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Disease COPD: Pathophysiology, Process, and Outcomes

COPD

Michael Smith, Pharm D, BCPS, CACP

Disclosure: • Dr Smith has no actual or potential conflict of  interest associated with this presentation. Grant recognition: • This activity was funded by an independent  professional education grant from Pfizer.

COPD Learning Objectives 1

Identify risk factors that contribute to the development  and exacerbation of COPD

2

Describe the progression of COPD from diagnosis  to end‐stage disease

3

Discuss outcomes associated with COPD  management

COPD

G lobal Initiative for Chronic O bstructive L ung D isease www.goldcpod.org

COPD Why COPD? • Highest risk of readmission at Backus Hospital • Chronic disease • Medication therapy is a cornerstone of  treatment • Proper treatment will decrease morbidity and  mortality

COPD Chronic Obstructive Pulmonary Disease is…. “a common ____①___ and __②___ disease,  is characterized by ___③___ airflow  limitation that is usually ___④____ and  associated with an enhanced chronic  inflammatory response in the airways and the  lung to noxious particles or gasses.” • Word Bank: – treatable, progressive, persistent, preventable WWW.GOLDCOPD.ORG

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COPD

COPD Chronic Obstructive Pulmonary Disease is…. “a common preventable and treatable disease,  is characterized by persistent airflow  limitation that is usually progressive and  associated with an enhanced chronic  inflammatory response in the airways and the  lung to noxious particles or gasses.” • Exacerbations and comorbidities contribute to  the overall severity in individual patients

Underlying Mechansims Parenchymal  Destruction Loss of alveolar  attachments Decrease of elastic  recoil

Small Airway Disease Airway inflamation Airway fibrosis,  luminal plugs Increased airway  resistance

WWW.GOLDCOPD.ORG

WWW.GOLDCOPD.ORG

COPD

COPD

Two Major Subtypes Emphysema

Chronic Bronchitis  Mucoid sputum production, decreased ciliary activity, impaired resistance to infection.  Irreversible narrowing of airways associated with increased resistance to airflow.  Blue Bloater

Irritation from environmental pollutants  or genetic predisposition

 Permanent, parenchymal destruction  Loss of alveolar attachments  Reduced lung elastic recoil causing airway collapse.  Pink Puffer

No longer differentiated in the GOLD guidelines

Airway Inflammation Increased mucous production and decreased mucociliary function

Continued inflammation causes scarring within the airways leading to obstruction and dyspnea

Causes hallmark COPD symptoms of coughing and sputum production

Irritation, inflammation, mucous production, and scarring predisposes patients to respiratory infections

Barnes PJ. N Engl J Med. 2000;343:269-280

Barnes PJ. N Engl J Med. 2000;343:269-280

COPD

COPD Risk Factors • Genetics • Smoking • Occupational dust – Farming, mining, cement

• Indoor air pollution • Outdoor air pollution

Barnes PJ. N Engl J Med. 2000;343:269-280

• Age • Gender • Early respiratory  infections • Socioeconomic status • Asthma • Chronic Bronchitis

WWW.GOLDCOPD.ORG

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COPD

COPD

Smoking • Cause of COPD in 80‐90% of  patients • 100‐200% increase in the  rate of FEV1 decline • 2‐20 fold increase in the risk  of death from COPD • Never smokers account for  only 23% of COPD

• Impairs ciliary movement • Inhibits alveolar  macrophages • Encourages hypertrophy  and hyperplasia of mucous  glands • Acutely increases smooth  muscle contraction

Air pollution • Increased incidence and  higher mortality rates of  COPD in industrialized  urban areas. • Exacerbations linked to  periods of heavy sulfur  dioxide pollution

Occupational Dust • Occupational exposure • 10% prevalence of  COPD in farm workers  • Most common  respiratory syndrome in  agricultural workers

Curr Opin Pulm Med. 2008;14:105-109

COPD

WWW.GOLDCOPD.ORG

COPD Epidemiology

Infection

Genetic

• Severe viral pneumonia in  child hood may lead to  small airways obstruction  (SAO) • Mortality, morbidity, and  frequency of respiratory  infections are increased in  patients with chronic  bronchitis

• Protease/antiprotease – Alpha‐1‐antitrypsin/elastase imbalance – Increased degradation of  elastin

• TNF‐alpha gene  polymorphism – May influence immune  response, increase  inflammatory damage

WWW.GOLDCOPD.ORG

COPD 1990

Decramer M. Lancet 2012;379:1341-51; WWW.GOLDCOPD.ORG

COPD

World Wide Projected Cause of Death Ischemic heart disease CVD disease Lower respiratory infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road traffic accident Lung cancer

• COPD is a leading cause of morbidity and mortality  world wide. • Caused 5% of all deaths in 2005 • In the US, age‐adjusted mortality due to COPD  doubled from 1970‐2002 • Rate has stabilized/declined in many nations,  skyrocketing in under developed lands. • Projected to be the #3 world‐wide killer by 2020

