Real life practice in COPD รศ.พญ. เบญจมาศ ช่วยชู สาขาวิชาโรคระบบการหายใจและวัณโรค ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดล 19 July 2013

หัวข้อ การวินิจฉัยโรค การประเมินผู้ป่วย การรักษา

หัวข้อ การวินิจฉัยโรค การประเมินผู้ป่วย การรักษา

นิยามโรคปอดอุดกั้นเรื้อรัง เป็นโรคที่สามารถป้องกันและรักษาได้ที่พบบ่อย ลักษณะสำคัญของโรคคือมีการอุดกั้นของหลอดลมอยู่ตลอดเวลาและมักเป็นมากขึ้นเรื่อยๆ ซึ่งเกี่ยวข้องกับการอักเสบเรื้อรังที่เพิ่มขึ้นมากกว่าปกติในหลอดลมและเนื้อปอดจากการกระตุ้นของอนุภาคหรือก๊าซที่เป็นอันตราย ภาวะกำเริบของโรคหรือโรคร่วมมีผลต่อความรุนแรงของโรค ดัดแปลงมาจาก 2013 Global Initiative for Chronic Obstructive Lung Disease

Systemic effects and comorbidities of COPD โรคปอดอุดกั้นเรื้อรังไม่ได้เป็นโรคที่เกิดปัญหาเฉพาะในปอดเพียงอย่างเดียว Systemic effects and comorbidities of COPD Barnes PJ and Celli BR. Eur Respir J 2009; 33: 1165–1185

Definition “Systemic effects” “Comorbidities” extrapulmonary manifestations which is the consequence of COPD “Comorbidities” highly prevalent diseases in COPD (e.g. cardiovascular, metabolic, muscular, and bone disorders) in aged patients represent the co-ocurrence. COPD is a complex disease with pulmonary and extrapulmonary manifestations The link between these domains of the disease is unclear. Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss. 2, pp 43–46, May 1, 2012

Aging Almost one-half of people aged > 65 years have > 3 chronic medical conditions, and one-fifth have five or more Aging itself is associated with a chronic low-grade inflammatory status and the theory that systemic inflammation is the common driver of chronic diseases would explain the high prevalence of chronic diseases with increasing age This so-called “inflamm-aging” seems to be the consequence of lifelong antigenic exposure leading to genetic modifications The individual capability of dealing with this inflammatory burden and developing protective mechanisms seems to modulate individual susceptibility to common causes of morbidity and mortality in elderly people Nussbaumer-Ochsner Y and Rabe KF. Chest 2011;139;165-173

การวินิจฉัยโรคปอดอุดกั้นเรื้อรัง คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดล Faculty of Medicine Siriraj Hospital, Mahidol University การวินิจฉัยโรคปอดอุดกั้นเรื้อรัง

การวินิจฉัยโรคปอดอุดกั้นเรื้อรัง สัมผัสปัจจัยเสี่ยง มีอาการ สูบบุหรี่ สัมผัสมลภาวะภายใน หรือภายนอกอาคาร เหนื่อย ไอเรื้อรัง มีเสมหะ (อาจไม่มีก็ได้) การวินิจฉัยจำเป็นต้องมีผลการตรวจสไปโรเมตรีย์ (spirometry) โดยมี FEV1/FVC < 0.7 หลังได้ยาขยายหลอดลม ดัดแปลงจาก GOLD 2013

(pre and post bronchodilator) Spirometry (pre and post bronchodilator)

Spirometry Post-bronchodilator FEV1/FVC < 0.70 ชายไทย อายุ 70 ปี เหนื่อยมา 3 ปี สูบบุหรี่ 20 ซอง-ปี ไม่เคยเป็นโรคหืด Pre-Rx Pred % pred Post-Rx % change FVC 2.04 2.55 80.0 2.05 80.4 5 FEV1 0.78 2.17 36 0.85 39.2 9 FEV1/FVC 38 85 45 41 48 FEF25-75% 0.31 3.37 PEF 177 388 46 219 56 Post-bronchodilator FEV1/FVC < 0.70

ข้อแตกต่างระหว่าง COPD และ Asthma ลักษณะทางคลินิก โรคปอดอุดกั้นเรื้อรัง (COPD) โรคหืด (Asthma) อายุที่เริ่มเป็น ส่วนใหญ่อายุมากกว่า 40 ปี ส่วนใหญ่ < 35 ปี แต่เกิดได้ทุกอายุ ประวัติการสูบบุหรี่ ส่วนใหญ่สูบบุหรี่ ( > 10 ซอง-ปี) ส่วนใหญ่ไม่สูบบุหรี่ แต่อาจสูบบุหรี่ได้ Atopy ไม่ค่อยพบ พบได้บ่อย ประวัติครอบครัว ไม่มี มักมีประวัติโรคภูมิแพ้หรือโรคหืด อาการไอ ไอเรื้อรังและมักมีเสมหะร่วมด้วย อาจไอเฉพาะช่วงเช้า ไม่มีไอเรื้อรัง อาจไอมากตอนกลางคืน ช่วงเช้ามืดขณะมีอาการหรือหลังออกกำลัง อาการเหนื่อย อาการเหนื่อยจะยังคงมีอยู่ระดับหนึ่งไม่หายไปและค่อยๆเพิ่มขึ้น มีช่วงปลอดอาการเหนื่อย อาจตื่นกลางดึกเพราะแน่นหน้าอก เหนื่อย หรือ มีเสียงวี้ด ความแปรปรวนของอาการในช่วงวันหรือแต่ละวัน สมรรถภาพปอด ต้องมี airflow obstruction (ถือเป็น hallmark ของ COPD) ปกติได้ แต่ในรายที่มีอาการขณะตรวจอาจพบ airflow obstruction Airflow obstruction not fully reversible (FEV1/FVC หลังได้ยาขยายหลอดลม < 0.7) reversible (characteristic ของ asthma) (FEV1 เพิ่มขึ้นหลังได้ยาขยายหลอดลม > 12% และ > 200 มล. Peak flow variability < 20% > 20% (characteristic ของ asthma) Diffusing capacity (DLCO) ลดลง ใน emphysema ปกติ ตำแหน่งของโรค airways และ parenchyma airways เซลล์อักเสบ neutrophil, CD8+T cell eosinophil, CD4+T cell การตอบสนองต่อยาสเตียรอยด์ steroid resistance steroid sensitive * ซอง-ปี หมายถึง จำนวนบุหรี่ที่สูบเป็นซองต่อวัน x จำนวนปีที่สูบ เช่นสูบบุหรี่ 10 มวน (1/2 ซอง) ต่อวัน นาน 20 ปี เท่ากับ 10 ซอง-ปี

