COPD Action Plans: Prevention and Treatment of Exacerbations

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COPD Action PlansPrevention and Treatment of
Exacerbations

• Symposium of Challenging Geriatric Issues
• Freeport Physicians Education Committee
• May 6, 2009

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Conflict of Interest
Eric P. Hentschel MD FRCPC Medical Director
CHEST Program SMGH Pulmonary Rehabilitation
Program GRH
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www.respiratoryguidelines.ca
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AECOPD Definition
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AECOPD Types

• Purulent vs. non-purulent
• Mild, Moderate or Severe
• Reported or un-reported
• Timing
• Isolated none 8wks before or after
• Initial followed within 8wks by another
• Recurrent-preceded within 8
  wks
• Relapsewithout 5 days
  asymptomatic
• Christmas exacerbations !

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Christmas COPD Exacerbations
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Causes of COPD Exacerbations

• Viruses- rhinovirus (common cold),
  influenza A/B, parainfluenza,
  coronavirus ?
  adenovirus, RSV, chlamydiae
• Bacteria- H. influenza, S. pneumoniae,
  M. catarrhalis, S. aureus, P.
  aeruginosa
• Pollutants- particulates, NO2, SO2, ozone
• Temperature
• Unknown- 30 ? Pulmonary embolism

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The Clot Thickens CHEST March 2009

• Prevalence of PE in AECOPD 20 ?
• PE has higher mortality in COPD
• Consider if - increased risk factors
• - failure to respond
• - if doesnt have
  significantly abnormal spirometry
• Spiral CT
• Remember prophylactic heparin

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Cost of Exacerbations of COPD
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Prevention of Annas AECOPD

• Smoking Cessation and Vaccinations ?
• Self-Management Education with
• Written AECOPD Action Plan
• ?
• Regular long-acting bronchodilator therapy
• ?
• Regular inhaled ICS/LABA therapy
• ?
• Pulmonary rehabilitation
• ?
• Oral corticosteroids for moderate/severe AECOPD

Frequency of Exacerbations
Can Respir J 200714(Suppl B)3B-32B.
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Clear, Strong, Personalized Manner Urge the
Smoker to Quit (?for ANNA)
100
75
FEV1 ( of value at age 25)
50
.
25
0
25
50
75
Age (years)
Fletcher C and Peto R, BMJ 1997116451648
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Modes of Influenza Transmission

• Influenza is transmitted person to person through
  close contact.
• exposure to large respiratory droplets
  (3 feet)
• direct contact transfer of virus from
  contaminated hands to the nose or eyes
• exposure to small-particle aerosols in the
  immediate vicinity of the infectious individual
  (3-6 feet)

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Precautions for Viral Infections

• Avoid people who are sick
• (1 day before and 7 days after and are
  asymptomatic)
• Close contact (6 ft)
• Avoid surfaces that may be contaminated
• Respiratory protection or mask
• Influenza vaccine including close contacts
• Wash Hands !

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Prevention of AECB
Handwashing!
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IDSA guidelines for seasonal influenza
 
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Benefits of COPD Self Management Education
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CHEST Program
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TORCH ICS/LABA Reduced Exacerbation Tate Over 3
Years
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Inhaled corticosteroids in patients with stable
chronic obstructive pulmonary disease a
systematic review and meta-analysis

• Drummond MB et al JAMA 2008 300 2407-16
• a significantly higher incidence of pneumonia
• 777 cases among 5405 patients in the treatment
  group and 561 cases among 5371 patients in the
  control group
• RR 1.34 95 CI, 1.03-1.75 P  .03

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OPTIONAL Study Hospitalizations for AECOPD
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Long-acting Anticholinergic Exacerbations
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UPLIFT Study Understanding Potential Long-term
Impacts on Function with Tiotropium
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Probability of COPD Exacerbation
n 3,006
n 2,986
Hazard ratio 0.86, (95 CI, 0.81- 0.91) p lt
0.001 (log-rank test)
Month
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Inhaled Anticholinergics and Risk of Major
Adverse Cardiovascular Events in Patients with
COPD A Systematic Review and Meta-analysis

• Singh JAMA 2008300(12) 1439-50
• 103 articles, 17 trials 14,783 patients
• Inhaled anticholinergics are associated with a
  significantly increased risk of cardiovascular
  death, MI, or stroke among patients with COPD
  1.8 vs 1.2
• RR 1.58 plt.001

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UPLIFT SAE Incidence (per 100 pt-yrs) Reported
By gt1 in Any Treatment Group
plt0.05 excluding lung cancer (multiple
different terms)
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Tashkin DP, et al. New Engl J Med.
20083591543-54.
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Optimal Pharmacotherapy
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Stratifying disease severity in COPD
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Optimal Pharmacotherapy of Moderate to Severe COPD
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Pulmonary Rehabilitation

• most effective therapeutic strategy for
  improving dyspnea, exercise endurance and QOL

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GRH-Freeport Health Centre

• Pulmonary Rehabilitation Program

Multidisciplinary Team
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CHEST Program

