Updates in COPD, Focusing on the Outpatient Setting Dr. Amy Ford Turner, DO Department of Pulmonary and Critical Care Medicine Cox Medical Group, Ferrell-Duncan Clinic July 2018 Multiple Choice Questions: 1. A 64yo Male presents to your office with a 6 month progressive symptoms of shortness of breath and cough. He has had 2 urgent care visits for episodes of acute bronchitis within the last year and has had 1-2 per year for the last 5 years. He smokes 1PPD for the last 40 years. He has had to quit his job as a construction manager due to his breathing. You perform a spirogram which shows severe obstruction, FEV1 39%. How would you rate the severity of his disease? A. GOLD Grade A B. GOLD Grade B C. GOLD Grade C D. GOLD Grade D Multiple Choice Questions: 2. The same patient above was given an albuterol inhaler from the urgent care center. He states that he was also given some antibiotics and a course of steroids, but as soon as he ran out of these, he is feeling worse again. What therapy do you choose to start depending on his GOLD Grade listed above? A. Leave him on the current inhaler and wait for the next episode of bronchitis. B. Place him on oxygen since oxygen helps everyone. C. Place him on an inhaled corticosteroid alone. D. Place him on a long-acting muscarinic agent + a long acting beta- agonist. Multiple Choice Questions: 3. The same patient listed above follows up with you 8 weeks later so you can check on his progress. His wife was able to convince him to quit smoking. He has been taking his treatment and feels better. Upon arrival, his oxygen saturation is 79%, but returns to 88% after rest for 10 minutes. How do you address this? A. Not do anything. B. Test him to see he if responds to oxygen with ambulation. C. Prescribe another inhaler. D. Place him on chronic oral steroids.
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Updates in COPD,Focusing on the
Outpatient SettingDr. Amy Ford Turner, DO
Department of Pulmonary and Critical Care Medicine Cox Medical Group, Ferrell-Duncan Clinic
July 2018
Multiple Choice Questions:1. A 64yo Male presents to your office with a 6 month
progressive symptoms of shortness of breath and cough. He has had 2 urgent care visits for episodes of acute bronchitis within the last year and has had 1-2 per year for the last 5 years. He smokes 1PPD for the last 40 years. He has had to quit his job as a construction manager due to his breathing. You perform a spirogram which shows severe obstruction, FEV1 39%. How would you rate the severity of his disease? A. GOLD Grade A B. GOLD Grade B C. GOLD Grade C D. GOLD Grade D
Multiple Choice Questions:2. The same patient above was given an albuterol inhaler from
the urgent care center. He states that he was also given some antibiotics and a course of steroids, but as soon as he ran out of these, he is feeling worse again. What therapy do you choose to start depending on his GOLD Grade listed above? A. Leave him on the current inhaler and wait for the next episode of
bronchitis. B. Place him on oxygen since oxygen helps everyone. C. Place him on an inhaled corticosteroid alone. D. Place him on a long-acting muscarinic agent + a long acting beta-
agonist.
Multiple Choice Questions:3. The same patient listed above follows up with you 8 weeks
later so you can check on his progress. His wife was able to convince him to quit smoking. He has been taking his treatment and feels better. Upon arrival, his oxygen saturation is 79%, but returns to 88% after rest for 10 minutes. How do you address this? A. Not do anything. B. Test him to see he if responds to oxygen with ambulation. C. Prescribe another inhaler. D. Place him on chronic oral steroids.
Multiple Choice Questions:
4. True or False: All patients with COPD should be tested for Alpha-1-antitrypsin disease? A. True. B. False.
Lecture objectives• Brief COPD Overview • Updates and review of GOLD 2017 guidelines
• Brief synopsis of Diagnosis and Severity • Management strategy based on 2017 guidelines • New bronchodilator regimens • Rehabilitation and Quality of Life goals
• Interventional Pulmonary and Surgical options • Lung transplant
*** There are certain aspects of COPD that will be left out due to time constraints.
Disclosures• None
* Use of GOLD Guidelines, tables, pictures, graphs were utilized with permission. These slides are depicted with the GOLD insignia at the top of the slide. ** Use of other slides were also used by permission from NEJM or UTD.
