Chronic Obstructive Pulmonary Disease (COPD) Medical Presentation

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COPD Presented by: Precilla CHIDIAC, PGY3 Pulmonology Under the supervision of: Pierre EDDE, MD CHU-NDS 2018 © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Chronic Obstructive Pulmonary Disease (COPD) © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD is currently the 4th leading cause of death in the world.1  3rd leading cause of death by 2020.2 > 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. COPD is associated with significant economic burden. Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population. 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128. 2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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COPD Definition © 2017 Global Initiative for Chronic Obstructive Lung Disease Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
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COPD Etiology, Pathobiology & Pathology © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease The most common respiratory symptoms: Dyspnea, Cough and/or sputum production. The main risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute / predisposing host factors: genetic abnormalities, abnormal lung development and accelerated aging. Men > Women Higher ≥ 40 year group compared to those < 40
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Factors that influence disease progression © 2017 Global Initiative for Chronic Obstructive Lung Disease Genetic factors Age and gender Lung growth and development Exposure to particles Socioeconomic status Asthma & airway hyper-reactivity Chronic bronchitis Infections
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease Post-bronchodilator FEV1/FVC < 0.70  persistent airflow limitation.
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Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease Comorbidities: cardiovascular disease, lung cancer. skeletal muscle dysfunction, metabolic syndrome, osteoporosis depression, Anxiety  influence mortality and hospitalizations independently.
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Medical History © 2017 Global Initiative for Chronic Obstructive Lung Disease Patient’s exposure to risk factors Past medical history Family history of COPD or other chronic respiratory disease. Pattern of symptom development History of exacerbations or previous hospitalizations for respiratory disorder Presence of comorbidities Impact of disease on patient’s life Social and family support available to the patient. Possibilities for reducing risk factors, especially smoking cessation.
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Spirometry © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Classification of severity of airflow limitation © 2017 Global Initiative for Chronic Obstructive Lung Disease
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ABCD Assessment Tool © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Alpha-1 antitrypsin deficiency (AATD) © 2017 Global Initiative for Chronic Obstructive Lung Disease AATD screening WHO recommends that all patients with a diagnosis of COPD should be screened once especially in areas with high AATD prevalence. AATD patients are typically < 45 years with panlobular basal emphysema (older AATD: typical distribution of emphysema-centrilobular apical). A low concentration (< 20% normal) is highly suggestive of homozygous deficiency.
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease Smoking cessation : greatest capacity to influence the natural history of COPD. Pharmacologic therapy can reduce COPD symptoms  reduce the frequency and severity of exacerbations improve health status and exercise tolerance. Each pharmacologic treatment regimen should be individualized Inhaler technique needs to be assessed regularly.
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© 2017 Global Initiative for Chronic Obstructive Lung Disease Influenza / Pneumococcal vaccination (PCV13 and PPSV23, are recommended for all patients ≥ 65 Y): decreases the incidence of lower respiratory tract infections. Pulmonary rehabilitation  improves symptoms QOL, and physical and emotional participation in everyday activities. LTOT: severe resting chronic hypoxemia  improves survival !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! long-term non-invasive ventilation: severe chronic hypercapnia + history of hospitalization for acute respiratory failure  decrease mortality !!!!!!!!!!!!! prevent re-hospitalization. surgical or bronchoscopic interventional treatments may be beneficial. In select patients with advanced emphysema refractory to optimized medical care, Palliative approaches are effective in controlling symptoms in advanced COPD.
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When indicated, Oxygen supplementation: a. Increases survival in patients with COPD b. Increases the quality of life in patients with COPD c. Decreases the frequency of exacerbation d. Decreases the rate of hospitalization e. 1 and 2 only
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Oxygen Therapy & Ventilatory Support in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease During exacerbations of COPD: Noninvasive ventilation (NIV) in the form of noninvasive positive pressure ventilation (NPPV) = standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
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Interventional Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Lung volume reduction surgery (LVRS): = surgical procedure in which parts of the lungs are resected  reduce hyperinflation  respiratory muscles more effective pressure generators by improving their mechanical efficiency. Due to the morbidity and mortality associated with LVRS, less invasive bronchoscopic approaches to lung reduction have been examined (endobronchial one-way valves, lung coils)
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Anti-inflammatory Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Anti-inflammatory Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment X
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment Pharmacologic therapies can reduce symptoms, and the risk and severity of exacerbations, as well as improve health status and exercise tolerance. Most of the drugs are inhaled.
