Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3286_Библиотеки_им_академика_М_И_Перельмана
.pdf
COPD in Older People Recent Advances in Geriatric Medicine, Vol. 1 109
intercostal muscle and diaphragm strength in older people compared to younger
ones [4].
Of concern, older people have decreased perception of increases in airway
resistance and less peripheral sensitivity to carbon dioxide [4]. The latter can lead
to an impaired ventilatory response if hypercapnia occurs. These changes may
result in disconnection between symptoms experienced and severity of respiratory
dysfunction as well as delays in seeking medical attention.
EVALUATION
Clinical features commonly associated with COPD include chronic cough,
persistent sputum production, dyspnoea and risk factors such as smoking and
occupation-related exposure to inhaled toxins. However clinical assessment alone
in older people with COPD can be challenging.
Spirometry is an objective and essential diagnostic tool of COPD and the Global
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines use
spirometry measurements to determine disease severity (Table 1) [6]. Based on
these guidelines, COPD is diagnosed in the presence of FEV
1
/FVC of <0.7. In one
study of community-dwelling older people, 75-80% was able to perform valid
spirometry [7]. However frail older adults with cognitive impairment may have
difficulties performing spirometry. Spirometry should be performed only in
symptomatic individuals followed by postbronchodilator measurement if airflow
obstruction is detected. In older people, the GOLD spirometry criteria may lead to
overdiagnosis of COPD because of the lung changes that occur normally with age,
as described earlier. Up to 20% of older people may be incorrectly diagnosed with
COPD if spirometry criteria alone are used without consideration of clinical
manifestations [8].
Other pulmonary testing may also be useful for COPD diagnosis. Lung volumes
are also related to symptom manifestation and functional limitation in COPD.
Hyperinflation, measured as lung volume measurements of inspiratory
capacity/total lung capacity, predicts survival better than FEV
1
in COPD [9]. A
reduction in the diffusion capacity of carbon monoxide is another useful clue to
the presence of COPD. A 6-min walk test is also useful to determine whether
https://t.me/med1917
110 Recent Advances in Geriatric Medicine, Vol. 1 Tuck Yean Yong
oxyhaemoglobin desaturation occurs in patients with moderate or severe COPD.
Those with FEV
1
<50% should also have their arterial blood gas measured to
assess for hypoxia and hypercapnia.
Table 1. Global Initiative for Obstructive Lung Disease (GOLD) criteria for chronic obstructive
pulmonary disease (COPD) staging.
Stage Post-Bronchodilator FEV
1
/FVC FEV
1
I (mild)
<70% of predicted ≥80% of predicted
II (moderate) <70% of predicted 50-79% of predicted
III (severe) <70% of predicted 30-49% of predicted
IV (very severe) <70% of predicted <30% of predicted or
<50% of predicted plus chronic respiratory failure
Chronic respiratory failure is defined as partial pressure of oxygen <60 mmHg (8.0 kPa) with or without
partial pressure of carbon dioxide >50 mmHg (6.7 kPa) while breathing air at sea level.
COMMON COMORBIDITIES
COPD is commonly associated with several extrapulmonary comorbidities that
can significantly influence a patient’s quality of life and care. Examples of these
comorbidities include cardiovascular diseases (CVD), osteoporosis, sarcopenia
and psychiatric disorders (Table 2) [10]. One of the mechanisms in the
development of comorbid conditions in COPD is thought to be related to low-
grade chronic inflammation [11].
In patients with COPD, CVD is common at rates two to three times as high as
those without COPD [12, 13]. Smoking is a common risk factor for both COPD
and CVD. Treatment of coronary artery disease (CAD) can be challenging.