ผู้ป่วยอายุมากกว่า 40 ปี FEV1/FVC < 0.7 หลังได้รับยาขยายหลอดลม ปัญหา ผู้ป่วยอายุมากกว่า 40 ปี FEV1/FVC < 0.7 หลังได้รับยาขยายหลอดลม สูบบุหรี่ มีประวัติภูมิแพ้ หรือเคยเป็นโรคหืด หรือครอบครัวเป็นโรคหืด สูบบุหรี่ อาการหอบมักเป็นกลางคืน มีเสียงวี้ด มาห้องฉุกเฉินบ่อย นอนโรงพยาบาลไม่นาน ไม่สูบบุหรี่ แต่ FEV1/FVC < 0.7 หลังได้รับยาขยายหลอดลม

Dx asthma ที่ ศิริราช age 52 yr. smoking 20 p-y

At age 61 yr. Reversible airflow obstruction % change of FEV1 > 12% และ > 200 mL (0.2L) ---- 32% , 240 mL

At age 65 yr.

Effect of Emphysema on Compliance and Diffusing Capacity (DLco) http://www.netterimages.com/image/1000.htm

ปัญหา ผู้ป่วยอายุมากกว่า 40 ปี สูบบุหรี่ อาการเข้าได้กับ COPD แต่ FEV1/FVC > 0.7 จะวินิจฉัยว่าเป็น COPD หรือไม่?

นิยามโรคปอดอุดกั้นเรื้อรัง เป็นโรคที่สามารถป้องกันและรักษาได้ที่พบบ่อย ลักษณะสำคัญของโรคคือมีการอุดกั้นของหลอดลมอยู่ตลอดเวลาและมักเป็นมากขึ้นเรื่อยๆ ซึ่งเกี่ยวข้องกับการอักเสบเรื้อรังที่เพิ่มขึ้นมากกว่าปกติในหลอดลมและเนื้อปอดจากการกระตุ้นของอนุภาคหรือก๊าซที่เป็นอันตราย ภาวะกำเริบของโรคหรือโรคร่วมมีผลต่อความรุนแรงของโรค ดัดแปลงมาจาก 2013 Global Initiative for Chronic Obstructive Lung Disease

ปัญหา ผู้ป่วยอายุมากกว่า 40 ปี สูบบุหรี่ อาการเข้าได้กับ COPD แต่ FEV1/FVC > 0.7 จะวินิจฉัยว่าเป็น COPD หรือไม่? ไม่ FEV1/FVC < 5 percentile of predicted value

การดูแลรักษาผู้ป่วยโรคปอดอุดกั้นเรื้อรัง

หัวข้อ การวินิจฉัยโรค การประเมินผู้ป่วย การรักษา

© 2013 Global Initiative for Chronic Obstructive Lung Disease เป้าหมายในการดูแลรักษาผู้ป่วย โรคปอดอุดกั้นเรื้อรังระยะสงบ (Stable COPD) Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality ลดอาการ ลดปัจจัยเสี่ยง © 2013 Global Initiative for Chronic Obstructive Lung Disease

Assess & monitor disease Reduce risk factors Manage stable COPD Manage exacerbations Management of COPD Notes The management of COPD depends on the stage of disease: Management of mild-to-moderate COPD involves the avoidance of risk factors to prevent disease progression and pharmacotherapy as needed to control symptoms [p32/col1/par1/ln4–7] Severe and very severe COPD often require the integration of several different disciplines, a variety of treatment approaches and a commitment of the clinician to the continued support of the patient as the illness progresses. [p32/col1/par1/ln7–11] In addition to patient education, health advice and pharmacotherapy, COPD patients may need specific counselling about smoking cessation, instruction in physical exercise, nutritional advice and continued nursing support. [p32/col1/par1/ln11–14] Not all approaches are needed for every patient, and assessing the potential benefit of each approach at each stage of the illness is a crucial aspect of effective disease management. [p32/col1/par1/ln15–19] Reference GOLD Guidelines (Updated 2007). Available at http://goldcopd.com.

© 2013 Global Initiative for Chronic Obstructive Lung Disease Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease

© 2013 Global Initiative for Chronic Obstructive Lung Disease Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease

Use the COPD Assessment Test(CAT) or mMRC Breathlessness scale Assess symptoms Use the COPD Assessment Test(CAT) or mMRC Breathlessness scale Clinical COPD Questionnaire (CCQ) © 2013 Global Initiative for Chronic Obstructive Lung Disease

http://www.catestonline.org/english/index_Thai.htm

http://www.catestonline.org/english/index_Thai.htm

เกณฑ์การให้คะแนน ภาวะหายใจลำบาก (Modified Medical Research Council Dyspnea Scale; mMRC) แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553

© 2013 Global Initiative for Chronic Obstructive Lung Disease Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease

Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1> 80% predicted GOLD 2: Moderate 50% < FEV1< 80% predicted GOLD 3: Severe 30% < FEV1< 50% predicted GOLD 4: Very Severe FEV1< 30% predicted *Based on Post-Bronchodilator FEV1 © 2013 Global Initiative for Chronic Obstructive Lung Disease

© 2013 Global Initiative for Chronic Obstructive Lung Disease Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease

นิยามของภาวะกำเริบเฉียบพลัน (COPD exacerbation) “An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” Clinical diagnosis GOLD Chest 2000;117;398S-401S 35

Bach PB. et al. Ann Intern Med. 2001;134:600-620.