• COPD Activation-Reactivation Program
• 2 week education and intro to exercise
• St. Marys Bathurst site
• Pre/Post Spirometry
• 6 minute walk test
• Smoking Cessation
• Fax Referral to 519-749-6816
• PRIISME Asthma and COPD Program
• Education/spirometry in MD Office

Angela Shaw RRT
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PRIISME COPD in LTC and Retirement Homes

• CTS COPD guidelines recommend self management
  education and regular exercise to all those with
  COPD
• PRIISME COPD is offering education for all staff
  and for all residents (and their families) with
  COPD
• PRIISME COPD will help the existing
  exercise/recreation staff develop safe exercise
  regimes for those with COPD

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AECOPD Prevention Strategies
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How do we treat Annas exacerbation?
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AECOPD Bronchodilators
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AECOPD Corticosteroids
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AECOPD Benefits of Oral Steroids
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AECOPD Antibiotics
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AECOPD Improvement with Antibiotics
Meta-Analysis of placebo-Controlled Trials
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AECOPD Sputum Color vs Bacterial Presence
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Treatment of Exacerbations
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Long-term Erythromycin Therapy Is Associated
with Decreased Chronic Obstructive Pulmonary
Disease Exacerbations

• Am. J. Respir. Crit. Care Med. 2008 178
  1139-1147
• erythromycin 250 mg bid over 12 months,
• RR 0.648 (95 confidence interval 0.489, 0.859
  P 0.003
• shorter duration exacerbations compared with
  placebo.

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Non-Invasive Ventilation (NIV)in AECOPD

• Reduces - dyspnea
• -RR
• -CO2
• Reduces intubation
• Reduces LOS
• Reduces mortality!
• Useful in extubating

More survivors More AECOPD!
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Acutely Admission to hospital? BIPAP? Increase
bronchodilators Prednisone Antibiotics Long
Term Add salmeterol/fluticasone Oxygen? Pulmonary
rehabilitation Action Plan
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Antibiotic Treatment of Purulent AECOPD
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Antibiotic Treatment of Purulent AECOPD
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OTTAWA MODEL
ACTION/ MAINTENANCE! take steps/prevent relapse
PREPARATION!-best course
CONTEMPLATION -tip the balance
PRECONTEMPLATION -raise doubt
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Smoking Cessation Counseling
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Acute Event Mortality

• COPD exacerbation
• 22-43 of patients hospitalized with a COPD
  exacerbation die within 1 year (1,2,3,4)
• In-hospital mortality rate for COPD exacerbations
  is 8-11 (1,2)

• Acute coronary syndrome
• 25 of men and 38 of women die within 1 year of
  a first recognized myocardial infarct (5,6)
• In-hospital acute MI mortality rate is 8-9.4
  (5,6)

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• Isolation precautions
• Standard and Contact precautions plus eye
  protection should be used for all patient care
  activities for patients being evaluated or in
  isolation for swine influenza A (H1N1) (i.e.,
  including all healthcare personnel who enter the
  patients room). Maintain adherence to hand
  hygiene by washing with soap and water or using
  alcohol-based hand sanitizer immediately after
  removing gloves and other equipment and after any
  contact with respiratory secretions.  Nonsterile
  gloves and gowns along with eye protection should
  be donned upon room entry. (See
  http//www.cdc.gov/ncidod/dhqp/ppe.html)
• Respiratory protection All healthcare personnel
  who enter the rooms of patients in isolation for
  swine influenza should wear a fit-tested
  disposable N95 respirator or equivalent (e.g.,
  powered air purifying respirator). Respiratory
  protection should be donned upon room entry.
• Note that this recommendation differs from
  current infection control guidance for seasonal
  influenza, which recommends that healthcare
  personnel wear surgical masks for patient care. 
  The rationale for the use of respiratory
  protection is that a more conservative approach
  is needed until more is known about the specific
  transmission characteristics of this new virus. 
  This recommendation is also outlined in the in
  the in the October 2006 Interim Guidance on
  Planning for the Use of Surgical Masks and
  Respirators in Healthcare Settings during an
  Influenza Pandemic http//www.pandemicflu.gov/pla
  n/healthcare/maskguidancehc.html.
• Management of visitors
• Limit visitors to patients in isolation for swine
  influenza A virus (H1N1) infection to persons who
  are necessary for the patient's emotional
  well-being and care.  Visitors who have been in
  contact with the patient before and during
  hospitalization are a possible source of swine
  influenza A virus (H1N1). Therefore, schedule and
  control visits to allow for appropriate screening
  for acute respiratory illness before entering the
  hospital and appropriate instruction on use of
  personal protective equipment and other
  precautions (e.g., hand hygiene, limiting
  surfaces touched) while in the patient's room. 
  Visitors should be instructed to limit their
  movement within the facility.
• Visitors may be offered a gown, gloves, eye
  protection, and respiratory protection (i.e., N95
  respirator) and should be instructed by
  healthcare personnel on their use before entering
  the patients room. 
• Duration of precautions
• Isolation precautions should be continued for
  seven (7) days from symptom onset or until the
  resolution of symptoms, whichever is longer.