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Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Inhibitors of PDE4
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Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D In some patients initial therapy with LABA/ICS may be the 1st choice: History and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts (still under debate)
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Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Education and self-management Physical activity Pulmonary rehabilitation programs Exercise training Self-management education End of life and palliative care Nutritional support Vaccination Oxygen therapy
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Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Oxygen therapy LTOT indications: PaO2 ≤ 55 mmHg or SaO2 ≤ 88% +/- hypercapnia confirmed 2x over a 3W period; or 55 55%).
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Monitoring and Follow-up © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacotherapy and other medical treatment In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen. Monitoring should focus on: Dosages of prescribed medications. Adherence to the regimen. Inhaler technique. Effectiveness of the current regime. Side effects. Treatment modifications should be recommended.
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. They are classified as: Mild (treated with short acting bronchodilators only, SABDs) Moderate (treated with SABDs + antibiotics and/or oral corticosteroids) or Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure. Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS !!!!!!!!!!!!
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
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ontraindications of Non Invasive ventilation for COPD in clude all of the following, except: a. Cardiovascular/hemodynamic instability b. Recent food intake/meal ingestion c. Impaired mental status d. Uncooperative patient e. Copious secretions
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Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Maintenance therapy with LABDs should be initiated as soon as possible before hospital discharge. Systemic corticosteroids (5-7D) can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalization duration. Antibiotics (5-7D) when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Methylxanthines are not recommended due to increased side effect profiles.
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GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease Definition and Overview Diagnosis and Initial Assessment Evidence Supporting Prevention & Maintenance Therapy Management of Stable COPD Management of Exacerbations COPD and Comorbidities
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COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease Some common comorbidities occurring in patients with COPD with stable disease include: Cardiovascular disease (CVD) ++ Heart failure Ischaemic heart disease (IHD) Arrhythmias !!!!!!!!!!!!!!!!!!!! Peripheral vascular disease !!!!!!!!!!!!!!!!!!!!! Hypertension Anxiety and depression COPD and lung cancer Metabolic syndrome and diabetes Osteoporosis GERD (associated with an increased risk of exacerbations and poorer health status) Bronchiectasis !!!!!!!!!!!!! OSA
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THANK YOU
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In COPD management, all of the following are considered bronchodilators, except: a. B 2 agonists b. Anticholinergics c. Methylxanthines d. Leukotriene receptor antagonists e. Formoterol, Indacaterol, Salmeterol, Salbutamol, Ipratropium bromide an d Tiotropium bromide.
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Dans l ’ asthme bronchique, un des éléments suivants n ’ a pas de rôle important dans les changements changements physiopathologiques. A. La contraction des fibres musculaires lisses B. L ’œ dème de la muqueuse bronchique C. L ’ hypersé cr étion du mucus. D. La libération des PAF. E. L ’ effet inflammatoire des macrophages
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Les β 2 de longue durée d ’ action sont indiqués dans les cas suivants, excepté un A. Dans l ’ Asthme sévère persistent. B. Dans l ’ Asthme modéré persistent. C. En association avec des corticoïdes inhales. D. En cas de crise aigue. E. Pour améliorer la compliance des malade
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Based on the GOLD Classification, timing of steroid inhaler s for the long term treatment of COPD is: a. Very early on, in stage 0 (i.e. at risk), to avoid progression of the disease. b. In the mild stage of the disease. c. In the moderate stage of the disease. d. In the severe stage of the disease. e. Late, in the very severe stage of the disease because the inflammation is different than asthma
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When it comes to formulations used in COPD treatment all ar e correct, except: a. Metered dose inhalers, dry powder formulations or Nebulizer solutions exist and are effec tive. b. Oral formulations are avoided because of undesirable systemic effects. c. Metered dose inhalers are as effective as Nebulizers if used adequately. d. Dry powder inhalers formulations are superior to metered dose inhalers formulations. XXX e. Long acting formulations are used for maintenance therapy.
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Concernant l ’ asthme bronchique, la désensibilisation est indiquée da ns une condition a. Systématiquement dans certaines régions du pays. b. Dès que le diagnostic de l ’ asthme est établi. c. Lorsque les mesures préventives sont possibles d. Lorsque le malade continue à faire des crises malgré un traitement adéquat e. Systématiquement en Pédiatrie
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asthme obstruction chronique des voies respiratoires de faible calibre est signe de mauvais pronostic