Practical Respiratory Update

1
Practical Respiratory Update

• GPVTS 2008
• Dr John Hughes

2
Practical GPVTS Update

• Asthma recent trials implication for
  treatment/BTS guidelines
• Inhaler devices
• Spirometry
• COPD Treatment different to Asthma -NICE/BTS
  guidelines
• Oxygen Treatment
• Physiotherapy in Respiratory conditions

3
BTS/SIGN GUIDELINES
Outcome Best possible control
Outcome Asthma control

• Controller
• Daily ICS
• Daily inhaled long-acting?2-agonist
• plus (if needed)

• Controller
• Daily ICS
• Daily inhaled long-acting?2-agonist

• When asthma is controlled, reduce therapy
• Monitor

• Controller
• Daily ICS

• Controller
• None

-theophylline-SR -leukotriene modifier
-oral long-acting ?2-agonist -oral
corticosteroid
Reliever
Rapid-acting inhaled ?2-agonist prn
STEP 1 Intermittent
STEP 2 Mild persistent
STEP 3 Moderate persistent
STEP 4 Severe persistent
Step down
Alternative controller and reliever medications
may be considered
BTS/SIGN. British Guideline on the Management of
Asthma. Thorax 2003 58 suppl.1.
Symb 03 13018 Date of Preparation December 2003
4
Treatment guidelines
Percentage of respondents who said that they were
very satisfied with the standard of their asthma
management, before and after being shown
international guidelines
That cant be right. My treatment doesnt do
that
Haughney J (2003 )
5
TOTAL CONTROL1

• Composite measure that builds on guideline
  definitions2
• NO daily symptoms
• NO rescue salbutamol use
• NO exacerbations
• NO night-time awakening
• NO emergency visits
• NO days with AM PEFlt80 predicted
• NO treatment-related side effects enforcing
  change in asthma therapy
• All of the above for at least 7 out of 8 weeks
  assessed

1. Boushey H et al. Abstract presented at the
World Asthma Meeting, February 1619, 2004,
Bangkok, Thailand 2. National Institutes of
Health, National Heart, Lung, and Blood
Institute. Global Initiative for Asthma. 2002
6
GOAL study design
Study Strata based on previous total daily dose
of ICS
Study treatment
Seretide 250 b.d.
gt5001000 mcg BDP equiv.
3,416 uncontrolled asthma patients
3
n1155
FP 250 b.d.
?500 mcg BDP equiv.
2
Seretide 100 b.d.
n1163
Steroid naive
1
FP 100 b.d.
n1098
Groups entered into a 4 -week run-in
Notes Seretide does not currently hold a
licence for initial maintenance
therapy fluticasone is as effective as
beclometasone at half the dose

7
STUDY FLOW
Seretide 50/100 µg bd FP 100 µg bd
Randomisation
TOTAL CONTROL?
Yes
No
Phase 1 Step Up Treatment Seretide 50/250 µg
bd FP 250 µg bd
Phase II - Continue Same Dose
Yes
TOTAL CONTROL?
No
Phase 1 Step Up Treatment Seretide 50/500 µg
bd FP 500 µg bd
Yes
TOTAL CONTROL?
No
0.5 mg/kg Prednisolone 10 days
Patient Complete
8
TOTAL CONTROL is an achievable aim in previously
uncontrolled patients
80
FP Phase I II
Seretide Phase I II
60
44
40
patients achieving TOTAL CONTROL
28
20
plt0.001 vs FP
0
Stratum 2 (low dose ICS)
Boushey H et al. Abstract presented at the World
Asthma Meeting, February 2004, Bangkok, Thailand
9
Asthma is a variable disease
Cold weather exercise
Allergens viral infection
Increased
Use of reliever medication or symptoms
Time
Asthma control
Decreased
Exacerbation
Exacerbation
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Exacerbation

• What advice would you give to asthmatic who
  develops a chest infection?

11
Inhaled Steroids

• Moderate dose and double at onset of flare-ups?
  OR
• Low dose and increase 4- to 5- fold at onset of
• flare-ups?

