Post on 15-Oct-2020
An Update on COPD
John Hurst PhD FRCP FHEA
Professor of Respiratory Medicine
UCL Respiratory
University College London, London, UK
@ProfHurst | j.hurst@ucl.ac.uk
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What is COPD?
What is (and what isn’t) an exacerbation of COPD?
Exacerbation management
Exacerbation prevention
Therapeutic goals in COPD
COPD and Multi-Morbidity
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Outline
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Mortality3 million people/year, 90% in LMIC
Morbidity33 million DALYs lost in LMIC
Economic Loss
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The GOLD Definition of COPD
COPD is a common, preventable and treatable disease that is characterised 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.
WHO/GOLD (www.goldcopd.org)
COPD
Chronic BronchitisEmphysema
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PHYSIOLOGICAL
DIAGNOSIS:
Post-BD FEV1/FVC <0.7
No more ‘average patient’
No more ‘one size fits all’
Not new, but
Technology: genetics, imaging
Communications
Computational Power
[with written patient permission]
Phenotypes in COPD
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[with written patient permission]
Phenotypes and Endotypes in COPD
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ENDOTYPE: Eosinophilic COPD
PHENOTYPE: Frequent Exacerbator
How many people in the UK vape?
→3.6M, about half the number who smoke
How many people who vaped had smoked?
→54% ex, 40% still, 6% never
=216,000 people
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VAPING
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VAPING“The cases demonstrate a heterogeneous collection of pneumonitis patterns that include acute eosinophilic pneumonia, organizing pneumonia, lipoid pneumonia, diffuse alveolar damage and acute respiratory distress syndrome (ARDS), diffuse alveolar hemorrhage, hypersensitivity pneumonitis, and the rare giant-cell interstitial pneumonitis”.
74 year old female
Known IHD
2 hours of central chest pain; no relief from nitrate
Myocardial Infarction?
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Case History
Elevated troponin
74 year old female
Known COPD
2 days of increased breathlessness, no relief from SABA
Exacerbation of COPD?
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Case History
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The GOLD Definition of COPD Exacerbation
an acute worsening of respiratory symptoms that result in additional therapy
WHO/GOLD (www.goldcopd.org)
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What is (and is not) an exacerbation of COPD?
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The real world Definition of COPD Exacerbation
an acute worsening of respiratory symptoms that result in additional therapy, and where other diagnoses have been considered and/or excluded
WHO/GOLD (www.goldcopd.org)
Pulmonary Reserve
Respiratory Failure
Milder COPD
Severe COPD
larger insult
smaller insult
ExacerbationSeverity = COPDSeverity + InsultSeverity + Co-Morbidity
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1990
2000
2010
2020
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Management of an Exacerbation
Oral CORTICOSTEROIDS
Increased dose and/or Frequency of BRONCHODILATORS
ANTIBIOTICS if change in sputum
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Exacerbation Aetiology
Mallia P et al. Am J Respir Crit Care Med 2011;183:734-742.
1990
2000
2010
2020
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Management of an Exacerbation
Oral CORTICOSTEROIDS
Increased dose and/or Frequency of BRONCHODILATORS
ANTIBIOTICS if change in sputum
Additional Therapies eg theophylline
O2
+/-
NIV
Assess and Manage Co-Morbidities
Implement Appropriate Exacerbation Prevention
Hospitalised Exacerbations
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4 25 3% in hospital
mortality% readmission in 30 days
Data from 2014 National COPD Audit
% mortality at
30 days
24 hour review and bundle
Q1: 23.5%
Q2: 33.8%
Q3: 42.3%
Q4: 40.1% (winter)
Q5: 46.0%
Q6: 50.7%
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National Audit and COPD
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Management of Stable COPD
Reduce Symptoms
Maximise Function
Prevent Exacerbations
Preserve Lung Function
Reduce Mortality
London Respiratory ‘Value Pyramid’
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Value in COPD
COPD in Welsh GP Practices, 2014-2015
SYMPTOMS mMRC ≥2
CAT≥10
mMRC 0-1
CAT<10
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Rx
≥2
*
1
0
RISK
Exacerbations
DC
A B A: Low Risk, Fewer Symptoms
B: Low Risk, More Symptoms
C: High Risk, Fewer Symptoms
D: High Risk, More Symptoms
SYMPTOMS mMRC ≥2
CAT≥10
mMRC 0-1
CAT<10
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Rx
≥2
*
1
0
RISK
Exacerbations
DC
A B
4
3
2
1
GOLD
Stage
FEV1
<30%
30-50%
50-80%
>80%
Exacerbation Prevention
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Pharmacological
Inhaled Steroids
LABA
LAMA
Macrolide
Mucolytic
Non-Pharmacological
*Pulmonary Rehab
Vaccination
Volume Reduction
Right Intervention, Right Patient, Right Time: Precision Medicine
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NICE, twicehttps://www.nice.org.uk/guidance/ng115
You are NICE compliant if using
• 5 days of amoxicillin / doxycycline / clarithromycin
• ‘Up to’ 7 days of corticosteroids, and considering safe stop
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NICE exacerbations
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“Triple Therapy”
Eosinophil cut? “Higher”.
https://www.nice.org.uk/guidance/indevelopment/gid-ng10128
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“Triple Therapy”
Eosinophil cut? “Higher”.
https://www.nice.org.uk/guidance/indevelopment/gid-ng10128
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New: Eosinophil-guided therapy
COPD is heterogeneous
Patients with eosinophilic may benefit from ICS/biologicals
Patients WITHOUT can be safely stepped down to LABA-LAMA
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New: Endobronchial Valves
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COPD and Multi-Morbidity
>47x106 hospital discharges in patients with COPD
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Cardiovascular Risk in COPD
Cumulative incidence of first MI Cumulative incidence of first CVA
The diagnosis of COPD requires spirometry
Exacerbation is a clinical diagnosis of exclusion
Management of an exacerbation hasn’t changed much (yet!)
Audit is a powerful driver of quality improvement
Prevention has changed! Optimise prevention.
Most patients with COPD have other problems too – be holistic
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Summary
Interested in clinical research?
Research overseas?
Come and talk to us.
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Research Opportunities
John Hurst PhD FRCP FHEA
Professor of Respiratory Medicine
UCL Respiratory
University College London, London, UK
@ProfHurst | j.hurst@ucl.ac.uk