COPD: A Common Four Letter Word - FIHN Aco€¦ · COPD: A Common Four Letter Word ... Philippines...
Transcript of COPD: A Common Four Letter Word - FIHN Aco€¦ · COPD: A Common Four Letter Word ... Philippines...
COPD: A Common Four Letter WordChapter V‐‐Toward a Better Understanding of Treatment
Neil Waravdekar, MD, FCCPFrederick Medical & Pulmonary Associates
Dr. Koilpillai’s Amendment
No problem with time limitsAs much time as you need
We will cover many topics in the next three hours
Quick summary about me:Frederick Native / Local talentGrew up in IjamsvilleGraduated from TJ High SchoolU of MD, College Park
BS, MicrobiologyHahnemann University (Drexel), Philadelphia, PA
MA, PhysiologyMDInternship & Residency
Penn State / Hershey Medical CenterPulmonary / CC Fellowship Instructor of Medicine
Frederick Medical & Pulmonary Associates 1995
When to refer to a Pulmonologist
Help needed in managing patientNew diagnosis of COPDModerate/Severe/Very Severe COPDPoor response to meds or failure of treatmentExacerbations in a year
2 or more – outpatientI or more inpatient
On oxygenCo‐morbidities
heart disease, arrhythmias, DM and steroidsOther
Q1.
A medication delivered by a nebulizer is better received at the alveolar level than one by metered dose inhaler.
A. TrueB. False
Proper inhaler technique
MDIs are an issueCorrect use ensures delivery (or not)
Re‐educate for proper use
Demonstration
Spacers?
Nebulizers: balance of help and nuisance
Utility:very youngvery oldpoor inhaler techniquefrequent exacerbations
NW advice: Never worship at the temple of the nebulizer when you should be in the ER
Q2.Beginning in 2001 a consensus report has been developed by experts in science and industry throughout the world and has been released and frequently updated to help in the diagnosis, treatment and management of COPD based on scientific and academic information. What is the name of that group?
A. STARTB. STOPC. GOLDD. BLU
A2.C. GOLD
START is what one does at the beginning of an exam or race and STOP is what is done at completion. GOLD is
Global Initiative for Chronic Obstructive Lung Disease
Blu is an e cigarette and these are notrecommended.
United StatesUnited States
United Kingdom
ArgentinaArgentina
AustraliaAustralia
BrazilBrazil
AustriaCanadaCanada
Chile
Belgium
ChinaChina
DenmarkDenmark
ColumbiaColumbia
CroatiaCroatia
EgyptEgypt
Germany
Greece
IrelandIreland
ItalyItaly
SyriaSyria Hong Kong ROC
Japan
Iceland
IndiaIndia
KoreaKorea
Kyrgyzstan
UruguayUruguay
MoldovaMoldova
NepalNepal
Macedonia
Malta
Netherlands
New Zealand
PolandPoland
NorwayNorway
Portugal
GeorgiaGeorgia
Romania
Russia
SingaporeSlovakia
Slovenia Saudi ArabiaSaudi Arabia
South AfricaSouth Africa
SpainSwedenSweden
ThailandThailand
SwitzerlandSwitzerland
UkraineUkraine
United Arab EmiratesUnited Arab Emirates
Taiwan ROC
VenezuelaVenezuela
Vietnam
Peru
Yugoslavia
Bangladesh
France
Mexico
Turkey Czech Republic
Pakistan
Israel
GOLD National Leaders
PhilippinesYeman
Kazakhstan
Mongolia
Albania
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Q3.
What sport has participants such as Dale Jr., Danica Patrick and the Busch brothers? (My favorite sport)
A. SoccerB. TennisC. NASCARD. Golf
Old notion:10‐15% of smokers develop COPD“a minority of those who smoke get COPD”not correct
Newer concept:50% of smokers followed longitudinally in
studies develop COPD
Lundback, Resp. Med. 97: 115‐22, 2003
Risk factors for developing COPD
1. Smokinga. Cigaretteb. Pipe/cigarc. MJd. Passive: second hand smokee. Pregnancy
risk to fetus in uterodecreased lung development
Risk factors for developing COPD
5. Smoke exposure in non‐smokersbiomass fuels
wooddungcrop wastecoal
poorly ventilated structure3 billion people in world
Risk factors for developing COPD6. Age7. Sex
M = Fmore females are smokingsome studies females more susceptible,
others not (?)8. Asthma
poorly controlled asthma leads to irreversible airway obstruction
For your practice:We just identified who may be at risk for COPD:‐ Smoker‐ Dust/particle/fume exposure‐ Chronic cough/sputum production‐ SOB‐ Older patient‐ Poorly controlled asthmatic‐ Family history of COPD
GOLD Definition of COPD“Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with a 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.”