12
Early intervention with an increased dose of
inhaled budesonide when asthma worsens helps
prevent severe exacerbations

• 213 pts
• 800mcg BUD bd 4 weeks
• Randomised 6 months Rx

13
Early intervention with an increased dose of
inhaled budesonide when asthma worsens helps
prevent severe exacerbations
Days with oral steroids
plt0.001
120
plt0.001
100
80
60
40
20
0
BUD 400 µg bid placebo qid
BUD 100 µg bid BUD 200 µg qid
BUD 100 µg bid placebo qid
Foresi A, et al. Chest 2000 117440-6.
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Typical Symbicort adjustable maintenance dosing
study design
Adults (18 years and older) Max dose 4
inhalations bid
Adjustable maintenance dosing
Run-in
R
Symbicort 100/6 µg or 200/6 µg
Gain control
Maintain control
-1
0
1
3
6
Months
2
3
4
5
Visits
1
Stallberg B et al. Int J Clin Pract
200357656-61.
15
Adjustable maintenance dosing step-down
criteria after gaining control

• Patients could step-down their maintenance dose
  to 1 inh. bid if, in the last 7 days, they had
• reliever use on ?2 days/occasions AND
• no night-time awakenings due to asthma

inh. inhalation(s)
Stallberg B et al. Int J Clin Pract
200357656-61.
16
Adjustable maintenance dosing criteria for
temporary step up at asthma worsening
Adults (18 years and older) Max dose 4
inhalations bid
inh. inhalation(s)
Stallberg B et al. Int J Clin Pract
200357656-61.
17
Symbicort adjustable maintenance dosing
improves exacerbation control more effectively
than fixed-dose Symbicort at an overall lower
drug load
Mean No. of Symbicort inhalations/day
Patients with ?1 exacerbation ()
plt0.05
10
plt0.001
9
4.0
8
3.5
7
3.0
6
2.5
5
2.0
4
1.5
3
1.0
2
0.5
1
0
0
AMD
Fixed dosing
AMD
Fixed dosing
Adults (18 years and older) Max dose 4
inhalations bid
Stallberg B et al. Int J Clin Pract
200357656-61.
18
Symbicort adjustable maintenance dosing is a
more cost-effective treatment than fixed dosing
Cost ()
600
plt0.001
500
400
300
200
100
0
Fixed dosing
AMD
Stallberg B et al. Int J Clin Pract
200357656-61.
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The COPD patient

• Generally over 35 years1
• A smoker or ex-smoker
• Presentation with
• cough
• excessive sputum production
• shortness of breath
• Recurrent bronchitis
• Dyspnoea is the reason most patients seek
  medical attention5

1. BTS, 1997 5. Pauwels, 2001
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DIAGNOSIS

• Confirm airflow obstruction by spirometry
• ALL health care workers Rx COPD access to
  competence in spirometry

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SPIROMETRY

• Perform if COPD likely
• FEV1 lt 80 Predicted
• AND
• FEV1/VC lt 70

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Spirometry Spirograms
FVC
FEV1
Obstructive
Healthy
Volume (litres)
FEV1
Restrictive
FEV1
Time (sec)
1 sec
23
Spirometry Spirograms
Normal
FEV1
Mild COPD
Moderate COPD
Volume (litres)
Severe COPD
Time (sec)
1 sec
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Spirometry

• FEV1/VC lt 70 obstructive
• FEV1 PRED for prognosis
• FEV1 PRED for severity and hence likely
  treatment
• Mild 50-80 pred
• Moderate 30-49pred
• Severe lt30 pred

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ICS IN COPD

• DO NOT effect decline in lung function
• Have NO proven benefits in mild (FEV1 50-80
  pred) COPD
• Reduce exacerbations by 25 in moderate to severe
  COPD (FEV1lt50)
• Improve health status and symptoms in SOME
  moderate to severe COPD patients

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ICS in COPD (2)

• The MAJORITY of COPD patients have mild or
  moderate disease FEV1 gt 50
• Therefore the MAJORITY should NOT be on ICS
• However some patients may experience symptoms
  with ICS withdrawal

28
Manage Exacerbations

• ? Exacerbations by appropriate use ICS,
  bronchodilators and vaccinations
• Self-management plans
• Starting appropriate antibiotics/steroids
• NIV
• Hospital at home/early discharge schemes

29
Exacerbations COPD

• Often leads to hospitalisation
• Hospital ? risk of mortality
• Severe COPD inpatient mortality 11
• ?? frequency severity ? ? pulm fn, ? airway
  inflammation more frequent bacterial
  colonisation

30
Exacerbations COPD

• Contribute to poorer quality of life
• ? risk of mortality the following year

31
Two placebo controlled studies looking at the
role of systemic steroids in COPD exacerbations
32
Davies L, Angus RM, Calverly PM. Oral
corticosteroids in patients admitted to Hospital
with exacerbations of COPD A prospective
randomised controlled trial. Lancet 1999354

• Objectives To determine the effect of
  Prednisolone on lung function, symptoms and to
  time to discharge in patients with exacerbations
  of COPD requiring hospital admission.
• Design Prospective , randomised, double-blind,
  placebo controlled trial.
• Intervention Prednisolone 30 mg. Once daily
  versus placebo, in addition to standard therapy.
• Duration Fourteen days

