king asthma copd 04-09-14 handout.ppt

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TalmadgeE.King,Jr.,M.D.KrevinsDistinguishedProfessorofMedicine

Chair,DepartmentofMedicineUniversityofCaliforniaSanFrancisco(UCSF)

SanFrancisco,CA

CurrentStrategiesforAsthmaandCOPD

Asthma3

ASTHMA

• Achronicinflammatorydiseaseoftheairways;

• Chronicinflammationleadstohyperresponsivenesstostimuli;

• Variableandreversibleairflowobstruction.

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Asthma• Acommonchronicdiseasesworldwide

– ~300millionpersonsareaffectedworldwide.

– ~14.9millionpersonsintheUS

– DramaticincreasesintheprevalenceofatopyandasthmainWesternizedcountriesandmorerecentlyinless‐developednations.

– Responsibleforabout• 500,000hospitalizations,

• 5,000deaths,and

• 134milliondaysofrestrictedactivityayear

Asthma• Optimalmanagementofasthma(wearebetter!)

– improvesqualityoflife

– decreasesthepoolofthoseatriskfordeath

– saveshealthcarecostsinemergencycare

DiagnosisofAsthma:3Steps1. Obtainahistoryofepisodic symptoms

ofairflowobstruction

2. Demonstratethatairflowobstructionisatleastpartiallyreversible

3. Excludealternativediagnoses =particularlyCOPDandvocalcordobstructioninadults,andaspirationandcysticfibrosisinchildren.

AlternativeDiagnoses• COPD

• Vocalcorddysfunction

• CHF

• Pulmonaryembolism

• Drug‐inducedcough

• Pulmonaryinfiltrationwitheosinophilia

• Obstructivesleepapnea

• Mechanicalobstruction– e.g.benignormalignanttumor

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CluestoDiagnosis•Recurrentepisodesofwheezing

• Troublesomecoughatnight

• Coughorwheezeafterexercise

• Cough,wheezeorchesttightnessafterexposuretoairbornedust,allergens

• Coldsthat“gotothechest” ortakemorethan10daystoclear

SpirometryEstablishestheDiagnosis

• Bydemonstratingobstruction:

– FEV1 <80%predicted

– FEV1/FVC<65%predictedorbelowthelowerlimitofnormal

• Bydemonstratingreversibility:

– FEV1 increases>12%and atleast200mL

MeasurementofPeakFlow• Whenspirometryisnormalbutpatientsstillhavesymptoms,followupwithpeakflowmonitoringfor1‐2weeksuponarisingandintheafternoonbeforeandafterinhaledbronchodilator.

• Differenceof20%betweenhighandlowreadingsonsamedaysuggestsasthma.

AsthmaGuidelines4EssentialComponents

1. Assessment&monitoring

2. Patienteducation

3. Controloffactorscontributingtoasthmaseverity

4. Pharmacologictreatment

National Asthma Education and Prevention Program: Expert panel Report 3

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• StepwiseapproachtomanagingRxexpandedto6stepswithrepositionedmedications

• Emphasisonpatienteducation/partnership

– educationatallpointsofcare

• Moreattentiontocontrolofenvironmentalfactorsorcomorbidconditions

– multifacetedapproaches

– considerationofSQimmunotherapyinpersistentasthma

– benefitfromtreatingcomorbidconditions

AsthmaGuidelines

Assessment&

Monitoring

Asthma Care: 4 Essential

Components

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Assessment&Monitoring• AssessasthmaseveritytoinitiateRx(basedoncurrent impairment)

• AssessasthmacontroltomonitorandadjustRx(basedontherisk offuturenegativeevents)

• Stepwiseapproach– Schedulefollow‐upcare

– assesscontrol

– medicationtechnique

– writtenactionplan

– adherenceateachvisit

Severityvs.Control•SEVERITY =intrinsicintensityofthediseaseprocess

–Emphasizedforinitiating therapy

•CONTROL =degreeofsuccessofRx

–Emphasizedformonitoringandadjustingtherapy

Eur Respir J. 2008 Sep;32:545-54

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AssessmentofImpairment• Keyelementsofimpairment:

– Patient’srecallofsymptoms

– Nighttimeawakenings

– Physicalactivity(esp.interferencewithnormalactivity)

– Needforrescuemedicationsinthepreceding2to4weeks(Short‐actingbeta2 agonistuse)

– Frequencyandseverityofexacerbations

– Qualityoflife

– Currentpulmonaryfunction

AssessmentofImpairment

• Patient‐centric,validatedtoolstoevaluatethecurrentasthmacontrolinclude:

