my presentation on gold
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Presented on november, 2012TRANSCRIPT
1
Global Strategy for Diagnosis, Management and Prevention of
Chronic Obstructive Pulmonary Disease
Revised 2011
Dr. Mashfiqul HasanResident, Phase A
Respiratory wing, Dept of MedicineBSMMU
2
lobal Initiative for Chronicbstructiveungisease
GOLD
© Global Initiative for Chronic Obstructive Lung Disease
WORLD COPD DAYNovember 14, 2012WORLD COPD DAYNovember 14, 2012
Raising COPD Awareness WorldwideRaising COPD Awareness Worldwide
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“It’s Not Too Late.”
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Evidence Category
Sources of Evidence
A Randomized controlled trials (RCTs). Rich body of data
B Randomized controlled trials(RCTs). Limited body of data
C Nonrandomized trialsObservational studies.
D Panel consensus judgment
Description of Levels of Evidence
6
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
REVISED 2011
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Definition of COPD
COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
Exacerbations and comorbidities
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Mechanisms Underlying Airflow Limitation in COPD
Small Airways Disease• Airway inflammation• Airway fibrosis, luminal
plugs• Increased airway
resistance
Parenchymal Destruction• Loss of alveolar
attachments• Decrease of elastic recoil
AIRFLOW LIMITATION
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Emphysema & chronic bronchitis Not included in the definition
Emphysema
Pathological term
Only one of several structural abnormalities
Chronic bronchitis
Independent disease entity
May precede or follow development of airflow limitation
Burden of COPD
Leading cause of morbidity and mortality worldwide
6th leading cause of death in 1990
Will be the 3rd leading cause of death by the year 2020
Risk Factors for COPD
• Lung growth and development • Gender• Age • Respiratory infections• Socioeconomic status• Asthma/Bronchial hyperreactivity• Chronic Bronchitis
• Genes• Exposure to particles Tobacco smoke Occupational dusts,
organic and inorganic Indoor air pollution from
heating and cooking with biomass in poorly ventilated dwellings
Outdoor air pollution
Risk Factors for COPD
Genes
Infections
Socio-economic status
Aging Populations
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
REVISED 2011
SYMPTOMS
chronic coughshortness of breath
EXPOSURE TO RISKFACTORS
tobaccooccupation
indoor/outdoor pollution
SPIROMETRY : Required to establish diagnosis
Diagnosis of COPD
sputum
Spirometry: Normal Trace Showing FEV1 and FVC
1 2 3 4 5 6
1
2
3
4
Volu
me,
liters
Time, sec
FVC5
1
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
Spirometry: Obstructive Disease
Volu
me,
liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
Assessment of COPD
1. Assess symptoms
2. Assess degree of airflow limitation using spirometry
3. Assess risk of exacerbations
4. Assess comorbidities
1. Assess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsAssess comorbidities
COPD Assessment Test (CAT)
or
mMRC Breathlessness scale
Assessment of COPD
Modified MRC (mMRC)Questionnaire
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1. Assess symptoms2. Assess degree of airflow limitation
Spirometry for grading severity
Assessment of COPD
Classification of Severity of Airflow Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1> 80% predicted
GOLD 2: Moderate 50% < FEV1< 80% predicted
GOLD 3: Severe 30% < FEV1< 50% predicted
GOLD 4: Very Severe FEV1< 30% predicted
*Based on Post-Bronchodilator FEV1
1. Assess symptoms2. Assess degree of airflow limitation
using spirometry3. Assess risk of exacerbations
Assess comorbidities1. History of exacerbations and
2. Spirometry
Assessment of COPD
Combined Assessment of COPD
Risk
(GO
LD C
lass
ifica
tion
of A
irflow
Lim
itatio
n)
Risk
(Exa
cerb
ation
his
tory
)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC>2CAT >10
Symptoms(mMRC or CAT score))
Combined Assessment of COPDRi
sk(G
OLD
Cla
ssifi
catio
n of
Airfl
ow L
imita
tion)
Risk
(Exa
cerb
ation
his
tory
)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC>2CAT >10
Symptoms(mMRC or CAT score))
Patient is now in one ofFour categories:
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More symptoms, high risk
Assess COPD Comorbidities
• Cardiovascular diseases• Skeletal muscle dysfunction• Osteoporosis• Anxiety and Depression• Metabolic syndrome• Lung cancer
May influence mortality and hospitalizations