The Impact of COPD• Affects more than 6.3% of the population in the U.S. (2013
data) • 3rd ranked cause of death in the U.S., killing 120,000 each year
(MMWR data, 2011). • Deaths have increased worldwide by 11.6% since 1990 (2015
data), 4th leading cause of death worldwide. • Prevalence of COPD increased by 44.2% since 1990. • Of those with COPD, 64.2% felt that dyspnea/SOB negatively
impacted their QOL.
COPD Definitions• Limitation of airflow that is
not fully reversible and is associated with an abnormal inflammatory response in the small airways and alveoli.
Global Initiative for Chronic Obstructive Lung Disease (GOLD)• "COPD is a common, preventable, and treatable disease that is
characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
• The chronic airflow limitation that characterizes COPD is caused by a mixture of small airways disease (e.g. obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person.
• Chronic inflammation causes structural changes, small airways narrowing, and destruction of lung parenchyma. A loss of small airways may contribute to airflow limitation and muco-ciliary dysfunction, a characteristic feature of the disease.“
COPD At-a-Glance Decision Tree
• Diagnosis
• History and physical • Rule out other causes • CXR, Pulse oximetry
• Assess Severity
• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)
• Management
• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation
Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)
Diagnosing COPD• Should be considered in any
patient with: • Dyspnea
• Progressive over time • Characteristically worse with
exertion • Persistent/Pervasive
• Chronic cough or sputum production
• Features vary: can be intermittent, may also be unproductive vs productive
• Signs and symptoms of COPD • Family history of COPD
• Physical Exam: • Barrel-shaped chest, Hoover’s sign (insp. retraction of the lower ribs),
prolonged expiration on exam, accessory muscle use. • *** Not all that wheezes is COPD or asthma • Digital clubbing is not common in COPD
• Chest radiograph, especially if they have not had one within 5 years • CT not needed unless some other disease process suspected or if annual CT
lung cancer screening is warranted
• Pulsoximetry annually
COPD At-a-Glance Decision Tree
• Diagnosis
• History and physical • Rule out other causes • CXR, Pulse oximetry
• Assess Severity
• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)
• Management
• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation
Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)
DiagnosingCOPD• Spirometry is
required to diagnose within the clinical context
• FEV1/FVC ratio to determine if airflow limitation is present
• ***Bronchodilator response of little clinical value other than helping to determine overlap syndromes or an extremely reactive airway
Symptoms do not usually occur until a threshold is met, usually when FEV1 is below 50%.*
*This threshold, where symptoms occur, can vary from patient to patient.
Pathology of COPD• Airway
• Chronic inflammation • Infiltration by certain cell types • Increased goblet and mucous glands • Fibrosis • Narrowing • Reduction of small airways • Airway collapse due to alveolar cell
wall destruction
• Pulmonary vessels • Hyperplasia of smooth m. and
► Consider two patients: ➢ Both patients with FEV1 < 30% of predicted ➢ Both with CAT scores of 18 ➢ But, one (Patient A) with 0 exacerbations in the past year
and the other (Patient B) with 3 exacerbations in the past year.
► Both would have been labelled GOLD D in the prior classification scheme.
► With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D.
► The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.
GOLD Grading System: ABCD Format
Patient A: 0 Exacerbations
Patient B: 3 Exacerbations
Management of Stable COPD: Goals• Prevent
Disease Progression
• Prevent and Treat Exacerbations
• Reduce Mortality
• Reduce Risk
• Relieve Symptoms
• Improve Exercise Tolerance
• Improve Health Status
• Reduce Symptoms
COPD At-a-Glance Decision Tree
• Diagnosis
• History and physical • Rule out other causes • CXR, Pulse oximetry
• Assess Severity
• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)
• Management
• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation
Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)
GOLD Guidelines: Prevention•Smoking cessation (Is included in ALL Guidelines)
• Is the #1 influence on the progression of COPD • The Lung Health Study (JAMA 1994) =
• Slowed decline of lung function • Reduced mortality rate
• Cochrane data base analysis (2016) of 16 studies (13,123 patients) found a combination of behavioral and pharmacotherapy is more effective in cessation.
