COPD Management GOLD Guidelines

Dr.Tasleem ArifDept. of Chest Medicine

SKIMS MC/H BEMINA SGR KMR

Goals• Prevent disease progression• Relieve symptoms• Improve exercise tolerance• Improve health status• Prevent and treat complications• Prevent and treat exacerbations• Reduce mortality• Prevent or minimize side effects from

treatment• Cessation of cigarette smoking

Components

• Assess and monitor disease• Reduce risk factors• Manage stable COPD• Manage acute exacerbations

Assess and Monitor Disease

Initial Visit• Pattern of symptom development• Exposure to risk factors• History of exacerbations or previous

hospitalizations for respiratory disorder• Past medical history• Family history• Social history

• Impact of disease on patient’s life• Effect on family routines• Feelings of depression or anxiety• Social and family support available to the

patient• Possibilities for reducing risk factors,

especially smoking cessation

Testing

• Spirometry• Initially and yearly

• ABG• Obtain if FEV1 < 40% predicted OR • Clinical signs of respiratory or right heart

failure• Respiratory Failure

• Alpha-1 antitrypsin• If patient <45 years old or strong family

history of COPD

Follow-Up Visits• Discuss new or worsening symptoms

• Perform spirometry if there is a substantial increase in symptoms OR if a complication occurs

• ABG• Patients with an FEV1 <40% predicted• Early signs of respiratory failure or CHF

• Monitor pharmacotherapy• Dosages• Adherence• Inhaler technique• Effectiveness of current regimen at

controlling symptoms• Side effects of treatment

Follow-up Visits• Monitor co-morbid conditions

• Bronchial carcinoma• Tuberculosis• Sleep apnea• Left heart failure

• Obtain appropriate information through CXR, ECG whenever symptoms suggest one of these conditions

Reduce Risk Factors

Risk Factors

• Tobacco smoke• Occupational dusts and

chemicals• Indoor and outdoor air

pollutants

Smoking Cessation• The single MOST effective and cost-effective

intervention to reduce the risk of developing COPD and to stop its progression• Offer this at EVERY visit to the health care

provider• Brief 3 minute period of counseling

• Three types of counseling are esp. effective:• Practical counseling• Social support as part of the treatment• Social support arranged outside of the treatment

• 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• Nicotine gum, inhaler, nasal spray, trasndermal

patch, sublingual tablet, lozenges• Bupropion• nortriptyline

Ask Systematically identify all tobacco users at every visit

Advise

Strongly urge all tobacco users to quit, in a clear, strong, and personalized manner

Assess

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 quittinge.g. quit plan, counseling, intra-treatment social support, extra-treatment social support, approved pharmacotherapy, supplementary materials

Arrange

Schedule a follow-up contact, either in person or via telephone

Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.

Smoking Prevention – What you can do as a provider:• Encourage comprehensive tobacco-

control policies and programs• Work with government officials to

pass legislation to establish smoke-free schools, public facilities, and work environments

• Encourage patients to keep smoke-free homes

Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.

Occupational Exposures

• Primary prevention• Eliminate or reduce exposures to

various substances in the workplace

• Secondary prevention• Surveillance and early detection

Indoor and Outdoor Air Pollution• Implement measures to reduce or avoid

indoor air pollution from biomass fuel burned for cooking and heating in poorly ventilated dwellings

• Advise patients to monitor public announcements of air quality

• Avoid vigorous exercise outdoors or stay indoors during pollution episodes, depending on COPD severity

Manage Stable COPD

General Principles• Determine disease

severity• Implement step-

wise treatment plan • Educate the patient

• Improve skills• Improve ability to

cope with illness• Improve health

status

• Prescribe Treatment• Pharmacologic• Non-

pharmacologic• Rehabilitation

− Exercise training

− Nutrition counseling

− education − Oxygen therapy

• Surgical interventionsGOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Stage Characteristics