Exacerbations Respiratory symptoms were classified as “major” symptoms (dyspnea, sputum purulence, sputum amount) “minor” symptoms (wheeze, sore throat, cough, and symptoms of a common cold which were nasal congestion /discharge) Exacerbations were defined as the presence for at least two consecutive days of increase in any two “major” symptoms or increase in one “major” and one “minor” symptom according to criteria modified from Anthonisen and colleagues The first of the two consecutive days was taken as the day of onset of exacerbation. Am J Respir Crit Care Med Vol 161. pp 1608–1613, 2000

Severity of exacerbations Moderate : treatment with systemic corticosteroids or antibiotics or both Severe: Hospitalization

Physiology of exacerbations in a hypothetical regular smoker with COPD by stage of severity Hansel TT and Barnes PJ, Lancet 2009; 374: 744–55

Greater airway inflammation TRIGGERS Trigger of COPD exacerbations and associated pathophysiological changes leading to increased exacerbation symptoms EFFECTS Inflamed COPD airway Greater airway inflammation Systemic inflammation Bronchoconstriction Oedema, mucus Expiratory flow limitation Wedzicha JA, Seemungal TA. Lancet. 2007;370:786-796. Cardiovascular comorbidity Exacerbation symptoms Dynamic hyperinflation

Wedzicha JA, Seemungal TA. Lancet. 2007;370:786-796.

© 2013 Global Initiative for Chronic Obstructive Lung Disease Risk of exacerbations > 2 exacerbations within the last yearor FEV1 < 50 % of predicted © 2013 Global Initiative for Chronic Obstructive Lung Disease

Frequent exacerbators represent stable COPD phenotype - independent of severity Proportion of subjects experiencing ≥2 exacerbations/year increases year-on-year Stable population provides potential to understand the cause(s) of the phenotype If you were a frequent exacerbator in year 1, chance are that you would also be a frequent exacerbator in year 2 and 3 ECLIPSE 3 year data Hurst et al. N Engl J Med 2010

The ‘frequent exacerbator phenotype’: Frequency/severity by GOLD Category THIS SLIDE CONTAINS 3 BUILDS Frequent exacerbators (those reporting 2 or more exacerbations per year) is more common in the very severe GOLD Category but almost ¼ of GOLD Category 2 subjects are frequent exacerbators and 7% of patients in GOLD Category 2 have been hospitalised in year 1 of the study Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more) ECLIPSE 1 year data Hurst et al. N Engl J Med 2010

© 2013 Global Initiative for Chronic Obstructive Lung Disease Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities © 2013 Global Initiative for Chronic Obstructive Lung Disease

Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss Alvar Agustı´ A and Faner R. Proc Am Thorac Soc Vol 9, Iss. 2, pp 43–46, May 1, 2012

Combined Assessment of COPD 4 (C) (D) > 2 3 (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) Risk 1 2 (A) (B) 1 mMRC 0-1 CAT < 10 mMRC>2 CAT >10 Symptoms (mMRC or CAT score))

Manage Stable COPD: PharmacologicTherapy FIRST CHOICE GOLD 4 ICS + LABA or LAMA ICS + LABA or LAMA > 2 GOLD 3 Exacerbations /year A B GOLD 2 SAMA prn or SABA prn LABA or LAMA 1 GOLD 1 mMRC 0-1 CAT < 10 mMRC >2 CAT >10

Manage Stable COPD: Non-pharmacologic Patient Group Essential Recommended Depending on local guidelines A Smoking cessation Physical activity Flu vaccination Pneumococcal vaccination B, C, D Pulmonary rehabilitation © 2013A Global Initiative for Chronic Obstructive Lung Disease

Interventions to reduce COPD exacerbations Mackay AJ, Hurst JR. Med Clin N Am 96 (2012) 789–809

Michael Rudolf

หัวข้อ การวินิจฉัยโรค การประเมินผู้ป่วย การรักษา

COPD Co-morbid diseases Stable Exacerbation Pharmacologic Rx Dyspnea Cough Sputum Stable Exacerbation Pharmacologic Rx Bronchodilator Corticosteroid Vaccination Non-pharmacologic Rx Stop smoking Pulmonary rehabilitation Oxygen therapy Surgical treatment Home management Hospital management Bronchodilator Corticosteroid Antibiotics Pulmonary rehabilitation Bronchodilator Systemic corticosteroid Oxygen Antibiotics Ventilatory support Pulmonary rehabilitation

แผนการรักษาผู้ป่วยโรคปอดอุดกั้นเรื้อรังตามระดับความรุนแรงของโรค Exacerbations per year > 2 1 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA LAMA ICS + LABA A B D C Less symptoms Low risk More symptoms Less symptoms High risk A B D C แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553

ระยะเวลาในการออกฤทธิ์ อาจ > 24 ชั่วโมง ใน sustained release ชนิดของยาขยายหลอดลม กลไกการออกฤทธิ์ ระยะเวลาในการออกฤทธิ์ วิธีบริหารยา ตัวอย่างยา 2-agonists สั้น (4-6 ชั่วโมง)* สูด, รับประทาน, ฉีด Salbutamol, terbutaline, fenoterol ยาว (> 12 ชั่วโมง) สูด Salmeterol Formoterol* Anticholinergics สั้น (6-8 ชั่วโมง) Ipratropium bromide ยาว (> 24 ชั่วโมง) Tiotropium Methylxanthines ไม่แน่นอน อาจ > 24 ชั่วโมง ใน sustained release รับประทาน, ฉีด Theophylline, aminophylline * Rapid onset 2-agonist

