COPD COPD. Update on COPD and Asthma
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1 Update on COPD and Asthma Talmadge E. King, Jr., M.D. Krevins Distinguished Professor of Medicine Chair, Department of Medicine University of California San Francisco (UCSF) San Francisco, CA COPD COPD COPD is de+ined as a preventable and treatable disease state characterized by air+low limitation that is not fully reversible. Air+low limitation is usually progressive and associated with an abnormal in+lammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. 3 1
2 Leukocyte Infiltration in COPD Smoker, Severe COPD Smoker, Mild COPD COPD highly prevalent, underdiagnosed, undertreated, and underperceived Immunostaining with monoclonal antibody anti-cd45 COPD Prevalence = 7 to 19% (M>W; white > blacks; increases with age) COPD is not solely a pulmonary disease but also one with important measurable systemic consequences. A new paradigm presents the disease as preventable and treatable. An Accelerated Decline In Lung Function Is The Single Most Important Feature Of COPD 4th-ranked cause of death in the US (~100,000 each year). 2
3 COPD: Cigarette smoking Cigarette smoking is the most important risk factor. Smoking leads to an in+lammatory response, oxidative stress, lung distruction, and interference with lung repair Smoking cessation: Slows the accelerated decline in COPD- related FEV1 Reduces all- cause mortality rates by 27% (by reduction in CV mortality) COPD The mortality rate from COPD for women has doubled over the past 20 yrs. Some studies suggest that women are more susceptible to the effects of tobacco smoke than men COPD: Importance of HyperinKlation Dyspnea perceived during exercise, including walking, more closely relates to the development of dynamic hyperinklation than to changes in FEV1. Improvement in exercise brought about by several therapies (bronchodilators, oxygen, lung volume reduction surgery, and even rehabilitation) is more closely related to delaying dynamic hyperin+lations than by improving the degree of air+low obstruction. COPD: A persistent Systemic InKlammatory state Associated with important systemic manifestations, especially in patients with more advanced disease. Imbalanced oxidative stress or abnormal immunologic response decreased fat- free mass impaired systemic muscle function anemia osteoporosis depression pulmonary hypertension, and cor pulmonale all of which are important determinants of outcome 3
4 COPD: a Treatable Disease Overall goals of treatment to prevent further deterioration in lung function, improve symptoms and quality of life, treat complications, and prolong a meaningful life COPD: a Treatable Disease Improved survival found with: Smoking cessation Long- term oxygen therapy in hypoxemic patients Noninvasive mechanical ventilation in some patients with acute- on- chronic respiratory failure LVRS for patients with upper- lobe emphysema and poor exercise capacity The TORCH (Towards a Revolution in COPD Health - - > 6,000 patients) Combination of salmeterol and +luticasone improved lung function and health status, AND Relative risk of dying decreased by 17.5% (over the 3 years of the study). Pulmonary rehabilitation and lung transplantation improve symptoms and the quality of life Spirometry = COPD Essential for diagnosis Signi+icantly underutilized Change in management occurs in >50% of patients with COPD when diagnosed in primary care practice Who Should Get Spirometry? Smoker/ex- smoker >40 yrs old who says yes to: Do you cough regularly? Do you cough up phlegm regularly? Do even simple chores make you short of breath? Do you wheeze when you exert yourself, or at night? Do you get frequent colds that persist longer than those of other people you know? 4
5 Approach to Patients with COPD ClassiKication of Severity ClassiKication of Severity GOLD Guidelines: COPD Management Assess and monitor the disease Reduce risk factors Manage stable COPD Manage exacerbations 5
