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ASTHMA - COPD
ASTHMA - COPD 
Dr. Nino JN Doydora 
Section of Pulmonary Medicine
Disclosures 
Novartis 
 A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to 
Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.) 
on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011 
 A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open 
label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate 
to Severe COPD May–October 2011 
Utsuka
Objectives: 
Review GINA 2014 guidelines on Asthma 
Review the GOLD 2014 guidelines on COPD 
Epidemiology 
Pathophysiology 
Signs and symptoms 
Diagnosis 
Treatment 
Approach to a patient with ACOS (Asthma-COPD 
Overlap Syndrome) GINA 2014
CASE 1 
19 year old female student 
CC: 3 days cough, wheezing, SOB 
Precipitated by exercise (frisbee) 
Relieved by salbutamol nebulization (past 3 nights) 
Self medicated with prednisone 10mg 1 dose 
(+) history of asthma attacks during childhood 
(+) family Hx of asthma (mother) 
(+) Hx of atopy and (+) allergy to crustaceans 
PE: talks in sentences with occasional wheeze
Asthma 
A reversible obstructive airway disease due to bronchial muscle constriction 
and airway inflammation; characterized by cough, wheezing and shortness of 
breath. 
Resolves spontaneously or with use of rescue meds. 
Exacerbations are caused by triggers. 
1 of 10 Filipino adults 
3 of 10 Filipino Children
ASTHMA – levels of control 
Characteristic Controlled Partly controlled Uncontrolled 
Daytime symptoms: 
wheezing, cough, SOB 
None >2x/week >3x/week 
Limitation of activities none any any 
Nocturnal awakening none any any 
Need for reliever meds < 2x / wk >2x/wk >2x/week
ACT – ASTHMA CONTROL TEST 
< 20 – suggests poor Asthma control
ACT – ASTHMA CONTROL TEST 
< 20 – suggests poor Asthma control
Diagnostics 
Spirometry – measures certain lung volumes; useful in diagnosing 
obstructive lung patterns 
Peak flow – screening test; measures maximum speed of expiration
Peak flow 
Patient’s Peak flow showed 65% from predicted
Treatment 
Non-pharmacologic 
Patient education 
Inhaler technique 
Pulmonary Rehabilitation Program 
Pharmacologic 
Oral medications 
Inhaled medications
t Commonly used Inhaled trreeaattmmeennttss ffoorr AAsstthhmmaa && CCOOPPDD 
Short Acting Bronchodilator 
Short Acting B2 Agonist agent (SABA) = Salbutamol, Terbutaline 
Short Acting Anti-Muscarinic agent (SAMA) = Ipratropium Bromide 
Long Acting Bronchodilator 
Long Acting B2 Agonist agent (LABA) = Salmeterol, Formoterol, 
indacaterol 
Long Acting Anti-Muscarinic agent (LAMA) = Tioptropium 
Inhaled Corticosteroid (ICS) = Fluticasone, Budesonide, beclomethasone 
Combination: SABA + SAMA = Salbutamol + Ipratropium (Pulmodual) 
Combination: LABA + ICS 
 Salmeterol + Fluticasone (Adeflo) 
 Formoterol + Budesonide
Treatment 
· Patient education 
· Inhaler technique and adherence to medications 
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 
Preferred 
Controller 
Choice 
NONE Low Dose ICS 
(Inhaled Steroid) 
Low dose 
ICS-LABA 
(ADEFLO) 
Medium/High 
ICS-LABA 
(ADEFLO) 
Refer for add 
on treatment 
(anti-IgE) 
Other 
Controller 
Options 
-- LTRA or 
methylxanthines 
(montileukast 
Or Theophylline) 
Medium/High 
ICS-LABA OR 
Low dose 
ICS/LABA + LTRA 
or /+ Theophylline 
High Dose 
ICS-LABA + 
LTRA or 
Theophylline 
Low dose oral 
steroid 
RELIEVER SABA – short acting B2-agonist (Salbutamol)
Strategies to ensure effective use of 
inhaler devices 
2014 
CHOOSE 