Should be looked for routinely and treated appropriately
Additional Investigations
•Chest X-ray
•Lung Volumes and Diffusing Capacity
•Oximetry and Arterial Blood Gases
•Alpha-1 Antitrypsin Deficiency Screening
•Exercise Testing
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
REVISED 2011
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Smoking cessation
• Greatest capacity to influence the natural history of COPD
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Treating tobacco use & dependence
• Warrants repeated treatment• Effective treatment exist & should be
offered• Smoking cessation counseling• Pharmacotherapies : varenicline,
bupropion, nicotine gum, inhaler, nasal spray, patch
• Cost effective
Brief Strategies to Help the Patient Willing to Quit Smoking
1. ASK Systematically identify all tobacco users at every visit
2. ADVISE Strongly urge all tobacco users to quit
3. ASSESS Determine willingness to make a quit attempt
4. ASSIST Aid the patient in quitting
5. ARRANGE Schedule follow-up contact
Pharmacological therapy for stable COPD
Beta2-agonists Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
MethylxanthinesInhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroidsPhosphodiesterase-4 inhibitors
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Bronchodilators in COPD
• Central to the symptom management• Inhaled : preferred• Choice depends on availability &
individual patient response• As needed or regular• Long acting : convenient, more
effective• Combination
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ICS in COPD
• Controversial • Limited to specific indications• Regular treatment with ICS improves
symptoms, lung function and quality of life in patients with FEV1 <60% predicted (Evidence A)
• Does not modify the long term decline of FEV1 nor mortality (Evidence A)
• Adverse effects
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Other pharmacological treatments
• Phosphodiesterase 4 inhibitors: Roflumilast• Vaccines• Antibiotics • Mucolytic & antioxidant agents• Immunoregulators • Antitussive • Vasodilators • Narcotics • Nedocromil & leukotriene modifier
Non-pharmacologic therapies : pulmonary rehabilitation
Improvements in exercise tolerance and symptoms of dyspnea and fatigue
Effective pulmonary rehabilitation program duration: 6 weeks
If exercise training is maintained at home the patient's health status remains above pre-rehabilitation levels
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Other treatments
• O2 therapy• Ventilatory support• Surgical treatments
– Lung volume reduction surgery– Bronchoscopic lung volume reduction– Lung transplantation– Bullectomy
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Major Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
REVISED 2011
Relieve symptoms Improve exercise tolerance Improve health status
Prevent disease progression Prevent and treat exacerbations Reduce mortality
Reducesymptoms
Reducerisk
Goals of Therapy
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Identify & reduce exposure to risk factors
• Tobacco smoke– Key intervention (Evidence A)
• Occupational exposures– Avoid continued exposures (Evidence D)
• Indoor & outdoor air pollution– Biomass fuel– Efficient ventilation, non polluting
cooking device (Evidence B)
Manage Stable COPD: Non-pharmacologic
Patient Essential Recommended Depending on local guidelines
ASmoking cessation (can include pharmacologic
treatment)Physical activity
Flu vaccinationPneumococcal
vaccination
B, C, DSmoking cessation (can include pharmacologic
treatment)Pulmonary rehabilitation
Physical activityFlu vaccinationPneumococcal
vaccination
Manage Stable COPD: Pharmacologic
Patient First choice Second choice Alternative Choices
ASAMA prn
orSABA prn
LAMAor
LABA or
SABA and SAMA
Theophylline
BLAMA
orLABA
LAMA and LABA SABA and/or SAMATheophylline
CICS +
LABA or LAMA
LAMA and LABAPDE4-inh.
SABA and/or SAMATheophylline
DICS +
LABA orLAMA
ICS andLAMA orICS + LABA and LAMA or
ICS+LABA and PDE4-inh.orLAMA and LABA or
LAMA and PDE4-inh.
CarbocysteineSABA and/or SAMA
Theophylline
Exac
erba
tions
per
yea
r
> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC>2CAT >10
GOLD 3
GOLD 2
GOLD 1
SAMA prnor
SABA prn
LABA or
LAMA
ICS + LABAor
LAMA
FIRST CHOICE
A B
DCICS + LABA
orLAMA
> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC> 2CAT > 10
GOLD 3
GOLD 2
GOLD 1
LAMA orLABA or
SABA and SAMA
LAMA and LABA ICS and LAMA orICS + LABA and LAMA or
ICS + LABA and PDE4-inh orLAMA and LABA or
LAMA and PDE4-inh.
