37 What is known about asthma? Asthma is a common and potentially serious chronic disease that can be controlled but not cured (and is unlikely ever to go into complete remission) Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs due to Bronchoconstriction (airway narrowing) Airway wall thickening Increased mucus Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress GINA 2016

38 Definition of asthma Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity. GINA 2016

39 Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK

40 Diagnosis of asthma symptoms Increased probability that symptoms are due to asthma if: More than one type of symptom (wheeze, shortness of breath, cough, chest tightness) Symptoms often worse at night or in the early morning Symptoms vary over time and in intensity Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells Decreased probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptoms Chronic production of sputum Shortness of breath associated with dizziness, light-headedness or peripheral tingling Chest pain Exercise-induced dyspnea with noisy inspiration (stridor) GINA 2017

41 Diagnosis of asthma variable airflow limitation Confirm presence of airflow limitation Document that FEV1/FVC is reduced (at least once, when FEV1 is low) FEV1/ FVC ratio is normally > in healthy adults, and >0.90 in children Confirm variation in lung function is greater than in healthy individuals The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted) Excessive diurnal variability from 1-2 weeks twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged) Significant increase in FEV1 or PEF after 4 weeks of controller treatment If initial testing is negative: Repeat when patient is symptomatic, or after withholding bronchodilators Refer for additional tests (especially children 5 years, or the elderly) GINA 2017, Box 1-2 Global Initiative for Asthma

42 Diagnosis of asthma physical examination Physical examination in people with asthma Often normal The most frequent finding is wheezing on auscultation, especially on forced expiration Wheezing is also found in other conditions, for example: Respiratory infections COPD Upper airway dysfunction Endobronchial obstruction Inhaled foreign body Wheezing may be absent during severe asthma exacerbations ( silent chest ) GINA 2017 Global Initiative for Asthma

43 Assessment of asthma 1. Asthma control - two domains Assess symptom control over the last 4 weeks Assess risk factors for poor outcomes, including low lung function 2. Treatment issues 3. Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan? What are the patient s attitudes and goals for their asthma? Comorbidities Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety These may contribute to symptoms and poor quality of life GINA 2017, Box 2-1 Global Initiative for Asthma

44 GINA assessment of asthma control A. Symptom control In the past 4 weeks, has the patient had: Level of asthma symptom control Wellcontrolled Partly controlled Uncontrolled None of these 1-2 of these 3-4 of these Daytime asthma symptoms more than twice a week? Yes No Any night waking due to asthma? Yes No Reliever needed for symptoms* more than twice a week? Yes No Any activity limitation due to asthma? Yes No B. Risk factors for poor asthma outcomes Assess risk factors at diagnosis and periodically Global Initiative for Asthma FEV the patient s GINA 2017 Box 2-2B (1/4)at start of treatment, after 3 to 6 months of treatment to record Measure

45 Assessment of risk factors for poor asthma outcomes Risk factors for exacerbations include: Ever intubated for asthma Uncontrolled asthma symptoms Having 1 exacerbation in last 12 months Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and periodically thereafter) Incorrect inhaler technique and/or poor adherence Smoking Elevated FeNO in adults with allergic asthma Obesity, pregnancy, blood eosinophilia Risk factors for fixed airflow limitation include: No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia Risk factors for medication side-effects include: Frequent oral steroids, high dose/potent ICS, P450 inhibitors GINA 2017, Box 2-2B (4/4) Global Initiative for Asthma

46 Assessing asthma severity How? Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations When? Assess asthma severity after patient has been on controller treatment for several months Severity is not static it may change over months or years, or as different treatments become available Categories of asthma severity Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low dose ICS) Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA) Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment GINA 2017 Global Initiative for Asthma

47 Initial controller treatment Before starting initial controller treatment Record evidence for diagnosis of asthma, if possible Record symptom control and risk factors, including lung function Consider factors affecting choice of treatment for this patient Ensure that the patient can use the inhaler correctly Schedule an appointment for a follow-up visit After starting initial controller treatment Review response after 2-3 months, or according to clinical urgency Adjust treatment (including non-pharmacological treatments) Consider stepping down when asthma has been wellcontrolled for 3 months GINA 2017, Box 3-4 (2/2) Global Initiative for Asthma

48 Stepwise management pharmacotherapy (the therapy is designed to both prevent and relive the obstruction) Diagnosis Symptom control & risk factors (including lung function) UPDATED 2017 Inhaler technique & adherence Patient preference Symptoms Exacerbations Side-effects Asthma medications Patient satisfaction Non-pharmacological strategies Lung function Treat modifiable risk factors STEP 5 STEP 4 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Other controller options RELIEVER Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* As-needed short-acting beta2-agonist (SABA) GINA 2017, Box 3-5 (2/8) (upper part) STEP 3 Low dose ICS/LABA** Refer for add-on treatment Med/high ICS/LABA e.g. tiotropium,* anti-ige, anti-il5* Med/high dose ICS Add tiotropium* Add low Low dose ICS+LTRA High dose ICS dose OCS + LTRA (or + theoph*) (or + theoph*) As-needed SABA or low dose ICS/formoterol# *Not for children <12 years **For children 6-11 years, the preferred Step 3 treatment is medium dose ICS For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy # Tiotropium by mist inhaler is an add-on treatment for patients 12 years with a history of exacerbations Global Initiative for Asthma

