Role of PT in COPD: what we should know and how we could do Chronic Obstructive Pulmonary Disease (COPD) Benjamas Chuaychoo MD Ph D Benjamas Chuaychoo, MD, Ph.D. Division of Respiratory Diseases and Tuberculosis Department of Medicine Faculty of Medicine Siriraj Hospital Faculty of Medicine Siriraj Hospital Mahidol University 24 June 2015
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Role of PT in COPD: what we should know and how we could do
Chronic Obstructive Pulmonary Disease (COPD)( )
Benjamas Chuaychoo MD Ph DBenjamas Chuaychoo, MD, Ph.D.Division of Respiratory Diseases and Tuberculosis
Department of MedicineFaculty of Medicine Siriraj HospitalFaculty of Medicine Siriraj Hospital
Pulmonary hypertension in COPD• Pulmonary hypertension in COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPDDefinition of COPD
COPD a common preventable and treatable COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive andlimitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and theinflammatory response in the airways and the lung to noxious particles or gases
Exacerbations and comorbidities contribute to the overall severity in individual patients
Pulmonary hypertension in COPD• Pulmonary hypertension in COPD
Human Airways
no gas exchange
gas exchangegas exchange
Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963, Springer‐Verlag Brashear RE, Rhodes ML. Chronic Obstructive Lung Disease. St. Louis: The CV. Mosby Co. 1978
generating capacity g g p y• adverse effects on cardiovascular function• assessment of the presence and severity of LHassessment of the presence and severity of LH
is useful clinical approach to assess impact of therapeutic interventions on symptoms, exercise tolerance and health-related quality of life
Rossi A et.al. Respir Med. 2015 Jul;109(7):785-802.
Human AirwaysHuman Airways Emphysema - defined pathologically as an abnormal permanent
no gas exchange
as an abnormal permanent enlargement of air spaces distal to the terminal bronchioles, accompanied by the destruction of alveolar walls and without obviousalveolar walls and without obvious fibrosis
gas exchange
Decreased DLCO
Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963,Modified from Weibel, E.R.: Morphometry of the human lung. Heidelberg, 1963, Springer‐Verlag Brashear RE, Rhodes ML. Chronic Obstructive Lung Disease. St. Louis: The CV. Mosby Co. 1978
Effect of Emphysema on Compliance d Diff i C i (DL )and Diffusing Capacity (DLco)
http://www.netterimages.com/image/1000.htm
Definition
• Chronic bronchitis– is a clinical diagnosis
“Presence of cough and sputum
Chronic bronchitis
– Presence of cough and sputum production for at least 3 months in each of two consecutive years”
C h
• Emphysema, or destruction of the gas exchanging surfaces of the lung (alveoli)
Cough
g g g ( )– is a pathological diagnosis– “Abnormal, permanent enlargement of
the airspaces distal to the terminal Normal
Emphysema
bronchiole, accompanied by destruction of their walls”
Pulmonary hypertension in COPD• Pulmonary hypertension in COPD
Who is/are COPD patient(s)?Who is/are COPD patient(s)?
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key P iPoints
• A clinical diagnosis of COPD should beA clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and achronic cough or sputum production, and a history of exposure to risk factors for the disease.
• Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV /FVCthe presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.airflow limitation and thus of COPD.
CRJ5 Sue i have inserted a bracket and shifted the obstructive label. The FVC in this slide is about 3.4 by eyeball - shoudl be moved down to3.2 or the numbers should be changed Christine Jenkins, 4/14/2008
Pulmonary hypertension in COPD• Pulmonary hypertension in COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPDDefinition of COPD
COPD a common preventable and treatable COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated tat o t at s usua y p og ess e a d assoc atedwith an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
J Med Assoc Thai. 2012 Aug;95(8):1021-7.Prevalence of osteoporosis and osteopenia in Thai COPD patients.Rittayamai N Chuaychoo B Sriwijitkamol ARittayamai N, Chuaychoo B, Sriwijitkamol A.
