Defining COPD. Georgina Grantham Community Respiratory Team Leader/ Respiratory Nurse Specialist

Transcription

1 Defining COPD Georgina Grantham Community Respiratory Team Leader/ Respiratory Nurse Specialist

2 Defining 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

3 Defining COPD Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation previously diagnosed as having chronic bronchitis and emphysema NICE National Institute for Health and Care Excellence Reference: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). June Available from [Accessed November 2015]

4 Aetiology COPD results from a gene-environment interaction Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

5 Pathogenesis COPD is characterised by an intense inflammatory response by the airways and alveoli to inhaled substances such as tobacco smoke Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930 6

6 Pathogenesis Tobacco smoking produces lung inflammation in everyone yet only 20 30% of heavy smokers develop COPD suggesting that the inflammatory response is exaggerated and amplified in those with increased genetic predisposition or environmental risk factors Reference: Hogg J. Airway Pathology Chapter 6. Asthma and COPD Basic Mechanisms and Clinical Management. Ed Barnes P. Academic Press

7 Pathogenesis The inflammatory response is characterised by increased numbers of Leukotrienes Interleukins TNF Oxidative stress in addition to increased concentrations of Neutrophils Macrophages T lymphocytes TNF tumour necrosis factor Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930 6

8 Pathological Changes This chronic cycle of inflammatory injury and repair leads to structural changes within the airway and alveoli Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

9 Inflammation in Asthma v COPD Although Asthma and COPD are both associated with chronic inflammation of the respiratory tract, there are differences in the inflammatory cells involved in the two diseases, which in turn account for differences in symptoms and response to treatment Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from:

10 Normal Asthma COPD Eosinophil Neutrophil Inflammation Inflammation

11 Phenotypes The term phenotype in the field of COPD is defined as: A single or combination of disease attributes that describe differences between individuals with COPD The relative contributions of chronic bronchitis and emphysema vary from patient to patient (NICE 2010) Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98; NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). June 2010

12 Phenotypes What is the main pathology on the inside? Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98

13 Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98 Mainly Chronic Bronchitis?

14 Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98 Mainly Emphysema?

15 Phenotypes Identifying the peculiarities of the different phenotypes of COPD will allow us to implement a more personalized treatment regime, in which the characteristics of the patients, together with their severity will be key to choosing the best treatment option Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98

16 Chronic Bronchitis Matching Pathology to Symptoms Main symptom typically excessive phlegm production Scooped out appearance on spirometry Typically reports phlegm production worse in the mornings but reduces as the day goes on Typically reports a history of frequent chest infections Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98

17 Emphysema Matching Pathology to Symptoms Main symptom typically breathlessness Steeple appearance on spirometry Typically does not report excessive phlegm production Typically does not report a history of frequent chest infections Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86 98

18 Multiple symptoms of COPD have a real impact on patient wellbeing SYMPTOMS 1 4 IMPACT ON WELL-BEING 1 5 Shortness of breath Cough Wheezing Chest tightness Sputum production Worse in morning Fatigue Activity/exercise limitation Anxiety and depression Apprehension about future events Lack of confidence about steps to take action Risk of increasing social isolation Loss of independence Reference: 1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: [date last accessed July 2017]2. O'Donnell DE. Eur Respir Rev. 2006;15:37 41; 3. Rennard S, et al. Eur Respir J. 2002;20: ; 4. Kessler R, et al. Eur Respir J. 2011;37:264 72; 5. Cleland JA, et al. Fam Pract. 2007;24:217 23

19 Assessment Tools

20 The MRC Breathlessness Score

21 COPD Assessment Test (CAT) Th

22 The FEV 1 Severity According to FEV 1 as a % of predicted > 80% Mild 50 80% Moderate 30 50% Severe < 30% Very severe

23 Number of Acute Exacerbations in Last 12/12

24 Management Goals 1. Reduce symptoms 2. Reduce frequency and severity of acute exacerbations 3. Improve health status and exercise tolerance References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary secondary care (partial update). June 2010; Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner.

25 Smoking Cessation Smoking cessation is the key intervention for all COPD patients who continue to smoke References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update) June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

26 Pulmonary Rehabilitation All COPD patients appear to benefit from rehabilitation and maintenance of physical activity, improving their exercise tolerance and experiencing decreased dyspnoea and fatigue References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

27 Vaccination Pneumococcal vaccination and an annual influenza vaccine should be offered to all patients with COPD References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner

28 Aim of pharmacologic therapy in COPD Reduce symptoms Reduce frequency and severity of exacerbations Improve health status and exercise tolerance Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Last accessed April

29 29 Pharmacology There are 2 main groups of medication that are used in the management of COPD Bronchodilators Corticosteroids References: Asthma and COPD: Basic Mechanisms and Clinical Management. 2nd Ed Peter Barnes Academic Press 2008; Lippincott s Illustrated Reviews: Pharmacology 5th edition, Harvey et al 2014; Basic and Clinical Pharmacology 12th edition Katzung et al 2012 LANGE basic; Sparrow J 2010 Pharmacological Management of COPD in The Management of COPD in Primary and Secondary Care Ed Lynes M&K Update

30 Bronchodilators Medications that increase the FEV 1 or change other spirometric variables, usually by altering airway smooth muscle tone, are termed bronchodilators, since the improvements in expiratory flow reflect widening of the airways Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Last accessed April

31 Bronchodilators Bronchodilators improve emptying of the lungs, tend to reduce dynamic hyperinflation at rest and during exercise and improve exercise performance Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Last accessed April

32 Bronchodilators Beta 2 agonists Antimuscarinics Short-acting (SABA) Long-acting (LABA) Short-acting (SAMA) Long-acting (LAMA) Salbutamol Terbutaline Formoterol Indacaterol maleate Olodaterol Salmeterol Ipratropium bromide Aclidinium bromide Glycopyrronium bromide Tiotropium bromide Umeclidinium bromide Reference: MIMS. Available at / [Accessed April 2017]

33 Inhaled corticosteroids The effects of inhaled corticosteroids on pulmonary and systemic inflammation in patients with COPD are controversial, and their role in the management of stable COPD is limited to specific indications Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Last accessed April

34 Inhaled corticosteroids Long-term treatment with inhaled corticosteroids is recommended for patients with severe and very severe COPD and frequent exacerbations that are not adequately controlled by long-acting bronchodilators Frequent exacerbations not adequately controlled by Long Acting Bronchodilators ( 2 per year) or 1 hospitalisation for exacerbation Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Last accessed April

35 Inhaled corticosteroids indications Increasing evidence suggests that patients with certain COPD phenotypes appear to benefit from ICS treatment including patients with: Asthma COPD Overlap Syndrome (ACOS) Frequent exacerbations Eosinophilia Reference: Ernst P. et al. Eur Resp J. 2015;45:525 37

36 Questions?