GOLD Guidelines: Prevention• Immunizations: PCV13 and PPSV23 are recommended for all
over >65
COPD At-A-Glance Decision Tree
• Diagnosis
• History and physical • Rule out other causes • CXR, Pulse oximetry
• Assess Severity
• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)
• Management
• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation
Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)
Treatment options: Bronchodilators•Recommended
• Long acting agents (LAMA, LABA) preferred over short acting (SABA)
• What agent to start is dependent on COPD subtype and category
• Inhaled preferred versus oral agents (i.e. PO albuterol, theophylline)
• May consider PDE4 inhibitor (Roflumilast) in recurrent exacerbations
• Macrolides daily may also be considered in recurrent exacerbations
• Low dose long acting opioids may be considered in severe disease
Alpha-1-Antitrypsin Deficiency• AAT is a protease inhibitor
that deals in the breakdown of elastase and other proteases.
• Because of this, the lung degrades due to the break down of Elastin.
• ***ALL COPD patients should be tested regardless of age or ethnicity***
• Treat as you would any COPD subclass
• Indications for treatment: • Homozygotes with lung
destruction, FEV < 65% • A1AT level <11mcmol/L or
<57mg/dl • Necrotizing panniculitis
• Types of treatment: • IV infusions • Weekly
COPD At-A-Glance Decision Tree
• Diagnosis
• History and physical • Rule out other causes • CXR, Pulse oximetry
• Assess Severity
• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)
• Management
• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation
Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)
Non-pharmacologic treatment• Education
• Written action plans beneficial, similar to asthma • Inhaler techniques
• Nutrition/Diet • Obesity and pulmonary cachexia are issues that can increase symptoms • Vitamin D deficiency (studies are underway)
• End of life discussions and Palliative Care • Deciding on when to refer can be tricky
• Life-threatening AECOPD = 10% die during admission, 50% may do not survive 4 years after. (Variability widely exists here)
• Decrease in 6MWT <50m, Bedridden/sedentary, pC02 or Pa02 worsening • Focusing on chronic dyspnea and a plan for the acute dyspnea crisis
Pulmonary rehab (GOLD Grade B, C, D)• Especially in those with recurrent exacerbations or high risk for
them • Reducing symptoms (dyspnea) • Improved exercise performance and activity level • Contraindications:
• Uncontrolled cardiac disease or severe pulmonary HTN • Other obstacles: dementia, neuromuscular weakness, arthritis issues,
language/cognitive barriers.
Goals of Pulmonary
rehab
Psychological supportEducation
Breathing Exercises
Strength Training
Endurance Training
Treating Hypoxemia: Oxygen Therapy• GOLD Stage 3-4 may require this • Must be in chronic stable steady state
• Indications = Severe hypoxemia at rest or with exertion • Pa02 <55mmHg, or Sp02 <88 • Signs of pulmonary hypertension, peripheral edema, polycythemia
• Rx: at least 18 hours/day, maintain Sp02 >90%
• Improves survival in severe hypoxemia • May improve QOL?
• New trials are looking at this again in moderate hypoxemia (LOTT Trial, NEJM 2016)
• Did not help progression to death or to 1st hospitalization
Lung transplantation• 2014, International Society for
Heart and Lung Transplantation (ISHLT)
• Guidelines for Selection:
• High risk of death in 2 years (>50%) if transplant not performed
• Survival past transplant >90 days,
• >5 years from general medical perspective
• Contraindications: • Malignancy in the last 2 years (except
localized skin cancer) • Advanced other organ failure • CAD not amenable to revascularization • Acute medical issues: sepsis, AMI, etc. • Uncorrectable bleeding disorder • Chronic infection, Active M.TB
infection • Chest wall or spinal deformity, severe • Obesity, BMI>35 • Medical noncompliance • Psychiatric conditions, Absence of
support system • Debility/Frailty with inability to rehab • Substance/Alcohol/Tobacco abuse or
dependency
Lung transplant (ISHLT guidelines)• Relative Contraindications: • Age >65 (** becoming less strict) • Obesity, BMI 30-34 • Malnutrition • Osteoporosis, severe/symptomatic • Previous extensive chest/lung surgery • Previous high risk infections • HIV • Ongoing Hepatitis B/C • Allograft Autoantibodies • Mechanical Ventilation/ECMO ***
Lung transplant for COPD (ISHLT guidelines)• Used to be most common Dx
for referral (ILD surpassed it) • When to refer:
• Disease progression despite optimum treatment
• Not a candidate for LVRS/endobronchial interventions
• BODE index >5 • pC02 >50mmHg, and/or Pa02
<60mmHg • FEV1 <25%
• When to list: • Bode index >7 • FEV1 <15-20% • AECOPD >3 or more per year • Or 1 severe exacerbation with
acute hypercapnia respiratory failure
• Moderate to severe pulmonary HTN
Lung Transplant for COPD• Choices:
• Single lung transplant • Bilateral lung transplant ***
• Agusti A, Calverley PM, Decramer M, Stockley RA, Wedzicha JA. Prevention of exacerbations in chronic obstructive pulmonary disease: knowns and unknowns. Chronic Obstr Pulm Dis. 2014; 1(2): 166-184.