49 Stepwise management + Provide guided self-management education Treat modifiable risk factors and comorbidities Advise about non-pharmacological therapies and strategies Consider stepping up if uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted Consider stepping down if symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. Global Initiative for Asthma

50 Low, medium and high dose inhaled corticosteroids Adults and adolescents ( 12 years) Inhaled corticosteroid Total daily dose (mcg) Low Medium High Beclometasone dipropionate (CFC) > >1000 Beclometasone dipropionate (HFA) > >400 Budesonide (DPI) > >800 Ciclesonide (HFA) > > n.a. 200 Fluticasone propionate (DPI or HFA) > >500 Mometasone furoate > > > >2000 Fluticasone furoate (DPI) Triamcinolone acetonide This is not a table of equivalence, but of estimated clinical comparability Most of the clinical benefit from ICS is seen at low doses High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with increased risk of systemic side-effects GINA 2017, Box 3-6 (1/2) Global Initiative for Asthma

51 Reviewing response and adjusting treatment How often should asthma be reviewed? 1-3 months after treatment started, then every 3-12 months During pregnancy, every 4-6 weeks After an exacerbation, within 1 week Stepping up asthma treatment Sustained step-up, for at least 2-3 months if asthma poorly controlled Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence) Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen May be initiated by patient with written asthma action plan Day-to-day adjustment For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen* Stepping down asthma treatment Consider step-down after good control maintained for 3 months Find each patient s minimum effective dose, that controls both symptoms and exacerbations *Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol GINA 2017 Global Initiative for Asthma

52 A flare-up or exacerbation is an acute or sub-acute worsening of symptoms and lung function compared with the patient s usual status Consider management of worsening asthma as a continuum GINA 2017 Self-management with a written asthma action plan Management in primary care Management in the emergency department and hospital Follow-up after any exacerbation Global Initiative for Asthma

53 Written asthma action plans medication options Increase inhaled reliever Increase frequency as needed Adding spacer (nebulizer) for pmdi may be helpful Early and rapid increase in inhaled controller Up to maximum ICS of 2000mcg BDP/day or equivalent Options depend on usual controller medication and type of LABA See GINA 2017 report Box 4-2 for details Add oral corticosteroids if needed Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days Children: 1-2mg/kg/day up to 40mg, usually 3-5 days UPDATED Morning dosing preferred to reduce side-effects 2017 Tapering not needed if taken for less than 2 weeks Remember to advise patients about common side-effects (sleep disturbance, increased appetite, reflux, mood changes) GINA 2017, Box 4-2 (2/2) Global Initiative for Asthma

54 Nebulizers, spacers Global Initiative for Asthma

55 Asthma-COPD overlap (ACO) Patients with features of both asthma and COPD have worse outcomes than those with asthma or COPD alone Frequent exacerbations Poor quality of life More rapid decline in lung function Higher mortality Greater health care utilization UPDATED 2017 Reported prevalence of overlap varies by definitions used Concurrent doctor-diagnosed asthma and COPD are found in 15 20% of patients with chronic airways disease Reported rates of overlap are between15 55% of patients with chronic airways disease, depending on the definitions used for asthma and COPD, and the population studied Prevalence varies by age and gender GINA 2017 Global Initiative for Asthma

56 Definitions UPDATED 2017 Asthma Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. [GINA 2017] COPD Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. [GOLD 2017] Asthma-COPD overlap [not a definition, but a description for clinical use] Asthma-COPD overlap (ACO) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Asthma-COPD overlap is therefore identified in clinical practice by the features that it shares with both asthma and COPD. This is not a definition, but a description for clinical use, as asthma-copd overlap includes several different clinical phenotypes and there are likely to be several different underlying mechanisms. GINA 2017, Box 5-1 (3/3) Global Initiative for Asthma