Short-acting Bronchodilators: Onset and Duration of Action P<0.001 for the combination versus each agent alone Ipratropium + Albuterol Albuterol Ipratropium Change in FEV1 (%) Speaker Notes In a 12-week prospective, double-blind, parallel-group evaluation, 534 patients with moderately severe stable COPD received by metered-dose inhaler a combination of β2-adrenergic agonist albuterol plus ipratropium or either agent separately. Results on days 1, 29, 57, and 85 showed that the combination treatment was statistically superior to either single agent alone in peak effect on FEV1, in the effect during the first 4 hours after dosing, and in total AUC for the FEV1 response. The graph in this slide shows the percent change above test day baseline in FEV1 response on day 85. The combination produced a significantly greater change than either agent alone (P<0.001 for each comparison). Additional Information The mean peak percent increases in FEV1 over baseline on the four test days were 31 to 33 percent for the combination, 24 to 25 percent for ipratropium, and 24 to 27 percent for albuterol. The differences between the combination and its components were statistically significant on all test days. The AUC0-4 means for the combination were 21 to 44 percent greater than the ipratropium mean values and 30 to 46 percent greater than for albuterol. Reference COMBIVENT Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. Chest. 1994;105:1411-1419. Post-dose (hours) COMBIVENT Inhalation Aerosol Study Group. Chest. 1994;105:1411-1419. Reproduced with permission from American College of Chest Physicians.

Potential Side Effects of COPD Therapy: 2-Agonists Side effects include: Palpitations Ventricular arrhythmias (rare) Sleep disturbance/poor sleep quality Tremor Hypokalaemia Speaker Notes Systemic side effects can occur from inhaled β2-agonists, including palpitations and tremor most commonly, and additionally hypokalaemia and ventricular arrhythmias. The systemic effects are mediated by drug absorbed through the lung and also by drug deposited in the pharynx and swallowed. Additional Information Although there are some differences, all of these bronchodilators currently used to achieve bronchodilation are selective for the β2 receptor. These adrenoceptors are also present in the heart where they mediate a complex array of effects. It is thus likely that cardiac effects of currently used β2-agonists are due to these cardiac receptors, rather than to lack of selectivity. Reference Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802.   Rennard SI. Lancet. 2004;364:791-802.

Potential Side Effects of COPD Therapy: Anticholinergic Agents Side effects are less common versus systemic agents (e.g., atropine) Dry mouth is most commonly reported adverse event Urinary retention may be a problem for patients with bladder outlet disease Speaker Notes Dry mouth is the most common symptom reported with the anticholinergic agent tiotropium, probably due to systemic absorption. Urinary retention could be a problem, especially for those with concurrent bladder outlet disease. Local effects can occur if tiotropium is accidentally sprayed directly into the eye. Additional Information Currently used inhaled anticholinergics are quaternary amines, and side-effects are markedly less than with systemic anticholinergics, such as atropine. Reference Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802.   Rennard SI. Lancet. 2004;364:791-802.

Sustained-release theophylline Narrow safety margin (10 -20 g/ml) (monitoring of theophylline blood level may be necessary) 400 g/day (low dose 200 g/day) Side effects CNS : seizures CVS : hypotension, arrhythmia GI : Nausea & vomiting Theodur® , Nuelin SR® หักครึ่งได้ห้ามบดห้ามเคี้ยว

Proposed mechanism of corticosteroid resistance in COPD patients. Proposed mechanism of corticosteroid resistance in COPD patients. Stimulation of normal alveolar macrophages activates NF-κB and other transcription factors to switch on histone acetyltransferase leading to histone acetylation and subsequently to transcription of genes encoding inflammatory proteins, such as tumor necrosis factor-α (TNF-α) and IL-8. Corticosteroids reverse this by binding to glucocorticoid receptors (GR) and recruiting HDAC-2. This reverses the histone acetylation induced by NF-κB and switches off the activated inflammatory genes. In COPD patients, cigarette smoke activates macrophages, as in normal subjects, but oxidative stress (acting through the formation of peroxynitrite) impairs the activity of HDAC-2. This amplifies the inflammatory response to NF-κB activation but also reduces the anti-inflammatory effect of corticosteroids, as HDAC-2 is now unable to reverse histone acetylation. MMP = matrix metalloproteinase. Barnes P J Chest 2006;129:151-155 ©2006 by American College of Chest Physicians

Side effect: corticosteroids Oral candidiasis Esophageal candidiasis Hoarseness

Oxygen therapy Three ways of administration Primary goal Longterm continuous therapy During exercise Relieve acute dyspnea Primary goal Increase PaO2 > 60 mmHg, SaO2 > 90% 90 Increase PaO2 > 60 mmHg, SaO2 > 90% ,which will preserve vital organ function by ensuring adequate delivery of oxygen

ข้อบ่งชี้ในการให้ Long-term oxygen therapy (> 15 hrs/day) PaO2 < 55 mm Hg หรือ SaO2 < 88% 55 mmHg < PaO2 < 60 mm Hg หรือ SaO2 of 88% ที่มีภาวะที่บ่งชี้ว่ามี chronic hypoxemia ได้แก่ pulmonary hypertension peripheral edema suggesting congestive cardiac failure polycythemia (hematocrit > 55%) LTOT จะให้ใน stable COPD ที่มี chronic hypoxemia ตามเกณฑ์ดังกล่าวข้างต้น กรณีที่ผู้ป่วยมีอาการกำเริบเฉียบพลันและมี hypoxemia อาจให้ออกซิเจนเป็นการชั่วคราว ถ้าหากยังมีภาวะ hypoxemia หลังจาก 3 เดือน จึงมีข้อบ่งชี้สำหรับ LTOT

Wongsurakiat P, Maranetra KN, Wasi C, Kositanont U, Dejsomritrutai W, Charoenratanakul S. Acute Respiratory Illness in Patients With COPD and the Effectiveness of Influenza Vaccination: A Randomized Controlled Study. CHEST 2004; 125:2011–2020