Coronary artery bypass grafting (CABG) is an effective treatment option for CAD
but more adverse postoperative outcomes potentially can occur in patients with
COPD because of impaired pulmonary reserve. In one study, patients with COPD
aged 75 years and older receiving corticosteroids had hospital mortality of 50%
with CABG [14]. This finding would suggest that alternate treatment other than
CABG may be considered more appropriate for those with severe COPD aged 75
years and above. Another treatment consideration is that a small number of
patients with COPD may experience bronchoconstriction if beta-blockers are used
https://t.me/med1917
COPD in Older People Recent Advances in Geriatric Medicine, Vol. 1 111
to treat CAD [15].
Table 2. Summary of common comorbidities in chronic obstructive pulmonary disease.
Comorbidity Prevalence Clinical Impact Treatment Considerations
Cardiovascular
diseases
16-53% Decreases survival and
quality of life
Cardioselective beta-blockers preferred
over non-cardioselective
Osteoporosis 8-69% Increases risk of fractures
and associated disability
Minimize oral and inhaled corticosteroid
use
Ensure adequate vitamin D intake
Sarcopenia 15% Decreases functional and
health status
Pulmonary rehabilitation
Ensure adequate vitamin D intake
Anxiety or depression 6-80% Increases exacerbations
Decreases survival and
quality of life
Standard therapy for anxiety/depression
Pulmonary rehabilitation
Cautious use of benzodiazepines,
mirtazapine and tricyclics
antidepressants
In COPD, the prevalence of osteoporosis can vary between 8.4% and 69% [16,
17]. The risk of osteoporosis is increased in people with moderate-to-severe
COPD compared to those without (odds ratio: 1.9%) [18]. This is particularly
relevant to older people with COPD because the prevalence of osteoporosis also
rises with increasing age. The presence of osteoporosis in patients with COPD has
adverse prognostic implications on respiratory function, in that thoracic vertebral
compression fractures are associated with pain, increased dyspnoea, worsening
kyphosis, decreased vital capacity and reduced exercise tolerance [19, 20]. The
identification and management of osteoporosis in COPD is similar to the general
guideline.
In one study, sarcopenia affected 15% of patients with stable COPD and was
associated with impaired functional and health status [21]. Sarcopenia does not
impact on response to pulmonary rehabilitation, which can lead to a reversal of
the syndrome in select patients [21]. There are still a limited number of studies on
this association and future investigations are needed to expand the understanding
of these two coexisting conditions.
Patients with COPD frequently have depressive and anxiety disorders. Depending
on the study population and diagnostic definition, the prevalence of depression in
https://t.me/med1917
112 Recent Advances in Geriatric Medicine, Vol. 1 Tuck Yean Yong
COPD has been reported between 8% and 80% [22, 23]. A meta-analysis of
studies using diagnostic clinical interview showed prevalence of anxiety among
patients with COPD of all ages as 10-55% in inpatients and 13-46% in outpatients
[24]. One study found that about 42-46% of older people with COPD meet the
diagnostic criteria for depression and anxiety disorders [25]. Anxiety or
depression in patients with COPD are associated with increased hospitalizations
with longer length of stay, increased mortality, decreased quality of life and
reduced exercise capacity [26, 27]. Limited studies have investigated the
treatment of depression or anxiety in COPD patients. At present standard
therapies are employed, including cognitive behavioural therapy, antidepressants
and anxiolytics [28]. However, medications such as benzodiazepines, mirtazapine
and tricyclic antidepressants, can suppress the respiratory drive and should be
used with caution [28]. Pulmonary rehabilitation has been demonstrated to reduce
symptoms of anxiety and depression, with associated improvement in quality of
life [28].
MANAGEMENT OF COPD
The core principles of COPD management include Case finding and Confirm
diagnosis, Optimise function, Prevent deterioration, Develop a care plan and
manage eXacerbations (COPD-X) [29, 30]. Even though COPD has no cure,
smoking cessation, domiciliary oxygen in hypoxaemic patients, non-invasive
ventilation in selective patients and lung volume reduction surgery in people with
upper lobe disease and poor exercise capacity have been found to be improve
survival [31]. So far, no statistically significant improvement in survival has been
observed with any of the pharmacological treatments [6]. In translating these
research findings, most clinical trials on COPD therapies tend to include few older
people [32].
