Recommendations from the Global Initiative for Chronic Obstructive Lung Disease

1. COPD DIAGNOSIS,
MANAGEMENT & TREATMENT
2018
Summary of: A Guide for Health Care Professionals
Jill Johnston ARNP

2. COPD PATHO
› Chronic airflow limitations due to alveolar
abnormalities
– Mixture of small airway diseases & parenchymal
destruction
› Obstructive bronchiolitis (small airway)
› Emphysema (parenchymal destruction)
2

3. COPD RISK FACTORS
› SMOKING
› AIR POLUTION
› OCCUPATIONAL EXPOSURE
› GENETICS
› AGE/GENDER
› LUNG GROWTH & DEVELOPMENT
› SOCIOECONOMIC STATUS
› ASTHMA & AIRWAY HYPERSENSITIVITY
› CHRONIC BRONCHITIS
› CHRONIC INFECTIONS
3

4. COPD DIAGNOSIS
› Suspect with
– Dyspnea – progressive over time, ↑ with exercise,
persistent
– Chronic cough – intermittent or unproductive, recurrent
wheeze
– Chronic sputum production – in any pattern
– Recurrent lower respiratory infections
– History of risk factors – smoking, exposure, family history,
childhood illnesses
› Confirm Diagnosis - Spirometry (post-bronchodilator)
– FEV1/FVC <0.70 confirms
4

5. COPD Differential Diagnosis
› Asthma
› CHF
› Bronchiectasis
› TB
› Obliterative Bronchiolitis
› Diffuse Panbronchiolitis
5

6. WHO Recommendations
› Alpha-1 antitrypsin deficiency screening (AATD)
– For all patients diagnosed with COPD
› <20% suggestive of homozygous deficiency
–Screen family members too
6

7. COPD Treatment
Non-Pharmacological
› Smoking Cessation
› Regular physical activity
› Reduction of Risk Factors
› Vaccinations
– < 65 y/o PPSV23, Pneumovax
– > 65 y/o PPSV23, Pneumovax PLUS PCV13, Prevnar
– Annual influenza vaccine
› Pulmonary Rehab
› Oxygen Therapy
7

8. CLASSIFICATIONS
–GOLD 1: Mild FEV1 > 80% of predicted
–GOLD 2: Moderate FEV1 50% - 79% of predicted
–GOLD 3: Severe FEV1 30% - 49% of predicted
–GOLD 4: Very Severe FEV1 < 30% of predicted
8

9. Treatment Algorithm
A
• Mild to infrequent symptoms (mild breathlessness with exercise)
• No hospitalizations within the pas 12 months
• Low risk for exacerbations (0-1 within the past 12 months)
• SABA or SAMA or SABA/SAMA
B
• Moderate to severe symptoms (unable to keep up with others of similar age due to
breathlessness)
• No hospitalizations within the pas 12 months
• Low risk for exacerbations (0-1 within the past 12 months)
• LABA and/or LABA/SABA and/or LAMA
C
• Mild to infrequent symptoms (mild breathlessness with exercise)
• High risk for exacerbations leading to hospitalization (> 2 within the past 12 months)
• LAMA or LABA/LAMA or LABA/ICS or LAMA/ICS & SABA
D
• Moderate to severe symptoms (unable to keep up with others of similar age due to
breathlessness)
• High risk for exacerbations leading to hospitalization (> 2 within the past 12 months)
• TRIPPLE THERAPY, consider phosphodiesterase-4 (PDE-4) inhibitor
• Consider long-term oral corticosteroids for FEV1< 50%
9

10. Additional information
Category C
– Consider withdrawal of ICS as soon as possible
› Symptomatic patients in categories B, C & D are
recommended to participate in pulmonary
rehabilitation.
10

11. Stable COPD Drugs
› - Short Acting Beta2–agonists (SABAs)
– FOR USE FOR OCCASIONAL SYMPTOMS
› Albuterol (ProAir HFA, Ventolin HFA, Salbutamol), fenoterol, Levalbuterol (Xopenex HFA),
terbutaline INH PRN
– Reduce symptoms
– Not on a regular basis
› - Long Acting Beta2-agonists (LABAs)
– PREFERRED OVER SABAs
› Saleterol (Serevent) & formoterol (Foradil, Performist) INH BID
– Improve FEV1, lung volumes, dyspnea, decrease exacerbation rates
› Indacaterol, oladaterol and vilanterol INH daily
› - Combination SABA/SAMA is found to have better results than
either alone
– Adverse Effects
› Tachycardia & tremor
11

12. COPD Treatment Stable cont.
› Short Acting Antimuscarinics Agonists (SAMAs)
– Ipatroprium (Atrtovent) & oxitropuim bromideINH daily, BID/TID or
PRN
› Improve FEV1, lung volumes, dyspnea, decrease exacerbation rates >
SABAs alone
› Long Acting Antimuscarinics Agonists (LAMAs)
– Tiotropium (Spiriva), aclidinium (Tudorza Pressair), umeclidinium &
glycopyrrolate bromide (Lonhala Magnair) INH BID
› Improve FEV1, lung volumes, dyspnea, decrease exacerbation rates > LABAs
› Tiotropium improves pulmonary rehab and exercise tolerance
– Indacaterol or oladaterol INH daily
– LAMAs are preferred over LABAs
› Adverse Effects
› Dry mouth
12

13. Stable COPD Drugs cont.
› - Methylxanthines
– Theophylline – most common
› Theophylline plus salmeterol = >improvement in dyspnea vs salmeterol alone
– Improve FEV1, lung volumes, dyspnea, decrease exacerbation rates > SABAs alone
› Adverse Effects
› Toxicity
› - Inhaled Corticosteroids (ICS)
– Beclomethasone dipropionate (Qvar)
– Budesonide (Pulmicort)
– Fluticasone (Flovent)
– Mometasone (Asmanex HFA)
– Not recommended for monotherapy or long-term use
› Adverse Effects
– Increases risk of pneumonia in patients with severe disease
13

14. COPD Combination Drugs .
› - SABAs/SAMAs Combinations
– Increases bronchodilation
› Superior compared to either medication alone
› Improve FEV1 & symptoms
› Fenoterol/ipratropium (Duovent UDV), Ipratropium bromide/albuterol (Combivent)
› - LABAs/LAMAs
– Low dose INH BID improves symptoms & decreases exacerbations
– Formoterol/aclidinium, formoterol/glycopyrrolate, indacaterol/glycopyrrolate,
vilanterol/umeclidium, olodaterol/tiotroprium
– Tiotropium and formoterol in separate INH = improved FEV1 response than
either alone
14

15. COPD Combination Drugs .
› - LABAs/ICS Combinations – more efficient than alone
– Budesonide/Formoterol (Symbicort)
– Fluticasone/Salmeterol (Advair)
– Mometasone/formoterol (Dulera)
› - ICS/LABAs/LAMAs – improve outcomes over ICS/LABA
or LAMA alone
15

16. COPD Combination Drugs .
› Phosphodiesterase-4 (PDE4) inhibitors
– Roflumilast (Daliresp)
› In patients with chronic bronchitis, severe and greater COPD exacerbations,
improvement is seen when combined with systemic corticosteroids
– Adverse Effects
› Most nausea, reduced appetite, weight loss, abdominal pain, diarrhea, sleep
disturbance, and headache
› Mucolytics
– Decrease exacerbations in select populations
› Mucomyst
› Leukotriene modifiers have not been tested in COPD
› Oral prednisone is not routinely recommended for STABLE COPD
16

17. • If current treatment is LABA/LAMA or LABA + ICS
• Switch to LABA/LAMA + ICS
• Overall reduction in moderate-severe exacerbations over
dual therapy
• Use of ICS can increase risks for pneumonia
• Long-term low dose corticosteroid
• Pulmonary rehabilitation
MODERATE-TO-SEVERE COPD
PERSISTENT SYMPTOMS
FREQUENT EXACERBATIONS
17

18. • Home care
• No signs of respiratory failure or other associated factors
• SABAs or SABA PLUS oral prednisone (40 mg daily for 5 days with taper)
• Follow up in 72 hours
• ABX if 2 out of 3 (5-7 or days)
• Increased sputum, purulent sputum or increased dyspnea
and one or more of the following
• > 65 y/o, FEV1 < 50%, > 2 exacerbations (12 mos), cardiac disease
• Consider adding LABA/ICS or LABA/LAMA
ACUTE COPD EXACERBATIONS
18

19. • DECISION TO HOSPITALIZE
• Based on severity of symptoms
• > 65 y/o
• Co-morbidities
• SpO2 </= 88% with supplemental O2 or increase in home O2 demand
• Decreased mental status
• PaCO2 > 55 or pH < 7.35 (ICU if PaCO2 >60
• Other signs of respiratory distress or frailty
• New onset peripheral edema, cyanosis, drowsiness, lack of home support
ACUTE COPD EXACERBATIONS
19

20. • Inpatient Care
• Chest x-ray, CBC, BMP, procalcitonin
• ABG if SpO2 < 92%
• SABA/SAMA INH Q4H and PRN
• Systemic steroids (oral or IV)
• Transition to ICS when stable
• Supplemental O2 (goal SpO2 88%-92%)
• Antivirals (test for influenza/RSV)
• Thromboprophylaxis (increased risk for DVT)
• Consider NIMV if PaCO2 >55
ACUTE COPD EXACERBATIONS
20

21. • Decision for ABX
• ABX if 2 out of 3 (5-7 or 14 days)
• Increased sputum, purulent sputum or increased dyspnea
and one or more of the following
• > 65 y/o, FEV1 < 50%, > 2 exacerbations (12 mos), the need for
NIMV or MV
or
• Worsening clinical status after 72 hours treatment
ACUTE COPD EXACERBATIONS 21

22. • Empiric Therapy (beta lactam or macrolides or
fluoroquinolones)
• Ceftriaxone, amoxicillin/clavulanic,
• Piperacillin/tazobactam, or meropenem, are first-line for
inpatient therapy in high-risk people
• >65 years
• Recent and/or prolonged hospitalization
• Poor functional status
• Recent and prolonged use of antibiotics
• Blood or sputum cultures
ACUTE COPD EXACERBATIONS 22

23. • Consider differentials
• CHF, interstitial lung disease, PE, bronchiectasis or
arrhythmias
• Chest CT, EKG, ECHO, BNP
• Home O2 if SaO2<88% confirmed 2x over a 3
week period
• or inability to sustain with exercise
• or CHF, pulmonary HTN or polycythemia
ACUTE COPD EXACERBATIONS
23

24. Reference
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global
Strategy for the Diagnosis, Management and Prevention of chronic
obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org
24