COPD Update. Muhammad Talha Khan MD. COPD Exacerbations. COPD Clinical Importance. COPD Pathophysiology. Overview/Objectives

Transcription

1 Overview/Objectives COPD Update Muhammad Talha Khan MD Pulmonologist St Croix Regional Medical Center, St Croix Falls, WI. Overview of COPD and disease impact Classification of COPD Severity Treatment Recommendations for acute exacerbations of COPD Pharmacological Non pharmacological What s new in inhaler therapy When to Refer. COPD Clinical Importance COPD Exacerbations. COPD is a major public health problem in USA 20 million cases estimated 112,000 deaths 750,000 hospitalizations 1.5 million UC/ED visits annual cost $23 billion 5th leading cause of death Increasing global prevalence Widely under diagnosed (37% in NHANES III) Single best predictor of COPD exacerbation is prior history of exacerbation regardless of severity of COPD COPD Pathophysiology SEE FULL PAGE at end of handout 1

2 Gold Guidelines Global Initiative for chronic obstructive lung disease. Disease collaborative project of the NHLBI and the WHO. Goals Increase awareness of COPD Decrease morbidity and mortality 2

3 Bode Index: Predicts 4 Year Survival in Patient with COPD Validated index in a cohort of 625 patients prospectively studied > 20 pack yr smoking hx FEV1/FVC < 70% Each variable independently evaluated Follow up at 6wk, then every 3 6 month for 2 years or until death End point was death from any cause and death from respiratory failure 3

4 COPD Exacerbations and Hospitalizations Any COPD exacerbation requiring hospitalization predicts about a 28% mortality at 1 year. 20% of patients hospitalized for copd exacerbations will be re admitted in 30 days. Attempts to reduce re admissions require much resources. Hospital Readmission Reduction Program penalizes hospitals for 30 day readmissions and this was extended to COPD in October Triggers for COPD Exacerbations 70% of time infectious cause Viral: rhinovirus, coronavirus, influenza, parainfluenza, adenovirus, RSV Bacteria: H. Flu, Moraxella catarrhalis, Streptococcal Pneumoniae, Pseudomonas 30% Environmental pollution, Pulmonary embolism, unknown cause. Prospective cohort study demonstrated a 25% prevalence of PE in patients hospitalized with copd presenting with severe exacerbation of unknown cause. COPD Treatments Smoking Cessation. Inhalers. Oxygen. Vaccinations. Pulmonary Rehab. Macrolides. Nocturnal Ventilatory Support. Lung volume reduction surgery. Lung transplant. 4

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7 Oxygen Therapy for COPD Mortality benefits for oxygen therapy in COPD severe resting hypoxia. PaO2<55 mmhg or PaO2<59 mmhg and cor pulmonale Lancet 1981 Annals Internal Medicine 1980 Currently no good randomized control trail demonstrating mortality benefit in moderate hypoxia. LOTT: Current on going randomized control trial on oxygen therapy in patients with hypoxia with activity and at night. Oxygen: goal oxygen saturations 88 92% 7

8 Pulmonary Rehab Pulmonary rehabilitation Meta analysis of 9 trials evaluating pulmonary rehabilitation post hospitalization for AECOPD. Decreased admissions rates OR 0.22, NNT 4 Decreased mortality OR 0.28, NNT 6 Increased quality of life For patients with moderate to severe COPD, who have a history of one or more moderate or severe COPD exacerbations in the previous year despite optimal maintenance inhaler therapy, we suggest the use of a long term macrolide to prevent acute exacerbations of COPD (Grade 2A) 8

9 Future for COPD Lung volume reduction surgery Stent placement (endobronchial Valves). Lung Transplantation Stem cell research Smoking cessation. PDE4 inhibitors. So what about those inhalers?!!!!!!!!!! 9

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11 For patients with moderate to severe COPD with chronic bronchitis and a history of at least one exacerbation in the previous year, we suggest the use of roflumilast to prevent acute exacerbations of COPD (Grade 2A) 11

12 Copyright American College of Chest Physicians. All rights reserved. From: Executive SummaryExecutive Summary: Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline Chest. 2015;147(4): doi: /chest Decision tree for prevention of AECOPD according to three key clinical questions using the PICO format: nonpharmacologic therapies, inhaled therapies, and oral therapies. Note that the wording used is recommended or not recommended when the evidence was strong (level 1) or suggested or not suggested when the evidence was weak (level 2). ER = emergency room; ICS = inhaled corticosteroid; LABA = long-acting β 2-agonist; LAMA = long-acting muscarinic antagonist; PDE4 = phosphodiesterase 4; PICO = population, intervention, comparator, outcome; SABA = short-acting β 2-agonist; SAMA = short-acting muscarinic antagonist. Acknowledgments Dr Dennis Niewoehner Dr Nickie Myers 12

13 Session 5 COPD: An Update on Newer Treatments