Chronic Obstructive Pulmonary Disease

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Chronic Obstructive Pulmonary Disease
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What is COPD?NICE Clinical Guideline 12, Feb 2004

• Disease characterised by airflow obstruction,
  which is usually progressive, not fully
  reversible, and does not change markedly over
  several months.
• Airflow obstruction is due to a combination of
  airway and parenchymal damage and is associated
  with chronic inflammation, which differs from
  that seen in asthma.

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So, what can we do for people with COPD?

• Early diagnosis contentious
• NICE recommendation
• (smoker gt35 years, presenting with symptoms)
• Smoking cessation most important
• NICE recommendation
• Pulmonary rehabilitation important
• Cochrane Review
• NICE recommendation
• Optimal drug management (including managing
  exacerbations)
• See later

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Symptoms NICE Clinical Guideline 12, Feb 2004

• Diagnosis relies on clinical judgement based on a
  combination of
• history
• physical examination
• confirmation of the presence of airflow
  obstruction using spirometry

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Assessment of severity of airflow obstruction
NICE Clinical Guideline 12, Feb 2004
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Stop smoking NICE Clinical Guideline 12, Feb
2004National Knowledge Week for COPD 2008.
Available from http//www.library.nhs.uk/respirat
ory/ViewResource.aspx?resID278340tabID290catID
5880

• Approximately 80 of COPD caused by smoking
• Smoking cessation is the only intervention that
  reduces decline in FEV1
• Best way to reduce incidence of COPD is to reduce
  prevalence of smoking
• campaigns aimed at smokers need to emphasise link
  between smoking and COPD
• Encouraging patients with COPD to stop smoking is
  one of the most important components of their
  management
• All COPD patients still smoking, regardless of
  age should be encouraged to stop, and offered
  help to do so, at every opportunity

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Management of stable COPDNICE Clinical Guideline
12, Feb 2004
Breathlessness and exercise limitation
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What about the role oflong-acting
bronchodilatorsin COPD?
NICE Clinical Guideline 12, Feb 2004
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(No Transcript)
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When should ICS be used?NICE Clinical Guideline
12, Feb 2004
Breathlessness and exercise limitation
Frequent exacerbations
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We need to weigh up the balance of risks and
benefits of prescribing ICS in COPD
Possible RISKS oral candidiasis hoarseness osteopo
rosis pneumonia
BENEFITS ? exacerbations possibly better QoL
Details are given on subsequent slides
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The TORCH StudyCalverley PMA, et al. N Engl J
Med 200735677589

• Comparing combination with salmeterol alone over
  three years
• NNT to prevent one moderate to severe
  exacerbation in one year is 8 (combination vs.
  salmeterol alone)
• NNH for one case of pneumonia in one year is 33
  (combination vs. salmeterol alone)

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Oral mucolytic agents and/or influenza vaccination
NICE Clinical Guideline 12, Feb 2004
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Oxygen therapyNICE Clinical Guideline 12, Feb
2004

• The need for oxygen therapy should be assessed
  in
• all patients with severe airflow obstruction
  (FEV1 less than 30 predicted)
• patients with cyanosis, polycythaemia, peripheral
  oedema, raised jugular venous pressure, oxygen
  saturations less than or equal to 92 breathing
  air.
• Assessment should also be considered in patients
  with moderate airflow obstruction (FEV1 3049
  predicted).