• Albert RK, Au DH, Blackford AL, Casaburi R, Cooper A, Criner GJ, et al. A randomized trial of long-term oxygen for COPD with moderate desaturation: The long-term oxygen treatment trial research group (LTOTT). N Engl J Med 2016;375:1617-27. DOI: 10.1056/NEJMoa1604344.
• Albert RK, Connett J, Bailey WC, Casaburi R, Cooper JA Jr, Criner GJ, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365(8):689. • Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease:
Towards a revolution in COPD health (TORCH) investigators. N Engl J Med 2007;356:775-89. • Celli B, Decramer M, Leimer I, Vogel U, Kesten S, Tashkin DP. Cardiovascular safety of tiotropium in patients with COPD. Chest 2010;137(1):20. • Chong J, Leung B, Poole P. Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017;9:CD002309. Epub 2017 Sep
19. • Cosio MG, Saetta M, Agusti A. Immunologic aspects of chronic obstructive pulmonary disease. N Engl J Med 2009;360:2445-54. • Farne HA, Cates CJ. Long-acting beta2-agonist in addition to tiotropium versus either tiotropium or long-acting beta2-agonist alone for chronic obstructive
pulmonary disease. Cochrane Database Syst Rev. 2015. • Ferguson GT, Make B. Management of stable chronic obstructive pulmonary disease. In: UpToDate, May 2018. • Ferguson GT, Make B. Management of refractory chronic obstructive pulmonary disease. In: UpToDate, May 2018. • Fishman, A, Martinez F, Naunheim K, Piantadosi S, Wise R, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe
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chronic obstructive pulmonary diseas and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med 2017;5: 691-706.
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Bibliography/References
Multiple Choice Questions:1. A 64yo Male presents to your office with a 6 month
progressive symptoms of shortness of breath and cough. He has had 2 urgent care visits for episodes of acute bronchitis within the last year and has had 1-2 per year for the last 5 years. He smokes 1PPD for the last 40 years. He has had to quit his job as a construction manager due to his breathing. You perform a spirogram which shows severe obstruction, FEV1 39%. How would you rate the severity of his disease? A. GOLD Grade A B. GOLD Grade B C. GOLD Grade C D. GOLD Grade D
Multiple Choice Questions:2. The same patient above was given an albuterol inhaler from
the urgent care center. He states that he was also given some antibiotics and a course of steroids, but as soon as he ran out of these, he is feeling worse again. What therapy do you choose to start depending on his GOLD Grade listed above? A. Leave him on the current inhaler and wait for the next episode of
bronchitis. B. Place him on oxygen since oxygen helps everyone. C. Place him on an inhaled corticosteroid alone. D. Place him on a long-acting muscarinic agent + a long acting beta-
agonist.
Multiple Choice Questions:3. The same patient listed above follows up with you 8 weeks
later so you can check on his progress. His wife was able to convince him to quit smoking. He has been taking his treatment and feels better. Upon arrival, his oxygen saturation is 79%, but returns to 88% after rest for 10 minutes. How do you address this? A. Not do anything. B. Test him to see he if responds to oxygen with ambulation. C. Prescribe another inhaler. D. Place him on chronic oral steroids.
Multiple Choice Questions:
4. True or False: All patients with COPD should be tested for Alpha-1-antitrypsin disease? A. True. B. False.