วัคซีนไข้หวัดใหญ่ เป็นเชื้อไวรัสไข้หวัดใหญ่ที่ตายแล้ว (Inactivated (killed) vaccine) ฉีดปีละครั้ง ฉีดได้ตลอดปี ที่ดีที่สุดก่อนเข้าฤดูฝน (มิถุนายน – ตุลาคม) ร่างกายจะสร้างภูมิคุ้มกันถึงระดับที่ป้องกันไข้หวัดใหญ่ หลังจากฉีดวัคซีนไปแล้ว 2 สัปดาห์ ใช้เพื่อป้องกันไข้หวัดใหญ่ แต่ไม่ได้ป้องกันไข้หวัดที่เกิดจากไวรัสตัวอื่น ขนาด 15 mcg (0.5 ซีซี) ฉีดเข้ากล้ามเนื้อ (IM) หรือ ขนาด 15 mcg ฉีดเข้าในผิวหนัง (ID) in aged > 60 ปี ขนาด 9 microgram ID in aged < 60 ปี

Pulmonary rehabilitation Evidence A Improves exercise capacity Reduces the perceived intensity of breathlessness Improves health-related quality of life Reduces the number of hospitalizations and days in the hospital Improve recovery after hospitalization for an exacerbation Reduces anxiety and depression associated with COPD Evidence B Strength and endurance training of the upper limbs improves arm function Benefits extend well beyond the immediate period of training Improves survival Enhances the effect of long-acting bronchodilators Evidence C Respiratory muscle training can be beneficial, especially when combined with general exercise training GOLD 2013

Components of pulmonary rehabilitation Patient assessment Exercise training (strongest level of evidence for benefit) Education Nutritional intervention Psychosocial support Ries AL et al. Chest. 2007;131:4S-42S.

Establishing pulmonary rehabilitation program Funding and promotion Where possible, dedicated funding should be sought to establish a PRP Costing estimates vary depending upon the health-care system, existing infrastructure and equipment, staffing and duration of the program Low cost programs in existing facilities have been shown to be effective Lack of resources ought not to deter clinicians from seeking to establish a PRP Jenkins S. Respirology.2010;15:1157–73

Conclusions I Spirometry is required to make diagnosis of COPD: post-bronchodilator FEV1/FVC < 0.7 Assessment of COPD: symptoms: CAT, mMRC scale, CCQ degree of airflow limitation: post-bronchodilator FEV1 % pred (stage 1-4) risk of exacerbations: previous exacerbation, severe COPD Comorbidities: cardiovascular disease, osteoporosis, anxiety/depression, DM

Conclusions II Combined assessment of symptoms and risk of exacerbations is the basis for non-pharmacologic and pharmacologic management of COPD Smoking cessation Influenza vaccination Pulmonary rehabilitation Bronchodilators + Inhaled corticosteroids

Thank you

Assess degree of airflow limitation using spirometry Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD revised 2011

Assess degree of airflow limitation using spirometry Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD revised 2011

COPD Assessment Test (CAT) Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD: assess symptoms COPD Assessment Test (CAT) Modified Medical Research Council Dyspnea Scale (mMRC scale) GOLD revised 2011

http://www.catestonline.org/english/index_Thai.htm

เกณฑ์การให้คะแนน ภาวะหายใจลำบาก (Modified Medical Research Council Dyspnea Scale; mMRC) แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553

Assess degree of airflow limitation using spirometry Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD revised 2011

In patients with FEV1/FVC < 0.70: Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* In patients with FEV1/FVC < 0.70: GOLD 1: Mild FEV1> 80% predicted GOLD 2: Moderate 50% < FEV1< 80% predicted GOLD 3: Severe 30% < FEV1< 50% predicted GOLD 4: Very Severe FEV1< 30% predicted *Based on Post-Bronchodilator FEV1 GOLD revised 2011

Assess degree of airflow limitation using spirometry Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD revised 2011

High risk of exacerbations Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations High risk of exacerbations > 2 exacerbations within the last year or FEV1 < 50 % of predicted value GOLD revised 2011

Frequent exacerbators represent stable COPD phenotype - independent of severity Proportion of subjects experiencing ≥2 exacerbations/year increases year-on-year Stable population provides potential to understand the cause(s) of the phenotype If you were a frequent exacerbator in year 1, chance are that you would also be a frequent exacerbator in year 2 and 3 ECLIPSE 3 year data Hurst et al. N Engl J Med 2010

The ‘frequent exacerbator phenotype’: Frequency/severity by GOLD Category (1) THIS SLIDE CONTAINS 3 BUILDS Frequent exacerbators (those reporting 2 or more exacerbations per year) is more common in the very severe GOLD Category but almost ¼ of GOLD Category 2 subjects are frequent exacerbators and 7% of patients in GOLD Category 2 have been hospitalised in year 1 of the study Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more) ECLIPSE 1 year data Hurst et al. N Engl J Med 2010

Assess degree of airflow limitation using spirometry Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Assess comorbidities GOLD revised 2011

COPD patients are at increased risk for: Cardiovascular diseases Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD Comorbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. GOLD revised 2011

Michael Rudolf

Improve exercise tolerance Improve health status Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Goals of Therapy Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality Reduce symptoms risk

Avoidance of risk factors - smoking cessation Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: All COPD Patients Avoidance of risk factors - smoking cessation - reduction of indoor pollution - reduction of occupational exposure Influenza vaccination

(C) (D) (B) (A) Risk Risk Symptoms Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD 4 (C) (D) > 2 3 (Exacerbation history) Risk (GOLD Classification of Airflow Limitation) Risk 2 (A) (B) 1 1 mMRC 0-1 CAT < 10 mMRC>2 CAT >10 Symptoms (mMRC or CAT score))

Exacerbations per year Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: PharmacologicTherapy FIRST CHOICE C D GOLD 4 ICS + LABA or LAMA ICS + LABA or LAMA > 2 GOLD 3 Exacerbations per year A B GOLD 2 SAMA prn or SABA prn LABA or LAMA 1 GOLD 1 mMRC 0-1 CAT < 10 mMRC >2 CAT >10

