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COPD 2006
Definition of COPD
A disease state characterized by airflow limitation that is not fully reversible..
COPD
Epidemiology of COPD
12.5 million patients with chronic bronchitis
1.6 million patients with emphysema
Stroke
Other CVD
COPD
59%
64%
35%
+163%
7%
1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998
www.goldcopd.com
COPD Patients
Stereotypical pictures of COPD patients
31
Pink Puffer
Blue Bloater
Causes of COPD
Cigarette smoking Alpha-1 antitrypsin deficiency Industrial causes
Diagnosis of COPD
History (dyspnea, cough, wheezing)
Spirometry
Spirometry in COPD
Normal FEV1 > 80% of predicted value Predicted value varies with age, height and sex Normal FEV1% > 70% Consider spirometry in past and present smokers over age 45, and patients with chronic cough, dyspnea or wheezing
80
60
Symptoms
FEV1 (%)
40 20 Disability
Death
0 20 30 40 50 60 70 80 90
Age (years)
Fletcher C, Peto R. Br Med J. 1977;1:1645-1648.
32
Volume
FRC IC
VT
FRC RV
RV
Normal
COPD
hyperinflation
diaphragm flattening
DYSPNEA
Dyspnea
Inactivity
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Pulmonary Rehabilitation
Pulmonary rehabilitation is a multidisciplinary service for patients with pulmonary disease and their families, provided by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individuals maximum level of independence and functioning in the community.
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Formoterol
Long-acting 2-agonist Dosage: 12 g b.i.d. via dry-powder inhaler Onset of action: 1-3 minutes Duration of action: dose-dependent (12hour duration with higher dose)
Theophylline
Bronchodilation Increase in central respiratory drive Increased cardiac output Increased muco-ciliary clearance Increased fatigue threshold of the diaphragm
Mucokinetic Agents
Guiafenesin SSKI Mucomyst P & PD
Advair now approved by the FDA for use in COPD with chronic bronchitis
Package insert recommendation for initial and follow-up dexa scan Package insert recommendation for periodic eye examinations
Post-ganglionic nerve Pre-synaptic M2 receptors (inhibitory) Neuromuscular junction ACh Post-synaptic M3 receptors (facilitate)
M1
Ipratropium Tiotropium 0.11 14.60
M2
0.035 3.600
M3
0.26 34.70
1.4
FEV1 (L)
1.3
1.2
1.1 -60
-5
30
60
120
180
240
300
360
Time (minutes)
p<0.05 on all test days
New
Characteristics
0: At Risk
Chronic symptoms Exposures to risk factors Normal spirometry
I. Mild
FEV1/FVC<70% FEV1>80% With or without symptoms
II. Moderate
FEV1/FVC<70% 50%>FEV1<80% With or without symptoms
III. Severe
FEV1/FVC<70% 30%>FEV1<50% With or without symptoms
Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments
NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated 2003).
LA Bronchodilators in COPD
Drugs lung symptoms exercise decrease function tolerance exacerbations ++ ++ +++ + + ++ ? +/+ ++
GOLD Stage 0
prn short-acting bronchodilator tiotropium + SABA tiotropium + salmeterol or formoterol salmeterol or formoterol + SABA salmeterol or formoterol + tiotropium
II
III
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Noninvasive Ventilation
Stable outpatient management Acute exacerbation treated in hospital increases pH reduces PaCO2 reduces breathlessness 1st 4 hours of Rx decreases length of hospital stay reduces intubation rate
Management of COPD
Smoking cessation
Pulmonary rehabilitation
Pharmacologic
Supplemental oxygen
Non-invasive ventilation
Surgical remedies
Lung Transplantation
Over 1500 lung transplants/year in the United States 4000 candidates awaiting transplant in the US late 2003 Provides significant improvement in both health-related and overall quality of life
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