5. Initial Visit
ā¢ Pattern of symptom development
ā¢ Exposure to risk factors
ā¢ History of exacerbations or previous
hospitalizations for respiratory disorder
ā¢ Past medical history
ā¢ Family history
ā¢ Social history
ā¢ Impact of disease on patientās life
ā¢ Effect on family routines
ā¢ Feelings of depression or anxiety
ā¢ Social and family support available to the
patient
ā¢ Possibilities for reducing risk factors,
especially smoking cessation
6. Testing
ā¢ Spirometry
ā¢ Initially and yearly
ā¢ ABG
ā¢ Obtain if FEV1 < 40% predicted OR
ā¢ Clinical signs of respiratory or right heart
failure
ā¢ Respiratory Failure
ā¢ Alpha-1 antitrypsin
ā¢ If patient <45 years old or strong family
history of COPD
7. Follow-Up Visits
ā¢ Discuss new or worsening symptoms
ā¢ Perform spirometry if there is a substantial
increase in symptoms OR if a complication
occurs
ā¢ ABG
ā¢ Patients with an FEV1 <40% predicted
ā¢ Early signs of respiratory failure or CHF
ā¢ Monitor pharmacotherapy
ā¢ Dosages
ā¢ Adherence
ā¢ Inhaler technique
ā¢ Effectiveness of current regimen at
controlling symptoms
ā¢ Side effects of treatment
8. Follow-up Visits
ā¢ Monitor co-morbid conditions
ā¢ Bronchial carcinoma
ā¢ Tuberculosis
ā¢ Sleep apnea
ā¢ Left heart failure
ā¢ Obtain appropriate information through CXR,
ECG whenever symptoms suggest one of
these conditions
10. Risk Factors
ā¢ Tobacco smoke
ā¢ Occupational dusts and
chemicals
ā¢ Indoor and outdoor air
pollutants
11. Smoking Cessation
ā¢ The single MOST effective and cost-effective
intervention to reduce the risk of developing COPD
and to stop its progression
ā¢ Offer this at EVERY visit to the health care
provider
ā¢ Brief 3 minute period of counseling
ā¢ Three types of counseling are esp. effective:
ā¢ Practical counseling
ā¢ Social support as part of the treatment
ā¢ Social support arranged outside of the treatment
ā¢ Several effective medications are available and at
least one of these medications should be added to
counseling if necessary and if there are no
contraindications
ā¢ Nicotine gum, inhaler, nasal spray, trasndermal
patch, sublingual tablet, lozenges
ā¢ Bupropion
ā¢ nortriptyline
12. Ask Systematically identify all tobacco users at
every visit
Advis
e
Strongly urge all tobacco users to quit, in a
clear, strong, and personalized manner
Asses
s
Determine willingness to make a quit
attempt.
e.g. within the next 30 days, how willing is
this person to make a quit attempt
Assist Aid the patient in quitting
e.g. quit plan, counseling, intra-treatment
social support, extra-treatment social
support, approved pharmacotherapy,
supplementary materials
Arran
ge
Schedule a follow-up contact, either in
person or via telephone
13. Smoking Prevention ā
What you can do as a provider:
ā¢ Encourage comprehensive tobacco-
control policies and programs
ā¢ Work with government officials to
pass legislation to establish smoke-
free schools, public facilities, and
work environments
ā¢ Encourage patients to keep smoke-
free homes
Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.