Most appropriate device 
The medication needed 
Available devices 
Cost 
Patient skills and patient’s choice 
Ensure no physical barriers, e.g. arthritis 
Avoid use of multiple different inhaler 
types to avoid confusion
Strategies to ensure effective use of 
inhaler devices 2014 
Clinicians should be able to demonstrate correct technique for each of 
the inhalers they prescribe 
For MDIs - use a spacer 
Improves delivery 
Reduces potential 
side-effects of ICS
Home meds and plans: 
Inhaled corticosteroid 
May add oral steroid for 3-5 days 
Round the clock reliever use for a few days then give on PRN basis 
If symptoms worsen : 
Follow-up in 3-5 days with chest X-ray 
Assess other possible causes of exacerbation 
Follow-up 2 weeks – 1 month after consult 
Measure peak flow on succeeding visits 
6-12 months of ICS therapy
Case 2: 
72 year old housewife 
CC: on and off cough, wheezing, shortness of breath 
Relieved by salbutamol nebulization 
lately is more bothersome after hosting a birthday party 
with grayish sputum, difficulty sleeping 
Has consulted several doctors; has 4 inhaler devices 
Passive smoker 
Previously hospitalized due to asthma 3 months ago 
PE: talks in phrases, (+) wheezing both lung fields
Case 2: 
Inhalers: 
77 female smoker 
•Tiotropium handihaler LAMA 
•Salbutamol MDI SABA 
•Procaterol swinghaler SABA 
•Formoterol + Budesonide turbohaler ICS-LABA 
•Budesonide turbohaler ICS
COPD: 2014 GOLD Definition 
Pink Puffer Blue Bloater 
 COPD 
characterized by airflow limitation that is not fully reversible 
and is usually progressive 
preventable and treatable 
exacerbations & co-morbidities contribute to the overall 
severity 
© 2014 Global Initiative for Chronic Obstructive Lung Disease
CUASES of COPD 
SMOKING 
1 pack/day 
In 10 years 
Pollution 
Exposure to 
Hazardous 
chemicals
Do we often see these COPD patients? 
Pink Puffer Blue Bloater 
COPD prevalence 
among Filipinos > 40 yo: 
2200%% Idolor et al. Respirology 2012.
Mortality comparisons with COPD 
exacerbation and AMI 
3 
50 
35 
69 
0 20 40 60 80 
Severe 
Moderate 
Shock 
No Shock 
% 
COPD Myocardial Infarction 
Swedish Registry 2008, GUSTO-1 Trial 2007
Asthma-COPD Overlap Syndrome - ACOS
How do we know they have COPD? 
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Acute exacerbation in COPD 
Increased symptoms 
Reduced lung function 
Accelerate lung function 
decline 
Deteriorate quality of life 
Increased economic cost 
Increased mortality 
“an acute event characterized by 
worsening of respiratory symptoms 
that is beyond normal day-to-day 
variations and leads to a change in 
medication.” 
Impact of 
acute 
exacerabatio 
ns in COPD 
GOLD Strategy Document 2014 (http://www.goldcopd.org/)
Vicious Cycle of Inflammation-Oxidative Stress- 
Exacerbations in COPD 
© 2014 Global Initiative for Chronic Obstructive Lung Disease 
Oxidative 
stress 
Anti-proteinase- 
Proteinase 
imbalance 
COPD Pathology: 
Exacerbations 
• Cigarette smoke 
• Occupational dust & fumes 
• Biomass fuels 
• Small airway fibrosis 
• Emphysema 
• Mucous hypersecretion 
• Systemic 
manifestations
Asthma-COPD Overlap Syndrome - ACOS
Modified British Medical Research Council (mMRC) Dyspnea Scale
COPD Assessment Test : CAT 
I never cough I cough all the time 
I have no phlegm (mucus) in my chest at all My chest is full of phlegm 
My chest does not feel tight at all My chest feels very tight 
When I walk up a hill or one flight When I walk up a hill or one flight 