0:At Risk

Normal spirometryChronic symptoms (cough, sputum)

I: Mild

FEV1/FVC < 70%

FEV1 >= 80% predicted

Usu. Chronic cough and sputum productionII: Moderate

50% <= FEV1 < 80% predicted

Progression of symptoms; dyspnea on exertion

III:Severe

30%<= FEV1 < 50% predicted

↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life

IVVery severe

FEV1< 30% predicted ORFEV1<50% predicted + chronic respiratory failure•Quality of life is appreciably impaired•Exacerbations may be life-threatening

Patient Education• Smoking cessation• Basic information about COPD and pathophysiology

of the disease• General approach to therapy and specific aspects

of medical treatment• Self-management skills• Strategies to help minimize dyspnea• Advice about when to seek help• Self-management and decision-making in

exacerbations• Advance directives and end-of-life issues

Medications• Goals

• Prevent and control symptoms• Reduce frequency and severity of exacerbations• Improve health status• Improve exercise tolerance

• No existing medications can modify the long-term decline in lung function

• Reduction of therapy once symptom control occurs is not normally possible

• COPD is progressive and over time will require progressive introduction of more treatments to attempt to limit the impact of these changes

Bronchodilators• Central to symptom management

• Used in all stages of COPD severity• Inhaled forms are preferred• Can be prescribed as needed OR regularly

to prevent or reduce symptoms• Long-acting inhaled bronchodilators are

more effective and convenient (but are more expensive)

• Combining drugs with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects

• All categories of bronchodilators have been show to increase exercise capacity without necessarily producing significant changes in FEV1

Bronchodilators• Beta2-agonists

• Short-acting: albuterol• Long-acting: salmeterol (Serevent™), formoterol

(Foradil™)• Anticholinergics

• Short acting: ipratropium bromide (Atrovent™)• Long acting: tiotropium bromide (Spiriva™)

• Methylxanthines (Theophylline™)

• Combination bronchodilators• Fenoterol/ipratropium (Duovent™)• Salbutamol/ipratropium (Combivent™)

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Glucocorticosteroids• Use if FEV1 < 50% predicted and repeated

exacerbations, e.g. three in the last three years• Severe COPD and Very Severe COPD

• Does not modify the long-term decline in FEV1 BUT does reduce the frequency of excacerbations and improves health status

• The combination of a long-acting beta2-agonist and an inhaled glucocorticosteroid is more effective than the individual components

• Long-term treatment with oral glucocorticoids is NOT recommended

Inhaled Glucocorticoids

• Beclomethasone (Vanceril™)• Budesonide (Pulmicort™)• Fluticasone (Flovent™)• Triamcinolone (Azmacort™)

Immunizations• Vaccines

• Influenza yearly•Reduces serious illness and death in COPD patients by approximately 50%

•Give once yearly: autumn OR twice yearly: autumn and winter

• Pneumovax •Sufficient data to support its general use in COPD is lacking, but it is commonly used

Other Medications?• Alpha-1 Antitrypsin Augmentation Therapy

• Only if this deficiency is present in an individual should they undergo treatment

• Antibiotics• Prophylactic use is NOT recommended• Can be used in the treatment of infectious

exacerbations of COPD• Mucolytic agents

• Overall benefits are small, so currently not recommended for widespread use

• Types:• Ambroxol• Erdosteine (Erdostin, Mucotec)• Carbocysteine (Mucodyne)• Iodinated gylerol (Expigen)

• Antioxidant agents• N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst)• Have been shown to reduce the frequency of

exacerbations and could have a role in the treatment of patients with recurrent exacerbations• More studies are needed

• Immunoregulators• Not recommended at this time• No reproducible studies are available

• Antitussives• Regular use is contraindicated in stable COPD

since cough has a significant protective role• Vasodilators

• Inhaled nitric oxide• Can worsen gas exchange because of altered hypoxic

regulation of ventilation-perfusion balance and is contraindicated in stable COPD