ICS+LABA and PDE4-inh.or Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: PharmacologicTherapy (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.) Patient First choice Second choice Alternative Choices A SAMA prn or SABA prn LAMA LABA SABA and SAMA Theophylline B LAMA and LABA SABA and/or SAMA C ICS +LABA PDE4-inh. D ICS + LABA ICS andLAMA or ICS + LABA and LAMA or ICS+LABA and PDE4-inh.or LAMA and LABA or LAMA and PDE4-inh. Carbocysteine

แผนการรักษาผู้ป่วยโรคปอดอุดกั้นเรื้อรังตามระดับความรุนแรงของโรค Exacerbations per year > 2 1 mMRC 0-1 CAT < 10 GOLD 4 mMRC >2 CAT >10 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA LAMA ICS + LABA A B D C Less symptoms Low risk More symptoms Less symptoms High risk A B D C แนวปฏิบัติบริการสาธารณสุข โรคปอดอุดกั้นเรื้อรัง พ.ศ. 2553

ระยะเวลาในการออกฤทธิ์ อาจ > 24 ชั่วโมง ใน sustained release ชนิดของยาขยายหลอดลม กลไกการออกฤทธิ์ ระยะเวลาในการออกฤทธิ์ วิธีบริหารยา ตัวอย่างยา 2-agonists สั้น (4-6 ชั่วโมง)* สูด, รับประทาน, ฉีด Salbutamol, terbutaline, fenoterol ยาว (> 12 ชั่วโมง) สูด Salmeterol Formoterol* Anticholinergics สั้น (6-8 ชั่วโมง) Ipratropium bromide ยาว (> 24 ชั่วโมง) Tiotropium Methylxanthines ไม่แน่นอน อาจ > 24 ชั่วโมง ใน sustained release รับประทาน, ฉีด Theophylline, aminophylline * Rapid onset 2-agonist

Short-acting Bronchodilators: Onset and Duration of Action P<0.001 for the combination versus each agent alone Ipratropium + Albuterol Albuterol Ipratropium Change in FEV1 (%) Speaker Notes In a 12-week prospective, double-blind, parallel-group evaluation, 534 patients with moderately severe stable COPD received by metered-dose inhaler a combination of β2-adrenergic agonist albuterol plus ipratropium or either agent separately. Results on days 1, 29, 57, and 85 showed that the combination treatment was statistically superior to either single agent alone in peak effect on FEV1, in the effect during the first 4 hours after dosing, and in total AUC for the FEV1 response. The graph in this slide shows the percent change above test day baseline in FEV1 response on day 85. The combination produced a significantly greater change than either agent alone (P<0.001 for each comparison). Additional Information The mean peak percent increases in FEV1 over baseline on the four test days were 31 to 33 percent for the combination, 24 to 25 percent for ipratropium, and 24 to 27 percent for albuterol. The differences between the combination and its components were statistically significant on all test days. The AUC0-4 means for the combination were 21 to 44 percent greater than the ipratropium mean values and 30 to 46 percent greater than for albuterol. Reference COMBIVENT Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. Chest. 1994;105:1411-1419. Post-dose (hours) COMBIVENT Inhalation Aerosol Study Group. Chest. 1994;105:1411-1419. Reproduced with permission from American College of Chest Physicians.

Potential Side Effects of COPD Therapy: 2-Agonists Side effects include: Palpitations Ventricular arrhythmias (rare) Sleep disturbance/poor sleep quality Tremor Hypokalaemia Speaker Notes Systemic side effects can occur from inhaled β2-agonists, including palpitations and tremor most commonly, and additionally hypokalaemia and ventricular arrhythmias. The systemic effects are mediated by drug absorbed through the lung and also by drug deposited in the pharynx and swallowed. Additional Information Although there are some differences, all of these bronchodilators currently used to achieve bronchodilation are selective for the β2 receptor. These adrenoceptors are also present in the heart where they mediate a complex array of effects. It is thus likely that cardiac effects of currently used β2-agonists are due to these cardiac receptors, rather than to lack of selectivity. Reference Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802.   Rennard SI. Lancet. 2004;364:791-802.

Potential Side Effects of COPD Therapy: Anticholinergic Agents Side effects are less common versus systemic agents (e.g., atropine) Dry mouth is most commonly reported adverse event Urinary retention may be a problem for patients with bladder outlet disease Speaker Notes Dry mouth is the most common symptom reported with the anticholinergic agent tiotropium, probably due to systemic absorption. Urinary retention could be a problem, especially for those with concurrent bladder outlet disease. Local effects can occur if tiotropium is accidentally sprayed directly into the eye. Additional Information Currently used inhaled anticholinergics are quaternary amines, and side-effects are markedly less than with systemic anticholinergics, such as atropine. Reference Rennard SI. Treatment of stable chronic obstructive pulmonary disease. Lancet. 2004;364:791-802.   Rennard SI. Lancet. 2004;364:791-802.

Sustained-release theophylline Narrow safety margin (10 -20 g/ml) (monitoring of theophylline blood level may be necessary) 400 g/day (low dose 200 g/day) Side effects CNS : seizures CVS : hypotension, arrhythmia GI : Nausea & vomiting Theodur® , Nuelin SR® หักครึ่งได้ห้ามบดห้ามเคี้ยว

Proposed mechanism of corticosteroid resistance in COPD patients. Proposed mechanism of corticosteroid resistance in COPD patients. Stimulation of normal alveolar macrophages activates NF-κB and other transcription factors to switch on histone acetyltransferase leading to histone acetylation and subsequently to transcription of genes encoding inflammatory proteins, such as tumor necrosis factor-α (TNF-α) and IL-8. Corticosteroids reverse this by binding to glucocorticoid receptors (GR) and recruiting HDAC-2. This reverses the histone acetylation induced by NF-κB and switches off the activated inflammatory genes. In COPD patients, cigarette smoke activates macrophages, as in normal subjects, but oxidative stress (acting through the formation of peroxynitrite) impairs the activity of HDAC-2. This amplifies the inflammatory response to NF-κB activation but also reduces the anti-inflammatory effect of corticosteroids, as HDAC-2 is now unable to reverse histone acetylation. MMP = matrix metalloproteinase. Barnes P J Chest 2006;129:151-155 ©2006 by American College of Chest Physicians