of stairs I am not breathless of stairs I am very breathless 
I am not limited doing any activities at home I am very limited doing activities at home 
I am confident leaving my home despite my I am not at all confident leaving my 
home lung condition because of my lung condition 
I sleep soundly I don't sleep soundly because of 
my lung condition 
I have lots of energy I have no energy at all
COPD Assessment Test : CAT 
I never cough I cough all the time 
I have no phlegm (mucus) in my chest at all My chest is full of phlegm 
My chest does not feel tight at all My chest feels very tight 
When I walk up a hill or one flight When I walk up a hill or one flight 
of stairs I am not breathless of stairs I am very breathless 
I am not limited doing any activities at home I am very limited doing activities at home 
I am confident leaving my home despite my I am not at all confident leaving my 
home lung condition because of my lung condition 
I sleep soundly I don't sleep soundly because of 
my lung condition 
SCORE: 35 
I have lots of energy I have no energy at all
Asthma-COPD Overlap Syndrome - ACOS
Asthma-COPD Overlap Syndrome - ACOS
COPD treatment: 2 MAIN GOALS 
Goals for treatment of stable COPD 
Relieve symptoms 
Improve exercise tolerance 
Improve health status 
And 
Prevent disease progression 
Prevent and treat exacerbations 
Reduce mortality 
REDUCE 
SYMPTOMS 
REDUCE 
RISK 
of exacerbation 
Global Strategy for the Diagnosis, Management and Prevention of COPD 
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014
THERAPEUTIC OPTIONS 
What is the single most effective intervention 
to slow the progression of COPD? 
1 
Home 
Oxygen 
2 
Pulmonary 
Rehab. 
3 
Smoking 
Cessation 
4 
Flu 
Vaccination 
Evidence A
How to start Treatment* 
Newly Diagnosed COPD Patient 
Active Reduction of Risk Factors 
1. Smoking Cessation 
2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years 
As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use 
LABA or LAMA 
 Assess : symptoms and RISK: 
 Pulmonary Rehabilitation 
 Long Acting Bronchodilator 
 LABA alone (indacaterol) or LAMA alone (Tiotropium) 
 Assess: More Symptoms low Exacerbation Risk 
 Add another Long acting bronchodilator 
 LABA + LAMA or LAMA + LABA 
 Assess: More Symptoms, High Exacerbation Risk 
 Progressive & Frequent Exacerbation 
 + ICS 
 LAMA + LABA + ICS 
Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options 
•Based on Pharmacologic first choice treatment, 
GOLD 2011 
• other treatment options available.
 ICS- inhaled steroid: fluticasone/budesonide/beclomethasone 
 SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium 
 SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)
Pharmacological Management of COPD 
Patient First Choice Second Choice Alternative Choice 
SABA or SAMA prn SABA and SAMA 
A 
LABA or LAMA 
Theophylline 
(Option: Doxofylline ) 
B 
Pulmodual Dilatair 
LABA or LAMA LABA and LAMA 
SABA and /or SAMA 
Theophylline 
(Option: Doxofylline ) 
C 
ICS +LABA or LAMA LABA and LAMA 
Dilatair 
PDE4 Inhibitor 
SABA and/ or SAMA 
Theophylline 
(Option: Doxofylline ) 
D 
ICS+ LABA and LAMA 
ICS + LAMA 
ICS + LABA + LAMA 
ICS and LABA and PDE 4 inh 
LABA + LAMA 
LAMA + PDE 4 inh 
Dilatair 
Carbocisteine 
SABA and/ or SAMA 
Theophylline 
(Option: Doxofylline ) 
Dilatair 
Adeflo 
Adeflo
GUIDED ASTHMA SELF-MANAGEMENT 
EDUCATION AND SKILLS TRAINING 
2014 
Inhaler use is a skill - must be learned and 
maintained 
Up to 70–80% are unable to use their inhaler 
correctly. 
