Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment Options for the Family Physician - PowerPoint PPT Presentation

Loading...

PPT – Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment Options for the Family Physician PowerPoint presentation | free to view - id: 172673-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment Options for the Family Physician

Description:

Discuss current guidelines for managing chronic obstructive pulmonary ... Make sure patient exhales as forcefully and as long as possible at least six seconds ... – PowerPoint PPT presentation

Number of Views:340
Avg rating:3.0/5.0
Slides: 53
Provided by: susanaf
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment Options for the Family Physician


1
Chronic Obstructive Pulmonary
Disease Diagnosis and Treatment Options for the
Family Physician
  • An evidence-based CME program developed by the
  • New Jersey Academy
  • of Family Physicians

2
Learning Objectives
  • Discuss current guidelines for managing chronic
    obstructive pulmonary disease (COPD)
  • Differentiate the COPD patient from those with
    asthma or other pulmonary diseases
  • Describe the usefulness of spirometry in
    diagnosing and managing COPD
  • Outline a comprehensive stepwise treatment plan
    for COPD

3
Epidemiology of COPD
  • The fourth leading cause of death in people over
    age 45
  • 120,000 deaths attributed to COPD in the year
    2000

Calverley PM, Walker P. Lancet.
2003362(9389)1053-1061. Global Strategy for the
Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease. Global Initiative
for Chronic Obstructive Lung Disease. http//www.g
oldcopd.com. National Heart, Lung, and Blood
Institute. COPD Data Fact Sheet, 2003.
http//www.nhlbi.nih.gov/health/public/lung/other/
copd_fact.htm
4
Percent Change in Age-Adjusted Death Rates, U.S.,
1965-1998
Proportion of 1965 Rate
5
Epidemiology of COPD
  • It is projected that by 2020, COPD will have
    become the third leading cause of death in the
    United States and worldwide
  • In 2000, for the first time, more women than men
    died of the disease

National Heart, Lung, and Blood Institute. COPD
Data Fact Sheet, 2003. http//www.nhlbi.nih.gov/h
ealth/public/lung/other/copd_fact.htm Murray CJ,
Lopez AD. Lancet. 1997349(9064)1498-1504.
6
Epidemiology of COPD
  • Direct medical costs were an estimated 20.9
    billion in 2004
  • More than 85 of cases arise from prolonged
    exposure to tobacco smoke
  • Morbidity and Mortality 2004 Chart Book on
    Cardiovascular, Lung, and Blood Diseases 2004.
  • http//www.nhlbi.nih.gov/resources/docs/cht-book.h
    tm.
  • Global Strategy for the Diagnosis, Management,
    and Prevention of Chronic Obstructive
  • Pulmonary Disease. Global Initiative for Chronic
    Obstructive Lung Disease.
  • http//www.goldcopd.com.

7
Epidemiology of COPD Risk Factors
  • Prolonged exposure
  • to tobacco smoke
  • Exposure to occupational
  • dusts and chemicals
  • Exposure to air pollution
  • Airway hyper-responsiveness
  • Asthma
  • Genetic factors

8
COPD Definition and Symptoms
Airflow limitation that is not fully reversible,
associated with an abnormal inflammatory response
to noxious particles or gases.
Dyspnea with activity
Chronic cough
Sputum production
Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary
Disease. Global Initiative for Chronic
Obstructive Lung Disease. http//www.goldcopd.com.

9
COPD Symptoms and Findings
  • Chronic cough
  • Sputum production
  • Dyspnea
  • Hypoxemia
  • Hypercapnia
  • Pulmonary hypertension
  • Cor pulmonale
  • Weight loss
  • Effort intolerance
  • Waking at night
  • Ankle swelling
  • Fatigue

10
The Natural History of COPD
  • A progressive disease, especially if exposure to
    the inciting agent (usually tobacco smoke)
    continues
  • Stopping exposure will slow or even halt further
    progression

11
COPD Guidelines
  • The Global Initiative for Chronic
  • Obstructive Lung Disease (GOLD)
  • Management Components
  • Assess and monitor the disease
  • Reduce risk factors
  • Manage stable COPD
  • Manage COPD exacerbations

12
COPD Guidelines Differential Diagnosis
  • COPD is under-diagnosed and often misdiagnosed
  • 16 million Americans have been diagnosed with
    COPD
  • An estimated 30 million actually have the disease
  • GOLD differentiates COPD from emphysema and
    chronic bronchitis
  • Similarities in symptoms and clinical
    presentation between COPD and asthma and other
    pulmonary diseases
  • Confronting COPD in America.
  • http//www.lungusa.org/press/lung_dis/asn_copd2160
    1.html.
  • Frontline Treatment of COPD A Monograph for
    Primary Care Physicians.
  • Snowdrift Pulmonary Conference 2000.

