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ERS-ATS COPD Guidelines Copyright European Respiratory Society 2005 These slides can be used freely for non-commercial purposes. Document authors ERS-ATS COPD Guidelines Document Goals and Objectives (1) pThe Standards for the Diagnosis and Treatment of Patients with COPD document updates the position papers on COPD published by the ATS and the ERS in 1995. pBoth organisations acknowledge the recent dissemination of the Global Initiative of Obstructive Lung Disease (GOLD) as a major contribution against COPD. pHowever, an adaptation of GOLD was deemed necessary to match specific requirements of the members of both societies. pThose requirements include specific recommendations on oxygen therapy, pulmonary rehabilitation, noninvasive ventilation, surgery in and for COPD, sleep, air travel, and end- of-life. ERS-ATS COPD Guidelines Document Goals and Objectives (2) These guidelines aim at: pImproving the quality of care provided to patients with COPD. pPromoting the use of a disease-oriented approach. pMaintaining a synchronous flow with the wider objectives of GOLD. pUsing an electronic, web-based format which can be updated any time a modification is deemed necessary. ERS-ATS COPD Guidelines Definition of COPD pChronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. pThe airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. ERS-ATS COPD Guidelines Epidemiology (1) pCOPD is a leading cause of morbidity and mortality worldwide, and results in an economic and social burden that is both substantial and increasing. pPrevalence and morbidity data greatly underestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced. ERS-ATS COPD Guidelines Epidemiology (2) pCOPD is the fourth leading cause of death in the USA and Europe, and COPD mortality in females has more than doubled over the last 20 years. Leading causes of death in the USA, 1998Number Heart disease724,269 Cancer538,947 Cerebrovascular disease (stroke)158,060 Respiratory diseases (COPD)114,381 Accidents94,828 Pneumonia and influenza93,207 Diabetes64,574 Suicide29,264 Nephritis26,265 Chronic liver disease24,936 All other causes of death469,314 ERS-ATS COPD Guidelines Epidemiology (3) pCOPD is a more costly disease than asthma and, depending on country, 5075% of the costs are for services associated with exacerbations. pTobacco smoke is by far the most important risk factor for COPD worldwide. pOther important risk factors are: Host factorsExposures Genetic factors Sex Airway hyperreactivity, IgE and asthma Smoking Socio-economic status Occupation Environmental pollution Perinatal events and childhood illness Recurrent bronchopulmonary infections Diet ERS-ATS COPD Guidelines Pathogenesis and Pathophysiology pPathogenesis nTobacco smoking is the main risk factor for COPD, although other inhaled noxious particles and gases may contribute. nIn addition to inflammation, an imbalance of proteinases and antiproteinases in the lungs, and oxidative stress are also important in the pathogenesis of COPD. pPathophysiology nThe different pathogenic mechanisms produce the pathological changes which, in turn, give rise to the physiological abnormalities in COPD: pmucous hypersecretion and ciliary dysfunction, pairflow limitation and hyperinflation, pgas exchange abnormalities, ppulmonary hypertension, psystemic effects. ERS-ATS COPD Guidelines Diagnosis of COPD (1) pDiagnosis of COPD should be considered in any patient who has the following: nsymptoms of cough nsputum production ndyspnoea nhistory of exposure to risk factors for the disease pSpirometry should be obtained in all persons with the following history: nexposure to cigarettes and/or environmental or occupational pollutants nfamily history of chronic respiratory illness npresence of cough, sputum production or dyspnoea ERS-ATS COPD Guidelines Diagnosis of COPD (2) Spirometry pSpirometric classification of COPD: nPost-bronchodilator FEV1/forced vital capacity 0.780 Mild COPD0.780 Moderate COPD0.75080 Severe COPD0.73050 Very severe COPD0.790% during rest, sleep and exertion. pActive patients