Oxygen therapy Three ways of administration Primary goal Longterm continuous therapy During exercise Relieve acute dyspnea Primary goal Increase PaO2 > 60 mmHg, SaO2 > 90% 90 Increase PaO2 > 60 mmHg, SaO2 > 90% ,which will preserve vital organ function by ensuring adequate delivery of oxygen

ข้อบ่งชี้ในการให้ Long-term oxygen therapy (> 15 hrs/day) PaO2 < 55 mm Hg หรือ SaO2 < 88% 55 mmHg < PaO2 < 60 mm Hg หรือ SaO2 of 88% ที่มีภาวะที่บ่งชี้ว่ามี chronic hypoxemia ได้แก่ pulmonary hypertension peripheral edema suggesting congestive cardiac failure polycythemia (hematocrit > 55%) LTOT จะให้ใน stable COPD ที่มี chronic hypoxemia ตามเกณฑ์ดังกล่าวข้างต้น กรณีที่ผู้ป่วยมีอาการกำเริบเฉียบพลันและมี hypoxemia อาจให้ออกซิเจนเป็นการชั่วคราว ถ้าหากยังมีภาวะ hypoxemia หลังจาก 3 เดือน จึงมีข้อบ่งชี้สำหรับ LTOT

Pulmonary rehabilitation Evidence A Improves exercise capacity Reduces the perceived intensity of breathlessness Improves health-related quality of life Reduces the number of hospitalizations and days in the hospital Reduces anxiety and depression associated with COPD Evidence B Strength and endurance training of the upper limbs improves arm function Benefits extend well beyond the immediate period of training Improves survival Improve recovery after hospitalization for an exacerbation Enhances the effect of long-acting bronchodilators Evidence C Respiratory muscle training can be beneficial, especially when combined with general exercise training GOLD revised 2011

Conclusions I Spirometry is required to make diagnosis of COPD: post-bronchodilator FEV1/FVC < 0.7 Assessment of COPD: symptoms: CAT, mMRC scale degree of airflow limitation: post-bronchodilator FEV1 % pred (stage 1-4) risk of exacerbations: previous exacerbation, severe COPD Comorbidities: cardiovascular disease, osteoporosis, anxiety/depression, DM

Conclusions II Combined assessment of symptoms and risk of exacerbations is the basis for non-pharmacologic and pharmacologic management of COPD Smoking cessation Influenza vaccination Pulmonary rehabilitation Bronchodilators + Inhaled corticosteroids

Thank you

Establishing pulmonary rehabilitation program Funding and promotion Where possible, dedicated funding should be sought to establish a PRP Costing estimates vary depending upon the health-care system, existing infrastructure and equipment, staffing and duration of the program Low cost programs in existing facilities have been shown to be effective Lack of resources ought not to deter clinicians from seeking to establish a PRP Jenkins S. Respirology.2010;15:1157–73

Equipment required for a pulmonary rehabilitation program Minimum requirement Optional Pulse oximeter Weights machine/multigym Polar heart rate monitor Stationary cycle Sphygmomanometer Spirometer Odometer (for walking test/track) Glucometer Stopwatch Inspiratory muscle training device Walking track/treadmill Rollator Hand weights Stairs/step Portable oxygen and nasal prongs Jenkins S. Respirology.2010;15:1157–73

Program setting Inpatient pulmonary rehabilitation Outpatient pulmonary rehabilitation Home-based rehabilitation ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413

Outpatient pulmonary rehabilitation is the most widely available of settings and may be hospital or community based Potential advantages include cost-effectiveness, a safe clinical environment, and availability of trained staff The majority of studies describing the benefits of pulmonary rehabilitation are derived from hospital-based outpatient programs ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413 โรงพยาบาลศิริราช (Hospital based) โรงพยาบาลแม่พริก (Community based)

Specificity of exercise training Lower extremity training is traditionally focused Cycling or walking Upper limb exercises should also be incorporated into the training program because many daily activities involve upper extremities e.g. arm cycle ergometer, free weights, and elastic bands Upper limb exercise training reduces dyspnea during upper limb activities and reduces ventilatory requirements for arm elevation ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413

Walking track, 6 minute walk test

Treadmill, bicycle

Endurance training Cycling or walking exercises is the most commonly applied High levels of intensity (60% maximal work rate) Total effective training > 30 minutes Interval training may be a reasonable alternative in case difficult to achieve the target time or intensity Interval training results in significantly lower symptom scores despite high absolute training loads, thus maintaining the training effects Cycling or walking exercises is the most commonly applied Optimally, the approach consists of relatively long exercise sessions at high levels of intensity (60% maximal work rate) The total effective training time should ideally exceed 30 minutes Interval training may be a reasonable alternative in case difficult to achieve the target time or intensity Interval training is a modification of endurance training where the longer exercise session is replaced by several smaller sessions separated by periods of rest or lower intensity exercise Interval training results in significantly lower symptom scores despite high absolute training loads, thus maintaining the training effects The recommendations of the ACSM include that the minimum duration of a session is 20 minutes effective exercise training ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413

Strength (or resistance) training Improve muscle mass and strength than endurance training two to four sets of 6 to 12 repetitions at intensities ranging from 50 to 85% of one repetition maximum Strength training may also result in less dyspnea during the exercise period, thereby making this strategy easier to tolerate than aerobic training Combination of endurance and strength training is probably the best strategy to treat peripheral muscle dysfunction in chronic respiratory disease, because it results in combined improvements in muscle strength and whole body endurance, without unduly increasing training time Improve muscle mass and strength than endurance training two to four sets of 6 to 12 repetitions at intensities ranging from 50 to 85% of one repetition maximum Strength training may also result in less dyspnea during the exercise period, thereby making this strategy easier to tolerate than aerobic training Combination of endurance and strength training is probably the best strategy to treat peripheral muscle dysfunction in chronic respiratory disease, because it results in combined improvements in muscle strength and whole body endurance, without unduly increasing training time ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413