– AsthmaTherapyAssessmentQuestionnaire(ATAQ)

– AsthmaControlQuestionnaire(ACQ)

– AsthmaControlTest(ACT)Aidan A. Long, MD: www.peerviewpress.com/d/p131

DetermineSeverityWhenInitiatingTherapy

ComponentsofSeverity

INTERMITTENTPERSISTENT

Mild Moderate Severe

Symptoms <2days/week >2days/week Daily Allday

Nighttimeawakenings <2days/month 3‐4x/month >1/week Upto7x/week

Short‐actingbeta2 agonistuse

<2days/week >2days/week Daily Severaltimesaday

Interferencewithnormalactivity None Minor Some Extreme

LungFunction FEV1 normal FEV1 >80% FEV1 60‐80% FEV1<60%

<2

DetermineSeverityWhenInitiatingTherapy

ComponentsofSeverity

INTERMITTENTPERSISTENT


Symptoms <2days/week >2days/week Daily Allday

Nighttimeawakenings <2days/month 3‐4x/month >1/week Upto7x/week

Short‐actingbeta2 agonistuse

<2days/week >2days/week Daily Severaltimesaday

Interferencewithnormalactivity None Minor Some Extreme

LungFunction FEV1 normal FEV1 >80% FEV1 60‐80% FEV1<60%

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AssessmentofRisk

Aidan A. Long, MD: www.peerviewpress.com/d/p131

ClassificationofAsthmaSeverity:BasedonRisk

Exacerbationsrequiringuseoforalsteroids

IntermittentPersistent


0‐1/yr

>2/yrLesssevere,

Longerinterval

>2/yr

>2/yrMoresevere,shorterinterval

InitialTreatment:Basedon

ClassificationofSeverity

6StepsofAsthmaManagement

Step

1

7



Persistent Asthma

Step

2



Persistent Asthma

Step

3



Persistent Asthma

Step

4



Persistent Asthma

Step

5

8


Persistent Asthma

Step

6


StepsinICSDosagesLow Medium High

Vanceril84mcg/puff

2‐6puffs 6‐10puffs >10puffs

Pulmicort DPI200mcg/inhalation

1‐2inhalations 2‐3 >3

Flovent110mcg/puff

2puffs 2‐6puffs >6puffs

Aerobid250mcg/puff

2‐4puffs 4‐8puffs >8puffs

MometasoneDPI200mcg/inhalation

1inhalation 2 3

Oncetreatmentisestablished,theemphasisisonassessingasthmacontroltodetermineifthegoalsfortherapyhave

beenmetandifadjustmentsintherapy(stepuporstepdown)

wouldbeappropriate.

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AfterInitialClassificationofSeverity,DetermineLevelofControl

ControlVeryPoorlycontrolled

Notwellcontrolled

WellControlled

Symptoms <2days/wk >2days/wk Allday

Nighttime

Awakenings<2/mo 1‐3x/wk >4/wk

Interferencewithnormalactivity None Some Extreme

SABAuse <2days/wk >2days/wk Several/day

FEV1 orpeakflow >80%best 60‐80%best <60%best

ACTquestionnaire >20 16‐19 <15

TheAsthmaControlTest

SOB

Interference with daily activities

Nighttime awakening

SABA inhaler use

Overall rating

5

5

5

5

5

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Worse Better

Adjust TreatmentbasedonControl

ControlVeryPoorlycontrolled

Notwellcontrolled

WellControlled

Step

Maintain,

Considerstepdown ifwellforatleast3months

Stepupby1step Stepupby1‐2steps

Oralsteroids?

No No Considershortcourse

FollowupRegular,

Q1‐6mos

Reevaluate

In2‐ 6wks

Reevaluate

In2weeks

BeforeStep‐upofTherapy

•Reviewadherence

• Inhalertechnique

•Environmentalcontrol

•Co‐morbidconditions

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PatientEducation


Components

2

PatientEducation/Partnership

• Self‐managementeducation

– Teachandreinforceself‐monitoring

•signsofworsening(symptomsorpeakflow)

•differencebetweenlong‐termcontrolandquickreliefmedications

•correctinhalertechnique

•avoidingenvironmentaltriggers

– Awrittenasthmaactionplan

PeakFlowMeters• Establishpatient’spersonalbestvalueandevaluatetheresponsetochangesintherapy.

