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CHRONIC OBSTRUCTIVE LUNG CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD), BRONCHIAL DISEASE (COPD), BRONCHIAL
ASTHMAASTHMA
GOLD GINAGOLD GINA
Chronic Obstructive Pulmonary Disease (COPD)
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► COPD is currently the fourth leading cause of death in the world.1
► COPD is projected to be the 3rd leading cause of death by 2020.2
► More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally.
► Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population.
1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.
2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.
Economic and Social Burden
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Economic burden of COPD
►COPD is associated with significant economic burden. ► COPD exacerbations account for the greatest
proportion of the total COPD burden.
►European Union: Direct costs of respiratory disease ~6% of
the total healthcare budget COPD accounting for 56% (38.6 billion
Euros) of the cost of respiratory disease.
►USA: Direct costs of COPD are $32 billion Indirect costs $20.4 billion.
COPD DefinitionCOPD Definition
Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and (COPD) is a common, preventable and treatable disease that is characterized by treatable disease that is characterized by persistent respiratory symptoms and persistent respiratory symptoms and airflow limitationairflow limitation that is due to airway that is due to airway and/or alveolar abnormalities usually and/or alveolar abnormalities usually caused by significant exposure to noxious caused by significant exposure to noxious particles or gases. particles or gases.
Factors that influence disease progression
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► Genetic factors
► Age and gender
► Lung growth and development
► Exposure to particles
► Socioeconomic status
► Asthma & airway hyper-reactivity
► Chronic bronchitis
► Infections
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
GenesGenes
InfectionsInfections
Socio-economic Socio-economic statusstatus
Aging PopulationsAging Populations© 2015 Global Initiative for Chronic Obstructive Lung Disease
Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
Clinical forms of COPDClinical forms of COPD
Pink puffer
Blue bloater
Medical History
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► Patient’s exposure to risk factors
► Past medical history
► Family history of COPD or other chronic respiratory disease.
► Pattern of symptom development
► History of exacerbations or previous hospitalizations for respiratory disorder
► Presence of comorbidities
► Impact of disease on patient’s life
► Social and family support available to the patient.
► Possibilities for reducing risk factors, especially smoking cessation.
Diagnosis and Initial Assessment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Assessment of COPDAssessment of COPD
Assess symptomsAssess symptoms
Assess degree of airflow Assess degree of airflow limitation using spirometrylimitation using spirometry
Assess risk of exacerbationsAssess risk of exacerbations
Assess comorbiditiesAssess comorbidities© 2015 Global Initiative for Chronic Obstructive Lung Disease
The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production that can be variable from day-to-day.
Dyspnea: Progressive, persistent and characteristically worse with exercise.
Chronic cough: May be intermittent and may be unproductive.
Chronic sputum production: COPD patients commonly cough up sputum.
Symptoms of COPD
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Assess symptomsAssess symptomsAssess degree of airflow limitation using Assess degree of airflow limitation using spirometryspirometry
Assess risk of exacerbationsAssess risk of exacerbations
Assess comorbiditiesAssess comorbidities
COPD Assessment Test (CAT)
or
Clinical COPD Questionnaire (CCQ)
or
mMRC Breathlessness scale
Global Strategy for Diagnosis, Management and Prevention of Global Strategy for Diagnosis, Management and Prevention of COPDCOPD
Assessment of COPDAssessment of COPD
© 2015 Global Initiative for Chronic Obstructive Lung Disease
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate 50% < FEV1 < 80% predicted
GOLD 3: Severe 30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Spirometry
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention Global Strategy for Diagnosis, Management and Prevention of COPDof COPD
Assess Risk of Assess Risk of ExacerbationsExacerbationsTo assess risk of exacerbations use To assess risk of exacerbations use
history of exacerbations and spirometry: history of exacerbations and spirometry:
Two or more exacerbations within the Two or more exacerbations within the last year last year oror an FEV an FEV1 1 < 50 % of predicted < 50 % of predicted value are indicators of high risk.value are indicators of high risk.
One or more hospitalizations for COPD One or more hospitalizations for COPD exacerbation should be considered high exacerbation should be considered high risk.risk.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Assessment of Exacerbation Risk
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.