Things to notePreventableTreatablePersistent airflow limitationProgressiveInflammatory response
No specific mention of:
New concepts since I got in the game
Use of single agent LABAs(COPD not Asthma)
LAMAsICS use in COPD (ICS/LABA)Reversibility in not just asthma but also COPDProgressive nature of COPD even after the
offending insult ceases‐running theme
Q4.Josephine Kamal is a 54 YO F heavy equipment operator and mechanic who is a smoker, has frequent cough with sputum production and SOB. Mom and Dad (also smokers) had COPD. Which test will help you in determining the severity of COPD?
A. WBCB. SpirometryC. Cholesterol profileD. Serum porcelain level
A4.B. Spirometry
Assesses airway obstruction
(FYI: use of statins to prevent AE COPD showed no positive effect.)
Grinder, NEJM 374: 685‐94, 2013
Spirometry
Normal
53 YO M
FVC 4.24L , 102%FEV1 3.46L, 106%FEV1/FVC 82%
Effort is key!Coaching is allowed.
SpirometryAbnormalObstruction“Moderate obstruction”
71 YO M with COPD
FVC 2.74L, 58%FEV1 1.59L, 46%FVC1/FVC 58%
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
NOTE: Based on Post-Bronchodilator FEV1
GOLD
GOLD Stage of COPD by FEV1
SpirometryAbnormalObstruction“Moderate obstruction”
71 YO WM with COPD
FVC 2.74L, 58%FEV1 1.59L, 46%FVC1/FVC 58%GOLD 3Severe COPD
Q5.
Does the stage of COPD help us define patients at risk and patients with higher mortality?
A. YesB. No
Assessing RiskFEV1 < 50 %, Gold 3 or Gold 4 = High risk patients
Also
Two or more exacerbations within the last year = High risk patient
One or more hospitalizations for COPD exacerbation = High risk patient
GOLD
Mortality and GOLD Stage
Stage FEV1 3 yr. mortalityGOLD 1 ≥80 ?GOLD 2 50‐80 11% (UPLIFT)GOLD 3 30‐50 15% (TORCH)GOLD 4 <30 24% (ECLIPSE)
GOLD
There are also other predictors of survival (ex. BODE).Bottom line:Higher GOLD Stage = worse mortality
Old NASCAR saying:“Cautions breed cautions.”Translation: when you have problems, these lead to more problems.
New Pulmonary understanding:Exacerbations lead to exacerbations (and decline in lung function).
Q7.
Our patient, Josephine Kamal, an active smoker, is diagnosed with COPD (GOLD 2) with an FEV1 of 71% post BD. Initiation of a medication is an important first intervention.
A. TrueB. False
Smoking and COPD
“Young doctor, without having your patient stop smoking, nothing can be accomplished.”
Clifford Zwillich, MD(on rounds at Penn State c. 1993)
Issues:Lung functionOptimization of efficacy of medsMy personal concern: opening them up to
inhale more smoke
Smoking and COPDReal Patient
Active smoker 5/21/2014 Quit Smoking (5/22/14) 4/20/2016FVC = 1.84L FEV1 = 1.26L 53% FVC = 2.50L FEV1 = 1.92L 83%
GOLD 2Moderate←
Normal→
WOW!
Smoking and COPD
NW rule:The first 3 things to think of in COPD are:
1. STOP SMOKING2. STOP SMOKING3. STOP SMOKING
Smoking and COPD
FMH Smoking Cessation ClinicShanna Figgins, Resp Care240‐566‐[email protected]
FREE!
Q8.
Which of the following have been shown to prevent AE COPD (acute exasperations of COPD)?
A. PPSV23 (Pneumovax)B. Influenza vaccineC. BothD. Neither
A.8.B. Influenza vaccine
ACCP/CTS guidelinesPPSV23
no improvement in AE COPD but is recommended, decreases CAP in COPD pts with FEV1 <40%
Influenza vaccinedecreases AE COPD and is recommended
NW bottom line: Give pulmonary vaccines
Chest 147(4): 894‐942 Prev. of AE COPD. ACCP & ATS Guidelines, 2015
Q9.