Non-Pharmacological Interventions
Smoking Cessation
Smoking cessation is beneficial even in older people with COPD. Mortality in
older adults improves with smoking cessation independent of the severity of
COPD [6]. Counselling and pharmacotherapy such as nicotine replacement,
https://t.me/med1917
COPD in Older People Recent Advances in Geriatric Medicine, Vol. 1 113
bupropion and varenicline, are safe and moderately effective interventions in
assisting people cease smoking [33, 34]. However, varenicline and bupropion
should be used with caution due to the risk of adverse neuropsychiatric symptoms
such as behavioural changes, agitation and depression [33, 34].
Physical Activity
Older people with COPD should be encouraged to engage in physical activity
regularly [35]. Patients with dyspnoea have a tendency to reduce their physical
activity leading to a vicious cycle of deconditioning, progressive dyspnoea with
activity and further reduction in physical activity.
Nutrition
In people with COPD, low body mass index (BMI) and low fat-free mass, even in
the setting of normal range BMI, independently predict mortality regardless of
disease severity [36]. Careful attention should be given to nutrition status and diet
as part of the management of COPD.
Pulmonary Rehabilitation
Pulmonary rehabilitation can address several aspects of COPD that are
particularly important for older people such as physical deconditioning, social
isolation, muscle wasting and weight loss. Pulmonary rehabilitation improves
dyspnoea and health-related quality of life; and reduces duration of hospitalization
in patients with COPD [37].
Pharmacological Interventions
Pharmacotherapy for COPD in older people is similar to younger ones. No
treatment has been found to change the long-term decrease in lung function but
can reduce symptoms and exacerbation rates, as well as improve quality of life
[6]. Treatment generally includes short- and long-acting agents used in a step-wise
approach according to symptom severity, pulmonary dysfunction and response to
medications.
https://t.me/med1917
114 Recent Advances in Geriatric Medicine, Vol. 1 Tuck Yean Yong
Bronchodilators
Bronchodilators, β
2
-agonists and anticholinergic agents have an important role in
the management of COPD. These agents can be used as monotherapy or in
combination.
Beta-2 Agonists
Inhaled short-acting β
2
-agonists as monotherapy are used widely for acute
symptom control in COPD. Inhaled long-acting β
2
-agonists, such as salmeterol
and formRterol, have been shown to improve some clinical outcomes. Salmeterol
improves respiratory symptoms and spirometric parameters and reduces the use of
short-acting bronchodilator [38].
In older people, β
2
-agonists are generally tolerated well but adverse effects such as
tremor, tachycardia and hypokalaemia should be considered [32]. These agents
have been associated with greater risk of arrhythmias such as supraventricular
tachycardia, ventricular tachycardia, and sudden death [32]. Patients with
underlying cardiac disease such as older people, are potentially more vulnerable to
these arrhythmias with the use of β
2
-agonists [39] but a higher mortality rate due
to these complications has not been observed in several large studies [40, 41].
Anticholinergics
Ipratropium, a short-acting anticholinergic agent, has been used frequently in
COPD. Ipratropium has been shown to improve lung volumes, exercise capacity
and exertional dyspnoea [42]. Several long-acting anticholinergics are currently
available for use in COPD. One of these long-acting anticholinergics, tiotropium,
has been shown to improve dyspnoea, quality of life, FEV
1
and frequency of acute
exacerbations [43]. Other new anticholinergic agents such as glycopyrronium
bromide and aclidinium bromide are also available. In randomised control trials,
glycopyrronium has been shown be superior to placebo and comparable with
tiotropium in reducing rates of COPD exacerbation [44, 45].
The most common side-effect associated with anticholinergic agents is dry mouth.
Many oral anticholinergic agents are associated with cognitive impairment but
this association has not observed with the use of ipratropium in older people [46].
https://t.me/med1917
COPD in Older People Recent Advances in Geriatric Medicine, Vol. 1 115
A meta-analysis on anticholinergic agent studies has suggested that these agents
are associated with a greater risk of cardiovascular adverse events [47] but this
has not been observed in a randomised controlled trial with tiotropium [43].