14. Occupational Exposures
ā¢ Primary prevention
ā¢ Eliminate or reduce exposures to
various substances in the
workplace
ā¢ Secondary prevention
ā¢ Surveillance and early detection
15. Indoor and Outdoor Air
Pollution
ā¢ Implement measures to reduce or avoid
indoor air pollution from biomass fuel
burned for cooking and heating in poorly
ventilated dwellings
ā¢ Advise patients to monitor public
announcements of air quality
ā¢ Avoid vigorous exercise outdoors or stay
indoors during pollution episodes,
depending on COPD severity
17. General Principles
ā¢ Determine disease
severity
ā¢ Implement step-
wise treatment plan
ā¢ Educate the patient
ā¢ Improve skills
ā¢ Improve ability to
cope with illness
ā¢ Improve health
status
ā¢ Prescribe
Treatment
ā¢ Pharmacologic
ā¢ Non-
pharmacologic
ā¢ Rehabilitation
ā Exercise
training
ā Nutrition
counseling
ā education
ā Oxygen therapy
ā¢ Surgical
interventionsGOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
18. Stage Characteristics
0:
At Risk
Normal spirometry
Chronic symptoms (cough, sputum)
I:
Mild
FEV1/FVC < 70%
FEV1 >= 80% predicted
Usu. Chronic cough and sputum production
II:
Moderate
50% <= FEV1 < 80% predicted
Progression of symptoms; dyspnea on exertion
III:
Severe
30%<= FEV1 < 50% predicted
ā dyspnea; repeated exacerbations which have an
impact on patientsā quality of life
IV
Very
severe
FEV1< 30% predicted OR
FEV1<50% predicted + chronic respiratory failure
ā¢Quality of life is appreciably impaired
ā¢Exacerbations may be life-threatening
19. Patient Education
ā¢ Smoking cessation
ā¢ Basic information about COPD and pathophysiology
of the disease
ā¢ General approach to therapy and specific aspects
of medical treatment
ā¢ Self-management skills
ā¢ Strategies to help minimize dyspnea
ā¢ Advice about when to seek help
ā¢ Self-management and decision-making in
exacerbations
ā¢ Advance directives and end-of-life issues
20. Medications
ā¢ Goals
ā¢ Prevent and control symptoms
ā¢ Reduce frequency and severity of exacerbations
ā¢ Improve health status
ā¢ Improve exercise tolerance
ā¢ No existing medications can modify the
long-term decline in lung function
ā¢ Reduction of therapy once symptom control
occurs is not normally possible
ā¢ COPD is progressive and over time will
require progressive introduction of more
treatments to attempt to limit the impact of
these changes
21. Bronchodilators
ā¢ Central to symptom management
ā¢ Used in all stages of COPD severity
ā¢ Inhaled forms are preferred
ā¢ Can be prescribed as needed OR regularly
to prevent or reduce symptoms
ā¢ Long-acting inhaled bronchodilators are
more effective and convenient (but are
more expensive)