• Respiratory stimulants• Doxapram (IV)• Almitrine bismesylate

• Not recommended in stable COPD

• Narcotics• Oral and parenteral opioids are effective for

treating dyspnea in patients with advanced COPD

• Use this with caution; benefits may be limited to a few sensitive subjects

• nebulized opioids: insufficient evidence .• Miscellaenous:

• Nedocromil• Leukotriene modifiers• Alternative healing methods

• None have been adequately studied in COPD patients at this time

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Stage 0: At Risk

• Avoid risk factors• Offer influenza vaccination

Stage I: Mild COPD

• Avoid risk factors

• Offer vaccination

• Use short-acting bronchodilators as needed

I: Mild

FEV1/FVC < 70%

FEV1 >= 80% predictedUsu. Chronic cough and sputum production

Stage II: Moderate COPD

• Avoid risk factors• Offer influenza

vaccine• Add short-acting

bronchodilators when needed

• Add regular treatment with 1 or more long-acting bronchodilators

• Add rehabilitation

II: Moderate

50% <= FEV1 < 80% predictedProgression of symptoms; dyspnea on exertion

Stage III: Severe COPD• Avoid risk factors• Offer influenza vaccine• Add short-acting

bronchodilators when needed

• Add regular treatment with 1 or more long-acting bronchodilators

• Add rehabilitation• Add inhaled

glucocorticoids if repeated exacerbations

III:Severe

30%<= FEV1 <50% predicted ↑ dyspnea; repeated exacerbations which have an impact on patients’ quality of life

Stage IV: Very Severe COPD• Avoid risk factors• Offer influenza

vaccination• Add short-acting

bronchodilators as needed

• Add rehabilitation• Add inhaled

glucocorticoids if repeated exacerbations

• Add long-term oxygen if chronic respiratory failure

• Consider surgical treatments

IVVery severe

FEV1< 30% predicted ORFEV1<50%

predicted + chronic respiratory failure•Quality of life is appreciably impaired•Exacerbations may be life-threatening

Non-Pharmacologic Therapy

Rehabilitation• COPD patients at all stages of severity benefit from exercise

training programs• Improves both exercise tolerance and symptoms of dyspnea and

fatigue• Goals

• Reduce symptoms• Improve quality of life• Increase physical and emotional participation in everyday activities

• Comprehensive program should include several types of health professionals:• Exercise training• Nutrition counseling• Education

• Minimum effective length of time = 2 months• Setting: inpatient OR outpatient OR home• Baseline and outcome assessments of each participant

should be made to quantify individual gains and target areas for improvement• Measurement of spirometry before and after a bronchodilator drug• Assessment of exercise capacity• Assessment of inspiratory and expiratory muscle strength and lower limb

strength

Oxygen Therapy• Stage IV - Severe COPD who have

• PaO2 at or below 55 mm Hg or SaO2 at or below 88% with or without hypercapnia OR

• PaO2 between 55-60 mm Hg or SaO2 88% IF pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (Hct > 55%)

• Based on awake PaO2 values

• GOAL• Increase baseline PaO2 to at least 60 mm Hg at

sea level and rest and/or produce SaO2 at least 90%

• Need to use at least 15 hours per day in patients with chronic respiratory failure to improve survival

• Can have a beneficial impact on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state

Surgical Treatment• Bullectomy

• Effective in reducing dyspnea and improving lung function in appropriately selected patient

• Lung volume reduction surgery• Parts of the lung are resected to reduce

hyperinflation• Does not improve life expectancy• Does improve exercise capacity in patients with

predominantly upper lobe emphysema and a low post-rehabilitation exercise capacity

• May improve global health status in patients with heterogeneous emphysema

• High hospital costs; still experimental/palliative

Surgical Treatment• Lung transplantation

• Improves quality of life and functional capacity in appropriately selected patient

• Criteria for referral:• FEV1 < 35% predicted• PaO2 < 55-60 mm Hg• PaCO2 > 50 mm Hg• Secondary pulmonary

hypertension• All four criteria must be present

COPD Patients and Surgery• Increased risk of post-operative

pulmonary complications• Risk of complications increases as

the incision approaches the diaphragm

• Epidural and spinal anesthesia have a lower risk than general anesthesia

• Postpone surgery if the patient has a COPD exacerbation

Manage Exacerbations

General Points• Most common causes of exacerbations are:

• Infection of the tracheobronchial tree• Air pollution• In 1/3 of severe exacerbations a cause cannot be identified

• Inhaled bronchodilators, theophylline, and systemic (preferably oral) glucocorticosteroids are effective treatments

• Patients with clinical signs of airway infection may benefit from antibiotic treatment• Increased volume of sputum• Change in color of sputum• Fever

• Non-invasive intermittent positive pressure ventilation (NIPPV) in exacerbations is helpful:• Improves blood gases and pH• Reduces in-hospital mortality• Decreases the need for invasive mechanical ventilation and

intubation• Decreases the length of hospital stay

Diagnosis and Assessment of Severity

• History• Increased breathlessness• Chest tightness• Increased cough and sputum• Change of color and/or tenacity of

sputum• Fever• Non-specific:

• Malaise, insomnia, sleepiness, fatigue, depression, or confusion

Assessment of Severity• Lung Function Tests

• PEF < 100 L/min. or FEV1 < 1 L = severe exacerbation

• Arterial Blood Gas• PaO2 < 60 mmHg and/or

SaO2 < 90% with or without PaCO2 < 50 mmHg when breathing room air = respiratory failure

• Chest x-ray• Look for complications

• Pneumonia• Alternative diagnoses

• ECG• Right ventricular

hypertrophy• Arrhythmias• Ischemia

• Sputum• Culture/sensitivity

• Comprehensive Metabolic Profile• Assess for electrolyte

disturbances, diabetes• Albumin to assess

nutrition

PLACE OF RX

• Home?• Hospital admission?

• Floor?• ICU?

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Indications for Hospital Admission

• Marked increase in intensity of symptoms such as sudden development of resting dyspnea

• Severe background COPD• Onset of new physical signs

• Cyanosis, peripheral edema• Failure of exacerbation to respond to initial

medical management• Significant co-morbidities• Newly occurring arrhythmias• Diagnostic uncertainty• Older age• Insufficient home support

Indications for ICU Admission• Severe dyspnea that responds

inadequately to initial emergency therapy

• Confusion, lethargy, coma• Persistent or worsening hypoxemia

(PaO2 < 40 mm Hg) and/or • Severe/worsening hypercapnia

(PaCO2 > 60 mm Hg) and/or • Severe/worsening respiratory

acidosis (pH < 7.25) despite supplemental oxygen and NIPPV

• NIPPV = non-invasive positive pressure ventilation

Management of Exacerbations• Risk of dying from an

exacerbation is closely related to:• Development of respiratory

acidosis• Presence of significant co-

morbidities• Need for ventilatory support

Severe Exacerbation, Non Life Threatening

• Assess severity of symptoms• Obtain arterial blood gas and chest x-ray• Administer controlled oxygen therapy

• Repeat ABG after 30 minutes• Bronchodilators• Glucocorticosteroids• Consider antibiotics• Consider non-invasive mechanical

ventilation• Monitor fluid balance and nutrition• Consider subcutaneous heparin therapy• Identify and treat associated conditions

(CHF, arrhythmias)

Management of COPD Exacerbations

• Controlled oxygen therapy• Administer enough to maintain PaO2 > 60 mmHG

or SaO2 > 90%• Monitor patient closely for CO2 retention or

acidosis• Bronchodilators (inhaled)

• Increase doses or frequency• Combine ß2 agonists and anticholinergics• Use spacers or air-driven nebulizers• Consider adding IV methylxanthine