► Classified as: Mild (treated with SABDs only) Moderate (treated with SABDs plus antibiotics
and/or oral corticosteroids) or Severe (patient requires hospitalization or visits
the emergency room). Severe exacerbations may also be associated with acute respiratory failure.
► Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS).
Differential Diagnosis
Prevention & Maintenance Therapy (1)
© 2017 Global Initiative for Chronic Obstructive Lung Disease
►Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.
►The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present.
►Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.
►Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side-effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices.
►Inhaler technique needs to be assessed regularly.
Prevention & Maintenance Therapy (2)
© 2017 Global Initiative for Chronic Obstructive Lung Disease
►Influenza vaccination decreases the incidence of lower respiratory tract infections.
►Pneumococcal vaccination decreases lower respiratory tract infections.
►Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities.
►In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival.
►In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.
Global Strategy for Diagnosis, Management and Prevention of Global Strategy for Diagnosis, Management and Prevention of COPDCOPD
Manage Stable COPD: Pharmacologic Manage Stable COPD: Pharmacologic TherapyTherapy
((Medications in each box are mentioned in alphabetical order, and therefore Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.)not necessarily in order of preference.)
Patient RecommendedFirst choice
Alternative choice Other PossibleTreatments
ASAMA prn
or SABA prn
LAMA or
LABA or
SABA and SAMA
Theophylline
BLAMA
or LABA
LAMA and LABASABA and/or SAMA
Theophylline
C
ICS + LABAor
LAMA
LAMA and LABA orLAMA and PDE4-inh. orLABA and PDE4-inh.
SABA and/or SAMATheophylline
D
ICS + LABAand/or LAMA
ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or
LAMA and LABA orLAMA and PDE4-inh.
CarbocysteineN-acetylcysteine
SABA and/or SAMATheophylline
Treatment of Stable COPDTreatment of Stable COPD
Model for the initiation, and then subsequent escalation and/or de-
escalation of pharmacologic management of COPD according to
the individualized assessment of symptoms and exacerbation risk
(GOLD 2017)
Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Pharmacologic Therapy
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Pharmacologic Therapy
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
►Education and self-management
►Physical activity
►Pulmonary rehabilitation programs
►Exercise training
►Self-management education
►End of life and palliative care
►Nutritional support
►Vaccination
►Oxygen therapy
Global Strategy for Diagnosis, Management and Prevention Global Strategy for Diagnosis, Management and Prevention of COPDof COPD
Manage Stable COPD: Non-Manage Stable COPD: Non-pharmacologicpharmacologic
PatientGroup
Essential Recommended Depending on local guidelines
ASmoking cessation (can include pharmacologic
treatment)Physical activity
Flu vaccinationPneumococcal
vaccination
B, C, D
Smoking cessation (can include pharmacologic
treatment)Pulmonary rehabilitation
Physical activityFlu vaccinationPneumococcal
vaccination
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Oxygen therapy
Long-term oxygen therapy is indicated for stable patients who have:
►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or
►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations
© 2017 Global Initiative for Chronic Obstructive Lung Disease
COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.
►They are classified as:
Mild (treated with short acting bronchodilators only, SABDs)
Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or
Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.
Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Nebulized magnesium as an adjuvent to salbutamol treatment in the setting of acute exacerbations of COPD has no effect on FEV1.
Global Strategy for Diagnosis, Management and Prevention of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD
Manage Exacerbations: Treatment Manage Exacerbations: Treatment OptionsOptions
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Antibiotics should be given to patients with:
Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.
Who require mechanical ventilation.
Global Strategy for Diagnosis, Management and Prevention of COPDGlobal Strategy for Diagnosis, Management and Prevention of COPD
Manage Exacerbations: Treatment Manage Exacerbations: Treatment OptionsOptions
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Classification of hospitalized patients
Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased compared with baseline or elevated > 60 mmHg or the presence of acidosis (pH < 7.25).