• Patientswithmoderatepersistentandseverepersistentasthmamaybenefitfromhavingapeakflowmeterathomeandmeasuringtheirleveluponarisingeachmorning.

PEF values(personal best, 80%,

50%)

Controller and

quick-relief medicine plan

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NormalPeakFlowVariesbyGender,Age,Ethnicity

PeakFlowMeters:Caveats• Extremelywidevariabilityeveninthepublishedpredictedpeakexpiratoryflowreferencevalues

• Effortdependent

• Pooratdetectingmildobstruction

• Referencevaluesdifferforeachbrandofmeter– normativebrand‐specificvaluescurrentlyarenotavailableformostbrands

• Helpsinmonitoringbutnotdiagnosis– Particularlyusefulforpatientswithoutgoodabilitytosensesymptoms

InhalerTechnique

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InhalerTechnique

44

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EnvironmentalFactors

&ComorbidConditions


Components

3

Environmentalfactorsandcomorbidconditions

•Reviewexposures

–adviseonwaystoreduceexposure

–Inpatientswithpersistentasthma,considerskinallergytestingandimmunotherapy

• Comorbidconditions

–ABPA,GEreflux,obesity,OSA,rhinitis&sinusitis, stress, depression, tobacco

Medications


Components

4

Medications• Long‐termcontrolmedications– InhaledCorticosteroids(ICS)

– Longactingbetaagonists(LABA)–salmeterol/formoterol– last>12h•NOTformonotherapy/tobeusedwithICS(Step3‐4)

– Cromolynsodium/nedocromil•Step2(Mildpersistent)

•PreventiveRxbeforeexerciseorexposuretoallergens

– Immunomodulators– omalizumab(anti‐IgE)•AdjunctiveRxifallergiesandStep5‐6care(Severepersistent)

•Administeredwhereequippedtotreatanaphylaxis

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SteroidTreatmentTips• Inhaledcorticosteroidsshouldbeusedforallpersistent asthma

• ICSmustbeusedwithLABA(salmeterol)

– duetohigherthanexpecteddeathrateswithLABAalone

• Fivedaycourseoforalcorticosteroidsdoesnotrequiretaper

• SmokersmayrequirehigherICSdoses

Summary• Stepwiseassessmentusedforinitialtherapyandadjustmentoftherapy

• LABAhasnorolealone

– onlyifusedtogetherwithICS

• ICSwithallpersistentasthma

• Patientstobepartnersincare

– asthmacontroltestformonitoring

– writtenasthmaactionplanforassessment/Rx

SmokersareDifferent

• Upto1/3ofasthmaticssmoke

• 44non‐smokersand39lightsmokerswithmildasthmaassignedtoICS2xdayorLTA1xday

– EvenwithsimilarFEV1,smokershadworsequalityoflife,moresymptoms

– ICSreducedsputumeosinophilsinboth

– ICSimprovedFEV1onlyinnon‐smokers

– LTAimprovedAMpeakflowonlyinsmokersLazarus et al. Am J Respir Crit Care Med. 2007;175:783-90

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COPD

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COPD•Apreventableandtreatablediseasestatecharacterizedbyairflowlimitationthatisnotfullyreversible.

• Airflowlimitation

– usuallyprogressiveand

– associatedwithanabnormalinflammatoryresponseofthelungstonoxiousparticlesorgases,primarilycausedbycigarettesmoking. Celli B. R. Chest 2008;133:1451-1462

COPD•Coughorwheeze•Sputumproduction•Dyspnea•Chesttightness•Worseningqualityoflife(oftenwithoutclearrecognition) Celli B. R. Chest 2008;133:1451-1462

COPD•Highlyprevalent(7to19%;M>W;white>blacks;increaseswithage)•Underdiagnosed(~12M),•Undertreated,•Underperceived,and•Verycostlycare(~$49.9Bin2010)

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AnAcceleratedDeclineInLungFunctionIsTheSingleMostImportantFeatureOfCOPD

3rd-ranked cause of death in

the US (~100,000 each

year).

COPD:Cigarettesmoking

• Mostimportantriskfactor.

• Smokingleadsto– aninflammatoryresponse,

– oxidativestress,

– lungdestruction,and

– interferencewithlungrepair

Smokers

Smoker, Severe COPD

Immunostaining with monoclonal antibody anti-CD45

Leukocyte Infiltration in COPD

Smoker, Mild COPD

COPD:Smokingcessation

•SlowstheaccelerateddeclineinCOPD‐relatedFEV1

•Reducesall‐causemortalityratesby27%(byreductioninCVmortality)

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COPD•ThemortalityratefromCOPDforwomenhasdoubledoverthepast20yrs.