13
COPD Guidelines Differential Diagnosis
  • Symptoms
  • Age of onset
  • Tobacco use
  • Airway hyper-responsiveness
  • Progression of symptoms
  • Airflow limitation

14
Differential Diagnosis COPD and Other
Cardiopulmonary Diseases
15
Differential Diagnosis COPD and Other
Cardiopulmonary Diseases
16
COPD Guidelines Spirometry
  • Should be used to help confirm a diagnosis of
    COPD
  • Normalized for age, gender and height
  • Measures the volumes of air a patient exhales as
    a function of time

17
Differential Diagnosis Spirometry
  • FVC the forced vital capacity, the maximal
    volume exhaled after a maximal inhalation
  • FEV1 the forced expiratory volume in 1 second
  • FEV1/FVC the ratio of forced vital capacity to
    forced expiratory volume in 1 second

18
Differential Diagnosis Spirometry

19
Practice Recommendation
Spirometry, in addition to clinical examinations,
improves COPD diagnostic accuracy compared
to clinical examination alone and it is a useful
diagnostic tool in individuals with symptoms
suggestive of possible COPD.
The evidence supporting this recommendation is
based on a meta-analysis of seven randomized
controlled trials. EBM Source Wilt TJ,
Niewoehner D, Kim C-B, et al. Use of Spirometry
for Case Finding, Diagnosis, and Management of
Chronic Obstructive Pulmonary Disease (COPD).
Evidence Report/Technology Assessment No. 121.
Agency for Healthcare Research and Quality.
September 2005. http//www.ahrq.gov/downloads/pub/
evidence/pdf/spirocopd/spiro.pdf
20
COPD Guidelines Ways to Ensure Proper
Spirometry Technique
  • Explain test to patient
  • Prepare patient through instruction and
    demonstration
  • Help patient maintain correct posture
  • Make sure patient inhales completely
  • Make sure patient exhales as forcefully and as
    long as possibleat least six seconds
  • Make sure patient keeps lips sealed
  • Confirm acceptability criteria are met
  • Record at least three acceptable maneuvers

21
The GOLD Classification of COPD Severity
22
The GOLD Classification of COPD Severity
23
The Goals of an Effective COPD Management Plan
  • Prevent disease progression, in most cases
    through smoking cessation
  • Relieve symptoms
  • Improve exercise intolerance
  • Improve health status
  • Prevent and treat complications
  • Prevent and treat exacerbations
  • Reduce mortality

24
Prevention of COPD Progression Smoking Cessation
  • Smoking cessation is paramount not only in
    reducing the risk of developing the disease but
    also in halting or slowing its progression.

25
Prevention of COPD Progression Smoking Cessation
Anthonisen NR et al. Am J Respir Crit Care Med.
2002166(5)675-679.
26
Smoking Cessation The Five As
  • ASK about tobacco use at each office visit
    implement office-wide documentation
  • ADVISE all patients who smoke to quit
  • ASSESS the patients willingness to quit provide
    motivation
  • ASSIST the patient through counseling and
    referral
  • ARRANGE follow-up to evaluate and encourage

27
Smoking Cessation
  • Promote telephone tobacco quit lines
  • 1-800-QUITNOW

28
Practice Recommendation
Smoking cessation is the single most
effective--and cost-effective-- intervention to
reduce the risk of developing COPD and stop its
progression.
The evidence supporting this recommendation is
based on endpoints of well-designed, randomized
controlled trials that provide a consistent
pattern of finding in the population for which
the recommendation is made. EBM Source Global
Initiative for Chronic Obstructive Lung Disease
(GOLD), World Health Organization (WHO), National
Heart, Lung and Blood Institute (NHLBI). Global
strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary
disease. 2005. National Guideline Clearinghouse.
http//www.guideline.gov/summary/summary.aspx?doc_
id8128nbr004530stringCOPDAND smoking
29
Managing Stable COPD Pharmacologic Treatment
  • Bronchodilators
  • ß2-agonists
  • Anticholinergics
  • Methylxanthines
  • Relax airway smooth muscle and improve lung
    emptying
  • Relatively small changes to FEV1, but larger
    changes in lung volume and a reduced perception
    of breathlessness

