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FEV1/FVC < 70% FEV1/FVC < 70% 30% < FEV1 < 50% predicted FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic respiratory failure. Consider surgical treatments
Definition of COPD
COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.
INFLAMMATION
DIABETES
OSTEOPOROSIS
GASTROINTESTINAL DISORDER
Agusti AG, et al. Eur Respir J. 2003;21:347-360. Agusti A. Proc Am Thorac Soc. 2007;4:522-525.
16.5
15 12.6
Percent of Subjects
IHD = ischaemic heart disease CHF = congestive heart failure RF = respiratory failure PVD = pulmonary vascular disease TM = thoracic malignancy
12 10 8 6
11
9.8
COPD No COPD
4 2 0
Hypertension IHD Diabetes Pneumonia CHF RF
2.9
3.6 1.6
3 0.4
PVD
2.6
1
TM
Reproduced with permission of Chest, from Comorbidity and Mortality in COPDRelated Hospitalizations in the United States, 1979 to 2001, Holguin F et al, Vol 128, pp 2005-2011, Copyright 2005.
35 30 25 20 15 10 5 0
RF
IHD = ischaemic heart disease CHF = congestive heart failure RF = respiratory failure PVD = pulmonary vascular disease TM = thoracic malignancy
25 22 22.5 19 14 12 10
COPD
No COPD
13
8.5
12 6.5
11
10 5 3
IHD
Hypertension
TM
Diabetes
PVD
Reproduced with permission of Chest, from Comorbidity and Mortality in COPDRelated Hospitalizations in the United States, 1979 to 2001, Holguin F et al, Vol 128, pp 2005-2011, Copyright 2005.
Higher Mortality
7 7
EFFECTS
Systemic inflammation
Cardiovascular comorbidity
Exacerbation symptoms
Dynamic hyperinflation
Reprinted from The Lancet, 370, Wedzicha JA, Seemungal TA, COPD exacerbations: defining their cause and prevention, 786-796, Copyright 2007, with permission from Elsevier.
8 8
Parenchymal Destruction
Loss of alveolar attachments Decrease of elastic recoil
AIRFLOW LIMITATION
Genes
Infections Socio-economic status
Aging Populations
Diagnosis of COPD
SYMPTOMS shortness of breath chronic cough sputum
A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation. Where possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly.
FVC
FEV1 = 4L
Volume, liters
3 2
FVC = 5L
FEV1/FVC = 0.8
1
Time, sec
Volume, liters
Obstructive
Time, seconds
Symptoms of COPD
The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production.
Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry Use the COPD Assessment Test(CAT) Assess risk of exacerbations Assess comorbidities or
mMRCBreathlessness scale
CAT:
Tidak ada dahak (riak) sama sekali Tidak ada rasa berat (tertekan) di dada
Saya selalu batuk Dada saya penuh dengan dahak (riak) Dada saya terasa berat (tertekan) sekali Ketika saya jalan mendaki / naik tangga, saya sangat sesak Aktivitas sehari-hari saya di rumah sangat terbatas Saya sangat khawatir keluar rumah karena kondisi paru saya Saya tidak dapat tidur nyenyak karena kondisi paru saya
Assessment of COPD
To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last yearor an FEV1 < 50 % of predicted value are indicators of high risk.
CombinedAssessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry Assess risk of exacerbations
4
(Exacerbation history)
(C)
3
(D)
>2
Risk
(A)
1 mMRC 0-1 CAT < 10
(B)
mMRC>2 CAT >10
Symptoms
(mMRC or CAT score))
Risk
(C) (A)
mMRC 0-1 CAT < 10
(D) (B)
mMRC>2 CAT >10
Symptoms
(mMRC or CAT score))
(C) (A)
(D) (B)
mMRC>2 CAT >10
>2
(Exacerbation history)
Risk
Risk
1 0
mMRC 0-1 CAT < 10
If GOLD 1 or 2 and only 0 or 1 exacerbations per year: Low Risk (A or B) If GOLD 3 or 4 or two or more exacerbations per year: High Risk (C or D)
2
1
Symptoms
(mMRC or CAT score))
(C) (A)
(D) (B)
mMRC>2 CAT >10
>2
(Exacerbation history)
Risk
Risk
1 0
mMRC 0-1 CAT < 10
2
1
Symptoms
(mMRC or CAT score))
4
(Exacerbation history)
(C)
3
(D)
>2
Risk
(A)
1 mMRC 0-1 CAT < 10
(B)
mMRC>2 CAT >10
Symptoms
(mMRC or CAT score))
Risk
< 10
B
C D
GOLD 1-2
GOLD 3-4 GOLD 3-4
1
>2 >2
>2
0-1 >2
10
< 10 10
Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer
These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.
Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude
Additional Investigations
assessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis.
tolerance assessed by walking distance or peak oxygen consumption, weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality.
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler Methylxanthines Inhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhaler Systemic corticosteroids Phosphodiesterase-4 inhibitors
convenient and more effective for symptom relief than short-acting bronchodilators. exacerbations and related hospitalizations and improve symptoms and healthstatus.
pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.
Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1<60% predicted.
beta2-agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD. of pneumonia.
COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis, the phospodiesterase-4 inhibitor (PDE-4), roflumilast, reduces exacerbations treated with oral glucocorticosteroids.
Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1< 40% predicted. The use of antibiotics, other than for treating infectious exacerbations of COPD and other bacterial infections, is currently not indicated.
recommended for patients with COPD that is unrelated to the genetic deficiency.
All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue. Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results.
If exercise training is maintained at home the patient's health status remains above prerehabilitation levels.
oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival in patients with severe, resting hypoxemia.
ventilation (NIV) with long-term oxygen therapy may be of some use in a selected subset of patients, particularly in those with pronounced daytime hypercapnia.
efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity.
In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity.
Identification and reduction of exposure to risk factors are important steps in prevention and treatment. Individualized assessment of symptoms, airflow limitation, and future risk of exacerbations should be incorporated into the management strategy. All COPD patients benefit from rehabilitation and maintenance of physical activity. Pharmacologic therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance.
Manage Stable COPD: Key Points Long-acting formulations of beta2-agonists and anticholinergicsare preferred over shortacting formulations. Based on efficacy and side effects, inhaled bronchodilators are preferred over oral bronchodilators. Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations.
Manage Stable COPD: Key Points Long-term monotherapy with oral or inhaled corticosteroids is not recommended in COPD. The phospodiesterase-4 inhibitor roflumilast may be useful to reduce exacerbations for patients with FEV1 < 50% of predicted, chronic bronchitis, and frequent exacerbations.
Reduce symptoms
Reduce risk
- smoking cessation
- reduction of indoor pollution - reduction of occupational exposure
Influenza vaccination
Patient
Essential
Recommended
Physical activity
B, C, D
Physical activity
Patient
First choice
Alternative Choices
Theophylline
ICS andLAMA or ICS + LABA and LAMA or ICS+LABA and PDE4-inh.or LAMA and LABA or LAMA and PDE4-inh.
>2
GOLD 2 GOLD 1
B
1
ICS and LAMA or ICS + LABA and LAMA or ICS + LABA and PDE4-inh or LAMA and LABA or LAMA and PDE4-inh.
>2
GOLD 2 GOLD 1
B
1
0
mMRC 0-1 CAT < 10 mMRC> 2 CAT > 10
D
>2
GOLD 2 GOLD 1
B
1
0
mMRC 0-1 CAT < 10 mMRC> 2 CAT >10
Manage Exacerbations
An exacerbation of COPD is:
an acute event characterized by a
worsening of the patients respiratory symptoms that is beyond normal dayto-day variations and leads to a change in medication.
Chestradiographs: useful to exclude alternative diagnoses. ECG: may aid in the diagnosis of coexisting cardiac problems. Whole bloodcount: identify polycythemia, anemiaor bleeding. Purulent sputum during an exacerbation: indication to begin
empirical antibiotic treatment. and poor nutrition.
Biochemical tests: detect electrolyte disturbances, diabetes, Spirometric tests:not recommended during an exacerbation.
ManageExacerbations:Treatment Options
ManageExacerbations: TreatmentOptions
Noninvasive ventilation (NIV): Improves respiratory acidosis, reduces respiratory rate, severity of dyspnea, complications and length of hospital stay. decreases mortality and needs for intubation.
GOLD Revision 2011
Manage Comorbidities
COPD often coexists with other diseases
ManageComorbidities
Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation, and hypertension) is a major comorbidity in COPD and probably both the most frequent and most important disease coexisting with COPD. Cardioselective beta-blockers are not contraindicated in COPD.
ManageComorbidities
Osteoporosis and anxiety/depression:often underdiagnosed and associated with poor health status and prognosis.
Serious infections: respiratory infectionsare especially Metabolic syndrome and manifest diabetes: more