6 Therapeutic Options for Patients at Risk for COPD and Those With Established Disease Approach To Patients With COPD With Exacerbations (Increased SOB, Cough, or Change in Color or Volume of Sputum. LAMA =LA muscarinic agent LVR = lung volume reduction MV = mechanical ventilation. COPD: Corticosteroids In outpatients, exacerbations necessitate a course of systemic corticosteroids (important to wean patients quickly) Standard doses of inhaled corticosteroid (ICS) aerosols, show minimal if any bene+its in the rate of decline of lung function. TORCH trial = combination of ICS and LABAs was superior to ICS alone (outcomes evaluated, including survival) Pneumonia (described as an adverse event but not precisely diagnosed) was more frequent in the patients receiving ICS ICS should not be prescribed alone but rather in combination with an LABA. Asthma 24 6
7 ASTHMA Asthma A common chronic diseases worldwide An estimated 14.9 million persons in the United States have asthma. The number of people with asthma increased by 102 percent between and A chronic inklammatory disease of the airways; Chronic inklammation leads to hyperresponsiveness to stimuli; Variable and reversible airklow obstruction. Asthma Optimal management of asthma (we are better!) improves quality of life decreases the pool of those at risk for death saves healthcare costs in emergency care Dramatic increases in the prevalence of atopy and asthma in Westernized countries and more recently in less- developed nations. ~ 300 million persons are affected worldwide. Responsible for about 500,000 hospitalizations, 5,000 deaths, and 134 million days of restricted activity a year. Diagnosis of Asthma: 3 Steps 1. Obtain a history of episodic symptoms of air+low obstruction 2. Demonstrate that airklow obstruction is at least partially reversible 3. Exclude alternative diagnoses = particularly COPD and vocal cord obstruction in adults, and aspiration and cystic +ibrosis in children. 7
8 COPD Alternative Diagnoses Vocal cord dysfunction CHF Pulmonary embolism Drug- induced cough Pulmonary inkiltration with eosinophilia Obstructive sleep apnea Mechanical obstruction e.g. benign or malignant tumor Clues to Diagnosis Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne dust, allergens Colds that go to the chest or take more than 10 days to clear Spirometry Establishes the Diagnosis By demonstrating obstruction: FEV 1 < 80% predicted FEV 1 /FVC < 65% predicted or below the lower limit of normal By demonstrating reversibility: FEV 1 increases >12% and at least 200 ml Measurement of Peak Flow When spirometry is normal but patients still have symptoms, follow up with peak Klow monitoring for 1-2 weeks upon arising and in the afternoon before and after inhaled bronchodilator. Difference of 20% between high and low readings on same day suggests asthma. 8
9 2007 Asthma Guidelines 4 Essential Components 1. Assessment & monitoring 2. Patient education 3. Control of factors contributing to asthma severity 4. Pharmacologic treatment National Asthma Education and Prevention Program: Expert panel Report Asthma Guidelines Stepwise approach to managing Rx expanded to 6 steps with repositioned medications Emphasis on patient education/partnership education at all points of care More attention to control of environmental factors or comorbid conditions multifaceted approaches consideration of SQ immunotherapy in persistent asthma bene+it from treating comorbid conditions Assessment & Monitoring Assess asthma severity to initiate Rx (based on current impairment) Assess asthma control to monitor and adjust Rx (based on the risk of future negative events) Stepwise approach Schedule follow- up care assess control medication technique written action plan adherence at each visit Severity vs. Control SEVERITY = intrinsic intensity of the disease process Emphasized for initiating therapy CONTROL = degree of success of Rx Emphasized for monitoring and adjusting therapy Eur Respir J Sep;32:
10 Assessment of Impairment Key elements of impairment: Patient s recall of symptoms Nighttime awakenings Physical activity (esp. interference with normal activity) Need for rescue medications in the preceding 2 to 4 weeks (Short- acting beta 2 agonist use) Frequency and severity of exacerbations Quality of life Current pulmonary function Assessment of Impairment Patient- centric, validated tools to evaluate the current asthma control include: Asthma Therapy Assessment Questionnaire (ATAQ) Asthma Control Questionnaire (ACQ) Asthma Control Test (ACT) Aidan A. Long, MD: Determine Severity When Initiating Therapy Components of Severity INTERMITTENT PERSISTENT Mild Moderate Severe Assessment of Risk Symptoms <2 days/week >2 days/week Daily All day Nighttime awakenings <2 days/month 3-4 x/month >1/week Up to 7x/ week Short- acting beta 2 agonist use <2 days/week >2 days/week Daily Several times a day Interference with normal activity None Minor Some Extreme Lung Function FEV 1 normal FEV 1 > 80% FEV % FEV 1 <60% Aidan A. Long, MD: 10