• Prevalence of osteoporosis 31.4% p• Prevalence of osteopenia 32.4% • Prevalence of osteoporosis in COPD patients was higher
th th t i t h d Th i l f hi t i l d tthan that in age-matched Thai males from historical data (31.4% vs. 12.6%, respectively).
• The predictive value of BMI < 20.5 kg/m2 and hs-CRP >The predictive value of BMI 20.5 kg/m2 and hs CRP 2.3 mg/L demonstrated risk of osteoporosis in COPD patients (adjusted Odds ratio 7.2 and 4.1, respectively).
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined AssessmentCombined Assessmentof COPDCombined Assessmentof COPDWhen assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk )
Patient Characteristic SpirometricClassification
Exacerbationsper year
CAT mMRC
exacerbations should be considered high risk.)
A Low RiskLess Symptoms GOLD 1-2 ≤ 1 < 10 0-1
B Low RiskM S t GOLD 1-2 ≤ 1 > 10 > 2B More Symptoms GOLD 1 2 ≤ 1 10 2
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD ComorbiditiesGlobal Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD ComorbiditiesAssess COPD ComorbiditiesAssess COPD ComorbiditiesCOPD patients are at increased risk for: COPD patients are at increased risk for: p
• Cardiovascular diseases• Osteoporosis
p
• Cardiovascular diseases• Osteoporosisp• Respiratory infections• Anxiety and Depression
p• Respiratory infections• Anxiety and Depression• Diabetes• Lung cancer
Bronchiectasis
• Diabetes• Lung cancer
Bronchiectasis• BronchiectasisThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely and
• BronchiectasisThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely andhospitalizations and should be looked for routinely, and
treated appropriately.hospitalizations and should be looked for routinely, and
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
All COPD patients benefit from exercise training
Therapeutic Options: Rehabilitation
All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigueand symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitation i 6 k th l thprogram is 6 weeks, the longer the program
continues, the more effective the results.
If exercise training is maintained at home, the patient's health status remains above pre-rehabilitation levels.
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage ExacerbationsGlobal Strategy for Diagnosis, Management and Prevention of COPD
Manage Exacerbations
A b ti f COPD i
Manage ExacerbationsManage Exacerbations
An exacerbation of COPD is:
“an acute event characterized by aan acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal daysymptoms that is beyond normal day-to-day variations and leads to a h i di i ”change in medication.”
Pulmonary hypertension in COPD• Pulmonary hypertension in COPD
DefinitionsDefinitions
AsthmaAsthma is a heterogeneous disease usually characterized by chronic airwayAsthma 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 2014]
COPDCOPD is a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronicairflow limitation that is usually progressive and associated with enhanced chronic inflammatory responses in the airways and the lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. [GOLD 2015]
Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation with several features usually associated with asthma and several features
yusually associated with COPD. ACOS is therefore identified by the features that it shares with both asthma and COPD.
GINA 2014, Box 5-1
Why is asthma–COPD overlap important?
• Prevalence: ACOS 20% of patients with obstructive airway disease (asthma or COPD) and 2% in general population
• Increased illness burden: ACOS leads to significant health status impairment, increased exacerbations and increased hospitalizationshospitalizations
• Treatment implications: – When asthma is not recognized, there is potential for increased
adverse events and drug toxicity from LABAadverse events and drug toxicity from LABA – Increased response to ICS and LABA in COPD patients with
asthmali it d id f t t t d ti b ACOS– limited evidence for treatment recommendations because ACOS patients are excluded from randomized controlled trials
LABA = long‐acting β2 agonists, ICS = inhaled corticosteroids
Gibson PG, et al. Thorax 2015;70:683–691.
