William P. Saliski Jr. DO Montgomery Pulmonary Consultants Management of Stable COPD Pharmacotherapy Oxygen Smoking Cessation Vaccinations Rehabilitation Surgery Future Discussions Assessing Severity Staging System (GOLD) Defines disease severity by FEV1 and ratio FEV1/FVC Used as a guide to manage patient therapy General Approach Pharmacotherapy prevent/decrease symptoms reduce exacerbations improve health status improve exercise capacity Short Acting Bronchodilators Beta agonists albuterol, levabuteral, pirbuterol (SABA) Anticholinergics ipratropium bromide
Short Acting Bronchodilators Names Albuterol Sulfate Levalbuterol Porbuterol Provental HFA Ventolin HFA Proair HFA Xopenex Maxair Ipatroprium Bromide Atrovent Beta Agonist Therapy Dosing : 2 Puffs as needed Side Effects : tremor, reflex tachycardia hypokalemia ( extreme use ) Combu Med Combivent Anticholinergic Therapy Dosing 2 puffs 4x/daily 18 meq/puff 200 puffs/canister Side Effects dry mouth, constipation? Cardiovascular side effects Combination Therapy (Combivent) Dosing 2 puffs 4x/daily Combination therapy increased FEV1 more than either agent alone Long Acting Bronchodilators (LABA) Salmeterol Serevent Formoterol Foradil Arfomoterol Brovena (nebulizer use) Tiotropium Spiriva Therapy in Gold II IV Beta Agonists (LABA) Dosing both are dry powder used 2x/daily Side Effects same as short acting agents increase risk of death (Smart trial)
Dosing dry powder 1x/daily Anticholinergics (Long Acting) Comparison Shopping Foradil> Serevent Spiriva>Foradil>Serevent Side Effects dry mouth, headache constipation, glaucoma (worsening) Foradil has rapid onset, lasts longer Spiriva affords better bronchodilation and better side effect profile Bronchodilators Plus Inhaled Glucocorticosteroids (ICS) COPD characterized by airway and systemic inflammation Numerous ICS on the market No real difference in products ICS should not be used as sole therapy Bronchodilator Plus ICS Advair Discus/Advair HFA (Fluticasone/Salmeterol)250 meq/50 mcg 2x/daily Symbicort 160/4.5 (Budesonide/Formeterol)2 puffs 2x/daily Side Effects (ICS) oral candidiasis, pneumonia, adrenal suppression
Triple Inhaler Therapy Stage III IV Gold LABA/ICS and tiotroprium bromide Decrease mortality, exacerbations, and hospitalizations Theophylline Mechanism of action controversial Offers moderate bronchodilation Long acting extended release preps Narrow LD 50 Metabolized in liver Keep serum level 8 to 12 mcg/ml Rarely Used Medications Systemic Glucocorticoids Mucoactive Agents Chronic Antibiotic Therapy Supplemental Therapy Oxygen Secretion Clearance Smoking Cessation Vaccinations Rehabilitation Nutrition Oxygen Therapy Long term oxygen therapy (LTOT) increases survival and improves quality of life Minimal adverse effects (humidify!) Close government regulation 2 billion dollars per year (Medicare)
LTOT Indications PaO2 55 mm Hg or SaO2 88 % Cor Pulmonale PaO2 59 mm Hg/SaO2 89 % (Hct > 55 %, EKG p pulmonale, CHF Desaturation with above numbers w/ exercise or at sleep Prescribing Oxygen Obtain baseline ABG (does O2 Sat correlate?) (is patient hypercarbic?) Keep PaO2 60 to 65 mm Hg Keep SaO2 92% Usually order 2L NC (continuous, exercise, sleep?) Equipment Selection Keep your patient mobile Select lightest, most portable Think liquid O2 Oxygen conserving device Secretion Clearance Postural drainage Flutter valve therapy Hydration? Oxygen concentrator (bedroom) Vaccinations Pneumococcal/polysaccharide vaccine COPD 65 yrs old COPD 65 yrs old w/ FEV1< 40% predicted Active tobacco use Give initial vaccine and 5 year booster Does not reduce mortality Vaccinations Influenza vaccination given to all patients with COPD Decrease risk of influenza significantly DOES NOT CAUSE THE FLU! Timing?
Clinician advice Smoking Cessation Nicotine replacement therapy Buproprion (Zyban) 150 mg Varenicline (Chantix) 1 mg Combination therapy best outcome Rehabilitation Low cost effective program Optimizes physical and social functioning Reduces hospitalization, LOS,? Mortality Medically supervised Rehabilitation Baptist Medical Center South Anita Jones 334.286.2859 Covered by Major Medical Insurances Nutrition 30% of patients with severe COPD are protein calorie malnourished Increase mortality, decrease muscle function, decrease immunity Try high caloric dietary supplements Magestrol acetate (Megace)