• Somestudiessuggestthatwomenaremoresusceptibletotheeffectsoftobaccosmokethanmen

COPD:ApersistentSystemicInflammatorystate

Consultant360 12/2011

COPD:ApersistentSystemicInflammatorystate

• Associatedwithimportantsystemicmanifestations,especiallyinpatientswithmoreadvanceddisease.Imbalancedoxidativestressorabnormalimmunologicresponse– decreasedfat‐freemass

– impairedsystemicmusclefunction

– anemia

– osteoporosis

– depression

– pulmonaryhypertension,andcorpulmonale

– all of which are important determinants of outcomeCelli B. R. Chest 2008;133:1451-1462

Spirometry=COPD•Essentialfordiagnosis

• Significantlyunderutilized

• Changeinmanagementoccursin>50%ofpatientswithCOPDwhendiagnosedinprimarycarepractice

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WhoShouldGetSpirometry?

Smoker/ex‐smoker>40yrsoldwhosays‘yes’to:

•Doyoucoughregularly?

•Doyoucoughupphlegmregularly?

•Doevensimplechoresmakeyoushortofbreath?

•Doyouwheezewhenyouexertyourself,oratnight?

•Doyougetfrequentcoldsthatpersistlongerthanthose of other people you know?

ApproachtoPatientswithCOPD

Celli B. R. Chest 2008;133:1451-1462

BODEIndex:ClassificationofSeverityClassificationofSeverity

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GOLDGuidelines:COPDManagement

•Assessandmonitorthedisease

•Reduceriskfactors

•ManagestableCOPD

•Manageexacerbations

COPD:aTreatableDisease

• Overallgoalsoftreatment

– topreventfurtherdeteriorationinlungfunction,

– improvesymptomsand

– qualityoflife,

– treatcomplications,and

– prolongameaningfullife

Celli B. R. Chest 2008;133:1451-1462

COPD:aTreatableDisease• Improvedsurvivalfoundwith:

– Smokingcessation– Long‐termoxygentherapyinhypoxemicpatients– Noninvasivemechanicalventilationinsomepatientswithacute‐on‐chronicrespiratoryfailure

– LVRSforpatientswithupper‐lobeemphysemaandpoorexercisecapacity

• TheTORCH(TowardsaRevolutioninCOPDHealth‐‐ >6,000patients)– Combinationofsalmeterolandfluticasoneimprovedlungfunctionandhealthstatus,AND

– Relativeriskofdyingdecreasedby17.5%(overthe3yearsofthestudy).

• Pulmonaryrehabilitationandlungtransplantationimprovesymptomsandthequalityoflife

Celli B. R. Chest 2008;133:1451-1462

TherapeuticOptionsforPatientsatRiskforCOPDandThoseWithEstablishedDisease

Celli B. R. Chest 2008;133:1451-1462

LAMA =LA muscarinic agent

LVR = lung volume reduction

MV = mechanical ventilation.

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COPD:ImportanceofHyperinflation

• Dyspneaperceivedduringexercise,includingwalking,morecloselyrelatestothedevelopmentofdynamichyperinflation thantochangesinFEV1.

• Improvementinexercisebroughtaboutbyseveraltherapies(bronchodilators,oxygen,lungvolumereductionsurgery,andevenrehabilitation)ismorecloselyrelatedtodelayingdynamichyperinflationsthanbyimprovingthedegreeofairflowobstruction. Celli B. R. Chest 2008;133:1451-1462

ApproachToPatientsWithCOPDWithExacerbations(IncreasedSOB,Cough,orChangeinColororVolume

ofSputum.

Celli B. R. Chest 2008;133:1451-1462

COPD:Corticosteroids• Inoutpatients,exacerbationsnecessitateacourseofsystemiccorticosteroids(importanttoweanpatientsquickly)

• Standarddosesofinhaledcorticosteroid(ICS)aerosols,showminimalifanybenefitsintherateofdeclineoflungfunction.

• TORCHtrial=combinationofICSandLABAswassuperiortoICSalone(outcomesevaluated,includingsurvival)

• Pneumonia(describedasanadverseeventbutnotpreciselydiagnosed)wasmorefrequentinthepatientsreceivingICS

• ICSshouldnotbeprescribedalonebutratherinbi ti ith LABA

king asthma copd 04-09-14 handout.ppt

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