30
Stable COPD Bronchodilators
  • Short-acting
  • May be prescribed on a regular/
  • as-needed basis
  • Predictable and dose-dependent side effects
  • Long-acting
  • Convenient dosing and better compliance
  • More effective as maintenance therapy

31
Practice Recommendation
Tiotropium reduces exacerbations and improves
quality of life in stable COPD and can be
recommended for clinical practice, although its
effects require more research, particularly to
see how it compares with other long-acting
bronchodilators.
The evidence supporting this recommendation is
based on 69 identified references and a
meta-analysis of nine randomized controlled
trials involving 6,584 patients. EBM Source
Barr RG, Bourbeau J, Camargo CA, et al.
Tiotropium for stable chronic obstructive
pulmonary disease. The Cochrane Database of
Systematic Reviews. 2006. http//www.cochrane.org
/reviews/en/ab002876.html
32
Management of COPD Treatment Algorithm
33
Stable COPD Second-line Therapy
  • Inhaled Corticosteroids
  • Consider adding for symptomatic patients with
    severe COPD despite maximal bronchodilators
  • Theophylline
  • Can be used in severe COPD patients not fully
    responsive to inhaled bronchodilators
  • Caution and monitoring advised because of low
    therapeutic index

34
COPD Medications Typically Used in the US
35
Stable COPD Pharmacologic Delivery Systems
  • Effectiveness of therapy directly related to
    ability to deliver medication to airways
  • Bronchodilator therapy can usually be
    administered with a hand-held MDI or DPI
  • Physician should instruct, demonstrate, assess
  • Nebulizer may be used as an alternative

36
Stable COPD Vaccines
  • Viral infection may be the cause of one third of
    all COPD exacerbations, paving the way for
    bacterial infections
  • Influenza vaccination is highly effective in
    preventing influenza-related acute respiratory
    illness
  • Pneumococcal vaccination of COPD patients
  • Reduces the number of hospitalizations
  • for pneumonia
  • Reduces mortality rates
  • Lowers medical care costs

37
Stable COPD Vaccines
  • An annual influenza vaccine as well as a
    pneumococcal vaccine should be recommended to all
    patients with COPD.

38
Stable COPD Non-pharmacologic Treatment
  • Oxygen Therapy
  • Improves exercise, sleep and cognitive
    performance in hypoxemic patients
  • Increases survival
  • Initiated in patients with very severe COPD,
    resting oxygen saturation lt 88
  • Goal is to maintain oxygen saturation gt 90
  • Patients should use therapy for 15 20 hours per
    day

39
Stable COPD Non-pharmacologic Treatment
  • Pulmonary Rehabilitation
  • Should include exercise training, education,
    nutrition counseling
  • Can improve quality of life for COPD patients
  • Can be initiated in inpatient, outpatient and
    home settings
  • Should be offered to any patient who is
    symptomatic despite medical therapy
  • Baseline and outcome assessments
  • of patients progress should be made

40
Practice Recommendation
Pulmonary rehabilitation relieves dyspnea and
fatigue and enhances patients sense of control
over their condition. These improvements are
moderately large and clinically significant. The
average improvement in exercise capacity is
modest. Rehabilitation forms an important
component of the management of COPD.
The evidence supporting this recommendation is
based on a meta-analysis of 23 randomized
controlled trials. EBM Source Y Lacasse, L
Brosseau, S Milne, et al. Pulmonary
rehabilitation for chronic obstructive pulmonary
disease. The Cochrane Database of Systematic
Reviews. 2006. http//www.cochrane.org/reviews/en
/ab003793.html
41
Stable COPD Surgical Treatments
  • Bullectomy
  • Lung volume reduction surgery (LVRS)
  • Lung transplantation

42
COPD Exacerbations
  • A sudden and sustained worsening of the COPD
    patients condition
  • The primary cause of urgent medical visits,
    hospital admissions, mortality among COPD
    patients
  • Results in 2.3 billion in direct medical costs
    annually

Niederman MS et al. Clin Ther. 199921(3)576-591.