Epidemiology • 12 million people in the United States have been diagnosed  (2006). • National Health and Nutrition Examination Survey (NHANES)  suggests that roughly 10 percent of the adult U.S. population  has evidence of impaired lung function consistent with COPD – 26 million • More common and more fatal in women

2020

Stomach cancer HIV Suicide

Lopez AD. Nat Med 1998;4:1241-3.; WWW.GOLDCOPD.ORG

http://www.medscape.com/viewarticle/707973_3

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COPD

COPD

Diagnosis • Diagnosis should be considered in any patient with  hallmark symptoms‐ dyspnea, chronic cough, chronic  sputum production, especially with exposure to risk  factors (smoking) • Dyspnea: Progressive, persistent and  characteristically worse with exercise • Chronic Cough: May be intermittent and may be  unproductive • Chronic Sputum Production: common symptom

Differential Diagnosis • Asthma – Reversible – Onset in childhood – Variable symptoms • CHF – Volume restriction – CXR: dilated heart • Bronchiectasis – Purulent sputum – Bacterial infection – CXR: bronchial dilation and wall  thickening

WWW.GOLDCOPD.ORG

Prabhu F. CPOPD and the gold guidelines ; www.slideworld.org

COPD

COPD

Diagnosis

Spirometry

• Chest Xray may show flattened diaphragm • Spirometry is required for diagnosis – FEV1/FVC 80% predicted 50% < FEV1 < 80% predicted 30% < FEV1 < 50% predicted FEV1 < 30% predicted; or 2

(C)

(D) Risk

3

2

(A)

(B)

1

1

(Exacerbation history)

Risk

(GOLD Classification of Airflow Limitation)

Fletcher CM, et al. BMJ. 1959;2:257-266.

0 mMRC 0-1 CAT < 10

mMRC > 2 CAT > 10

Symptoms

Patient

Characteristic

Spirometric Classification

Exacerbations per year

mMRC

CAT

A

Low Risk Less Symptoms

GOLD 1‐2

≤ 1

0‐1

2

≥ 10

C

High Risk Less Symptoms

GOLD 3‐4

>2

0‐1

D

High Risk More Symptoms

GOLD 3‐4

>2

2

(mMRC or CAT score)) WWW.GOLDCOPD.ORG

WWW.GOLDCOPD.ORG

COPD

COPD

Prognosis

Prognosis

The Body‐mass index (B), the degree of airflow Obstruction (O) and Dyspnea (D), and  Exercise capacity (E)  BODE index — developed to assess an individual's risk of  death from COPD Variable

Points on BODE Index 0

1

2

3

FEV1 (% predicted)

≥65

50‐64

36‐49

≤35

6‐Minute Walk Test (meters)

≥350

250‐349

150‐249

≤149

MMRC Dyspnea Scale

0‐1

2

3

4

Body Mass Index

˃21

≤21

Celli BR. NEJM 2004;350:1005

Quartile 1: BODE Quartile 2: BODE Quartile 3: BODE Quartile 4: BODE

0-2 2-4 5-6 7-10

Celli BR. NEJM 2004;350:1005

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COPD

COPD

Goals of Therapy  Reduce Symptoms  Relieve symptoms  Improve exercise tolerance  Improve health status

Goals of Therapy  • Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

Reduce Risk  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality

• None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.

WWW.GOLDCOPD.ORG

WWW.GOLDCOPD.ORG

COPD

COPD

Avoidance of risk factors • Smoking cessation • Reduction of indoor pollution • Smoking cessation • Reduction of occupational exposure

Quit Smoking

Pulmonary Rehab

• Most effective (and cost‐ effective) intervention to slow  progression • Ask • Advise • Assess • Assist • Arrange

ATS/ERS:

• Smoking cessation • Influenza vaccination WWW.GOLDCOPD.ORG

COPD

•

•

Evidence‐based, multidisciplinary, and  comprehensive intervention for  patients with chronic respiratory  diseases who are symptomatic and  often have decreased daily life  activities.  Pulmonary rehabilitation is designed to  reduce symptoms, optimize functional  status, increase participation, and  reduce health care costs by stabilizing  or reversing systemic manifestations of  the disease.

Am J Respir Crit Care Med. 2006;173(12):1390.

WWW.GOLDCOPD.ORG

COPD

http://www.medscape.com/viewarticle/707973_3

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COPD

COPD

• RS is a 66yo male with who was diagnosed with  COPD 2 years ago (FEV1= 70% of predicted).  He  continues to smoke and is poorly compliant with his  medications.  He has hypertension, hyperlipidemia and anxiety.  He has been walking nightly with his  wife to loose weight.  His chief complaint today is  that when he walks with his wife he easily gets short  of breath on small hills.   He had 2 COPD  exacerbations last year. • What GOLD patient category does he fall into?

Combined Assessment Patient

Characteristic

Spirometric Classification

Exacerbations per year

mMRC

CAT

A

Low Risk Less Symptoms

GOLD 1‐2

≤ 1

0‐1

2

≥ 10

C

High Risk Less Symptoms

GOLD 3‐4

>2

0‐1

D

High Risk More Symptoms

GOLD 3‐4

>2

>2