Unfortunately, many health care providers are unable 
to correctly demonstrate how to use the inhalers they 
prescribe 
Most people with incorrect technique are unaware 
that they have a problem 
There is no ‘perfect’ inhaler - patients can have 
problems using any inhaler device
Strategies to ensure effective use of 
inhaler devices 2014 
Clinicians should be able to demonstrate correct technique for each of 
the inhalers they prescribe 
For MDIs - use a spacer 
Improves delivery 
Reduces potential 
side-effects of ICS
A New Twist to 
FDC ICS-LABA Inhaler 
Therapy 
Twist 
Miat Monodose DPI
Salmeterol xinafoate/ Fluticasone 
propionate (Adeflo) via Adehaler 
 Passive DPI (aerolizer) 
 breath actuated 
 compact, portable, easy to use 
 no hand-mouth coordination 
required 
 Inhalation by capsule loaded by the 
patient 
 40 capsules/ box 
 Lactose carrier 
 IFR > 60 lpm; no breath hold 
 Protect from humidity 
Sims MW. Chest 140(3):781–788, 2011. 
Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011. 
Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003. 
50/250 mcg 
50/500 mcg
Asthma-COPD Overlap Syndrome - ACOS
Dry Powder Inhaler
Dry Powder Inhaler 
Wrong Right
Case 3 
55 year old, male, teacher 
CC: cough, wheezing, shortness of breath 7 days 
Precipitated by exposure to dust (he rides a motorbike) 
Sneezing, itchy throat 
Unable to sleep due to SOB, partially relieved by salbu neb 
(+) history of childhood asthma 
(+) 20 pack year (current) smoker 
(+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with 
pneumonia as outpatient. 
PE: talks in sentences, (+) wheezing both lung fields
What will you give to this patient? 
A. SABA (Salbutamol PRN) 
B. ICS (Budesonide) 
C. LAMA (Tiotropium) 
D. LABA (Indacaterol) 
E. ICS+LABA (Fluticasone + Salmeterol)
Asthma-COPD Overlap Syndrome - ACOS
ACOS (Asthma-COPD Overlap)
Asthma-COPD Overlap Syndrome - ACOS
For a patient, count the 
number of checked boxes in 
each column. If 3 or more 
are checked for either 
asthma or COPD , that 
diagnosis is suggested. But 
if there are similar numbers 
of checked boxes in each 
column, ACOS should be 
considered.
ACOS (Asthma-COPD Overlap)
Spirometry:
ACOS (Asthma-COPD Overlap)
Approach to ACOS 
(Asthma-COPD Overlap Syndrome) 
Asthma >> ICS (Inhaled corticosteroid) 
COPD >> LABA (long acting B2 agonist) 
ACOS >> ICS + LABA
Approach to ACOS 
(Asthma-COPD Overlap Syndrome) 
At least among adults, ACOS might represent a severe form of asthma, 
characterized by greater risk of hospitalizations and exacerbations 
ACOS is likely the result of early asthma that has progressed to fixed 
airway obstruction because airway remodeling and of its interaction 
with smoking 
Treatment may prevent a steeper decline of lung function among 
ACOS. 
De Marie Et. Al. ERS 2013 Presentation
Patient Education
Asthma-COPD Overlap Syndrome - ACOS
SMOKER'S PRAYER 
Heavenly Father, hear my plea, 
and grant my lungs serenity. 
Give me strength to kick the smoking 
that's been causing all my choking. 
Let my breath be fresh and clean 
without a trace of nicotine. 
Each ciggie I smoke so often 
Adds another nail in my coffin 
Guide me Lord, by Your holy means 
past all those cigarette machines. 
It hurts to hear My Loved ones say 
kissing ya's like lickin' an ashtray. 
Please oh Lord, Hear my voice, 
give me will power, while I have a choice. 
I ask Your help and it's no wonder 
because if I don't quit, I'm six feet under.
Health 
Is wealth 
Thank you!