Inhaled Corticosteroids
In patients with moderate to severe COPD, inhaled corticosteroids (ICSs) are
recommended [48] but efficacy in terms of improving FEV
1
and mortality is
limited [49]. In older people, long-term high-dose ICSs should be used with
caution because of the potential to cause cataracts, open-angle glaucoma, thrush
and increased risk of pneumonia and bone fragility [50].
Combination Therapies
Combination therapies (long-acting β
2
-agonists and ICSs) have been shown to be
more effective in reducing acute exacerbations of COPD than using either agent
alone [51] and demonstrated a trend towards lower mortality [40]. The
combination of formoterol and tiotropium has been shown to produce
improvements in airflow, hyperinflation and need for rescue therapy [52].
Several combinations of long-acting β
2
-agonists and long-acting anticholinergics
will be available in the near future. One study has been published on the use of a
once daily fixed dose combination of both glycopyrronium (50 μg) and indDcaterol
(110 μg) in severe to very severe COPD [27]. This combination reduced the rate
of moderate to severe exacerbations by 12% compared to glycopyrronium alone
but no significant reduction was observed in comparison with open-label
tiotropium. Studies involving older people have not been reported yet.
Combinations with inhaled corticosteroids, long-acting β
2
-agonists and long-
acting anticholinergics have also been studied in a clinical trial [51]. The triple
combination (fluticasone, salmeterol and tiotropium) reduced the number of
severe exacerbations requiring hospital admissions by 47%. However further
studies are required to confirm the efficacy of triple therapy in older people.
Delivery Systems of Inhaled Medications
Inhaled medications can be delivered through meter-dosed inhalers, dry-powder
https://t.me/med1917
116 Recent Advances in Geriatric Medicine, Vol. 1 Tuck Yean Yong
inhaler and nebulizer. The efficacy of inhaled agents is dependent on the amount
of drug delivered to the lower airways. However, older people often have
difficulties using these inhalers because of arthritis, poor manual dexterity, muscle
weakness, visual or cognitive impairment [53, 54].
Meter-dose inhalers have the advantage of high dose-to-dose reproducibility.
However an important disadvantage of this device that should be taken into
consideration in older people is the need to coordinate breathing and inhaler
activation. In about 30% of older people, improper use of meter-dose inhalers can
lead to a high degree of pharyngeal deposition and reduce efficacy of treatment
[53]. In the same study, the use of a spacer can reduce pharyngeal deposition [53]
but adherence is generally poor [55].
Dry-powder inhalers are breath-actuated and do not require coordination of
inspiration and inhaler activation [56]. In one study, most older people rated the
dry-powder inhaler (83% of participants) easier to use compared to metered dose
inhalers (54%) [55]. However a dry-powder inhaler may require additional
instructions and may prove challenging for older adults with cognitive
impairment. Despite this challenges, dry-powder inhaler was still more effective
than metered-dose inhaler in older people with cognitive impairment [57]. A
further consideration with the use of dry-powder inhaler is the need for the patient
to have a higher inspiratory flow rate, some requiring up to 30-60 L/min,
compared with a minimum of 25 L/min in metered-dose inhalers [55].
Immunizations
Annual influenza vaccine is recommended for all patients with COPD.
Observational studies showed that annual influenza immunization in patients with
COPD reduced rates of hospitalizations for influenza and pneumonia (52%
reduction), all-cause mortality and cost [58, 59]. Pneumococcal polysaccharide
vaccine is recommended for all patients with COPD aged 65 years or older [6].
Surgical Interventions
Lung volume reduction surgery may be beneficial in selected patients with COPD.