43
COPD Exacerbations
  • Primary symptomincreased dyspneamay be
    accompanied by wheezing and tightening of chest,
    increased cough and volume of sputum, a change in
    the color of sputum
  • Possible malaise, insomnia, sleepiness, fatigue,
    fever, depression, confusion
  • Most commonly caused by infection of the airways
    and air pollution
  • Assessed through a targeted history and
    physical, spirometry, arterial blood gases or
    pulse oximetry, chest x-ray

44
COPD Exacerbations Indications for Hospital
Assessment or Admission
  • Impaired level of consciousness
  • Acute confusion
  • Sudden onset of resting dyspnea
  • Severe COPD history
  • Failure to respond to initial medical management
    of exacerbation
  • Cyanosis or peripheral edema
  • Significant co-morbidities
  • Newly occurring arrhythmias
  • Uncertain diagnosis
  • Older age
  • Bed confinement
  • Insufficient home support

45
Managing COPD Exacerbations
  • Bronchodilators
  • Short-acting, inhaled ß2-agonists are the
    preferred treatment
  • If no response, an anticholinergic is recommended
  • The role of long-acting inhaled bronchodilators
    in conjunction with short-acting agents has not
    been assessed
  • Use of intravenous aminophylline is controversial
  • In the case of a severe exacerbation or
    inadequate response, a methylxanthine may be
    considered, but requires careful monitoring

46
Managing COPD Exacerbations
  • Corticosteroids
  • Used in addition to bronchodilator therapy, for
    the COPD patient with an exacerbation who is
    admitted to the hospital or who is an outpatient
    with significant increase in breathlessness
  • Safe and efficacious dose 30 to 40 mg oral
    prednisone daily for 10 to 14 days
  • Long-term use not advised

47
Practice Recommendation
Corticosteroids assist the recovery of people
with COPD who experience an acute exacerbation
but there are some side effects of treatment.
The evidence supporting this recommendation is
based on a meta-analysis of 10 randomized
controlled trials. EBM Source Wood-Baker RR,
Gibson PG, Hannay M, et al. Systemic
corticosteroids for acute exacerbations of
chronic obstructive pulmonary disease. The
Cochrane Database of Systematic Reviews.
2006. http//www.cochrane.org/reviews/en/ab001288.
html
48
Managing COPD Exacerbations
  • Antibiotics
  • Have proven beneficial in treating acute
    infective exacerbations of COPD
  • Should be used in patient whose sputum has become
    more purulent, who shows evidence of infiltrate
    on chest x-ray, or who shows clinical signs of
    pneumonia
  • Treatment may include ampicillin, a macrolide, a
    quinilone, or tetracycline

49
Managing COPD Exacerbations
  • Ventilatory support
  • In COPD patients with acute ventilatory failure,
    NIPPV reduces acidosis and PaCO2, and decreases
    dyspnea
  • NIPPV reduces in-hospital mortality, intubation
    rates, length of stay
  • In some patients, conventional endotracheal
    intubation and mechanical ventilation may be
    necessary
  • Physician should have awareness of patients
    wishes and advance directives

50
Managing COPD Exacerbations
  • End-of-life Care
  • Patient Education
  • Self-management

51
Websites for Additional Information on COPD
  • Global Initiative for Chronic Obstructive
  • Lung Disease (COPD) www.goldcopd.com
  • Canadian Thoracic Society www.lung.ca/cts
  • American Thoracic Society www.thoracic.org
  • National Institute for Health
  • and Clinical Excellence
  • www.nice.org.uk
  • American Academy of Family Physicians
  • Tar Wars Program
  • www.tarwars.org

52
Conclusions
  • COPD is an enormous public health problem that
    can be addressed only with increased public
    awareness, improved delivery of care, and
    effective therapies
  • The family physician is uniquely positioned as
    the point of first contact for COPD patients
  • New guidelines provide an excellent framework for
    diagnosing and managing
    COPD
About PowerShow.com