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Asthma-COPD Overlap Syndrome - ACOS

  • 2. ASTHMA - COPD Dr. Nino JN Doydora Section of Pulmonary Medicine
  • 3. Disclosures Novartis  A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.) on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011  A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate to Severe COPD May–October 2011 Utsuka
  • 4. Objectives: Review GINA 2014 guidelines on Asthma Review the GOLD 2014 guidelines on COPD Epidemiology Pathophysiology Signs and symptoms Diagnosis Treatment Approach to a patient with ACOS (Asthma-COPD Overlap Syndrome) GINA 2014
  • 5. CASE 1 19 year old female student CC: 3 days cough, wheezing, SOB Precipitated by exercise (frisbee) Relieved by salbutamol nebulization (past 3 nights) Self medicated with prednisone 10mg 1 dose (+) history of asthma attacks during childhood (+) family Hx of asthma (mother) (+) Hx of atopy and (+) allergy to crustaceans PE: talks in sentences with occasional wheeze
  • 6. Asthma A reversible obstructive airway disease due to bronchial muscle constriction and airway inflammation; characterized by cough, wheezing and shortness of breath. Resolves spontaneously or with use of rescue meds. Exacerbations are caused by triggers. 1 of 10 Filipino adults 3 of 10 Filipino Children
  • 7. ASTHMA – levels of control Characteristic Controlled Partly controlled Uncontrolled Daytime symptoms: wheezing, cough, SOB None >2x/week >3x/week Limitation of activities none any any Nocturnal awakening none any any Need for reliever meds < 2x / wk >2x/wk >2x/week
  • 8. ACT – ASTHMA CONTROL TEST < 20 – suggests poor Asthma control
  • 9. ACT – ASTHMA CONTROL TEST < 20 – suggests poor Asthma control
  • 10. Diagnostics Spirometry – measures certain lung volumes; useful in diagnosing obstructive lung patterns Peak flow – screening test; measures maximum speed of expiration
  • 11. Peak flow Patient’s Peak flow showed 65% from predicted
  • 12. Treatment Non-pharmacologic Patient education Inhaler technique Pulmonary Rehabilitation Program Pharmacologic Oral medications Inhaled medications
  • 13. t Commonly used Inhaled trreeaattmmeennttss ffoorr AAsstthhmmaa && CCOOPPDD Short Acting Bronchodilator Short Acting B2 Agonist agent (SABA) = Salbutamol, Terbutaline Short Acting Anti-Muscarinic agent (SAMA) = Ipratropium Bromide Long Acting Bronchodilator Long Acting B2 Agonist agent (LABA) = Salmeterol, Formoterol, indacaterol Long Acting Anti-Muscarinic agent (LAMA) = Tioptropium Inhaled Corticosteroid (ICS) = Fluticasone, Budesonide, beclomethasone Combination: SABA + SAMA = Salbutamol + Ipratropium (Pulmodual) Combination: LABA + ICS  Salmeterol + Fluticasone (Adeflo)  Formoterol + Budesonide
  • 14. Treatment · Patient education · Inhaler technique and adherence to medications STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Preferred Controller Choice NONE Low Dose ICS (Inhaled Steroid) Low dose ICS-LABA (ADEFLO) Medium/High ICS-LABA (ADEFLO) Refer for add on treatment (anti-IgE) Other Controller Options -- LTRA or methylxanthines (montileukast Or Theophylline) Medium/High ICS-LABA OR Low dose ICS/LABA + LTRA or /+ Theophylline High Dose ICS-LABA + LTRA or Theophylline Low dose oral steroid RELIEVER SABA – short acting B2-agonist (Salbutamol)
  • 15. Strategies to ensure effective use of inhaler devices 2014 CHOOSE Most appropriate device The medication needed Available devices Cost Patient skills and patient’s choice Ensure no physical barriers, e.g. arthritis Avoid use of multiple different inhaler types to avoid confusion
  • 16. Strategies to ensure effective use of inhaler devices 2014 Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe For MDIs - use a spacer Improves delivery Reduces potential side-effects of ICS
  • 17. Home meds and plans: Inhaled corticosteroid May add oral steroid for 3-5 days Round the clock reliever use for a few days then give on PRN basis If symptoms worsen : Follow-up in 3-5 days with chest X-ray Assess other possible causes of exacerbation Follow-up 2 weeks – 1 month after consult Measure peak flow on succeeding visits 6-12 months of ICS therapy
  • 18. Case 2: 72 year old housewife CC: on and off cough, wheezing, shortness of breath Relieved by salbutamol nebulization lately is more bothersome after hosting a birthday party with grayish sputum, difficulty sleeping Has consulted several doctors; has 4 inhaler devices Passive smoker Previously hospitalized due to asthma 3 months ago PE: talks in phrases, (+) wheezing both lung fields
  • 19. Case 2: Inhalers: 77 female smoker •Tiotropium handihaler LAMA •Salbutamol MDI SABA •Procaterol swinghaler SABA •Formoterol + Budesonide turbohaler ICS-LABA •Budesonide turbohaler ICS
  • 20. COPD: 2014 GOLD Definition Pink Puffer Blue Bloater  COPD characterized by airflow limitation that is not fully reversible and is usually progressive preventable and treatable exacerbations & co-morbidities contribute to the overall severity © 2014 Global Initiative for Chronic Obstructive Lung Disease
  • 21. CUASES of COPD SMOKING 1 pack/day In 10 years Pollution Exposure to Hazardous chemicals
  • 22. Do we often see these COPD patients? Pink Puffer Blue Bloater COPD prevalence among Filipinos > 40 yo: 2200%% Idolor et al. Respirology 2012.