Management of Exacerbations
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Asthma is a common and potentially serious chronic disease Asthma is a common and potentially serious chronic disease that that can be controlled but not cured can be controlled but not cured (and is unlikely ever to go (and is unlikely ever to go into complete remission)into complete remission)
Symptoms are associated with Symptoms are associated with variable expiratory airflowvariable expiratory airflow, i.e. , i.e. difficulty breathing air out of the lungs due to difficulty breathing air out of the lungs due to Bronchoconstriction (airway narrowing)Bronchoconstriction (airway narrowing) Airway wall thickeningAirway wall thickening Increased mucusIncreased mucus
Symptoms may be triggered or worsened by factors such as Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stressviral infections, allergens, tobacco smoke, exercise and stress
What is known about asthma?What is known about asthma?
GINA 2016
Asthma is a heterogeneous disease, usually Asthma is a heterogeneous disease, usually characterized by characterized by chronic airway inflammationchronic airway inflammation. .
It is defined by the history of respiratory symptoms It is defined by the history of respiratory symptoms such as such as wheeze, shortness of breath, chest tightness wheeze, shortness of breath, chest tightness and cough and cough that that vary over time and in intensityvary over time and in intensity..
Definition of asthmaDefinition of asthma
GINA 2016
Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
IncreasedIncreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: More than one type of symptom (wheeze, shortness of breath, More than one type of symptom (wheeze, shortness of breath,
cough, chest tightness)cough, chest tightness) Symptoms often worse at night or in the early morningSymptoms often worse at night or in the early morning Symptoms vary over time and in intensitySymptoms vary over time and in intensity Symptoms are triggered by viral infections, exercise, allergen Symptoms are triggered by viral infections, exercise, allergen
exposure, changes in weather, laughter, irritants such as car exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smellsexhaust fumes, smoke, or strong smells
DecreasedDecreased probability that symptoms are due to asthma if: probability that symptoms are due to asthma if: Isolated cough with no other respiratory symptomsIsolated cough with no other respiratory symptoms Chronic production of sputumChronic production of sputum Shortness of breath associated with dizziness, light-headedness Shortness of breath associated with dizziness, light-headedness
or peripheral tinglingor peripheral tingling Chest painChest pain Exercise-induced dyspnea with noisy inspiration (stridor)Exercise-induced dyspnea with noisy inspiration (stridor)
Diagnosis of asthma – Diagnosis of asthma – symptomssymptoms
GINA 2017
© Global Initiative for Asthma
Confirm presence of airflow limitation Document that FEV1/FVC is reduced (at least once, when FEV1 is low) FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children Confirm variation in lung function is greater than in healthy individuals
The greater the variation, or the more times variation is seen, the greater probability that the diagnosis is asthma
Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and >200mL; children: increase >12% predicted)
Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily amplitude x 100/daily mean, averaged)
Significant increase in FEV1 or PEF after 4 weeks of controller treatment
If initial testing is negative:• Repeat when patient is symptomatic, or after withholding
bronchodilators• Refer for additional tests (especially children ≤5 years, or the elderly)
Diagnosis of asthma – variable airflow limitation
GINA 2017, Box 1-2
© Global Initiative for Asthma
Physical examination in people with asthma
Often normal The most frequent finding is wheezing on auscultation,
especially on forced expiration Wheezing is also found in other conditions, for example:
Respiratory infections COPD Upper airway dysfunction Endobronchial obstruction Inhaled foreign body
Wheezing may be absent during severe asthma exacerbations (‘silent chest’)
Diagnosis of asthma – physical examination
GINA 2017
© Global Initiative for Asthma
1. Asthma control - two domains Assess symptom control over the last 4 weeks Assess risk factors for poor outcomes, including low
lung function2. Treatment issues
Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan? What are the patient’s attitudes and goals for their asthma?
3. Comorbidities Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety These may contribute to symptoms and poor quality of life
Assessment of asthma
GINA 2017, Box 2-1
© Global Initiative for Asthma
GINA assessment of asthma control
A. Symptom control
In the past 4 weeks, has the patient had:Well-
controlledPartly
controlledUncontrolled
• Daytime asthma symptoms more than twice a week?
Yes No
None of these
1-2 of these
3-4 of these
• Any night waking due to asthma?
Yes No
• Reliever needed for symptoms* more than twice a week?
Yes No
• Any activity limitation due to asthma?