(aminophylline) if needed

Management of COPD Exacerbations

• Glucocorticosteroids (oral or IV)• Recommended as an addition to bronchodilator therapy• If baseline FEV1 < 50% predicted

• 30-40 mg oral prednisolone x 7-10 days OR nebulized budesonide (Pulmicort™)

• Antibiotics• IF breathlessness and cough are increased AND sputum

is purulent and increased in volume• Choice of antibiotics should reflect local antibiotic

sensitivity for the following microbes:• S. pneumoniae• H. influenzae• M. catarrhalis

Management of COPD Exacerbations

• Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing > 25 mL sputum per day OR with lobar atelectasis.

Management of COPD Exacerbations

• Ventilatory Support• Decrease mortality and morbidity• Relieve symptoms• Used most commonly in Stage IV, Very

Severe COPD• Forms:

• Non-invasive using negative or positive pressure devices

• invasive/mechanical with oro- or naso-tracheal tube OR tracheostomy

NIPPV

• Success rates of 80-85%• Increases pH, reduces PaCO2,

reduces severity of breathlessness

• Decreases length of hospital stay

• Decreases mortality/intubation rate

NIPPV (C-PAP, Bi-PAP)

• Selection criteria• Moderate to severe dyspnea with

use of accessory muscles and paradoxical abdominal motion

• Moderate to severe acidosis (pH < 7.35) and hypercapnia (PaCO2 > 45 mmHg)

• Respiratory frequency > 25 breaths/minute

NIPPV• Exclusion criteria

• Respiratory arrest• Cardiovascular instability

• Hypotension• Arrhythmias• Myocardial infarction

• Somnolence, impaired mental status, lack of cooperation

• High aspiration risk – viscous/copius secretions

• Recent facial or gastroesophageal surgery• Cranio-facial trauma, fixed nasopharyngeal

abnormalities• Extreme obesity

Indications for Invasive Mechanical Ventilation

• Severe dyspnea with use of accessory muscles and paradoxical abdominal motion

• Respiratory rate > 35 breaths/minute• Life-threatening hypoxemia: PaO2 < 40 mm Hg• Severe acidosis (pH < 7.25) and hypercapnia

(PaCO2 > 60 mm Hg)• Respiratory arrest• Somnolence, impaired mental status• Cardiovascular complications

• Hypotension/shock/heart failure• Other complications

• Metabolic abnormalities/sepsis/pneumonia/pulmonary embolism/barotrauma/massive pleural effusion

• NIPPV failure

Use of Invasive Ventilation in End-Stage COPD

• Hazards:• Ventilator-acquired pneumonia

• Increased prevalence of multi-resistant organisms• Barotrauma• Failure to wean to spontaneous ventilation

• Mortality among COPD patients with respiratory failure is no greater than mortality among patients ventilated for non-COPD reasons

Discharge Criteria• Inhaled Beta2-agonist use is at most every 4 hours• Patient is able to walk across the room• Patient is able to eat and sleep without frequent

awakening• Patient has been clinically stable for 12-24 hours• ABGs are stable for 12-24 hours• Patient/home caregiver fully understands correct

use of medications• Follow-up and home care arrangements have been

completed• Patient, family, and physician are confident that

patient can manage successfully

Follow-Up Assessment after Hospital Discharge

• 4-6 weeks after discharge• Assess:

• Ability to cope in usual environment• Inhaler technique• Understanding of recommended treatment

regimen• Measure FEV1• Determine need for long-term oxygen

therapy and/or home nebulizer (for patients with very severe COPD, Stage IV)

THANK YOU

REFERENCES• National Heart, Lung, and Blood Institute Data

Fact Sheet for Chronic Obstructive Pulmonary Disease

• GOLD (Global Initiative for Chronic Obstructive Lung Disease) Executive Summary, April 2001

• GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. Updated July 2005. www.goldcopd.org – Accessed August 21, 2006.

• 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.