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KEY RESULTS

• Steroid treated group had
• ? More rapid improvement in spirometry
• ? Greater improvement in spirometry (28 to
  42, placebo 26 to 32)
• ? Improved symptoms ( well being, mobility and
  sleep quality)
• ? Shorter hospital stay ( 7 days, 9 days placebo)

34
Niewoehner DE, Erbland ML, Deupree RH, Collins
D, Gross NJ, Light RW et al.effect of systemic
glucocorticoids on exacerbations of COPD. N.Eng J
Med 1999,-340 1941-7

• OBJECTIVES To evaluate the efficacy of systemic
  corticosteroids in patients admitted to hospital
  for acute exacerbations of COPD.
• DESIGN Prospective, randomised, double-blind,
  placebo controlled trial.
• INTERVENTION Initial intravenous
  methylprednisolone and subsequent oral Prednisone
  (starting at 60mg. daily) for 8 weeks versus
  identical steroid regime for 2 weeks versus
  placebo, in addition to standard therapy.
• DURATION Eight weeks

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KEY RESULTS

• ? Treatment failures lower in steroid-treated
  group at 30 days (23 vs 33 placebo)
• and at 90 days (37 vs 48 placebo)
• ? Shorter hospital stays (1.2 days)
• Faster improvement in lung function
• ? Two weeks as effective as 8

36
CONCLUSIONS

• ? Steroids lead to more rapid improvement in
  lung function and shorter hospital stays
• ? Prolong the time to next exacerbation
• ? Treatment for no more than two weeks
• ? Not an indication for long term therapy

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AECOPD LV dysfunction (LVD)

• 148 pts ICU acute COPD
• 31 Acute LV dysfunction
• 13.5 possible LV dysfunction
• ? natriuretic peptides Troponin T
• Abroug et al
  AJRCCM 2006174990-6

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COPD

• OXYGEN THERAPY

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Oxygen

• 21 air

40
What are the benefits of Oxygen?

• To prolong life in persistent hypoxaemia
• To reduce comorbidity in persistent hypoxaemia
• To improve exercise performance
• To reduce breathlessness acutely

41
Oxygen delivery

• Continuous
• Intermittent
• Ambulatory
• Cylinder
• Portable cylinder
• Concentrator
• Liquid

42
REMEMBER

• Oxygen treats hypoxia which is not the same as
  breathlessness!!

43
Hypoxia and COPD

• Type 1 respiratory failure
• PaO2 low PaCO2 normal or low

• Type 11 respiratory failure
• PaO2 low PaCO2 raised

44
Domiciliary Oxygen Therapy

• Long term Oxygen Therapy
• (15 hours per day)
• Ambulatory Oxygen Therapy
• (supplementary oxygen during exertion)
• Short Burst Oxygen Therapy
• (Palliation of breathlessness)
• Temporary/Emergency Oxygen Therapy
• (Acute episodes)

45
O2

• Oxygen should ONLY be prescribed after careful
  evaluation of the need.
• If indicated assessment with O2 saturation or
  blood gases should be performed
• Do not give on a placebo basis

46
Evidence for LTOT

• Long term oxygen therapy -home oxygen prescribed
  for 15 hours or more a day for hypoxic patients
  with chronic lung disease
• ? mortality morbidity
• MRC Lancet 1981 1091
  (I)681-686
• NOTT (Nocturnal oxygen therapy
  trial)
• Ann
  intern Med 1980 93 391-8

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LTOT indications

• Absolute
• COPD
• Hypoxia PaO2 lt7.3 kPa (55mmHg)
• Oedema
• PaCO2 lt 6.0 kPa (45 mmHg)
• FEV1 lt 1.5 L
• VC lt 2.0 L

48
LTOT indications

• Stable phase repeat gt 3 weeks
• PaO2 lt 0.6 kPa (5 mmHg)

49
LTOT

• Aim
• Minimum 15 hrs/day1-4litres nasal prongs
• gt 2 l/min humidification
• PaO2 gt 8 kPa (60 mmHg) (gt90 saturation)
• Avoid hypercapnia (? PaCO2)

50
Indications for ambulatory oxygen therapy

• Greater than 4 desaturation on exertion to below
  90
• Evidence of improvement in walking distance on
  oxygen therapy
• Minimal exercise desaturation on ambulatory
  therapy
• Patient needs to be willing to use for
  exertion/activities of daily living

51
Palliative O2

• Lung Cancer
• Pulmonary Fibrosis
• Emphysema (end stage)
• Muscle/neurological disorders

52
LTOT support

• Trained nurses/Pulm Fn Technicians
• Regular domiciliary monitoring
• Review Consultant Chest Physician/ Respiratory
  Nurse Specialist
• Smoking cessation
• BTS/RCP guidelines

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Oxygen Categories HOOF
54
Oxygen costs excluding VAT