require portable oxygen. pIf oxygen was prescribed during an exacerbation, recheck ABGs after 3090 days. pWithdrawal of oxygen because of improved Pa,O2 in patients with a documented need for oxygen may be detrimental. pPatient education improves compliance. ERS-ATS COPD Guidelines Long-term oxygen therapy (3) Home treatment Pa,O2: arterial oxygen tension; Sa,O2: arterial oxygen saturation; ABG: arterial blood gases. ERS-ATS COPD Guidelines Management of stable COPD pPharmacological therapy pLong-term oxygen therapy pPulmonary rehabilitation pNutrition pSurgery in and for COPD pSleep pAir travel ERS-ATS COPD Guidelines Pulmonary rehabilitation pPulmonary rehabilitation is a multidisciplinary programme of care that is individually tailored and designed to optimise physical and social performance and autonomy. pPulmonary rehabilitation should be considered for patients with COPD who have dyspnoea or other respiratory symptoms, reduced exercise tolerance, a restriction in activities because of their disease, or impaired health status. pPulmonary rehabilitation programmes include: nexercise training, neducation, npsychosocial/behavioural intervention, nnutritional therapy, noutcome assessment, npromotion of long-term adherence to the rehabilitation recommendations. ERS-ATS COPD Guidelines Management of stable COPD pPharmacological therapy pLong-term oxygen therapy pPulmonary rehabilitation pNutrition pSurgery in and for COPD pSleep pAir travel ERS-ATS COPD Guidelines Nutrition pWeight loss and a depletion of fat-free mass (FFM) may be observed in stable COPD patients. pBeing underweight is associated with an increased mortality risk. pCriteria to define weight loss are: nWeight loss 10% in the past 6 months or 5% in the past month. pNutritional therapy may only be effective if combined with exercise or other anabolic stimuli. UnderweightBMI 50 yrs Normal weightBMI 12,000 m (40,000 feet) as long as the cabin is pressurised from 1,800 2,400 m (6,0008,000 feet). This is equivalent to an inspired oxygen (O2) concentration at sea level of 15%. pPatients with COPD can exhibit falls in arterial O2 tension (Pa,O2) that average 25 mmHg (3.3 kPa). pPre-flight assessment can help determine O2 needs and the presence of co-morbidities. pMost airlines will provide supplemental O2 on request. pThere is increasing evidence that patients on long flights may be at increased risk for deep vein thrombosis. ERS-ATS COPD Guidelines Exacerbation of COPD pDefinition, evaluation and treatment pIn-patient oxygen therapy pAssisted ventilation ERS-ATS COPD Guidelines Exacerbation of COPD pDefinition, evaluation and treatment pIn-patient oxygen therapy pAssisted ventilation ERS-ATS COPD Guidelines Definition, evaluation and treatment (1) pThe definition of COPD exacerbation is an acute change in a patients baseline dyspnoea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy. pCauses of exacerbation can be both infectious and non-infectious. pMedical therapy includes bronchodilators, corticosteroids, antibiotics and supplemental oxygen therapy. ERS-ATS COPD Guidelines Definition, evaluation and treatment (2) pIndications for hospitalisation of patients with a COPD exacerbation nPresence of high-risk co-morbid conditions, including pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure nInadequate response of symptoms to outpatient management nMarked increase in dyspnoea nInability to eat or sleep due to symptoms nWorsening hypoxaemia nWorsening hypercapnia nChanges in mental status nInability of the patient to care for her/himself nUncertain diagnosis nInadequate home care ERS-ATS COPD Guidelines Definition, evaluation and treatment (3) pThe Operational Classification of Severity is as follows: ambulatory (Level I), requiring hospitalisation (Level II) and acute respiratory failure (Level III). Level ILevel IILevel III Clinical history Co-morbid conditions History of frequent exacerbations Severity of COPD + + Mild/moderate + + Moderate/severe + + Severe Physical findings Haemodynamic evaluation Use accessory respiratory muscles, tachypnoea Persistent symptoms after initial