57 STEP 2 SYNDROMIC DIAGNOSIS IN ADULTS (i) Assemble the features for asthma and for COPD that best describe the patient. (ii) Compare number of features in favour of each diagnosis and select a diagnosis Features: if present suggest - ASTHMA COPD Age of onset Before age 20 years After age 40 years Pattern of symptoms Variation over minutes, hours or days Persistent despite treatment Worse during the night or early morning Good and bad days but always daily symptoms and exertional dyspnea Triggered by exercise, emotions including laughter, dust or exposure to allergens Chronic cough & sputum preceded onset of dyspnea, unrelated to triggers Lung function Record of variable airflow limitation (spirometry or peak flow) Record of persistent airflow limitation (FEV1/FVC < 0.7 post-bd) Lung function between symptoms Normal Abnormal Past history or family history Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD, chronic bronchitis or emphysema Family history of asthma, and other allergic conditions (allergic rhinitis or eczema) Time course No worsening of symptoms over time. Variation in symptoms either seasonally, or from year to year May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks Chest X-ray Normal Heavy exposure to risk factor: tobacco smoke, biomass fuels Symptoms slowly worsening over time (progressive course over years) Rapid-acting bronchodilator treatment provides only limited relief Severe hyperinflation NOTE: These features best distinguish between asthma and COPD. Several positive features (3 or more) for either asthma or COPD suggest that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACO DIAGNOSIS Asthma Some features of asthma Features of both Some features of COPD COPD CONFIDENCE IN DIAGNOSIS Asthma Asthma Could be ACO Possibly COPD COPD GINA 2017, Box 5-4 GINA 2014 UPDATED 2017 Global Initiative for Asthma

58 Step 3 - Spirometry Spirometric variable Normal FEV1/FVC pre- or post-bd Asthma UPDATED 2017 COPD Compatible with asthma Not compatible with diagnosis (GOLD) Post-BD FEV1/FVC <0.7 Indicates airflow limitation; may improve Required for diagnosis by GOLD criteria Overlap Not compatible unless other evidence of chronic airflow limitation Usual in asthmacopd overlap (ACO) FEV1 80% predicted Compatible with asthma Compatible with GOLD Compatible with mild (good control, or interval category A or B if post- ACO between symptoms) BD FEV1/FVC <0.7 FEV1<80% predicted Compatible with asthma. Indicates severity of A risk factor for airflow limitation and risk exacerbations of exacerbations and mortality Indicates severity of airflow limitation and risk of exacerbations and mortality Usual at some time in Post-BD increase in FEV1 >12% and 200mL course of asthma; not from baseline (reversible always present airflow limitation) Common in COPD and more likely when FEV1 is low Common in ACO, and more likely when FEV1 is low Post-BD increase in FEV1 >12% and 400mL from baseline Unusual in COPD. Consider ACO Compatible with diagnosis of ACO GINA 2017, Box 5-3 High probability of asthma Global Initiative for Asthma

59 Initial therapy UPDATED 2017 If syndromic assessment suggests asthma as single diagnosis Start with low-dose ICS Add LABA and/or LAMA if needed for poor control despite good adherence and correct technique Do not give LABA alone without ICS If syndromic assessment suggests COPD as single diagnosis Start with bronchodilators or combination therapy Do not give ICS alone without LABA and/or LAMA If differential diagnosis is equally balanced between asthma and COPD, i.e. asthma-copd overlap Start treatment as for asthma, pending further investigations Start with ICS at low or moderate dose Usually also add LABA and/or LAMA, or continue if already prescribed GINA 2017 Global Initiative for Asthma

60 β 2 - agonists Short-acting: Salbutamol Fenoterol Terbutaline Long-acting: Salmeterol Formoterol Indakaterol

61 Medications to Treat Asthma: How to Use a Spray Inhaler The health-care provider should evaluate inhaler technique at each visit.

62 Inhaled anticholinergics Short-acting: Ipratropium bromide (Atrovent, Ipravent) Tiotropium bromide : Tiotropium bromide (Spiriva)

63 Combined bronchodilators Beta 2 - agonist + anticholinergic: Berodual (fenoterol + ipratropium bromide) Duolin (salbutamol + ipratropium bromide)

64 Methylxanthines Fast and shortacting: Euphylline Aminophylline Long-acting: Teotard Doxofylline (Puroxan, Aerofyllin)...

65 Roflumilast: (Daxas ), (DalirespTM) Phosphodiesterase inhibitor with selective action on its isoenzyme IV (IFDE-4), which predominates in inflammatory cells Shows anti-inflammatory activity in the airways: inhibits chemotaxis and activation of leukocytes, production of cytokines reduces the number of neutrophils and eosinophils

66 Anti-inflammatory medicines in bronchoobstructive syndrome treatment

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69 Pulmonary rehabilitation of COPD Oxygen - a highly effective treatment for patients with stage III-IV COPD, the only one which is able to reduce mortality (A) Respiratory exercises provides only short-term effect (P) Physiotherapy unreasonable in COPD and useless in terms of evidence-based medicine treatment: light and electrotherapy, bioresonance therapy, electric, intranasal electrophoresis, UHF, iv laser irradiation and other (D) No evidence is the use of acupuncture, homeopathy, herbal medicine.