Posts tagged COPD
Teaching the 5th years in the final gasp of their medical school career, the APART course last week ran them through some scenarios of acutely unwell patients. This was quite literally their last two hours of medical school before starting work in August and I was surprised at the sea of blank faces when they were faced with a COPD patient in type two respiratory failure. The progressive (simulated) decline of the patient (accompanied by my now legendary impressions of “elderly confused woman” and “obstructed airway”) did little to trigger the request for non invasive ventilation. Comments like “ask ITU to keep an eye on them” did little to quell the rising panic in my little respiratory educationalist heart. Once the topic of NIV was broached there remained an air of mild confusion and the whiff of misunderstood acronyms in the air. What is BiPAP, CPAP, NIPPV? Can’t you just tube them all? I find myself relieved that the new and improved respiratory teaching for the second years will go some way to exposing our students to this most oft used and useful of therapies, but what of the students in the more senior years? DundeeChest 3.0 to the rescue….? When I find some useful web resources in this area I will post them, but I have to admit I’ve come up short so far.
This weekend is the Drive4COPD 300 at the Daytona International Speedway (Where DundeeChest spent his Honeymoon; true story). I can find no information regarding the Drive4COPD bit, but I assume it’s to promote the plight of CODP sufferers? All that particulate matter floating about in the pit lane must have something to do with, mustn’t it?
The race is today, and Tom Petty will drive the pace car, only a 5 litre V8 mustang, or something. Who will win? Who will drive round in a circle 120 times? The outcome will be determined on….. the last corner probably.
Apparently the 300 mile race is a sprint.
A recent paper in Chest has suggested that the staple treatment for COPD may not be the knees of the bees after all. Inhaled corticosteroids (ICS) have been the cornerstone of COPD management for some time, with the aim of reducing inflammation and (hopefully) cutting exacerbation rate. The TORCH study successfully did away with thoughts of ICS improving survival (ahh, the agony of p=0.052) but at least we have the principle of symptom control to cling to don’t we? Well, don’t we?
The clever bods from Chandigarh, India have taken 11 large prospective, double-blind, randomized, placebo-controlled trials and passed it through their Metaregression-ometer and come up with the conclusion that “The benefits of ICS in preventing COPD exacerbations seems to be overstated”. The collected statistics from the 8,164 patients pooled from seminal papers including ISOLDE, TRISTAN and TORCH showed that “we did observe a modest benefit of ICS in preventing COPD exacerbations in patients with FEV 1 < 50%. However, this finding was not further substantiated on a metaregression analysis wherein we did not observe a significant effect of baseline values of FEV 1 (percentage predicted) on the benefits from ICS compared with placebo. Thus, ICS is likely to have only modest benefits in preventing COPD exacerbations, if at all, and should be judiciously used in patients with COPD keeping in mind the risk-benefit ratio.”
I’ll admit my utter ignorance of the nuances of metaregression analysis and its potential flaws when used like this, but I would hope that the use of words such as “likely” and “modest” would hint that the analysis has scope to be challenged by people with more statistical savvy than my good self. Mind you, it doesn’t really matter does it, what with the veritable panacea of COPD drugs at our disposal…………(right, anyone got shares in Roflumilast?).
The mainstay of COPD management is bronchodilatation – the local, and national guidelines rely on beta-2 agonists, and anti-cholinergics. Recent(ish) data from the TORCH study suggested that inhaled corticosteroids increase the risk of fatal and non-fatal pneumonias.
Unopposed long acting beta agonists have been linked with increased cardiovascular death in asthmatics, although not in COPD. The most recent ’scare’ has been whether Spiriva increases cardiovascular death in COPD patients. Today the FDA rule that there is no compelling evidence to that effect.
To learn more about COPD visit the COPD GOLD guidelines pages, or the NICE guidelines on COPD. We’ll be updating our local guidance on COPD soon, so keep checking the Knowledge Base section for updates.
To see some patients with COPD, come to ward 3, any day of any week!