Essoufflement et COPD: on change de stratégie!

Les nouvelles directives GOLD pour les COPD sont sorties…. Un résumé ci-dessous

Dyspnée

A chaque consultation, hyper important d’amener ses patients à se mobiliser (descendre de l’ascenseur un étage avant, de l’autobus un arrêt avant, etc…)

C’est la meilleure manière de diminuer la dyspnée de vos patients COPD, mieux que tous les médicaments du monde.

Dans la règle, l’entourage et le patient vont dire: faut lui éviter de s’essouffler, on utilise la chaise roulante, on amène la voiture dans l’allée de l’immeuble, etc…

C’est tout le contraire…. Chaque fois que le patient s’essouffle, même un peu, il améliore à terme sa dyspnée…

Nouvelles Guidelines GOLD

Stéroïdes inhalés (seuls ou en association) réservés uniquement aux COPD avec une éosinophilie…. seulement si plus de 300/µL (> 100/µL pour les patients avec exacerbations sévères). Pour les autres, pas de bénéfice et augmentation de l’incidence des pneumonies.

A : symptômes légers bêtas-2

B : symptômes sévères mais pas d’exacerbations bêtas-2 longue durée

C et D : catégories qui disparaissent

E : symptômes sévères >1 exacerbation / hospitalisation dans l’année bêtas-2 longue durée + muscarinic

Décompensations : augmentation des aérosols, selon gravité 5 jours de prednisone 40 mg/j, antibiotiques si expectorations purulentes.

Découvrez le « pocket guide » des guidelines 2023 ici

2023 GOLD Guidelines for Chronic Obstructive Pulmonary Disease

David J. Amrol, MD

Dual long-acting bronchodilators are recommended for patients who require daily therapy.

In 2023, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) panel released its fifth major revision. New, more inclusive definitions of chronic obstructive pulmonary disease (COPD) and COPD exacerbations are included, along with important updates on treatment (NEJM JW Gen Med May 15 2023 and Am J Respir Crit Care Med 2023; 207:819).

Non–fully reversible airflow limitation on spirometry (FEV1/FVC <0.7 post-bronchodilation) in patients with chronic respiratory symptoms confirms COPD. The previous ABCD assessment scheme (with 4 combinations of symptoms and exacerbations) has been revised to 3 groups: A (mild symptoms and low exacerbation risk), B (increased symptoms but no exacerbations), and E (any symptom level with ≥2 moderate exacerbations or 1 hospitalization the previous year).

Group A patients should be treated with short- or long-acting bronchodilators. Group B and E patients should be treated with both long-acting β-agonists (LABAs) and long-acting antimuscarinic agents (LAMAs). If group E patients have eosinophilia (eos, ≥300 cells/µL; or eos, ≥100 cells/µL, with severe exacerbations), an inhaled corticosteroid (ICS) can be added. ICS monotherapy or ICS/LABA combinations should not be used. For patients with eos <100 cells/µL and continued exacerbations despite maximal inhaled therapy, roflumilast or a macrolide can be added. Smoking cessation, vaccination (i.e., influenza, pneumococcus, COVID-19, Tdap and zoster), pulmonary rehabilitation, and oxygen therapy (for PaO2, <55 mm Hg) still are essential. The respiratory syncytial virus vaccine was not approved when the GOLD guideline was published but now is recommended by the U.S. CDC for all adults with COPD who are 60 or older.

Exacerbations are classified based on dyspnea scores, respiratory and heart rate, oxygen saturation, CRP, and, if severe, arterial blood gas measurement. Mild exacerbations are managed with short-acting bronchodilators. Moderate exacerbations are managed with short-acting bronchodilators, 5 days of prednisone (40 mg), and possibly antibiotics for patients with purulent sputum. Severe exacerbations are treated with addition of supplemental oxygen and possible noninvasive ventilation.

The biggest changes in these guidelines for clinicians are the A/B/E grouping and use of combination LABA/LAMA for initial therapy for all patients in group B or E. This practice can be difficult with cost and insurance limitations, and I frequently still must start with LAMA monotherapy. ICS should be reserved for patients with eosinophilia, as almost all benefit is seen in patients with eos ≥300 cells/µL, and ICS are associated with excess pneumonia in patients with COPD.