LAMA and LABA
SECOND CHOICE
A
DC
B
Exac
erba
tions
per
yea
r
> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC> 2CAT >10
GOLD 3
GOLD 2
GOLD 1Theophylline
PDE4-inh.SABA and/or SAMA
Theophylline
CarbocysteineSABA and/or SAMA
Theophylline
SABA and/or SAMATheophylline
ALTERNATIVE CHOICES
A
DC
B
Exac
erba
tions
per
yea
r
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Monitoring & follow up
• Disease progression & development of complications
• Monitor pharmacotherapy • Exacerbation history• Comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities
REVISED 2011
• an acute event
• characterized by a worsening of the patient’s respiratory symptoms
• that is beyond normal day-to-day variations and
• leads to a change in medication
Acute Exacerbation
Impact on symptoms
and lungfunction
Negativeimpact on
quality of life
Consequences Of COPD Exacerbations
Increasedeconomic
costs
Acceleratedlung function
decline
IncreasedMortality
EXACERBATIONS
• Respiratory tract infection (Bacterial or viral)
• Exposure to pollutants
• Interruption of maintenance therapy
• Overlaping
Precipitating factors
• Pulse oxymetry, ABG
• Chest radiograph
• ECG
• CBC
• Sputum for CS
• Biochemical tests
• Spirometry : Not recommended
Investigation for acute exacerbation
• Marked increase in the intensity of symptoms
• Onset of new physical signs
• Failure to respond to initial medical management
• Severe underlying COPD
• Frequent exacerbations
• Serious comorbidities
• Older age
• Insufficeint home support
Potential indications for hospital assessment and admission
• Pharmacologic treatment
• Respiratory support
Treatment of exacerbation
• Short acting bronchodilators
• Systemic corticosteroid
• Antibiotics
Pharmacologic treatment
• Short acting bronchodilators
• Short acting inhaled β2 agonist with or without short acting anticholinergic (Evidence C)
• No significant difference betweent MDI with or without spacer and nebuliser
• IV methylxanthines only to be used in selected cases (Evidence B)
Pharmacologic treatment
• Shorten recovery time, improve FEV1 & PaO2, reduce the risk of early relapse, treatment failure & length of hospital stay (Evidence A)
• 30-40 mg prednisolone for 10-14 days (Evidence D)
• Nebulised budesonide may be an alternative
Pharmacologic treatment: Coticosteroids
• Indications
• Increased dyspoea, sputum purulence, sputum volume (Evidence B)
• Increased sputum purulence with one other cardinal symptoms (Evidence C)
• Mechanical ventilation (Evidence B)
• Length of antibiotic therapy : 5-10 days (Evidence D)
• The choice of antibiotic
• Route of administration
Pharmacologic treatment: Antibiotics
• Appropriate fluid balance
• Diuretics
• Anticoagulants
• Treatment of comorbidities
• Nutrition
Pharmacologic treatment: others
Respiratory support
• Oxygen therapy– Key component of hospital treatment– Target saturation of 88-92%– ABG should be checked 30-60 minutes later– Venturi masks for accurate & controlled delivery
Ventilatory support
• Non-invasive
• Invasive
Indications for NIV
At least one of following:• Respiratory acidosis • Severe dyspnea with clinical signs suggestive
of respiratory muscle fatigue, increased work of breathing or both (Use of respiratory accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces)
Indications for ICU admission
– Severe dyspnoea that responds inadequately to initial emergency therapy
– Changes in mental status– Persistent or worsening hypoxemia (PaO2 <
5.3 kPa, 40 mm Hg) and/or severe/worsening respiratory acidosis (PH <7.25) despite supplemental O2 & noninvasive ventilation
– Need for invasive mechanical ventilation– Need for vasopressors – hemodynamic
instability
Indications for invasive mechanical ventilation
– Unable to tolerate NIV or NIV failure– Respiratory or cardiac arrest– Respiratory pauses with loss of consciousness or gasping– Diminished consciousness, psychomotor agitation
inadequately controlled by sedation– Massive aspiration– Persistent inability to remove respiratory secretions – Heart rate <50 /min with loss of alertness– Severe hemodynamic instability without response to fluids
and vasoactive drugs– Severe ventricuar arrhythmia– Life threatening hypoxemia in patients unable to tolerate
NIV
Discharge criteria
• Able to use long acting bronchodilators with or without ICS
• Inhaled SABA therapy is required no more frequently than every 4 hrs
• Able to walk across room• Able to eat & sleep• Stable for 12-24 hrs• Fully understand correct use of medication• F/U & home care arrangement• Patient, family & physician are confident
Checklist at time of discharge
• Maintenance pharmacotherapy regimen• Reassessment of inhaler technique• Education regarding role of maintenance
regimen• Completion of steroid therapy & antibiotics• Need for LTOT• Follow up visit in 4-6 weeks• Management plan for comorbidities
Home management of exacerbation
• Nurse administered home care• Effective & practical alternative to
hospitalization in selected patient without acidotic respiratory failure (Evidence A)
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Thank you