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The Guidelines welcomes central role of LAMA/LABA Therapy within 2017 GOLD Strategy for COPD

  • COPD is a serious and progressive life threatening but manageable lung disease.

  • Total deaths from COPD are projected to increase by more than 30 % in the next 10 years.

  • The Global Burden of Disease Study reports a prevalence of 251 million cases of COPD globally in 2016.

  • COPD is predicted to become the third leading cause of death globally by 2030.

  • More than 90% of COPD deaths occur in low­ and middle­income countries.

Key facts

Fact sheet

about Chronic obstructive pulmonary disease

Symptoms Burden and Exacerbation History are the only drivers to pharmacologic therapy recommendations

The Guidlines welcomes central role of LAMA/LABA therapy within 2017 GOLD Strategy for COPD

The new Strategy:

• Pharmacologic treatment recommendations are tailored to patients' needs based on symptoms and exacerbation history

• LAMA/LABA therapy now an essential cornerstone for COPD treatment across the spectrum of people with COPD specially in GOLD groups B-D

• Clearer guidance for physicians on which subset of patients may benefit from the addition of ICS

PREVIOUS COPD ASSESSMENT

GOLD guidelines 2017 Classification

and Treatment updates

In summery the new refined ABCD assesment facilitates grouping and helps better tailor COPD therapy to suit patients needs

Mr Smith remains un group D due to his exacerbation history.

However his Treatment Recommendations change profoundly.

The New Assessment Separate Spirometry from ABCD

Refined GOLD Guidelines 2017

Both Patient would've been in group D in the prior Classification

Mrs brown is only grouped in group D due to her lung function

but with a high symptom load and no exacerbation...

Mrs Brown is regrouped into group B

Consequently her Treatment Recommendation change significantly

FEV1 is now only used for Diagnosis, Prognosis and Non-pharmacologic Treatment Decision

PREVIOUS COPD ASSESSMENT

54 Years

51 Years

What can we expect from a combination of bronchodilators in COPD?

WISDOM TRIAL

Summary

COPD - Practice Essential

History

  • Most patients with (COPD) seek medical attention late in the course of their disease.

  • Patients often ignore the symptoms because they start gradually and progress over the course of years.

  • Patients often modify their lifestyle to minimize dyspnea and ignore cough and sputum production.

  • With retroactive questioning, a multiyear history can be elicited.

Signs and symptoms

Patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease.

Symptoms include the following:

  • Cough, usually worse in the mornings and productive of a small amount of colorless sputum

  • Breathlessness: The most significant symptom, but usually does not occur until the sixth decade of life

  • Wheezing: May occur in some patients, particularly during exertion and exacerbations

Physical Examination

The sensitivity of physical examination in detecting mild to moderate COPD is relatively poor, but physical signs are quite specific and sensitive for severe disease. Findings in severe disease include the following:

  • Tachypnea and respiratory distress with simple activities

  • Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces (Hoover sign)

  • Cyanosis

  • Elevated jugular venous pulse (JVP)

  • Peripheral edema

Sponsored By Boehringer Ingelheim

Dr. Youssef Moussa

Family Medicine MD.

2018

Six-Minute Walking Distance

The distance walked in 6 minutes (6MWD) is a good predictor of all-cause and respiratory mortality in patients with moderate COPD. [2, 3] Patients with COPD who desaturate during the 6MWD have a higher mortality rate than do those who do not desaturate.

Consequently, this test is used as a part of the BODE index (body mass index, obstruction [FEV1], dyspnea [modified Medical Research Council dyspnea scale], and exercise capacity [6MWD]), [28] which was designed to help predict mortality in COPD patients.

Many patients with long-standing COPD develop secondary pulmonary hypertension from chronic hypoxemia and vascular remodeling.

Findings of severe pulmonary hypertension on echocardiogram or cardiac catheterization warrant further workup.

Two-Dimensional Echocardiography

High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography and is highly specific for diagnosing emphysema (outlined bullae are not always visible on a radiograph).

Computed Tomography

Chest Radiography

As demonstrated in the images below, frontal and lateral chest radiographs of patients with emphysema reveal signs of hyperinflation, including flattening of the diaphragm, increased retrosternal air space, and a long, narrow heart shadow. Rapidly tapering vascular shadows accompanied by hyperlucency of the lungs are other signs of emphysema.

Chronic bronchitis is associated with increased bronchovascular markings and cardiomegaly.

With complicating pulmonary hypertension, the hilar vascular shadows are prominent, with possible right ventricular enlargement and opacity in the lower retrosternal air space.

BNP is secreted by the ventricles of the heart when there is increased stretch of the myocytes (ie, in CHF).

By measuring BNP, it was thought that the ability to differentiate between CHF and COPD exacerbations would become much easier. However, clinical observation and research have shown that in cases of mild CHF exacerbation, differentiation between CHF and COPD is still not straightforward.

New biomarkers such as pro-BNP peptide assays are in development and may prove helpful in differentiating COPD from CHF exacerbations in the future

B-Type Natriuretic Peptide

The pathogens cultured most frequently during exacerbations are Streptococcus pneumoniae and Haemophilus influenzae.

Moraxella catarrhalis is also a common organism, and Pseudomonas aeruginosa can be seen in patients with severe obstruction.

Sputum Evaluation

Measure alpha1-antitrypsin (AAT) in all patients younger than 40 years or in those with a family history of emphysema at an early age.

The diagnosis of severe AAT deficiency is confirmed when the serum level falls below the protective threshold value of 11 mmol/L (ie, in the range of 3-7 mmol/L).

Specific phenotyping is reserved for patients in whom serum levels are 7-11 mmol/L or when genetic counseling or family analysis is needed.

Alpha1-Antitrypsin

Patients with COPD tend to retain sodium. In addition, serum potassium should be monitored carefully, because diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels.

Beta-adrenergic agonists also increase renal excretion of serum calcium and magnesium, which may be important in the presence of hypokalemia.

Serum Chemistries

Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity of disease exacerbation.

Patients with mild COPD have mild to moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia may develop, with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted value. Lung mechanics and gas exchange worsen during acute exacerbations.

In general, renal compensation occurs even in chronic CO2 retainers (ie, bronchitics); thus, pH usually is near normal.

Generally, consider any pH below 7.3 to be a sign of acute respiratory compromise.

Arterial Blood Gas Analysis

The Guidelines welcomes central role of LAMA/LABA Therapy within 2017 GOLD Strategy for COPD

  • Pulmonary function tests are essential for the diagnosis and assessment of the severity of disease,

  • They are helpful in following its progress.

  • FEV1 is a reproducible test and is the most commonly used index of airflow obstruction.

Pulmonary Function Tests

COPD: Testing, Diagnostics, and What to Expect

The value of patient history and physical examination was addressed in the 2011 update to the (ACP/ACCP/ATS/ERS) guideline for diagnosis and management of stable COPD.

According to the 2011 guideline, a history of more than 40 pack-years of smoking was the best single predictor of airflow obstruction; however, the most helpful information was provided by a combination of the following 3 signs :

  • Self-reported smoking history of more than 55 pack-years
  • Wheezing on auscultation
  • Self-reported wheezing

Patients typically present with a combination of signs and symptoms of

chronic bronchitis,

emphysema, and

reactive airway disease.

These include cough, worsening dyspnea, progressive exercise intolerance, sputum production, and alteration in mental status.

Symptoms include the following:

Productive cough or acute chest illness

Breathlessness

Wheezing

Thanks for your Attention

Low Risk

More Symptoms

Low Risk

Less Symptoms

Low Risk

More Symptoms

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