Yes No
B. Risk factors for poor asthma outcomes• Assess risk factors at diagnosis and periodically• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessmentASSESS PATIENT’S RISKS FOR:• Exacerbations• Fixed airflow limitation• Medication side-effects
GINA 2017 Box 2-2B (1/4)
Level of asthma symptom control
© Global Initiative for Asthma
Assessment of risk factors for poor asthma outcomes
GINA 2017, Box 2-2B (4/4)
Risk factors for exacerbations include:
• Ever intubated for asthma• Uncontrolled asthma symptoms• Having ≥1 exacerbation in last 12 months• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)• Incorrect inhaler technique and/or poor adherence• Smoking• Elevated FeNO in adults with allergic asthma• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
© Global Initiative for Asthma
How? Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations When?
Assess asthma severity after patient has been on controller treatment for several months
Severity is not static – it may change over months or years, or as different treatments become available
Categories of asthma severity Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA
or low dose ICS) Moderate asthma: well-controlled with Step 3 (low-dose
ICS/LABA) Severe asthma: requires Step 4/5 (moderate or high dose
ICS/LABA ± add-on), or remains uncontrolled despite this treatment
Assessing asthma severity
GINA 2017
© Global Initiative for Asthma
Before starting initial controller treatment Record evidence for diagnosis of asthma, if possible Record symptom control and risk factors, including lung function Consider factors affecting choice of treatment for this patient Ensure that the patient can use the inhaler correctly Schedule an appointment for a follow-up visit
After starting initial controller treatment
Review response after 2-3 months, or according to clinical urgency
Adjust treatment (including non-pharmacological treatments)
Consider stepping down when asthma has been well-controlled for 3 months
Initial controller treatment
GINA 2017, Box 3-4 (2/2)
© Global Initiative for Asthma
Stepwise management – pharmacotherapy(the therapy is designed to both prevent and relive
the obstruction)
*Not for children <12 years
**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
Tiotropium by mist inhaler is an add-on treatment for patients ≥12 years with a history of exacerbations
GINA 2017, Box 3-5 (2/8) (upper part)
Diagnosis
Symptom control & risk factors(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other controller
options
RELIEVER
STEP 1 STEP 2STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low dose ICS
Leukotriene receptor antagonists (LTRA)Low dose theophylline*
Med/high dose ICSLow dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol#
Low dose ICS/LABA**
Med/high ICS/LABA
PREFERRED CONTROLLER
CHOICE
Add tiotropium*
High dose ICS + LTRA (or + theoph*)
Add low dose OCS
Refer for add-on
treatment e.g.
tiotropium,* anti-IgE, anti-IL5*
UPDATED 2017
© Global Initiative for Asthma
Provide guided self-management education Treat modifiable risk factors and comorbidities Advise about non-pharmacological therapies and strategies
Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first
Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, provided FEV1 is 70% predicted
Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised.
Stepwise management +
© Global Initiative for Asthma
Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years)
This is not a table of equivalence, but of estimated clinical comparability Most of the clinical benefit from ICS is seen at low doses High doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects
Inhaled corticosteroid Total daily dose (mcg)Low Medium High
Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000
Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone furoate (DPI) 100 n.a. 200
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
GINA 2017, Box 3-6 (1/2)
© Global Initiative for Asthma
How often should asthma be reviewed? 1-3 months after treatment started, then every 3-12 months During pregnancy, every 4-6 weeks After an exacerbation, within 1 week
Stepping up asthma treatment Sustained step-up, for at least 2-3 months if asthma poorly controlled
• Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence)
Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen• May be initiated by patient with written asthma action plan
Day-to-day adjustment• For patients prescribed low-dose ICS/formoterol maintenance and reliever