therapy Stable Not present No Stable + + Stable/unstable + + Diagnostic procedures Oxygen saturation Arterial blood gases Chest radiograph Blood tests Serum drug concentrations Sputum gram stain and culture Electrocardiogram Yes No No No If applicable No No Yes Yes Yes Yes If applicable Yes Yes Yes Yes Yes Yes If applicable Yes Yes +: unlikely to be present; +: likely to be present; +: very likely to be present ERS-ATS COPD Guidelines Definition, evaluation and treatment (4) pLevel I: outpatient treatment Patient education Check inhalation technique Consider use of spacer devices Bronchodilators Short-acting 2-agonist and/or ipratropium MDI with spacer or hand-held nebuliser as needed Consider adding long-acting bronchodilator if patient is not using it Corticosteroids (the actual dose may vary) Prednisone 3040 mg per os q day for 10 days Consider using an inhaled corticosteroid Antibiotics May be initiated in patients with altered sputum characteristics Choice should be based on local bacteria resistance patterns Amoxicillin/ampicillin, cephalosporins Doxycycline Macrolides If the patient has failed prior antibiotic therapy consider: Amoxicillin/clavulanate Respiratory fluoroquinolones ERS-ATS COPD Guidelines Definition, evaluation and treatment (5) pLevel II: treatment for hospitalised patient Bronchodilators Short acting 2-agonist (albuterol, salbutamol) and/or Ipratropium MDI with spacer or hand-held nebuliser as needed Supplemental oxygen (if saturation 90%. pMain delivery devices include nasal cannula and venturi mask. pAlternative delivery devices include nonrebreather mask, reservoir cannula, nasal cannula or transtracheal catheter. pArterial blood gases should be monitored for arterial oxygen tension (Pa,O2), arterial carbon dioxide tension (Pa,CO2) and pH. pArterial oxygen saturation as measured by pulse oximetry (Sp,O2) should be monitored for trending and adjusting oxygen settings. pPrevention of tissue hypoxia supercedes CO2 retention concerns. pIf CO2 retention occurs, monitor for acidaemia. pIf acidaemia occurs, consider mechanical ventilation. ERS-ATS COPD Guidelines In-patient oxygen therapy (2) Algorithm to correct hypoxaemia in an acutely ill chronic obstructive pulmonary disease patient. ABG: arterial blood gas; Pa,O2: arterial oxygen tension; O2: oxygen; Sa,O2: arterial oxygen saturation; Pa,CO2: arterial carbon dioxide tension; NPPV: noninvasive positive pressure ventilation. ERS-ATS COPD Guidelines Exacerbation of COPD pDefinition, evaluation and treatment pIn-patient oxygen therapy pAssisted ventilation ERS-ATS COPD Guidelines Assisted ventilation (1) pNoninvasive positive pressure ventilation (NPPV) should be offered to patients with exacerbations when, after optimal medical therapy and oxygenation, respiratory acidosis (pH 7.36) and or excessive breathlessness persist. All patients considered for mechanical ventilation should have arterial blood gases measured. pIf pH 7.30, NPPV should be delivered under controlled environments such as intermediate intensive care units (ICUs) and/or high-dependency units. pIf pH 7.25, NPPV should be administered in the ICU and intubation should be readily available. pThe combination of some continuous positive airway pressure (CPAP) (e.g. 48 cmH2O) and pressure support ventilation (PSV) (e.g. 1015 cmH2O) provides the most effective mode of NPPV. ERS-ATS COPD Guidelines Assisted ventilation (2) pPatients meeting exclusion criteria should be considered for immediate intubation and ICU admission. pExclusion criteria include: nrespiratory arrest, ncardiovascular instability, nimpaired mental status, nsomnolence, ninability to cooperate, ncopious and/or viscous secretions with high aspiration risk, nrecent facial or gastro-oesophageal surgery; craniofacial trauma and/or fixed naso-pharyngeal abnormality, nburns, nextreme obesity. pIn the first hours, NPPV requires the same level of assistance as conventional mechanical ventilation. ERS-ATS COPD Guidelines Assisted ventilation (3) Flow-chart for the use of noninvasive positive pressure ventilation (NPPV) during exacerbation of COPD complicat