α-1 Antitrypsin Deficiency and COPD: Screening, Classification, and Management, Slides of Pneumology

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Management of Stable COPD

Definition

GOLD

Airflow limitation

{ not fully reversible

{ progressive

{ abnormal inflammatory response to

noxious particles or gases

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Definition contd..

ATS

Airflow limitation due to chronic bronchitis or

emphysema

Πgenerally progressive

Πairway hyperreactivity

Πpartially reversible

Airflow Limitation Reversibility

in FEV1 > 12 > 10 > 12

in FEV1 > 200ml > 200ml

ATS ERS GOLD

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Diagnosis

{ Symptoms + spirometry

{ Management of COPD largely symptom driven

{ Only an imperfect relationship between the

degree of airflow limitation and symptoms

Measurement of Airflow Limitation

Spirometry

{ Gold standard for diagnosis and assessment of COPD

{ Postbronchodilator FEV1 < 80% of predicted value + FEV1/FVC < 70% - confirms airflow limitation that is not fully reversible

{ FEV1/FVC more sensitive FEV1/FVC < 70% - early sign of airflow limitation when FEV1 remains normal (≥ 80% predicted)

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Measurement of Airflow Limitation

If spirometry unavailable

o PEF good substitute if spirometry not available In COPD PEF may underestimate degree of airways obstruction

o Prolongation of FET > 6 sec → crude guide to FEV1/FVC ratio < 50%

o 6 minute walking test performed by measuring distance covered in 6 minutes when patient walks at his/her own speed (under physician supervision) o can be performed at the primary care level

Bronchodilator reversibility testing

{ To help rule out a diagnosis of asthma

{ To establish a patient’s best attainable lung

function

{ To gauge a patient’s prognosis.

Post BDR FEV1 → more reliable prognostic marker

than pre-BDR FEV

IPPB study→ degree of bronchodilator response

inversely related to rate of FEV

decline in COPD patients

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Measurement of Airflow Limitation

{ Ratio of inspiratory to total lung capacity - an independent risk factor for mortality in patients with COPD *

{ This ratio may be a better assessment tool than FEV

{ Inspiratory capacity and lung volumes may better reflect the functional response and the improvement of symptoms and exercise tolerance induced by bronchodilator agents

• Am J Respir Crit Care Med 2005;171:591–

BODE index

{ BODE index (Body mass index, airflow Obstruction,

Dyspnea, and Exercise capacity) - a stronger predictor than FEV1 of the risk of hospitalization and death among patients with COPD '

{ Might provide useful prognostic information

' N Engl J Med 2004;350:1005– ' Chest 2005;128:3810–

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Exercise testing

o Functional exercise capacity - the strongest correlate of physical activity in daily life

o Recommended for more comprehensive evaluation of severity and response to treatment

o Endurance shuttle test - sensitive test for detecting changes in exercise capacity induced by bronchodilators ' and rehabilitation

' Am J Respir Crit Care Med 2005;172:1517–

ABG

{ FEV1 < 40% predicted

{ Clinical signs of respiratory failure

{ Right heart failure

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Classification of Severity

Stage

0: At Risk

I: Mild COPD

II: Moderate COPD

III: Severe COPD

IV: Very Severe

Characteristics

. normal spirometry . chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . FEV1 ≥80% predicted ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70%. 50% ≤FEV1 < 80% predicted . ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . 30% ≤FEV1 < 50% predicted . ± chronic symptoms (cough, sputum production) . FEV1/FVC < 70% . FEV1 < 30% predicted or FEV1 < 50% predicted + chronic respiratory failure

Ongoing monitoring and assessment

{ Monitor disease progression and development of complications (JVP,pitting ankle edema s/o RVF), symptoms of hypercapnia (bounding pulse, warm extremities, flaps and tremulousness) & hypoxia (tremors, restlessness, mental obtundation and cyanosis)

Spirometry - if increase in symptoms or a complication

{ Monitor pharmacotherapy and other medical Rx

{ Monitor exacerbation sputum volume / dyspnea / purulent sputum

{ Monitor Comorbidities LVF, Ca bronchus, PTB, sleep apnea,

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Reduce risk factors

{ Quit Smoking

{ Elimination or reduction of exposures to

various substances in the workplace

{ ↓ exposure to indoor / outdoor pollution

General measures

{ (1) avoiding open burning of crop residue

(2) use of water to suppress dust (3) wearing masks at work place in areas of dust generation

