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R10 Respirology
Airway Disease
Toronto Notes 2019
GOLD Classification of the Severity of COPD
GOLD 1 Mild FEV1 ≥80% of predicted
GOLD 2 Moderate 50% ≤FEV1 <80% of predicted GOLD 3 Severe 30% ≤ FEV1 <50% of predicted GOLD 4 Very Severe FEV1 <30% of predicted Note: weak correlation between FEV1 and symptoms
Remember to step down therapy to lowest doses which control symptoms/signs of bronchoconstriction
Influenza Vaccine for Patients with Chronic Obstructive Pulmonary Disease
Cochrane DB Syst Rev 2006;1:CD002733
Study: Cochrane Systematic Review. 11 RCTs included, 6 specifically in COPD patients.
Population: Six of the studies were done on COPD patients in particular, while the others were on elderly and high-risk individuals. Asthma patients were excluded.
Intervention: Live or inactivated virus vaccines vs. placebo. Outcome: Exacerbation rates, hospitalizations, mortality, lung function and adverse effects.
Results: In patients with COPD, inactive vaccine correlated with fewer exacerbations per vaccinated subject than placebo (weighted mean difference (WMD) -0.37, 95%
Cl -0.64 to -0.11). Inactivated vaccine resulted in fewer influenza-related infections than placebo (WMD 0.19, 95% Cl 0.07-0.48). There was also an increased risk of local mild, transient adverse reactions with the vaccine. Conclusions: There appears to be a reduction in influenza- related infections, as well as exacerbations in patients with COPD receiving the vaccine.
Systemic Corticosteroids for Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Cochrane DB Syst Rev 2014: CD001228
Study: Cochrane systematic review 16 studies. Population: 1,787 patients with acute COPD exacerbations. Intervention: Oral or parenteral corticosteroids vs. placebo. Outcome: Treatment failure, risk of relapse, time to next COPD exacerbation, likelihood of adverse event, length of hospital stay, and lung function at end of treatment. Results: Systemic corticosteroids reduced the risk of treatment failure by over half compared with placebo in nine studies (n =917) with median treatment duration
14 d, odds ratio (OR) 0.48 (95% CI 0.35-0.67). The evidence was graded as high quality and it would have been necessary to treat nine people (95% CI 7-14) with systemic corticosteroids to avoid one treatment failure. There was moderate-quality evidence for a lower rate
of relapse by one month for treatment with systemic corticosteroidintwostudies(n=415)(hazardratio
(HR) 0.78; 95% CI 0.63-0.97). Mortality up to 30 d was
not reduced by treatment with systemic corticosteroid compared with control in 12 studies (n = 1,319; OR 1.00; 95% CI 0.60-1.66). FEV1, measured up to 72 hours, showed significant treatment benefits (7 studies; n =649; mean difference (MD) 140 mL; 95% CI 90-200); however, this benefit was not observed at later time points. The likelihood of adverse events increased with corticosteroid treatment (OR 2.33; 95% CI 1.59-3.43). The risk of hyperglycemia was significantly increased (OR 2.79; 95% CI 1.86-4.19). For general inpatient treatment, duration of hospitalization was significantly shorter with corticosteroid treatment (MD -1.22 d; 95% CI -2.26 to -0.18), with no difference in length of stay in the intensive care unit (ICU) setting. Comparison of parenteral versus oral treatment showed no significant difference in the primary outcomes of treatment failure, relapse or mortality or for any secondary outcomes. Conclusion: There is high-quality evidence to support treatment of exacerbations of COPD with systemic corticosteroid by the oral or parenteral route in reducing the likelihood of treatment failure and relapse by 1 mo, shortening length of stay in hospital inpatients not requiring assisted ventilation in ICU and giving earlier improvement in lung function and symptoms. There is no evidence
of benefit for parenteral treatment compared with oral treatment with corticosteroid on treatment failure, relapse or mortality. There is an increase in adverse drug effects with corticosteroid treatment, which is greater with parenteral administration compared with oral treatment.
Signs and Symptoms
Table 14. Clinical Presentation and Investigations for Chronic Emphysema
Bronchitis (Blue Bloater*)
Emphysema (Pink Puffer*)
Symptoms
Chronic productive cough Purulent sputum Hemoptysis
Dyspnea (± exertion) Minimal cough
Tachypnea
Decreased exercise tolerance
Signs
Cyanosis (2o to hypoxemia and hypercapnia) Peripheral edema from RVF (cor pulmonale)
Crackles, wheezes Prolonged expiration if obstructive Frequently obese
Pink skin
Pursed-lip breathing Accessory muscle use Cachectic appearance due to anorexia and increased work of breathing Hyperinflation/barrel chest Hyperresonant percussion Decreased breath sounds Decreased diaphragmatic excursion
Investigations
PFT:
 FEV1,  FEV1/FVC
N TLC,or N DLCO
CXR:
AP diameter normal bronchovascular markings Enlarged heart with cor pulmonale
PFT:
 FEV1,  FEV1/FVC TLC (hyperinflation) RV (gas trapping)  DLCO
CXR:
AP diameter
Flat hemidiaphragm (on lateral CXR)
cardiac silhouette retrosternal space
Bullae
peripheral vascular markings
*Note that the distinction between “blue bloaters” and “pink puffers” is more of historical than practical interest as most COPD patients have elements of both
Table 15. Treatment of Stable COPD
Treatment
PROLONG SURVIVAL Smoking Cessation Vaccination
Home Oxygen
Details
Nicotine replacement, bupropion, varenicline
Behavioural therapy, nicotine replacement, bupropion, varenicline
Prevents cor pulmonale and decreases mortality if used >15h/d; indicated if: (1) PaO2 <55 mmHg or
(2) PaO2 <60 mmHg with cor pulmonale or polycythemia
SYMPTOMATIC RELIEF (no mortality benefit)
Bronchodilators (mainstay of current drug therapy, used in combination)
Short-acting anticholinergics (e.g. ipratropium bromide) and short-acting β2-agonists (e.g. salbutamol, terbutaline)
SABAs: rapid onset but significant side effects at high doses (e.g. hypokalemia)
Short-acting anticholinergics slightly more effective than SABAs with fewer side effects but slower onset
Using a combination of both is superior to monotherapy
LABAs (e.g. salmeterol, formoterol, indacaterol) and long-acting anticholinergics (e.g. tiotropium bromide, glycopyrronium bromide)
More sustained effects for moderate to severe COPD
LAMAs more effective at decreasing exacerbation rates than LABAs Using a combination of both is superior than monotherapy
Inhaled corticosteroid (ICS) + LABA combination (e.g. Advair®: fluticasone + salmeterol, Symbicort®: budesonide + formoterol)
Theophylline: weak bronchodilator; limited evidence to suggest combination with bronchodilator
Side effects: nervous tremor, nausea/vomiting/diarrhea, tachycardia, arrhythmias, sleep changes
PDE4 inhibitor: roflumilast (Daxas®) anti-inflammatory medication useful in COPD with chronic bronchitis, severe airflow obstruction, frequent exacerbations
ICS monotherapy has been shown to increase the incidence of pneumonia in COPD; ICS should only be used with a LABA in combination in patients with a history of exacerbations
Oral steroids are important when treating exacerbations; chronic systemic glucocorticoids are generally not recommended due to unfavourable benefit to risk ratio
Lung volume reduction surgery (resection of emphysematous parts of lung, associated with higher mortality if FEV1 <20%), lung transplant
Patient education, eliminate respiratory irritants/allergens (occupational/environmental), exercise rehabilitation to improve physical endurance
Corticosteroids
Surgical Other