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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,COPD: Guidelines Update and Newer Therapies,The Problem,Pathogenesis,Key Clinical Concepts,Life Prolonging vs. Symptomatic Therapy,Spirometry - The Sixth Vital Sign,Use of clinical practice guidelines,COPD Exacerbations,New Horizons,Outline,Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998,0,Proportion of 1965 Rate,1965 - 98,59%,64%,35%,+163%,7%,Coronary,Heart,Disease,Stroke,Other CVD,COPD,All Other,Causes,COPD in the United States,Age-Adjusted Death Rates* for COPD by State: 1995-1997,Deaths/100,000 Pop,Highest 46-61 (11),High 41-45 (13),Low 36-40 (13),Lowest 19-35 (13),*Morbidity and Mortality: 2000 Chart Book on Cardiovascular, Lung, and Blood Diseases. May 2000.,x,x,x,COPD - Pathogenesis,Tobacco Smoke,Chronic Inflammation*,Emphysema,Chronic Bronchitis,*CD8+ T-lymphocytes,Macrophages,Neutrophils,IL-8 and TNF,Proteinases,Oxidative Stress,Host factors,Anti-oxidants,Anti-proteinases,Repair Mechanisms,COPD Therapy Concepts,Life prolonging vs. symptomatic therapies,Spirometry - the 6th vital sign,Use of clinical practice guidelines,COPD Therapy,Smoking Cessation,Oxygen,Reduce exacerbations,Pulmonary Rehabilitation,LVRS (selected patients),Lung Transplantation,MDI Therapy,SA beta-2 agonists,LA beta-2 agonists,SA and LA Anticholinergics,Theophylline,Corticosteroids (inhaled or oral),Combination Preparations,SABA and anticholinergic,LABA and corticosteroids,Prolong Life,Symptomatic,Spirometry - The Sixth Vital Sign,Indications: Symptoms or 10 pack year smoker,COPD Practice Guidelines,European Thoracic Society - 1995,American Thoracic Society - 1995,British Thoracic Society - 1997,Veterans Administration - 1998, 2001,GOLD - 2003* ( :/ goldcopd ),ACCP/ACP - 2001* (Ann Int Med 134:595, 2001),* Evidence-based,Consensus and Evidence-based Guidelines,For comparisons:,Stoller JK. New Eng J Med 346:988, 2002,GOLD Workshop Report,Assess and monitor disease,Reduce risk factors,Manage stable COPD,Education,Pharmacologic,Non-pharmacologic,Manage exacerbations,Management of COPD Stage 0: At Risk,Characteristics Recommended Treatment,Risk factors,Chronic symptoms,- cough,- sputum,No spirometric abnormalities,Adjust risk factors,Immunizations,Management of COPD Stage I: Mild COPD,Characteristics Recommended Treatment,FEV,1,/FVC ,80 % predicted,With or without symptoms,Short-acting bronchodilator as needed,Management of COPD Stage II: Moderate COPD,Characteristics Recommended Treatment,FEV,1,/FVC 70%,50%,FEV,1, 80% predicted,With or without symptoms,Treatment with one or more long-acting bronchodilators,Rehabilitation,Management of COPD Stage III: Severe COPD,Characteristics Recommended Treatment,FEV,1,/FVC 70%,30%,FEV,1,3/year),Management of COPD Stage IV: Very Severe COPD,Characteristics Recommended Treatment,FEV,1,/FVC 70%,FEV,1,3/year),Treatment of complications,Rehabilitation,Long-term oxygen therapy if respiratory failure,Consider surgical options,Bronchodilator Therapy,Inhaled therapy (with spacer) preferred,Long-acting preparations more convenient,Combined preparations improve effectiveness and decrease risk of side effects,Ipratroprium-albuterol,Fluticasone-salmeterol,Budesonide-formoterol,MDI almost always as effective as nebulizers (in equal doses),Some General Principles,Effectiveness of BronchodilatorTherapy,?,FEV1 does not always correlate with symptoms,Concept of “dynamic hyperinflation” in COPD,Quality of life issues are important,Chronic fatigue,Depression,Physical immobility,Dyspnea,COPD - Surgical Options,Giant Bullous Disease,Consider bullectomy if see normal lung compression,Lung Volume Reduction Surgery*,FEV1 (20% pred) plus diffuse emphysema or Dlco20% pred = high risk of surgical death,Upper lobe emphysema and low exercise capacity = decreased mortality, increased exercise and QOL,Lung Transplantation,FEV125,Other,LMWH, fluids, diet,Guidelines,Ann Int Med 134:595, 2001,COPD Therapy - New Horizons,Newer anti-inflammatory agents,Matrix metalloproteinase inhibitors,Specific phosphodiesterase (PDE4) inhibitors,Cilomilast,Rofumilast,Piklanilast,Anabolic steroids,Repair agents,Retinoic acid,Long-acting anti-muscarinic agents,tiotropium,Tiotropium,470 patients - stable COPD,3 month, randomized, double blind, once daily tiotropium vs. placebo,Conclusions:,Increased FEV1 and FVC,No,tachyphylaxis,Decreased rescue,albuterol,Decreased wheezing, SOB,Dry mouth in 9.3%,Casaburi et al. CHEST 118:1294, 2000,Specific M1 and M3 Muscarinic Blockade,Tiatroprium,Specific M1 and M3 Muscarinic Blockade,1207 patients, double blind, randomized trial,qd tiotropium,vs. bid,salmeterol,vs. placebo,Conclusions: Tiotropium,Fewer exacerbations,Increased time to first exacerbation,Fewer admissions,Increased QOL,Brusasco et al. Thorax 58:399:2003,Lung Volumes in Obstructive Disease,Lung Volumes in Obstructive Disease,Normal,Normal,COPD,COPD,RV,RV,RV,RV,TLC,TLC,FRC,FRC,Room to,Room to,Breathe,Breathe,Room to,Room to,Breathe,Breathe,TLC,TLC,FRC,FRC,Volume,Volume,-800,-600,-400,-200,0,200,400,600,Difference from placebo,FEV,FVC,IC,FRC,RV,TLC,0.05 versus placebo,ODonnell et all ERJ 2004 (in press).,*,*,*,*,*,*,Tiotropium Exercise Trial: Difference from Placebo,with Tiotropium for,Resting Pulmonary Function,Day 21,Day 42,1,ODonnell et al. In press, 2004,Chronic Obstructive Pulmonary Disease,Effective vs. symptomatic therapies,Spirometry is useful and under-utilized,Clinical pathways are helpful and cost effective,Role of surgery has been clarified,Significance of frequent exacerbations,Several new and promising avenues of therapy on the horizon,Take Home Points,
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