{ use of smokeless ‘chullahs’

{ Substitution of solid fuels with LPG or electricity is the best approach

Pharmacotherapy for smoking

cessation

Quit rates { Placebo 6% { NRT and behavioural therapy 9% { Bupropion (6-9 wks) 18% at 1 yr

Treatment Options

Pharmacologic therapy

o Bronchodilators

o Glucocorticosteroids

o Vaccines

o Alpha-1 antitrypsin

augmentation therapy

o Antibiotics

o Mucolytics

o Antioxidants

o Immunoregulators

o Antitussives

o Vasodilators

o Respiratory Stimulants

o Narcotics

o Others

Non-pharmacologic

o Pulmonary

rehabilitation

o Oxygen

o Ventilatory support

o Surgery

Bullectomy Lung Volume Reduction Surgery (LVRS) Lung Transplantation

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General principles

{ None of the existing medications shown to modify long-term decline in lung function { Smoking cessation and continuous long-term oxygen treatment only pharmacologic interventions that modify natural history of COPD

{ Stepwise increase in treatment

{ Treatment response variable

Bronchodilators

{ Bronchodilator medications are central to symptom management in COPD

{ Inhaled therapy preferred

{ Choice between ß2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects

{ Bronchodilators prescribed on an as-needed or on a regular basis to prevent or reduce symptoms

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ß2-agonists

Relax airway smooth muscle by stimulating ß2- adrenergic receptors, which c-AMP Oral therapy slower in onset & more side effects o Resting sinus tachycardia o Tremor o Hypokalemia o O 2 consumption show tachyphylaxis

IV: Very Severe

III: Severe

II: Moderate

0: At I: Mild Risk

New (2003)

Therapy at Each Stage of COPD

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 i nhaled glucocorticosteroids if repeated exacerbations Add l ong-term oxygen if chronic respiratory failure Consider surgical treatments

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ß2-agonists

Salmeterol 25-50 (MDI & DPI) 12+

Formoterol 4.5–12 (MDI & DPI) 12+

Long-acting

Terbutaline 400, 500 (DPI) 4-

Salbutamol 100, 200 (MDI & DPI) 4-

Fenoterol 100-200 (MDI) 4-

Short-acting

Duration of Drug Inhaler(ug) Action (hrs)

Anticholinergics

Salbutamol/Ipratropium 75/15 (MDI) 6-

Fenoterol/Ipratropium 200/80 (MDI) 6-

Combination

Tiotropium 18 (DPI) +

Long-acting

Oxitropium bromide 100 (MDI) 7-

Ipratropium bromide 20, 40 (MDI) 6-

Short-acting

Anticholinergics

Duration of Drug Inhaler (ug) Action (hrs)

4, 8, 16 mg Methyl-prednisolone 10-2000 mg (Pill)

5-60 mg Prednisone (Pill)

Systemic glucoco rticosteroids

25/50, 125, 250 (MDI)

Salmeterol/Fluticasone 50/100, 250, 500 (DPI)

(9/320) (DPI)

Formoterol/Budesonide 4.5/80, 160 (DPI)

Combination

Triamcinolone 100 (MDI) 40

Fluticasone 50-500 (MDI & DPI)

0.20, 0.25, Budesonide 100, 200, 400 (DPI) 0.

Beclomethasone 50-400 (MDI & DPI) 0.2-0.

Oral

Solution Drug Inhaler for

Glucocorticosteroids

{ long-term inhaled steroids reduce mortality from all causes in patients with COPD

Thorax 2005;60:992–

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Tiotropium

{ Tiotropium, a long-acting anticholinergic agent,reduces frequency of exacerbations & use of health care resources in patients with moderate to severe COPD

Ann Intern Med 2005;143:317–

Theophylline

{ Oral theophylline only if inhaled treatments have failed to provide adequate relief

{ All studies that have shown efficacy of theophylline in COPD were done with slow-release preparations

{ Addition of theophylline to ß2-agonists or anticholinergics may produce additional improvements in lung function and health status

{ Combination of salbutamol with theophylline in a single tablet not recommended