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Management of COPD


									          William P. Saliski Jr. DO
Montgomery Pulmonary Consultants
Management of Stable COPD
 Pharmacotherapy
 Oxygen
 Smoking Cessation
 Vaccinations
 Rehabilitation
 Surgery
 Future Discussions
Assessing Severity
          Staging System (GOLD)

  Defines disease severity by FEV1 and ratio

 Used as a “guide” to manage patient therapy
General Approach
 Pharmacotherapy - prevent/decrease symptoms

                 - reduce exacerbations

                 - improve health status
                 - improve exercise capacity
Short Acting Bronchodilators
  Beta agonists - albuterol, levabuteral,

  Anticholinergics - ipratropium bromide
      Short Acting Bronchodilators -Names

Albuterol Sulfate -   Provental HFA
                      Ventolin HFA
                      Proair HFA

Levalbuterol -        Xopenex

Porbuterol -          Maxair

Ipatroprium Bromide – Atrovent

Combu-Med -           Combivent
       Beta Agonist Therapy

Dosing : 2 Puffs – as needed

Side Effects : tremor, reflex tachycardia
               hypokalemia ( extreme use )
     Anticholinergic Therapy
Dosing – 2 puffs 4x/daily
       - 18 meq/puff
        -200 puffs/canister

Side Effects - dry mouth, constipation
               ? Cardiovascular side effects
        Combination Therapy

Dosing – 2 puffs 4x/daily

Combination therapy increased FEV1 more
than either agent alone
    Long Acting Bronchodilators
Salmeterol – Serevent

Formoterol – Foradil

Arfomoterol – Brovena (nebulizer use)

Tiotropium – Spiriva

Therapy in Gold II – IV
              Beta Agonists

Dosing – both are dry powder
         used 2x/daily

Side Effects – same as short acting agents
             - increase risk of death (Smart
            (Long Acting)

Dosing – dry powder

Side Effects – dry mouth, headache
       constipation, glaucoma (worsening)
     Comparison “Shopping”
Foradil> Serevent

-Foradil has rapid onset, lasts longer
-Spiriva affords better bronchodilation and
  better side effect profile
     Bronchodilators Plus Inhaled
      Glucocorticosteroids (ICS)
COPD characterized by airway and systemic

Numerous ICS on the market

No real difference in products

ICS should not be used as sole therapy
     Bronchodilator Plus ICS
Advair Discus/Advair HFA
(Fluticasone/Salmeterol)250 meq/50 mcg

Symbicort 160/4.5
(Budesonide/Formeterol)2 puffs- 2x/daily

Side Effects (ICS) oral candidiasis, pneumonia,
adrenal suppression
       Triple Inhaler Therapy
 Stage III-IV Gold

 LABA/ICS and tiotroprium bromide

 Decrease mortality, exacerbations, and
 Mechanism of action controversial
 Offers moderate bronchodilation
 Long acting extended release preps
 Narrow LD 50
 Metabolized in liver
 Keep serum level 8 to 12 mcg/mL
    Rarely Used Medications
 Systemic Glucocorticoids

 Mucoactive Agents

 Chronic Antibiotic Therapy
        Supplemental Therapy
 Oxygen

 Secretion Clearance

 Smoking Cessation

 Vaccinations

 Rehabilitation

 Nutrition
              Oxygen Therapy
 Long term oxygen therapy (LTOT)
   increases survival and improves quality of life

 Minimal adverse effects (humidify !)

 Close government regulation

 2 billion dollars per year (Medicare)
             LTOT Indications
 PaO2 ≤ 55 mm Hg or SaO2 ≤ 88 %

 Cor Pulmonale – PaO2 ≤ 59 mm Hg/SaO2 ≤ 89 %

 (Hct > 55 %, EKG - p pulmonale, CHF

 Desaturation with above numbers w/ exercise or at
        Prescribing Oxygen
Obtain baseline ABG
         (does O2 Sat correlate?)
         (is patient hypercarbic?)

Keep PaO2 60 to 65 mm Hg
Keep SaO2≥92%
Usually order 2L NC
(continuous, exercise, sleep?)
      Equipment Selection
 Keep your patient mobile

 Select lightest, most portable

 Think liquid O2

 Oxygen conserving device

 Oxygen concentrator (bedroom)
       Secretion Clearance
 Postural drainage

 Flutter valve therapy

 Hydration ?
Pneumococcal/polysaccharide vaccine
 COPD ≥ 65 yrs old
 COPD ≤ 65 yrs old w/ FEV1< 40% predicted
 Active tobacco use

 Give initial vaccine and 5 year booster
 Does not reduce mortality
Influenza vaccination
      given to all patients with COPD

Decrease risk of influenza significantly


Timing ?
           Smoking Cessation
 Clinician advice

 Nicotine replacement therapy

 Buproprion -(Zyban) 150 mg

 Varenicline – (Chantix) 1 mg

 Combination therapy- best outcome
 Low cost effective program

 Optimizes physical and social functioning

 Reduces hospitalization, LOS, ? Mortality

 Medically supervised

   Baptist Medical Center South

     Anita Jones 334.286.2859

Covered by Major Medical Insurances
Exercise Equipment
30% of patients with severe COPD are
 protein-calorie malnourished

Increase mortality, decrease muscle function,
  decrease immunity
Try high caloric dietary supplements
Magestrol acetate (Megace)
What you don’t want to have

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