11 ClassiKication of Asthma Severity: Based on Risk Exacerbations requiring use of oral steroids Intermittent 0-1/yr Persistent Mild Moderate Severe >2/yr Less severe, Longer interval >2/yr >2/yr More severe, shorter interval Initial Treatment: Based on ClassiKication of Severity 6 Steps of Asthma Management Steps in ICS Dosages Vanceril 84 mcg/puff Pulmicort DPI 200 mcg/ inhalation Flovent 110 mcg/puff Aerobid 250 mcg/puff Mometasone DPI 200 mcg/inhalation Low Medium High 2-6 puffs 6-10 puffs > 10 puffs 1-2 inhalations 2-3 >3 2 puffs 2-6 puffs > 6 puffs 2-4 puffs 4-8 puffs > 8 puffs 1 inhalation
12 After Initial ClassiKication of Severity, Determine Level of Control Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate. The Asthma Control Test Worse Better Control Well Controlled Symptoms Nighttime Awakenings Interference with normal activity Not well controlled Very Poorly controlled <2 days/wk >2 days/wk All day <2/mo 1-3x/wk >4/wk None Some Extreme SABA use <2 days/wk >2 days/wk Several/day FEV1 or peak Klow >80% best 60-80% best <60% best ACT questionnaire > <15 Before Step- up of Therapy Interference with daily activities 5 SOB 5 Review adherence Nighttime awakening 5 Inhaler technique SABA inhaler use 5 Environmental control 5 Co- morbid conditions Overall rating 25 12
13 Patient Education/Partnership Self- management education Teach and reinforce self- monitoring signs of worsening (symptoms or peak +low) difference between long- term control and quick relief medications correct inhaler technique avoiding environmental triggers A written asthma action plan Peak Flow Meters Establish patient s personal best value and evaluate the response to changes in therapy. Patients with moderate persistent and severe persistent asthma may benekit from having a peak Klow meter at home and measuring their level upon arising each morning. Controller and quick-relief medicine plan Normal Peak Flow Varies by Gender, Age, Ethnicity PEF values (personal best, 80%, 50%) 13
14 Peak Flow Meters: Caveats Extremely wide variability even in the published predicted peak expiratory +low reference values Effort dependent Poor at detecting mild obstruction Reference values differ for each brand of meter normative brand- speci+ic values currently are not available for most brands Helps in monitoring but not diagnosis Particularly useful for patients without good ability to sense symptoms Environmental factors and comorbid conditions Review exposures advise on ways to reduce exposure In patients with persistent asthma, consider skin allergy testing and immunotherapy Comorbid conditions ABPA, GE re+lux, obesity, OSA, rhinitis & sinusitis, stress, depression, tobacco abuse Medications Long- term control medications Inhaled Corticosteroids (ICS) Long acting beta agonists (LABA) salmeterol/formoterol last > 12 h NOT for monotherapy / to be used with ICS (Step 3-4) Cromolyn sodium/nedocromil Step 2 (Mild persistent) Preventive Rx before exercise or exposure to allergens Immunomodulators omalizumab (anti- IgE) Adjunctive Rx if allergies and Step 5-6 care (Severe persistent) Administered where equipped to treat anaphylaxis Steroid Treatment Tips Inhaled corticosteroids should be used for all persistent asthma ICS must be used with LABA (salmeterol) due to higher than expected death rates wtih LABA alone Five day course of oral corticosteroids does not require taper Smokers may require higher ICS doses 14
15 Smokers are Different Up to 1/3 of asthmatics smoke 44 non- smokers and 39 light smokers with mild asthma assigned to ICS 2x day or LTA 1x day Even with similar FEV1, smokers had worse quality of life, more symptoms ICS reduced sputum eosinophils in both ICS improved FEV1 only in non- smokers LTA improved AM peak +low only in smokers Lazarus et al. Am J Respir Crit Care Med. 2007;175: Summary Stepwise assessment used for initial therapy and adjustment of therapy LABA has no role alone only if used together with ICS ICS with all persistent asthma Patients to be partners in care asthma control test for monitoring written asthma action plan for assessment/rx 15
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