The best candidates for this type of surgery are those with FEV
1
>20% of
https://t.me/med1917
COPD in Older People Recent Advances in Geriatric Medicine, Vol. 1 117
predicted and a normal partial pressure of carbon dioxide or upper-lobe-
predominant disease and moderate exercise tolerance [60]. Findings from the lung
volume reduction surgery demonstrated higher short-term mortality (7%) but
better long-term survival [61]. However, the benefits of such surgery in the older
age group have not been specifically evaluated.
Other Therapies
Like younger people with severe COPD, oxygen therapy is indicated for older
people if the room air resting partial oxygen pressure is <55 mmHg, or <60
mmHg in the presence of pulmonary hypertension or polycythemia. Most
recommendations support more than 15 hours of use to obtain maximal benefit.
Long-term oxygen therapy in these patients has been demonstrated to improve
exercise ability, cognitive function and mortality [62, 63].
Theophylline is infrequently used in current practice but may be considered in
patients with difficult to control COPD. However severe adverse drug events can
occur with theophylline, especially in older people. Theophylline has a narrow
therapeutic range of 10-20 μg/mL. It inhibits all phosphodiesterase enzyme
subsets in a nonspecific way which explains the wide range of adverse effects.
Older people have a higher risk of adverse drug events when taking theophylline
because of concomitant diseases, reduced drug clearance and potential drug-drug
interactions in the setting of polypharmacy.
New agents including combined phosphodiesterase 3 and 4 inhibitors, such as
RPL554 [64], and monoclonal antibody against interleukin 1 receptor
(medimmune-8986) [65] are currently under investigation for the prevention of
acute exacerbations. Further work will be required to determine their efficacy in
the older population.
MANAGEMENT OF ACUTE EXACERBATIONS
Severe exacerbations of COPD adversely affect health status and may cause
permanent loss of lung function [66, 67]. Most of the acute exacerbations are
thought to result from infections but about one-third may be of non-infectious
origin [68]. A number of strategies can reduce the morbidity and mortality
https://t.me/med1917
118 Recent Advances in Geriatric Medicine, Vol. 1 Tuck Yean Yong
associated with acute exacerbations of COPD in older people.
In the treatment of exacerbations of COPD, oxygen supplementation should be
titrated to achieve a target oxygen saturation range of 88-92%. This approach has
been shown to have a greater than twofold reduction in mortality, compared with
routine administration of high-concentration oxygen therapy [69]. This practice is
equally applicable in older people with exacerbation of COPD.
Antibiotics are often used during COPD exacerbations but data is conflicting
about their effectiveness. In severe COPD, effectiveness has been shown when
two of these symptoms are present: increased dyspnoea, sputum volume and
sputum purulence [68]. As compared with placebo, antibiotics reduce the relative
risk of treatment failure (defined as no resolution or clinical deterioration) by
about 50% when used during exacerbations of COPD [70].
Oral corticosteroids are useful for moderate-to-severe exacerbations of COPD. In
randomized trials, treatment with prednisolone at 30-40 mg a day for 7-10 days
lowered the relative risk of treatment failure (defined as intensification of therapy,
rehospitalisation, or a return to the emergency department) by about 30% [71, 72].
Courses of corticosteroids extending more than 14 days do not confer any
additional benefit and increase the risk of adverse events [71].
Noninvasive positive pressure ventilation, either continuous positive airway
pressure or bi-level positive airway pressure, may also be beneficial for
management of COPD exacerbations in older people. A Cochrane review
concluded that noninvasive positive airway pressure should be included as an
adjunct therapy in suitable patients with respiratory failure from an episode of
COPD exacerbation [73]. The challenge in an older population is identifying the
suitable individual with respiratory failure for such therapy. Furthermore, 13-29%
of patients are unable to tolerate the noninvasive mask.
Studies evaluating new anti-inflammatory drugs such as etanercept [74] and
zileuton (anti-leukotriene inhibitor) [75], positive expiratory pressure therapy [76]
and early inpatient respiratory rehabilitation [77] have not been found to be
beneficial in terms of reducing hospital length of stay, readmission, treatment
failure or recovery of physical function. A novel p38 mitogen activated protein
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана