Julia Rogers MSN RN CNS FNPBC Diagnosis and Overview Therapeutic Options Manage Stable COPD Manage Exacerbations Airway and systemic inflammation Underrecognized underdiagnosed ID: 647804
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Slide1
Current Therapyfor Chronic Obstructive Pulmonary Disease
Julia Rogers, MSN, RN, CNS, FNP-BCSlide2
Diagnosis and OverviewTherapeutic
Options
Manage Stable COPD
Manage
Exacerbations
Slide3
Airway and systemic inflammationUnder-recognized / under-diagnosedThird leading cause of death in United StatesExpected to be third leading cause of death worldwide by 2020.
Chronic Bronchitis
Emphysema
Alpha 1 Anti-
trypsin DeficiencyAsthma Others closely related Cystic Fibrosis Bronchiolitis Bronchiectasis
Chronic Obstructive DiseaseSlide4
Consider COPD if DyspneaChronic CoughSputum productionExposure to riskSpirometry is
REQUIRED
to make diagnosis
DIAGNOSISSlide5
SYMPTOMSCOPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD(http://catestonline.org).
Breathlessness Measurement using the Modified British Medical Research Council (
mMRC
) Questionnaire
: relates well to other measures of health status and predicts future mortality risk.Clinical COPD Questionnaire (CCQ):
Self-administered questionnaire developed to measure clinical control in patients with COPD (http://www.ccq.nl). Slide6
SYMPTOMS
Use
the COPD Assessment
Test(CAT) OR mMRC
Breathlessness scale OR Clinical COPD Questionnaire (CCQ) Slide7
GOLD Spirometric Classification of COPDStage
Characteristics
I: Mild COPD
FEV1/FVC <70 percent
FEV1 ≥80 percent predictedII: Moderate COPDFEV1/FVC <70 percent50 percent ≤FEV1 <80 percent predicted
III: Severe COPD
FEV1/FVC <70 percent
30 percent ≤FEV1 <50 percent predicted
IV: Very Severe COPD
FEV1/FVC <70 percent
FEV1 <30 percent predicted or FEV1 <50 percent predicted plus chronic respiratory failureSlide8
GOLD Classification of COPD
Patient
Characteristic
Spirometric Classification
Exacerbations per year
mMRC
CAT
A
Low Risk
Less Symptoms
GOLD 1-2
≤ 1
0-1
< 10
B
Low Risk
More Symptoms
GOLD 1-2
≤ 1
>
2≥ 10CHigh Risk Less SymptomsGOLD 3-4> 20-1< 10DHigh RiskMore SymptomsGOLD 3-4> 2> 2≥ 10
Patient is now in one of
four categories:
A: Les symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high riskSlide9
Diagnosis and Overview
Therapeutic
Options
Manage Stable COPD
Manage Exacerbations Slide10
Relieve SymptomsImprove exercise toleranceImprove health statusPrevent disease progressionPrevent and treat exacerbationsReduce mortality
PHARMOCOTHERAPY GOALS
Reduce
symptoms
Reduce
risk
© 2013 Global Initiative for Chronic Obstructive Lung DiseaseSlide11
Diagnosis and Overview
Therapeutic
Options
Manage Stable COPD
Manage ExacerbationsSlide12
Inhaled BronchodilatorsBeta2–agonistsShort actingLong acting Anticholinergics
Short acting
Long acting
Inhaled steroid
Systemic steroidCombination therapySABA + anticholinergicLABA + corticosteroidsOral BronchodialtorsGlucocorticosteroids
Phosphodiesterase-4 Inhibitor
Methylxanthines
TREATMENTSlide13
Short ActingAlbuterol Pro-Air® HFA – 90 mcgVentolin® HFA – 90mcgProventil® HFA – 90mcg
AccuNeb
® 1.25-5mg
Alupent
® MDI .65mg or 4% and 6% nebLevalbuterolXopenex® HFA – 90mcgXopenex ® neb – .63mg -1.25mg
Pirbuterol
Maxair
® - 200mcg
BETA
2
AGONISTSlide14
DosingInhaler 90mcg / metered inhalation dose 2-4 puffs every 4 – 6 hours as needed2-3 puffs 3 to 4 times a day routinelyAlupent Inhaler .65mg 2-3 puffs 3-4 times per day routinely NebulizerAlbuterol 2.5-5mg every 4 -8 hours as neededXopenex® 0.63-1.25mg three times daily (every 6-8 hours)Alupent® 0.4%, 0.6% 3-4 times per day up to every 4 hours
Oral
Albuterol
2-4 mg three to four times daily
Max 8mg four times per day SHORT ACTING BETA2-AGONISTSlide15
RisksOveruse Tremor Reflex tachycardiaPeripheral artery dilationHypokalemia
Benefits
Improves lung function
Short Acting
Increased exercise capacityDecreases dyspneaDecreases coughSHORT ACTING BETA2-AGONISTSlide16
DosingHFA Inhaler 17mcg / metered inhalation dose Ipratropium HFA 2 inhaltions 4 times per day Up to 8 puffs four times per day NebulizerIpratropium Bromide Solution 500mcg/2.5ml three to four times daily SHORT ACTING ANTICHOLINERGICSlide17
Risks Anticholinergic effectTachycardiaBenefits Improves lung function
Short Acting
Increased exercise capacity
Decreases dyspnea
Decreases coughANTICHOLINERGICSlide18
Short Acting Short acting beta agonist and AnticholinergicCombivent Respimat 20mcg/100mcgOne inhalation four times a dayDuonebs 0.5mg/2.5mg / 3mlOne vial 4-6 times per day
COMBINATION THERAPYSlide19
RisksTremorTachycardiaAnxietyHeadacheInsomniaAnticholinergic effect
Benefits
Immediate relief
SHORT ACTING
COMBINATION THERAPYSlide20
DosingSalmeterol (Serevent Diskus®)50mcg - one inhalation twice daily Formoterol (Foradil® Aerolizer®, Perforomist™)12 mcg capsule inhaled every 12 hours via
Aerolizer
™ device
Arformoterol
(Brovana®)Nebulization - 15 mcg twice daily / maximum: 30 mcg/dayIndacaterol® 75mcg one inhaltion daily with neoinhalerLONG ACTING BETA2-AGONISTSlide21
RisksAnxietyTachycardiaIncreased risk of hospitalizationsBenefits
Decrease exacerbations
Improves lung function
Improves health-related quality of life
Possibly decrease in mortalityLONG ACTING BETA2-AGONISTSlide22
DosingTiotropiumSpiriva Handihaler ® Dosing-1 capsule (18 mcg) 2 inhalations of one capsule once daily using HandiHalerAclidinium BromideTurdoza Pressair
®
400mcg one inhalation twice a day.
LONG ACTING ANTICHOLINERGICSlide23
RisksAnticholinergic effectDO NOT use if patient has narrow angle glaucomaBronchospasms
Benefits
Improves lung function
Decreases hyperinflation
Decreases dyspneaDecreases exacerbationsSlows decline in FEV1LONG ACTING ANTICHOLINERGIC THERAPYSlide24
TheophyllineMain purpose is in refractory COPDLeast preferredToxicityNot much benefitAdd on therapyDosage
10 mg/kg per day
Up to 300mg daily for initial dose
Twice a day dosing
MonitoringPeak serum levels3-7 hours after morning doseNormal serum levels 8-12mcg / mlOnce patient is within normal limits check every 6 monthsMETHLYXANTHINESlide25
DosingFluticasone (Flovent® Diskus®; Flovent® HFA)Flovent HFA 44mcg 110mcg 220mcg Flovent Diskus 50mcg 100mcg 250mcgone inhalation twice dailyBudesonide
Pulmicort
Flexihaler
® 90mcg or 180mcg two inhalations twice a day Pulmicort respules®.25mg or .5mg or 1mg per nebulizer 1 vial once dailyInhaled GlucocorticoidSINGLE THERAPYSlide26
DosingMometasone / Formoterol HFADulera 100/5mcg or 200/5mcg Two inhaltions twice a day Budesonide / Formoterol HFASymbicort 80/4.5mcg or 160/4.5 mcg
Two inhalation twice a day
Fluticasone
with
Salmeterol HFA DiscusAdvair Discus 100/50mcg, 250/50mcg,,500/50mcg one inhalation bidAdvair HFA 45/21mcg, 115/21mcg, 230/21mcg two inhalations bidFluticasone with VilanterolBreo Ellipta 100/25mcg DPIOne inhalation once daily Inhaled Glucocorticoid
COMBINATION THERAPYSlide27
RisksIncrease pneumoniaDysphoniaThrushCough Throat irritationReflex
bronchoconstriction
Systemic effects
Benefits
Reduce inflammationDecrease exacerbationsSlows the progression of symptomsMinimal impact on lung functionMinimal impact on mortalityNever use as SOLE therapy
INHALED STEROIDSSlide28
Acute UseExacerbations Chronic UseAvoid If used - start out at minimal amount 1mgNeed objective measurement of improvementSYSTEMIC STEROIDS
Generic name
Brand name
How it is given
Dosage
Methylprednisolone
Medrol
Tablet
4-48 mg
Prednisolone
/
prednisolon
Prelone
Tablet
2.5-60 mg
Prednisone
Deltasone
Tablet
5-60 mgSlide29
RisksSystemic effectsEdemaWeight gainIncreased morbidity and mortalityQuick withdrawal
Benefits
Reduce inflammation
Less dyspnea
Increases exercise capacityQuality vs quantity of lifeImproves lung function – short term useSYSTEMIC STEROIDSSlide30
RomflilastDaliresp 500mcg one tablet dailyPHOSPHODIESTERASE-4 INHIBITORSSlide31
RisksNo change in symptomsBenefits Reduces exacerbation riskIncreased FEV1
Improved quality of life
PHOSPHODIESTERASE-4 INHIBITORSSlide32
Long Acting Beta Agonist plus Inhaled Glucocorticoid plusLong Acting AnticholinergicImproves lung functionImproves quality of lifeReduces hospitalizationsTRIPLE INHALER THERAPYSlide33
Helps symptomsThick tenacious mucusDoes Not help lung functionAgentsGuaifenesin – expectorantAcetylcysteine – mucolyticFluid intake - helpful or hindrance?MUCOACTIVE AgentsSlide34
Azithromycin 250mg once daily Erythromycin 500mg bidMoxafloxacin 400mg dailyIf using antibiotic more than twice in 2 months if chest x-ray was done, get a CTChronic ANTIBIOTIC therapy Slide35
Exercise oximetrySix minute walk testQualificationsSpO2 <88% SpO2 <90% with secondary condition i.e. Heart failureStart at liter flow that increases SpO2 >90%Order portable tankTake into consideration activity level, mobilityOXYGENSlide36
CounselingOral AgentsBuproprionChantix Patches Nicotine tapering systemGumVisualizationMeditationSMOKING CESSATION
MOST IMPORTANTSlide37
InfluenzaH1N1PneumoniaVACCINATIONSSlide38
Physician orderedBenefitsImproves exercise capacityImproves quality of lifeDecreases dyspnea Decreases health care utilizationMay reduce mortalityREHABILITATIONSlide39
Protein calorie malnutritionIncreases mortalityImpairs respiratory functionDiminishes immune competenceReplacementHigh calorie dietary supplementsMegace AcetateNUTRITIONSlide40
OpiatesSevere dyspnea Anti-anxietyAnxiety related to dyspnea in late stages of diseasePsychoactiveDepression and anxiety related to disease processSurgery Lung reductionTransplantAlpha1 Antitrypsin treatmentOTHER TREATMENTSlide41
Palliative care End of Life Hospice care Communication with advanced COPD patients about end-of-life care and advance care planning gives patients and their families the opportunity to make informed decisions.OTHER TREATMENTSlide42
Exacerbations per year> 2
1
0
mMRC
0-1
CAT < 10
GOLD 4
mMRC
>
2
CAT
>
10
GOLD 3
GOLD 2
GOLD 1
SAMA prnor SABA prnLABA or LAMAICS + LABAor LAMAManage Stable COPD: Pharmacologic TherapyRECOMMENDED FIRST CHOICEABDCICS + LABAand/or LAMA© 2013 Global Initiative for Chronic Obstructive Lung DiseaseSlide43
Exacerbations per year> 2
1
0
mMRC
0-1
CAT < 10
GOLD 4
mMRC
>
2
CAT
>
10
GOLD 3
GOLD 2
GOLD 1 LAMA or LABA orSABA and SAMALAMA andLABALAMA and LABA orLAMA and PDE4-inh orLABA and PDE4-inh Manage Stable COPD: Pharmacologic TherapyALTERNATIVE CHOICEABDCICS + LABA and LAMA orICS + LABA and PDE4-inh orLAMA and LABA orLAMA and PDE4-inh© 2013 Global Initiative for Chronic Obstructive Lung DiseaseSlide44
Exacerbations per year> 2
1
0
mMRC
0-1
CAT < 10
GOLD 4
mMRC
>
2
CAT
>
10
GOLD 3
GOLD 2
GOLD 1 TheophyllineSABA and/or SAMATheophylline SABA and/or SAMATheophyllineManage Stable COPD: Pharmacologic TherapyOTHER CHOICESABDCCarbocysteineSABA and/or SAMATheophylline© 2013 Global Initiative for Chronic Obstructive Lung DiseaseSlide45
COPD
EXACERBATIONS
Diagnosis and Overview
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Slide46
Defined as an acute event characterized by worsening of symptoms beyond ormal day-to-day variations.Dyspnea CoughSputumFever
Wheeze
Assessment is key
Most exacerbations from bacterial or viral infection. (50-60%)
Some are related to serious medical conditions. (30%)Congestive Heart FailureAspirationPulmonary Embolus (20%)Environmental Conditions (10%)ACUTE EXACERBATIONSSlide47
Assess severity of symptoms blood gases, chest X-rayAdminister controlled oxygen therapy and repeat arterial blood gas measurement after 30-60 minutesBronchodilators: Increase doses and/or frequency Combine 2-agonists and anticholinergicsConsider adding intravenous methylxanthinesAdd glucocorticosteroidsConsider antibiotics when signs of bacterial infectionConsider noninvasive mechanical ventilation
ER TREATMENT
346*Slide48
PHARMACOLOGICAL THERAPY
Treatment Goals
Determine / eliminate cause
Optimize lung function
Improve oxygenationSecretion clearancePrevent complicationsSlide49
Mainstay therapy is short-acting beta agonistsAlbuterolRapid onsetBronchodilationNebulizer 1.25-5mg (diluted to 3ml with normal saline)Use every 1-4 hours as neededMetered Dose Inhaler4-8 puffs (90mcg / puff) every 1-4 hours as needed
Inhaled Bronchodilators
BETA AGONISTSlide50
Short-Acting anticholinergics used with Short-acting beta agonistsAlbuterol/Ipratropium Increased bronchodilation when used together Nebulizer500 mcg every 4 hours as neededMetered Dose Inhaler2 puffs (18mcg / puff) every 4 hours as needed
Inhaled Bronchodilators
ANTICHOLINERGICSlide51
Improves lung functionReduces hospital stayTreat for 7-10 daysIVSevere exacerbationsORALRapid absorption
INHALED
When IV steroid stopped transition to inhaled
GLUCOCORTICOIDSSlide52
IVMethylprednisolone 60mg -125mg two to four times per dayDexamethasone .75-9 mg per day in divided doses every 6-12 hours ORALPrednisone 30mg-40mg daily tapering dose over 10-14 days INHALEDOne inhalation twice dailyGLUCOCORTICOIDSSlide53
Three cardinal symptoms Increased dyspneaIncreased sputum volumeIncreased sputum purulence Mechanically ventilated patients. ANTIBIOTICSSlide54
Use for 5-14 daysUncomplicated Advanced MacrolideAzithromycin, ClarithromycinCephalosporinCefuroxime, Cefpodoxime, CefdinirDoxycycline
Trimethoprim
/
Sulfamethoxazole
ComplicatedFluoraquinoloneMoxifloxicin, Gemifloxacin, LevofloxacinAmoxicillin / Clavulanate If no better in 48 hours re-evaluateANTIBIOTICSSlide55
GroupDefinitionMicroorganisms
Group A
Mild exacerbation:
No risk factors for
poor outcomeH. Influenzae S. pneumoniae
M.
Catarrhalis
Chlamydia
Pneumoniae
Viruses
Group B
Moderate
exacerbation with
risk factor(s) for
poor outcome
Group A plus,
presence of
resistant organisms
(B-
lactamase producing,penicillin-resistant S. pneumoniae), Enterobacteriaceae(K.pneumoniae,E. coli, Proteus, Enterobacter)Group CSevereexacerbation withrisk factors forP. aeruginosainfectionGroup B plus:P. aeruginosaPOTENTIAL MICROORGANISMS Slide56
Oral TreatmentAlternative OralTreatment
Parenteral
Treatment
Group A
Patients withonly onecardinalsymptomc
should not
receive
antibiotics
If indication then:
B -
lactam
(Penicillin,
Ampicillin
/
Amoxicillind
)
Tetracycline
Trimethoprim
/
Sulfamethoxazole
B-
lactam/B- lactamaseinhibitor(Co-amoxiclav)Macrolides(Azithromycin,Clarithromycin,Roxithromycine)Cephalosporins- 2nd or 3rdGenerationKetolides(Telithromycin)ANTIBIOTIC TREATMENTSlide57
Oral TreatmentAlternative Oral TreatmentParenteral
Treatment
Gr
oup
B B-lactam/B-lactamase
inhibitor
(Co-
amoxiclav
)
Fluoroquinolone
(
Gemifloxacin
,
Levofloxacin
,
Moxifloxacin
)
B-
lactam
/
B-
lactamaseinhibitor(Co-amoxiclav,ampicillin/sulbactam)Cephalosporins- 2nd or 3rdgenerationFluoroquinolone(Levofloxacin,Moxifloxacin)ANTIBIOTIC TREATMENTSlide58
Oral TreatmentAlternative OralTreatment
Parenteral
Treatment
Gr
oup CIn patients at riskfor pseudomonasinfections:
Fluoroquinolone
(Ciprofloxacin,
Levofloxacin
-
high
dosef
)
Fluoroquinolone
(Ciprofloxacin,
Levofloxacin
-
high
dosef
)
or
B-
lactam withP.aeruginosaactivityANTIBIOTIC TREATMENTSlide59
Assess at Follow-Up Visit 4-6 Weeks After Discharge from HospitalAbility to cope in usual environment Measurement of FEV1Reassessment of inhaler techniqueUnderstanding of recommended treatment regimenNeed for long-term oxygen therapy and/or home nebulizer
FOLLOW UP OFFICE VISITSlide60
Estimated 14% of patients admitted with an exacerbation will die within 3 months.Baseline changesPROGNOSISSlide61
References available upon requestE-Mail juliarogersnp@gmail.comQUESTIONS