regimen* Stepping down asthma treatment
Consider step-down after good control maintained for 3 months Find each patient’s minimum effective dose, that controls both
symptoms and exacerbations
Reviewing response and adjusting treatment
GINA 2017
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
© Global Initiative for Asthma
A flare-up or exacerbation is an acute or sub-acute worsening of symptoms and lung function compared with the patient’s usual status
Consider management of worsening asthma as a continuum
Self-management with a written asthma action plan Management in primary care Management in the emergency department and hospital Follow-up after any exacerbation
GINA 2017
© Global Initiative for Asthma
Increase inhaled reliever Increase frequency as needed Adding spacer (nebulizer) for pMDI may be helpful
Early and rapid increase in inhaled controller Up to maximum ICS of 2000mcg BDP/day or equivalent Options depend on usual controller medication and type of LABA See GINA 2017 report Box 4-2 for details
Add oral corticosteroids if needed Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days Children: 1-2mg/kg/day up to 40mg, usually 3-5 days Morning dosing preferred to reduce side-effects Tapering not needed if taken for less than 2 weeks Remember to advise patients about common side-effects (sleep
disturbance, increased appetite, reflux, mood changes)
Written asthma action plans – medication options
GINA 2017, Box 4-2 (2/2)
UPDATED 2017
© Global Initiative for Asthma
Nebulizers, spacers
© Global Initiative for Asthma
Patients with features of both asthma and COPD have worse outcomes than those with asthma or COPD alone Frequent exacerbations Poor quality of life More rapid decline in lung function Higher mortality Greater health care utilization
Reported prevalence of overlap varies by definitions used Concurrent doctor-diagnosed asthma and COPD are found in
15–20% of patients with chronic airways disease Reported rates of overlap are between15–55% of patients with
chronic airways disease, depending on the definitions used for ‘asthma’ and ‘COPD’, and the population studied
Prevalence varies by age and gender
Asthma-COPD overlap (ACO)
GINA 2017
UPDATED 2017
© Global Initiative for Asthma
Definitions
GINA 2017, Box 5-1 (3/3)
Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. [GINA 2017]
COPD
Chronic obstructive pulmonary disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. [GOLD 2017]
Asthma-COPD overlap [not a definition, but a description for clinical use]
Asthma-COPD overlap (ACO) is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Asthma-COPD overlap is therefore identified in clinical practice by the features that it shares with both asthma and COPD.This is not a definition, but a description for clinical use, as asthma-COPD overlap includes several different clinical phenotypes and there are likely to be several different underlying mechanisms.
UPDATED 2017
© Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2017, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS(i) Assemble the features for asthma and for COPD that best describe the patient.(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days
Worse during the night or early morning
Triggered by exercise, emotionsincluding laughter, dust or exposureto allergens
Persistent despite treatment
Good and bad days but always dailysymptoms and exertional dyspnea
Chronic cough & sputum preceded onset of dyspnea, unrelated to triggers
Lung function Record of variable airflow limitation(spirometry or peak flow)
Record of persistent airflow limitation(FEV1/FVC < 0.7 post-BD)
Lung function betweensymptoms
Normal Abnormal
Past history or family history Previous doctor diagnosis of asthma
Family history of asthma, and other allergic conditions (allergic rhinitis or eczema)
Previous doctor diagnosis of COPD,chronic bronchitis or emphysema
Heavy exposure to risk factor: tobaccosmoke, biomass fuels
Time course No worsening of symptoms over time.Variation in symptoms either seasonally, or from year to year
May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks
Symptoms slowly worsening over time(progressive course over years)
Rapid-acting bronchodilator treatmentprovides only limited relief
Chest X-ray Normal Severe hyperinflation
DIAGNOSIS
CONFIDENCE INDIAGNOSIS
Asthma
Asthma
Some featuresof asthma
Asthma
Features of both
Could be ACO
Some featuresof COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggestthat diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACO
UPDATED 2017
© Global Initiative for Asthma
Step 3 - Spirometry
Spirometric variable Asthma COPD Overlap
Normal FEV1/FVCpre- or post-BD
Compatible with asthma Not compatible withdiagnosis (GOLD)
Not compatible unlessother evidence of chronicairflow limitation
FEV1 ≥80% predicted Compatible with asthma(good control, or intervalbetween symptoms)
Compatible with GOLDcategory A or B if post-BD FEV1/FVC <0.7
Compatible with mildACO
Post-BD increase in FEV1 >12% and 400mLfrom baseline
- High probability ofasthma
Unusual in COPD.Consider ACO
Compatible withdiagnosis of ACO
Post-BD FEV1/FVC <0.7- Indicates airflowlimitation; may improve
Required for diagnosisby GOLD criteria
Usual in asthma-COPD overlap (ACO)
Post-BD increase in FEV1 >12% and 200mLfrom baseline (reversibleairflow limitation)
- Usual at some time incourse of asthma; notalways present
Common in COPD andmore likely when FEV1 is low
Common in ACO, andmore likely when FEV1 islow
FEV1<80% predicted Compatible with asthma.A risk factor for exacerbations
Indicates severity ofairflow limitation and riskof exacerbations and mortality
Indicates severity ofairflow limitation and riskof exacerbations and mortality
GINA 2017, Box 5-3
UPDATED 2017
© Global Initiative for Asthma
If syndromic assessment suggests asthma as single diagnosis Start with low-dose ICS Add LABA and/or LAMA if needed for poor control despite good
adherence and correct technique Do not give LABA alone without ICS
If syndromic assessment suggests COPD as single diagnosis Start with bronchodilators or combination therapy Do not give ICS alone without LABA and/or LAMA
If differential diagnosis is equally balanced between asthma and COPD, i.e. asthma-COPD overlap Start treatment as for asthma, pending further investigations Start with ICS at low or moderate dose Usually also add LABA and/or LAMA, or continue if already
prescribed
Initial therapy
GINA 2017
UPDATED 2017
β 2 - β 2 - agonistsagonists Short-actingShort-acting::
Salbutamol Salbutamol Fenoterol Fenoterol TTerbutalineerbutaline
Long-actingLong-acting:: SSalmeterol almeterol Formoterol Formoterol IndakaterolIndakaterol
Medications to Treat Asthma: How to Use a Spray Inhaler
The health-care provider should evaluate inhaler technique at each visit.
Inhaled anticholinergicsInhaled anticholinergics
Short-actingShort-acting:: Ipratropium Ipratropium
bromidebromide ((AtroventAtrovent, , IpraventIpravent))
Tiotropium Tiotropium bromide bromide :: Tiotropium Tiotropium
bromidebromide ((SpirivaSpiriva))
Combined bronchodilatorsCombined bronchodilators
BetaBeta 2 - 2 - agonistagonist + anticholinergic: + anticholinergic:
• BerodualBerodual ( (fenoterolfenoterol + + ipratropium ipratropium bromidebromide))
• DuolinDuolin ((salbutamolsalbutamol + + ipratropium ipratropium bromidebromide))
MethylxanthinesMethylxanthines
Fast and short-Fast and short-actingacting: : EuphyllineEuphylline AminophyllineAminophylline
Long-actingLong-acting:: TeotardTeotard DoxofyllineDoxofylline
((Puroxan,Puroxan, AerofyllinAerofyllin) ) ......
Roflumilast:(Daxas®®), (DalirespTM)
Phosphodiesterase inhibitor with selective action on its isoenzyme IV (IFDE-4), which predominates in inflammatory cells
Shows anti-inflammatory activity in the airways:
• inhibits chemotaxis and activation of leukocytes, production of cytokines• reduces the number of neutrophils and eosinophils
Anti-inflammatory Anti-inflammatory medicines in medicines in
bronchoobstructive bronchoobstructive syndrome treatment syndrome treatment
Pulmonary rehabilitation of COPDPulmonary rehabilitation of COPD
Oxygen - Oxygen - a highly effective treatment for patients with a highly effective treatment for patients with stage III-IV COPD, the only one which is able to reduce stage III-IV COPD, the only one which is able to reduce mortalitymortality (A) (A)
Respiratory exercises Respiratory exercises provides only short-term effect provides only short-term effect (P)(P)
Physiotherapy unreasonable in COPD and useless in Physiotherapy unreasonable in COPD and useless in terms of evidence-based medicine treatment: light and terms of evidence-based medicine treatment: light and electrotherapy, bioresonance therapy, electric, electrotherapy, bioresonance therapy, electric, intranasal electrophoresis, UHF, iv laser irradiation and intranasal electrophoresis, UHF, iv laser irradiation and other (D)other (D)
No evidence is the use of acupuncture, homeopathy, No evidence is the use of acupuncture, homeopathy, herbal medicine.herbal medicine.