ā¢ Combining drugs with different mechanisms
and durations of action may increase the
degree of bronchodilation for equivalent or
lesser side effects
ā¢ All categories of bronchodilators have been
show to increase exercise capacity without
necessarily producing significant changes
in FEV1
23. Glucocorticosteroids
ā¢ Use if FEV1 < 50% predicted and repeated
exacerbations, e.g. three in the last three
years
ā¢ Severe COPD and Very Severe COPD
ā¢ Does not modify the long-term decline in
FEV1 BUT does reduce the frequency of
excacerbations and improves health status
ā¢ The combination of a long-acting beta2-
agonist and an inhaled glucocorticosteroid
is more effective than the individual
components
ā¢ Long-term treatment with oral
glucocorticoids is NOT recommended
25. Immunizations
ā¢ Vaccines
ā¢ Influenza yearly
ā¢Reduces serious illness and death in
COPD patients by approximately 50%
ā¢Give once yearly: autumn OR twice
yearly: autumn and winter
ā¢ Pneumovax
ā¢Sufficient data to support its general
use in COPD is lacking, but it is
commonly used
26. Other Medications?
ā¢ Alpha-1 Antitrypsin Augmentation Therapy
ā¢ Only if this deficiency is present in an individual
should they undergo treatment
ā¢ Antibiotics
ā¢ Prophylactic use is NOT recommended
ā¢ Can be used in the treatment of infectious
exacerbations of COPD
ā¢ Mucolytic agents
ā¢ Overall benefits are small, so currently not
recommended for widespread use
ā¢ Types:
ā¢ Ambroxol
ā¢ Erdosteine (Erdostin, Mucotec)
ā¢ Carbocysteine (Mucodyne)
ā¢ Iodinated gylerol (Expigen)
27. ā¢ Antioxidant agents
ā¢ N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst)
ā¢ Have been shown to reduce the frequency of
exacerbations and could have a role in the
treatment of patients with recurrent
exacerbations
ā¢ More studies are needed
ā¢ Immunoregulators
ā¢ Not recommended at this time
ā¢ No reproducible studies are available
ā¢ Antitussives
ā¢ Regular use is contraindicated in stable COPD
since cough has a significant protective role
ā¢ Vasodilators
ā¢ Inhaled nitric oxide
ā¢ Can worsen gas exchange because of altered hypoxic
regulation of ventilation-perfusion balance and is
contraindicated in stable COPD
28. ā¢ Respiratory stimulants
ā¢ Doxapram (IV)
ā¢ Almitrine bismesylate
ā¢ Not recommended in stable COPD
ā¢ Narcotics
ā¢ Oral and parenteral opioids are effective for
treating dyspnea in patients with advanced
COPD
ā¢ Use this with caution; benefits may be limited to a few
sensitive subjects
ā¢ nebulized opioids: insufficient evidence .
ā¢ Miscellaenous:
ā¢ Nedocromil
ā¢ Leukotriene modifiers
ā¢ Alternative healing methods
ā¢ None have been adequately studied in COPD patients at
this time
GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
30. Stage I: Mild COPD
ā¢ Avoid risk
factors
ā¢ Offer
vaccination
ā¢ Use short-acting
bronchodilators
as needed
I:
Mild
FEV1/FVC < 70%
FEV1 >= 80%
predicted
Usu. Chronic
cough and
sputum
production
31. Stage II: Moderate
COPD
ā¢ Avoid risk factors
ā¢ Offer influenza
vaccine
ā¢ Add short-acting
bronchodilators
when needed
ā¢ Add regular
treatment with 1
or more long-
acting
bronchodilators
ā¢ Add rehabilitation
II:
Modera
te
50% <= FEV1 <
80% predicted
Progression of
symptoms;
dyspnea on
exertion
32. Stage III: Severe COPD
ā¢ Avoid risk factors
ā¢ Offer influenza vaccine
ā¢ Add short-acting
bronchodilators when
needed
ā¢ Add regular treatment
with 1 or more long-
acting bronchodilators
ā¢ Add rehabilitation
ā¢ Add inhaled
glucocorticoids if
repeated exacerbations
III:
Sever
e
30%<= FEV1
<50% predicted
ā dyspnea;
repeated
exacerbations
which have an
impact on
patientsā quality
of life
33. Stage IV: Very Severe COPD
ā¢ Avoid risk factors
ā¢ Offer influenza
vaccination
ā¢ Add short-acting
bronchodilators as
needed
ā¢ Add rehabilitation
ā¢ Add inhaled
glucocorticoids if
repeated exacerbations
ā¢ Add long-term oxygen if
chronic respiratory
failure
ā¢ Consider surgical
treatments
IV
Very
severe
FEV1< 30%
predicted OR
FEV1<50%
predicted +
chronic
respiratory
failure
ā¢Quality of life is
appreciably
impaired
ā¢Exacerbations
may be life-
threatening
35. Rehabilitation
ā¢ COPD patients at all stages of severity benefit from exercise
training programs
ā¢ Improves both exercise tolerance and symptoms of dyspnea and
fatigue
ā¢ Goals
ā¢ Reduce symptoms
ā¢ Improve quality of life
ā¢ Increase physical and emotional participation in everyday activities
ā¢ Comprehensive program should include several types of
health professionals:
ā¢ Exercise training
ā¢ Nutrition counseling
ā¢ Education
ā¢ Minimum effective length of time = 2 months
ā¢ Setting: inpatient OR outpatient OR home
ā¢ Baseline and outcome assessments of each participant
should be made to quantify individual gains and target areas
for improvement
ā¢ Measurement of spirometry before and after a bronchodilator drug
ā¢ Assessment of exercise capacity
ā¢ Assessment of inspiratory and expiratory muscle strength and lower limb
strength
36. Oxygen Therapy
ā¢ Stage IV - Severe COPD who have
ā¢ PaO2 at or below 55 mm Hg or SaO2 at or below
88% with or without hypercapnia OR
ā¢ PaO2 between 55-60 mm Hg or SaO2 88% IF
pulmonary hypertension, peripheral edema
suggesting congestive heart failure, or
polycythemia (Hct > 55%)
ā¢ Based on awake PaO2 values
ā¢ GOAL
ā¢ Increase baseline PaO2 to at least 60 mm Hg at
sea level and rest and/or produce SaO2 at least
90%
ā¢ Need to use at least 15 hours per day in patients with
chronic respiratory failure to improve survival
ā¢ Can have a beneficial impact on hemodynamics,
hematologic characteristics, exercise capacity, lung
mechanics and mental state
37. Surgical Treatment
ā¢ Bullectomy
ā¢ Effective in reducing dyspnea and improving lung
function in appropriately selected patient
ā¢ Lung volume reduction surgery
ā¢ Parts of the lung are resected to reduce
hyperinflation
ā¢ Does not improve life expectancy
ā¢ Does improve exercise capacity in patients with
predominantly upper lobe emphysema and a low
post-rehabilitation exercise capacity
ā¢ May improve global health status in patients
with heterogeneous emphysema
ā¢ High hospital costs; still experimental/palliative
38. Surgical Treatment
ā¢ Lung transplantation
ā¢ Improves quality of life and
functional capacity in
appropriately selected
patient
ā¢ Criteria for referral:
ā¢ FEV1 < 35% predicted
ā¢ PaO2 < 55-60 mm Hg
ā¢ PaCO2 > 50 mm Hg
ā¢ Secondary pulmonary
hypertension
ā¢ All four criteria must be present
39. COPD Patients and
Surgery
ā¢ Increased risk of post-operative
pulmonary complications
ā¢ Risk of complications increases as
the incision approaches the
diaphragm
ā¢ Epidural and spinal anesthesia have
a lower risk than general anesthesia
ā¢ Postpone surgery if the patient has a
COPD exacerbation
41. General Points
ā¢ Most common causes of exacerbations are:
ā¢ Infection of the tracheobronchial tree
ā¢ Air pollution
ā¢ In 1/3 of severe exacerbations a cause cannot be identified
ā¢ Inhaled bronchodilators, theophylline, and systemic
(preferably oral) glucocorticosteroids are effective
treatments
ā¢ Patients with clinical signs of airway infection may benefit
from antibiotic treatment
ā¢ Increased volume of sputum
ā¢ Change in color of sputum
ā¢ Fever
ā¢ Non-invasive intermittent positive pressure ventilation
(NIPPV) in exacerbations is helpful:
ā¢ Improves blood gases and pH
ā¢ Reduces in-hospital mortality
ā¢ Decreases the need for invasive mechanical ventilation and
intubation
ā¢ Decreases the length of hospital stay
42. Diagnosis and
Assessment of Severity
ā¢ History
ā¢ Increased breathlessness
ā¢ Chest tightness
ā¢ Increased cough and sputum
ā¢ Change of color and/or tenacity of
sputum
ā¢ Fever
ā¢ Non-specific:
ā¢ Malaise, insomnia, sleepiness,
fatigue, depression, or
confusion
43. Assessment of Severity
ā¢ Lung Function Tests
ā¢ PEF < 100 L/min. or FEV1
< 1 L = severe
exacerbation
ā¢ Arterial Blood Gas
ā¢ PaO2 < 60 mmHg and/or
SaO2 < 90% with or
without PaCO2 < 50
mmHg when breathing
room air = respiratory
failure
ā¢ Chest x-ray
ā¢ Look for complications
ā¢ Pneumonia
ā¢ Alternative diagnoses
ā¢ ECG
ā¢ Right ventricular
hypertrophy
ā¢ Arrhythmias
ā¢ Ischemia
ā¢ Sputum
ā¢ Culture/sensitivity
ā¢ Comprehensive
Metabolic Profile
ā¢ Assess for electrolyte
disturbances, diabetes
ā¢ Albumin to assess
nutrition
44. PLACE OF RX
ā¢ Home?
ā¢ Hospital admission?
ā¢ Floor?
ā¢ ICU?
GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
45. Indications for Hospital
Admission
ā¢ Marked increase in intensity of symptoms such as
sudden development of resting dyspnea
ā¢ Severe background COPD
ā¢ Onset of new physical signs
ā¢ Cyanosis, peripheral edema
ā¢ Failure of exacerbation to respond to initial
medical management
ā¢ Significant co-morbidities
ā¢ Newly occurring arrhythmias
ā¢ Diagnostic uncertainty
ā¢ Older age
ā¢ Insufficient home support
46. Indications for ICU
Admission
ā¢ Severe dyspnea that responds
inadequately to initial emergency
therapy
ā¢ Confusion, lethargy, coma
ā¢ Persistent or worsening hypoxemia
(PaO2 < 40 mm Hg) and/or
ā¢ Severe/worsening hypercapnia
(PaCO2 > 60 mm Hg) and/or
ā¢ Severe/worsening respiratory
acidosis (pH < 7.25) despite
supplemental oxygen and NIPPV
47. Management of
Exacerbations
ā¢ Risk of dying from an
exacerbation is closely related
to:
ā¢ Development of respiratory
acidosis
ā¢ Presence of significant co-
morbidities
ā¢ Need for ventilatory support
48. Severe Exacerbation,
Non Life Threatening
ā¢ Assess severity of symptoms
ā¢ Obtain arterial blood gas and chest x-ray
ā¢ Administer controlled oxygen therapy
ā¢ Repeat ABG after 30 minutes
ā¢ Bronchodilators
ā¢ Glucocorticosteroids
ā¢ Consider antibiotics
ā¢ Consider non-invasive mechanical
ventilation
ā¢ Monitor fluid balance and nutrition
ā¢ Consider subcutaneous heparin therapy
ā¢ Identify and treat associated conditions
(CHF, arrhythmias)
49. Management of COPD
Exacerbations
ā¢ Controlled oxygen therapy
ā¢ Administer enough to maintain PaO2 > 60 mmHG
or SaO2 > 90%
ā¢ Monitor patient closely for CO2 retention or
acidosis
ā¢ Bronchodilators (inhaled)
ā¢ Increase doses or frequency
ā¢ Combine Ć2 agonists and anticholinergics
ā¢ Use spacers or air-driven nebulizers
ā¢ Consider adding IV methylxanthine
(aminophylline) if needed
50. Management of COPD
Exacerbations
ā¢ Glucocorticosteroids (oral or IV)
ā¢ Recommended as an addition to bronchodilator therapy
ā¢ If baseline FEV1 < 50% predicted
ā¢ 30-40 mg oral prednisolone x 7-10 days OR nebulized
budesonide (Pulmicortā¢)
ā¢ Antibiotics
ā¢ IF breathlessness and cough are increased AND sputum
is purulent and increased in volume
ā¢ Choice of antibiotics should reflect local antibiotic
sensitivity for the following microbes:
ā¢ S. pneumoniae
ā¢ H. influenzae
ā¢ M. catarrhalis
51. Management of COPD
Exacerbations
ā¢ Manual or mechanical chest
percussion and postural
drainage may be beneficial in
patients producing > 25 mL
sputum per day OR with lobar
atelectasis.
52. Management of COPD
Exacerbations
ā¢ Ventilatory Support
ā¢ Decrease mortality and morbidity
ā¢ Relieve symptoms
ā¢ Used most commonly in Stage IV, Very
Severe COPD
ā¢ Forms:
ā¢ Non-invasive using negative or positive
pressure devices
ā¢ invasive/mechanical with oro- or naso-tracheal
tube OR tracheostomy
53. NIPPV
ā¢ Success rates of 80-85%
ā¢ Increases pH, reduces PaCO2,
reduces severity of
breathlessness
ā¢ Decreases length of hospital
stay
ā¢ Decreases mortality/intubation
rate
54. NIPPV (C-PAP, Bi-PAP)
ā¢ Selection criteria
ā¢ Moderate to severe dyspnea with
use of accessory muscles and
paradoxical abdominal motion
ā¢ Moderate to severe acidosis (pH <
7.35) and hypercapnia (PaCO2 > 45
mmHg)
ā¢ Respiratory frequency > 25
breaths/minute
56. Indications for Invasive
Mechanical Ventilation
ā¢ Severe dyspnea with use of accessory muscles and
paradoxical abdominal motion
ā¢ Respiratory rate > 35 breaths/minute
ā¢ Life-threatening hypoxemia: PaO2 < 40 mm Hg
ā¢ Severe acidosis (pH < 7.25) and hypercapnia
(PaCO2 > 60 mm Hg)
ā¢ Respiratory arrest
ā¢ Somnolence, impaired mental status
ā¢ Cardiovascular complications
ā¢ Hypotension/shock/heart failure
ā¢ Other complications
ā¢ Metabolic abnormalities/sepsis/pneumonia/pulmonary
embolism/barotrauma/massive pleural effusion
ā¢ NIPPV failure
57. Use of Invasive Ventilation
in End-Stage COPD
ā¢ Hazards:
ā¢ Ventilator-acquired pneumonia
ā¢ Increased prevalence of multi-resistant organisms
ā¢ Barotrauma
ā¢ Failure to wean to spontaneous ventilation
ā¢ Mortality among COPD patients with
respiratory failure is no greater than
mortality among patients ventilated for non-
COPD reasons
58. Discharge Criteria
ā¢ Inhaled Beta2-agonist use is at most every 4 hours
ā¢ Patient is able to walk across the room
ā¢ Patient is able to eat and sleep without frequent
awakening
ā¢ Patient has been clinically stable for 12-24 hours
ā¢ ABGs are stable for 12-24 hours
ā¢ Patient/home caregiver fully understands correct
use of medications
ā¢ Follow-up and home care arrangements have been
completed
ā¢ Patient, family, and physician are confident that
patient can manage successfully
59. Follow-Up Assessment
after Hospital Discharge
ā¢ 4-6 weeks after discharge
ā¢ Assess:
ā¢ Ability to cope in usual environment
ā¢ Inhaler technique
ā¢ Understanding of recommended treatment
regimen
ā¢ Measure FEV1
ā¢ Determine need for long-term oxygen
therapy and/or home nebulizer (for
patients with very severe COPD, Stage
IV)
61. REFERENCES
ā¢ National Heart, Lung, and Blood Institute Data
Fact Sheet for Chronic Obstructive Pulmonary
Disease
ā¢ GOLD (Global Initiative for Chronic Obstructive
Lung Disease) Executive Summary, April 2001
ā¢ GOLD Pocket Guide to COPD Diagnosis,
Management, and Prevention. A Guide for Health
Care Professionals. Updated July 2005.
www.goldcopd.org ā Accessed August 21, 2006.
ā¢ Fiore MC, Bailey WC, Cohen SJ, et. al. Treating
Tobacco Use and Dependence. Quick Reference
Guide for Clinicians. Rockville, MD: U.S.
Department of Health and Human Services. Public
Health Service. October 2000.