  • 23. Mortality comparisons with COPD exacerbation and AMI 3 50 35 69 0 20 40 60 80 Severe Moderate Shock No Shock % COPD Myocardial Infarction Swedish Registry 2008, GUSTO-1 Trial 2007
  • 25. How do we know they have COPD? © 2014 Global Initiative for Chronic Obstructive Lung Disease
  • 26. Acute exacerbation in COPD Increased symptoms Reduced lung function Accelerate lung function decline Deteriorate quality of life Increased economic cost Increased mortality “an acute event characterized by worsening of respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.” Impact of acute exacerabatio ns in COPD GOLD Strategy Document 2014 (http://www.goldcopd.org/)
  • 27. Vicious Cycle of Inflammation-Oxidative Stress- Exacerbations in COPD © 2014 Global Initiative for Chronic Obstructive Lung Disease Oxidative stress Anti-proteinase- Proteinase imbalance COPD Pathology: Exacerbations • Cigarette smoke • Occupational dust & fumes • Biomass fuels • Small airway fibrosis • Emphysema • Mucous hypersecretion • Systemic manifestations
  • 29. Modified British Medical Research Council (mMRC) Dyspnea Scale
  • 30. COPD Assessment Test : CAT I never cough I cough all the time I have no phlegm (mucus) in my chest at all My chest is full of phlegm My chest does not feel tight at all My chest feels very tight When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless I am not limited doing any activities at home I am very limited doing activities at home I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition I sleep soundly I don't sleep soundly because of my lung condition I have lots of energy I have no energy at all
  • 31. COPD Assessment Test : CAT I never cough I cough all the time I have no phlegm (mucus) in my chest at all My chest is full of phlegm My chest does not feel tight at all My chest feels very tight When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless I am not limited doing any activities at home I am very limited doing activities at home I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition I sleep soundly I don't sleep soundly because of my lung condition SCORE: 35 I have lots of energy I have no energy at all
  • 34. COPD treatment: 2 MAIN GOALS Goals for treatment of stable COPD Relieve symptoms Improve exercise tolerance Improve health status And Prevent disease progression Prevent and treat exacerbations Reduce mortality REDUCE SYMPTOMS REDUCE RISK of exacerbation Global Strategy for the Diagnosis, Management and Prevention of COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014
  • 35. THERAPEUTIC OPTIONS What is the single most effective intervention to slow the progression of COPD? 1 Home Oxygen 2 Pulmonary Rehab. 3 Smoking Cessation 4 Flu Vaccination Evidence A
  • 36. How to start Treatment* Newly Diagnosed COPD Patient Active Reduction of Risk Factors 1. Smoking Cessation 2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use LABA or LAMA  Assess : symptoms and RISK:  Pulmonary Rehabilitation  Long Acting Bronchodilator  LABA alone (indacaterol) or LAMA alone (Tiotropium)  Assess: More Symptoms low Exacerbation Risk  Add another Long acting bronchodilator  LABA + LAMA or LAMA + LABA  Assess: More Symptoms, High Exacerbation Risk  Progressive & Frequent Exacerbation  + ICS  LAMA + LABA + ICS Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options •Based on Pharmacologic first choice treatment, GOLD 2011 • other treatment options available.
