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COPD: Treatment

by Charles Vega, MD
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    00:01 So, let's talk about the management of patients with COPD.

    00:05 And first, it's about getting the diagnosis right, and so we talked about the GOLD criteria.

    00:12 The next step is really to think about smoking because it is the number one risk factor.

    00:16 If we don't address smoking in patients with COPD, we know they’re progressively going to get worse.

    00:23 80% of patients with COPD have a smoking history.

    00:27 Doesn't correlate very well between the total amount smoked and the diagnosis of COPD.

    00:33 So, in some people, you don't have to smoke a lot necessarily, even 10 to 15 pack years to develop COPD.

    00:40 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.

    00:49 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.

    00:58 So, that’s something to think about in a patient with dyspnea coming from particularly the poorer world and having no smoking history, do consider particulate history.

    01:12 And asthma is frequently mistaken for COPD, but asthma can actually develop into COPD.

    01:18 And that's why you do spirometry because COPD is marked by that no reversal with a bronchodilator, but whereas asthma is.

    01:27 It usually improves in terms of that FEV1/FVC ratio following bronchodilator use.

    01:34 That's critical for differentiating the two disorders because they’re related, but different.

    01:39 Chest x-ray, less accurate because many patients with COPD don’t necessarily have those classic chest x-ray findings.

    01:45 And in straightforward cases of COPD, you don't have to do lung volumes.

    01:50 You can get away with simple spirometry with a bronchodilator.

    01:55 So, let’s talk about quitting smoking in the management of COPD.

    01:59 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.

    02:08 Of course, those who continue to smoke were much higher than non-smokers.

    02:12 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.

    02:25 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.

    02:37 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.

    02:49 Let’s look at 93,000 Japanese adults.

    02:52 They didn't have any lung disease at baseline.

    02:54 And here we are measuring the hazard ratio on the y-axis for COPD death based on smoking status.

    03:03 So, again, compared with continuous smokers – and there were 285 deaths in this study.

    03:10 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.

    03:20 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.

    03:33 All right. Let’s focus on exercise.

    03:36 Now, pulmonary rehabilitation frequently forgotten among patients with COPD, but it can be effective.

    03:43 This is a Cochrane review of 65 randomized trials of pulmonary rehabilitation.

    03:49 Most programs were 8 to 12 weeks in duration.

    03:52 There was improvements in quality of life, exercise tolerance and respiratory symptoms in these trials.

    03:59 There is probably a slight superiority for inpatient versus outpatient programs.

    04:05 And really, the key to the program's efficacy was exercise.

    04:08 It didn’t come down to so much counseling and how to manage dyspnea and how to use their medications better.

    04:13 Exercise was the most important part of pulmonary rehab.

    04:18 And so, really, what they concluded was that rehabilitation was effective, but it was important to find the best practice.

    04:24 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.

    04:37 And I just put a plug in here.

    04:39 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.

    04:48 All right.

    04:49 Let’s talk about the as-needed drug experience.

    04:52 So, here's 652 patients in a trial.

    04:54 They all had moderate to severe COPD.

    04:56 They’re randomized to albuterol, ipratropium or the combination thereof.

    05:01 Combination was superior in spirometry to either drug alone.

    05:06 There wasn't really a difference though in terms of symptom scores, quality-of-life scores or physician rating of patient symptoms.

    05:13 And there was also no serious adverse events with treatment.

    05:16 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.

    05:26 The main thing with COPD is using controller agents and there are a number of options available.

    05:31 So, this is a comparison between a long-acting beta agonist, salmeterol, or tiotropium, a long-acting anti-muscarinic agent.

    05:40 The main outcome that they’re looking among these 7,300 adults was exacerbations over one year.

    05:47 The rate of exacerbations was lower in the group receiving tiotropium.

    05:52 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.


    About the Lecture

    The lecture COPD: Treatment by Charles Vega, MD is from the course Chronic Care. It contains the following chapters:

    • Treatment of COPD
    • Quit Smoking
    • Step 3: Exercise
    • Step 4: The prn Experience
    • Step 5: Control

    Included Quiz Questions

    1. ...nearly the same risk of death by chronic obstructive pulmonary disease as people who have never smoked.
    2. ...about half risk of death by chronic obstructive pulmonary disease as people who are still smoking.
    3. ...the same risk of death by chronic obstructive pulmonary disease as those who continue smoking.
    4. ...about two-thirds the risk of death by chronic obstructive pulmonary disease as people who are still smoking.
    5. ...a zero percent chance of dying from chronic obstructive pulmonary disease.
    1. Spirometry with bronchodilator
    2. Chest X-ray
    3. Spiral CT angiogram
    4. Clinical history and physical exam
    5. Peak flow meter measure of lung volumes
    1. Inpatient pulmonary rehabilitation exercise.
    2. Outpatient pulmonary rehabilitation counselling.
    3. Ipratropium therapy.
    4. Short acting beta agonist therapy.
    5. Annual flu vaccination.
    1. Long-acting antimuscarinic agents (tiotropium).
    2. Long acting beta agonists (salmeterol).
    3. Short acting beta agonists (albuterol).
    4. Short acting beta agonist and anticholinergic combination inhalers (ipratropium + albuterol).
    5. Anticholinergic agents (ipratropium).

    Author of lecture COPD: Treatment

     Charles Vega, MD

    Charles Vega, MD


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