So, let's talk about the management
of patients with COPD.
And first, it's about getting the diagnosis right,
and so we talked about the GOLD criteria.
The next step is really to think about smoking
because it is the number one risk factor.
If we don't address smoking in patients with COPD,
we know they’re progressively going to get worse.
80% of patients with COPD have a smoking history.
Doesn't correlate very well
between the total amount smoked
and the diagnosis of COPD.
So, in some people,
you don't have to smoke a lot necessarily,
even 10 to 15 pack years to develop COPD.
But I think one thing that’s important
and it’s an emerging risk factor for COPD,
particularly among people who
immigrate to the United States,
is exposure of particulate matter.
That could be in a big factory in Asia
where the patient worked for 20 years,
could be from home cooking in a different country
where there’s poor ventilation.
So, that’s something to think about in a patient
coming from particularly the poorer world
and having no smoking history,
do consider particulate history.
And asthma is frequently mistaken for COPD,
but asthma can actually develop into COPD.
And that's why you do spirometry
because COPD is marked by that
no reversal with a bronchodilator,
but whereas asthma is.
It usually improves in terms of that FEV1/FVC ratio
following bronchodilator use.
That's critical for differentiating the two disorders
because they’re related, but different.
Chest x-ray, less accurate because
many patients with COPD
don’t necessarily have those
classic chest x-ray findings.
And in straightforward cases of COPD,
you don't have to do lung volumes.
You can get away with simple
spirometry with a bronchodilator.
So, let’s talk about quitting smoking
in the management of COPD.
So, this is a study
of 8,000 adults and they’re followed for 25 years,
looking at the incidence of moderate to severe COPD.
Of course, those who continue
to smoke were much higher
But, look, even folks who quit
within five years of the final assessment – so,
they smoked for 20 years,
they had a lower risk of COPD.
So, you can smoke on a long-term basis,
but at any point that you can stop smoking,
you’re going to make either
your risk of COPD less
or your risk of more severe COPD less.
So, therefore, reducing smoking at all stages
before they have COPD all the way
up until they have moderate to severe COPD
is critical for the health of patients.
Let’s look at 93,000 Japanese adults.
They didn't have any lung disease at baseline.
And here we are measuring
the hazard ratio on the y-axis for COPD death
based on smoking status.
compared with continuous smokers – and
there were 285 deaths in this study.
Compared with continuous smokers there on the right,
those who had quit for at least five years
had a much lower incidence of death due to COPD.
And those who quit ten years, obviously,
they were able to get their
risk of death due to COPD
similar to that of individuals who had never
smoken in the first place – smoked in the first place.
All right. Let’s focus on exercise.
Now, pulmonary rehabilitation frequently
forgotten among patients with COPD,
but it can be effective.
This is a Cochrane review of 65 randomized
trials of pulmonary rehabilitation.
Most programs were 8 to 12 weeks in duration.
There was improvements in quality of life,
exercise tolerance and
respiratory symptoms in these trials.
There is probably a slight superiority for
inpatient versus outpatient programs.
And really, the key to the program's
efficacy was exercise.
It didn’t come down to so much
counseling and how to manage dyspnea
and how to use their medications better.
Exercise was the most important
part of pulmonary rehab.
And so, really, what they concluded
was that rehabilitation was effective,
but it was important to find the best practice.
Where should these classes take place?
How long should they last?
What’s the appropriate coursework?
Seems like exercise is really the key
coursework for pulmonary rehab programs.
And I just put a plug in here.
Don't forget among patients with any level of COPD,
they need to have the full pneumococcal
vaccine and flu – and regular flu vaccine series too.
Let’s talk about the as-needed drug experience.
So, here's 652 patients in a trial.
They all had moderate to severe COPD.
They’re randomized to albuterol,
ipratropium or the combination thereof.
Combination was superior in spirometry to either drug alone.
There wasn't really a difference though
in terms of symptom scores,
quality-of-life scores or physician
rating of patient symptoms.
And there was also no serious
adverse events with treatment.
The conclusion from that study would say
it’s better to probably use something both together
versus something apart, but not a big
difference in terms of the as-needed drugs.
The main thing with COPD is using controller agents
and there are a number of options available.
So, this is a comparison between a
long-acting beta agonist, salmeterol,
or tiotropium, a long-acting anti-muscarinic agent.
The main outcome that they’re
looking among these 7,300 adults
was exacerbations over one year.
The rate of exacerbations was lower
in the group receiving tiotropium.
Tiotropium was also better for moderate to severe exacerbations,
time to first exacerbation
and the rate of adverse events
was similar between these two groups.