Usual features of asthma, COPD and ACOSUsual features of asthma, COPD and ACOSACOS ACOS
Feature Asthma COPD ACOS
Age of onset Usually childhood but can Usually >40 years Usually ≥40 years but may
Pattern of i t
Symptoms vary over time(d t d l
Chronic usually continuoust ti l l
Respiratory symptomsi l di ti l d
Age of onset Usually childhood but cancommence at any age
Usually >40 years Usually ≥40 years, but mayhave had symptoms aschild/early adult
respiratorysymptoms
(day to day, or over longerperiod), often limitingactivity. Often triggered byexercise, emotionsincluding laughter dust or
symptoms, particularlyduring exercise, with ‘better’and ‘worse’ days
including exertional dyspneaare persistent, but variabilitymay be prominent
including laughter, dust, orexposure to allergens
Lung function Current and/or historicalvariable airflow limitation, e g BD reversibility AHR
FEV1 may be improved bytherapy, but post-BDFEV /FVC <0 7 persists
-Airflow limitation not fullyreversible, but often withcurrent or historicale.g. BD reversibility, AHR FEV1/FVC <0.7 persists current or historicalvariability
Lung functionbetween symptoms
May be normal Persistent airflow limitation Persistent airflow limitation
reduced by treatment present, comorbiditiescontribute to impairment
are reduced by treatment. Comorbidities can contributeto impairment.
GINA 2014, Box 5-2A (2/3)
Features that (when present) favorasthma or COPDFeatures that (when present) favorasthma or COPDasthma or COPDasthma or COPD
Feature Favors asthma Favors COPDAge of onset Before age 20 years After age 40 yearsg g y g y
Pattern of respiratorysymptoms
Symptoms vary overminutes, hours or daysWorse during night or early morningTriggered by exercise, emotions including
laughter dust or exposure to allergens
Symptoms persist despite treatmentGood and bad days, but always daily
symptoms and exertional dyspneaChronic cough and sputum precededS d i di i f i di
Lung function Record of variable airflow limitation (spirometry, peak flow)
Normal between symptoms
Record of persistent airflow limitation (post-BD FEV1/FVC <0.7)
Abnormal between symptoms
laughter, dust, or exposure to allergens Chronic cough and sputum preceded onset of dyspnea, unrelated to triggersSyndromic diagnosis of airways disease
The shaded columns list features that, when present, best distinguish between asthma and COPD. Normal between symptoms Abnormal between symptoms
Past history or family history
Previous doctor diagnosis of asthmaFamily history of asthma, and other allergic
conditions (allergic rhinitis or eczema)
Previous doctor diagnosis of COPD, chronic bronchitis or emphysema
Heavy exposure to a risk factor: tobacco smoke biomass fuels
gFor a patient, count the number of check boxes in each column. If 3 or more boxes are checked for either asthma orsmoke, biomass fuels
Time course No worseningof symptoms over time. Symptoms vary seasonally, or from year to year
May improve spontaneously or respond
Symptomsslowly worsening over time (progressive course over years)
Rapid-acting bronchodilator treatment provides only limited relief
If 3 or more boxes are checked for either asthma or COPD, that diagnosis is suggested.
If there are similar numbers of checked boxes in h l th di i f ACOS h ld b
May improve spontaneously, or respond immediately to BD or to ICS over weeks
provides only limited reliefeach column, the diagnosis of ACOS should be considered.
Step 3 - SpirometryStep 3 - Spirometry
Spirometric variableAsthma COPD ACOSNormal FEV1/FVC Compatible with asthma Not compatible with Not compatible unless pre- or post-BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post-BD FEV1/FVC <0.7 Indicatesairflow limitation; may improve
Required for diagnosis by GOLDcriteria
Usual in ACOS
FEV1 =80% predicted Compatible with asthma (good control, or interval between symptoms)
Compatible with GOLD category A or B if post-BD FEV1/FVC <0.7
Compatible with mild ACOS
y p y
FEV <80% di t d C tibl ith th I di t it f I di t it f
P t BD i i U l t ti i C i COPD d C i ACOS d
FEV1 <80% predicted Compatible with asthma. A risk factor for exacerbations
Indicates severity of airflow limitation and risk of exacerbations and mortality
Indicates severity of airflow limitation and risk of exacerbations and mortality
Post-BD increase in FEV1 >12% and 200mL from baseline (reversible airflow limitation)
Usual at some time in course of asthma; not always present
Common in COPD and more likely when FEV1 is low, but consider ACOS