Intensity of exercise > 60% of the peak exercise capacity A Borg score of 4 to 6 for dyspnea or fatigue is usually a reasonable target Alternatively, heart rate at the gas exchange threshold or power output has also been used to target training intensity > 60% of the peak exercise capacity is empirically considered sufficient to elicit some physiologic training effects, although higher percentages are likely to be more beneficial and are often well tolerated In clinical practice, symptom scores can be used to adjust training load; these scores are anchored to a stable relative load and can be used throughout the training program A Borg score of 4 to 6 for dyspnea or fatigue is usually a reasonable target Alternatively, heart rate at the gas exchange threshold or power output has also been used to target training intensity ATS/ERS statement on pulmonary rehabilitation. Am J Respir Crit Care Med.2006;173:1390–413

Modified BORG scale ไม่เหนื่อยเลย 0.5 แทบไม่เหนื่อย 1 เหนื่อยน้อยมาก 2 ไม่เหนื่อยเลย 0.5 แทบไม่เหนื่อย 1 เหนื่อยน้อยมาก 2 เหนื่อยเล็กน้อย 3 เหนื่อยปานกลาง 4 เหนื่อยค่อนข้างมาก 5 เหนื่อยมาก 6 7 เหนื่อยมากๆ 8 9 เหนื่อยมากเกือบที่สุด 10 เหนื่อยมากที่สุดจนทนไม่ไหว

Lower limb endurance training – walking, cycling Training the muscles of ambulation is a mandatory Walking, ground-based or utilizes a treadmill, is an essential component as it is an important activity in daily life Training using a cycle ergometer is also beneficial as this modality imposes a greater specific load on the quadriceps muscles than walking Supervised ground-based walking training results in a significantly greater increase in walking endurance capacity compared with supervised cycle based training in daily life. Training using a cycle ergometer is also beneficial as this modality imposes a greater specific load on the quadriceps muscles than walking.95 However, supervised ground-based walking training results in a significantly greater increase in walking endurance capacity compared with supervised cyclebased training. Jenkins S. Respirology.2010;15:1157–73

Tests and measurements recommended for patient assessment Exercise capacity - Field-based walking test* Tests most commonly used: six-minute walk test (6MWT) Incremental shuttle walk test (ISWT) Endurance shuttle walk test (ESWT) Measures recorded before a PRP should be the best of two tests Two 6MWTs do not appear to be required at post-program assessment 6MWT and ISWT can be used to prescribe initial training intensity MID 6MWT: ranges from 25 to 54 m, approximately 10% of the 6MWD measured before commencing the PRP ISWT: approximately 48 m ESWT: unknown MID = minimal important difference in patients with COPD PRP = pulmonary rehabilitation program * - Indicates that the assessment is essential Jenkins S. Respirology.2010;15:1157–73

Less symptoms High risk More symptoms High risk

© 2013 Global Initiative for Chronic Obstructive Lung Disease Definition of COPD COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with 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. © 2013 Global Initiative for Chronic Obstructive Lung Disease

Mechanisms Underlying Airflow Limitation in COPD Global Strategy for Diagnosis, Management and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance Parenchymal Destruction Loss of alveolar attachments Decrease of elastic recoil AIRFLOW LIMITATION GOLD revised 2011

Manage Stable COPD: Goals of Therapy Reduce symptoms risk Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality © 2013 Global Initiative for Chronic Obstructive Lung Disease

Burden of COPD Mathers CD, Loncar D. PLoS Med 3(11): e442. doi:10.1371/journal.pmed.0030442

การวินิจฉัย มีปัจจัยเสี่ยงต่อการเกิดโรคปอดอุดกั้นเรื้อรัง ที่สำคัญได้แก่ สูบบุหรี่ (โดยเฉพาะสูบตั้งแต่ 10 ซอง-ปี*ขึ้นไป) สัมผัสมลภาวะภายในและภายนอกอาคาร เป็นต้น 2. ผู้ป่วยมีอาการ เหนื่อย ไอเรื้อรัง หรือ มีเสมหะเรื้อรัง ซึ่งอาการเหนื่อยมักเป็นมากขึ้นเรื่อยๆ แต่บางรายอาจไม่มีอาการโดยเฉพาะในระยะแรกของโรค 3. ผลการตรวจสมรรถภาพปอดมีค่าของ FEV1/FVC < 0.7 หลังได้รับยาขยายหลอดลม ซึ่งเป็นการยืนยันว่าผู้ป่วยยังคงมีภาวะหลอดลมอุดกั้นแม้ได้ยาขยายหลอดลม ซึ่งเป็นลักษณะสำคัญของโรคปอดอุดกั้นเรื้อรัง ผู้ป่วยที่สงสัยโรคปอดอุดกั้นเรื้อรังควรส่งตรวจสไปโรเมตรีย์เพื่อยืนยันการวินิจฉัย * ซอง-ปี หมายถึง จำนวนบุหรี่ที่สูบเป็นซองต่อวัน x จำนวนปีที่สูบ เช่นสูบบุหรี่ 10 มวน (1/2 ซอง) ต่อวัน นาน 20 ปี เท่ากับ 10 ซอง-ปี

Risk Factors for COPD Genes Lung growth and development Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD Genes Exposure to particles Tobacco smoke Occupational dusts, organic and inorganic Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings Outdoor air pollution Lung growth and development Gender Age Respiratory infections Socioeconomic status Asthma/Bronchial hyperreactivity Chronic Bronchitis GOLD revised 2011

Diagnosis of exacerbations A worsening of the following two or more major symtoms for at least 2 consecutive days Dyspnea Sputum volume Sputum purulence Or A worsening of any 1 major symptom together with an increase in any one of the following minor symptoms for at least 2 consecutive days Sore throat Colds (nasal discharge and/or nasal congestion) Fever without other cause Cough Wheeze