  • 37.  ICS- inhaled steroid: fluticasone/budesonide/beclomethasone  SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium  SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)
  • 38. Pharmacological Management of COPD Patient First Choice Second Choice Alternative Choice SABA or SAMA prn SABA and SAMA A LABA or LAMA Theophylline (Option: Doxofylline ) B Pulmodual Dilatair LABA or LAMA LABA and LAMA SABA and /or SAMA Theophylline (Option: Doxofylline ) C ICS +LABA or LAMA LABA and LAMA Dilatair PDE4 Inhibitor SABA and/ or SAMA Theophylline (Option: Doxofylline ) D ICS+ LABA and LAMA ICS + LAMA ICS + LABA + LAMA ICS and LABA and PDE 4 inh LABA + LAMA LAMA + PDE 4 inh Dilatair Carbocisteine SABA and/ or SAMA Theophylline (Option: Doxofylline ) Dilatair Adeflo Adeflo
  • 39. GUIDED ASTHMA SELF-MANAGEMENT EDUCATION AND SKILLS TRAINING 2014 Inhaler use is a skill - must be learned and maintained Up to 70–80% are unable to use their inhaler correctly. Unfortunately, many health care providers are unable to correctly demonstrate how to use the inhalers they prescribe Most people with incorrect technique are unaware that they have a problem There is no ‘perfect’ inhaler - patients can have problems using any inhaler device
  • 40. Strategies to ensure effective use of inhaler devices 2014 Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe For MDIs - use a spacer Improves delivery Reduces potential side-effects of ICS
  • 41. A New Twist to FDC ICS-LABA Inhaler Therapy Twist Miat Monodose DPI
  • 42. Salmeterol xinafoate/ Fluticasone propionate (Adeflo) via Adehaler  Passive DPI (aerolizer)  breath actuated  compact, portable, easy to use  no hand-mouth coordination required  Inhalation by capsule loaded by the patient  40 capsules/ box  Lactose carrier  IFR > 60 lpm; no breath hold  Protect from humidity Sims MW. Chest 140(3):781–788, 2011. Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011. Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003. 50/250 mcg 50/500 mcg
  • 45. Dry Powder Inhaler Wrong Right
  • 46. Case 3 55 year old, male, teacher CC: cough, wheezing, shortness of breath 7 days Precipitated by exposure to dust (he rides a motorbike) Sneezing, itchy throat Unable to sleep due to SOB, partially relieved by salbu neb (+) history of childhood asthma (+) 20 pack year (current) smoker (+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with pneumonia as outpatient. PE: talks in sentences, (+) wheezing both lung fields
  • 47. What will you give to this patient? A. SABA (Salbutamol PRN) B. ICS (Budesonide) C. LAMA (Tiotropium) D. LABA (Indacaterol) E. ICS+LABA (Fluticasone + Salmeterol)
  • 51. For a patient, count the number of checked boxes in each column. If 3 or more are checked for either asthma or COPD , that diagnosis is suggested. But if there are similar numbers of checked boxes in each column, ACOS should be considered.
  • 55. Approach to ACOS (Asthma-COPD Overlap Syndrome) Asthma >> ICS (Inhaled corticosteroid) COPD >> LABA (long acting B2 agonist) ACOS >> ICS + LABA
  • 56. Approach to ACOS (Asthma-COPD Overlap Syndrome) At least among adults, ACOS might represent a severe form of asthma, characterized by greater risk of hospitalizations and exacerbations ACOS is likely the result of early asthma that has progressed to fixed airway obstruction because airway remodeling and of its interaction with smoking Treatment may prevent a steeper decline of lung function among ACOS. De Marie Et. Al. ERS 2013 Presentation
  • 59. SMOKER'S PRAYER Heavenly Father, hear my plea, and grant my lungs serenity. Give me strength to kick the smoking that's been causing all my choking. Let my breath be fresh and clean without a trace of nicotine. Each ciggie I smoke so often Adds another nail in my coffin Guide me Lord, by Your holy means past all those cigarette machines. It hurts to hear My Loved ones say kissing ya's like lickin' an ashtray. Please oh Lord, Hear my voice, give me will power, while I have a choice. I ask Your help and it's no wonder because if I don't quit, I'm six feet under.
  • 60. Health Is wealth Thank you!