William P. Saliski Jr. DO Montgomery Pulmonary Consultants

Transkript

1 William P. Saliski Jr. DO Montgomery Pulmonary Consultants

2 Financial Disclosures Astra- Zeneca Regional Speaker Pfizer Regional Speaker

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4 Management of Stable COPD Pharmacotherapy Oxygen Smoking Cessation Vaccinations Rehabilitation Surgery Future Discussions

5 Assessing Severity Staging System (GOLD) Defines disease severity by FEV1 and ratio FEV1/FVC Used as a guide to manage patient therapy

6 Global Ini=a=ve For COPD GOLD Stage I: Mild COPD FEV1 80 % II: Moderate COPD FEV1 between % III: Severe COPD FEV1 between 30-50% IV: Very Severe COPD FEV1 < 30%

7 General Approach Pharmacotherapy - prevent/decrease symptoms - reduce exacerbations - improve health status - improve exercise capacity

8 Short Ac=ng Bronchodilators Beta agonists (SABA) - albuterol, levabuteral, pirbuterol Anticholinergics - ipratropium bromide

9 Short Ac=ng Bronchodilators - Names Albuterol Sulfate - Levalbuterol - Pirbuterol - Proventil HFA Ventolin HFA Proair HFA Xopenex Maxair Ipatroprium Bromide Atrovent Combu- Med - Combivent

10 Beta Agonist Therapy Dosing : 2 Puffs every 4-6 hours as needed 90 mcg/ puff 200 puffs/ canister Side Effects : tremor, reflex tachycardia hypokalemia ( extreme use )

11 An=cholinergic Therapy Dosing 2 puffs 4x/daily - 18 meq/puff puffs/canister Side Effects - dry mouth, constipation? Cardiovascular side effects

12 Combina=on Therapy (Combivent) Dosing 2 puffs 4x/daily Combination therapy increased FEV1 more than either agent alone

13 Long Ac=ng Bronchodilators Salmeterol Serevent (LABA) Formoterol Foradil Arfomoterol Brovana (nebulizer use) Therapy in Gold II IV

14 Beta Agonists (LABA) Dosing both are dry powder used 2x/daily Side Effects same as short acting agents trial) - increase risk of death (Smart

15 Tiotropium Spiriva An=cholinergics (Long Ac=ng) Dosing dry powder 1x/daily Side Effects dry mouth, headache constipation, glaucoma (worsening)

16 Comparison Shopping Foradil> Serevent Spiriva>Foradil>Serevent - Foradil has rapid onset, lasts longer - Spiriva affords better bronchodilation and better side effect profile

17 Bronchodilators Plus Inhaled Glucocor=costeroids (ICS) COPD characterized by airway and systemic inflammation Numerous ICS on the market No real difference in products ICS should not be used as sole therapy

18 Triple Inhaler Therapy Stage III- IV Gold LABA/ICS and tiotroprium bromide Decrease mortality, exacerbations, and hospitalizations

19 Bronchodilator Plus ICS Advair Discus/Advair HFA (Fluticasone/Salmeterol)250 meq/50 mcg 2x/ daily Symbicort 160/4.5 (Budesonide/Formeterol)2 puffs- 2x/daily Side Effects (ICS) oral candidiasis, pneumonia, adrenal suppression

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23 Theophylline Mechanism of action controversial Offers moderate bronchodilation Long acting extended release preps Narrow LD 50 Metabolized in liver Keep serum level 8 to 12 mcg/ml

24 Rarely Used Medica=ons Systemic Glucocorticoids Mucoactive Agents Chronic Antibiotic Therapy

25 Supplemental Therapy Oxygen Secretion Clearance Smoking Cessation Vaccinations Rehabilitation Nutrition

26 Oxygen Therapy Long term oxygen therapy (LTOT) increases survival and improves quality of life Minimal adverse effects (humidify!) Close government regulation 2 billion dollars per year (Medicare)

27 LTOT Indica=ons PaO2 55 mm Hg or SaO2 88 % Cor Pulmonale PaO2 59 mm Hg/SaO2 89 % (Hct > 55 %, EKG - p pulmonale, CHF Desaturation with above numbers w/ exercise or at sleep

28 Prescribing Oxygen Obtain baseline ABG (does O2 Sat correlate?) (is patient hypercarbic?) Keep PaO2 60 to 65 mm Hg Keep SaO2 92% Usually order 2L NC (continuous, exercise, sleep?)

29 Equipment Selec=on Keep your patient mobile Select lightest, most portable Think liquid O2 Oxygen conserving device Oxygen concentrator (bedroom)

30 Secre=on Clearance Postural drainage Flutter valve therapy Hydration?

31 Vaccina=ons Pneumococcal/polysaccharide vaccine COPD 65 yrs old COPD 65 yrs old w/ FEV1< 40% predicted Active tobacco use Give initial vaccine and 5 year booster Does not reduce mortality

32 Vaccina=ons Influenza vaccination given to all patients with COPD Decrease risk of influenza significantly DOES NOT CAUSE THE FLU! Timing?

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34 Clinician advice Smoking Cessa=on Nicotine replacement therapy Buproprion - (Zyban) 150 mg Varenicline (Chantix) 1 mg Combination therapy- best outcome

35 Rehabilita=on Low cost effective program Optimizes physical and social functioning Reduces hospitalization, LOS,? Mortality Medically supervised

36 Rehabilita=on Baptist Medical Center South Anita Jones Covered by Major Medical Insurances

37 Exercise Equipment

38 Nutri=on 30% of patients with severe COPD are protein- calorie malnourished Increase mortality, decrease muscle function, decrease immunity Try high caloric dietary supplements Magestrol acetate (Megace)

39 Surgery Lung Volume Reduction Surgery (LVRS) Reduces lung volume by wedge excision of emphysematous tissue National Emphysema Treatment Trial (NETT) Modest improvements in spirometry, lung volumes, exercise capacity, quality of life? Improves long term survival (selected patients)

40 Surgery Transplantation BLT vs SLT 10 year survival lowest FEV1 < 20%. DLCO < 20%, homogeneous blebs No longer most common reason for transplant

41 Future Direc=ons PDE 4 inhibitors Roflumilast Macrolide Antibiotics Bronchoscopic Lung Volume Reduction Biologic Lung Volume Reduction

42 What you don t want to have