Which agent should not be used alone in COPD?A. ICS (inhaled corticosteroid)B. LABA (long acting beta2 agonist)C. LAMA (Long acting muscarinic agonist)
A9.
A. ICS
Use ICS/LABA
For moderate, severe and very severe COPD use of ICS alone is not indicated. ICS/LABA does decrease exacerbations and thus is approved
NW caveat: Use of a LAMA/LABA and ICS would be ok
Chest 147(4): 894‐942 Prev. of AE COPD. ACCP & ATS Guidelines, 2015
The Main Event
What you have been waiting for:
HOW DO I CHOSE COPD MEDS FOR MY PATIENT?
Stratify by GOLD Stage (and/or exacerbation history) and symptoms.
Remember, you are not alone.
COPD Treatment
The medications:SABA: albuterol, levalbuterolSAMA: ipratropium
(M=muscarinic=anticholinergic)LABA: formoterol, aformoterol, indacterol,
olodaterol, salmeterol, vilanterolLAMA: aclidinium, tiotropium, umeclindiniumICS: beclomethasone, budesonide, fluticasoneOthers
Risk
(GOLD
Classificatio
n of Airflow Lim
itatio
n))
Risk
(Exacerbation history)
≥ 2or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
BreathlessnessmMRC 0–1 mMRC > 2
COPD Treatment
GOLD Exacerbations
Risk
(GOLD
Classificatio
n of Airflow Lim
itatio
n))
Risk
(Exacerbation history)
≥ 2or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
0
Symptoms
Low SXHigh Risk
High SXHigh Risk
Low SXLow Risk
CAT < 10
4
3
2
1
CAT > 10
BreathlessnessmMRC 0–1 mMRC > 2
COPD Treatment
GOLD Exacerbations
High SXLow Risk
Risk
(GOLD
Classificatio
n of Airflow Lim
itatio
n))
Risk
(Exacerbation history)
≥ 2or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
BreathlessnessmMRC 0–1 mMRC > 2
COPD Treatment
GOLD Exacerbations
COPD Treatment
Assessing DyspneamMRC: Modified Medical Research Council QuestionnaireNW versionGrade Symptoms occur with:0 No/ only with strenuous exertion1 Rushing or Hill2 Level ‐ walk slow or stop3 Level – stop 100 yards 4 Dressing or don’t go out
Risk
(GOLD
Classificatio
n of Airflow Lim
itatio
n))
Risk
(Exacerbation history)
≥ 2or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
0
Symptoms
(C) (D)
(A) (B)
CAT < 10
4
3
2
1
CAT > 10
BreathlessnessmMRC 0–1 mMRC > 2
COPD Treatment
GOLD Exacerbations
Exacerbatio
ns per year
0
CAT < 10mMRC 0‐1
GOLD 4
CAT > 10 mMRC > 2
GOLD 3
GOLD 2
GOLD 1
SAMA prnor
SABA prn
LABA or
LAMA
ICS + LABAor
LAMA
RECOMMENDED FIRST CHOICE
A B
DC
ICS + LABAand/orLAMA
2 or more or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
Exacerbatio
ns per year
0
CAT < 10mMRC 0‐1
GOLD 4
CAT > 10 mMRC > 2
GOLD 3
GOLD 2
GOLD 1
ALTERNATIVE CHOICE
A B
DC
2 or more or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
LAMA and LABA or
LAMA and PDE4‐inh or
LABA and PDE4‐inh
ICS + LABA and LAMA or
ICS + LABA and PDE4‐inhor
LAMA and LABA or
LAMA and PDE4‐inh.
LAMA or
LABAor
SABA and SAMA
LAMA and LABA
Exacerbatio
ns per year
0
CAT < 10mMRC 0‐1
GOLD 4
CAT > 10 mMRC > 2
GOLD 3
GOLD 2
GOLD 1
OTHER POSSIBLE TREATMENTS
A B
DC
2 or more or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
SABA and/or SAMA
Theophylline
Carbocysteine
N-acetylcysteine
SABA and/or SAMA
Theophylline
TheophyllineSABA and/or SAMA
Theophylline
Exacerbatio
ns per year
0
CAT < 10mMRC 0‐1
GOLD 4
CAT > 10 mMRC > 2
GOLD 3
GOLD 2
GOLD 1
SAMA prnor
SABA prn
LABA or
LAMA
ICS + LABAor
LAMA
NW recommends:RECOMMENDED FIRST CHOICE
A B
DC
ICS + LABAand/orLAMA
2 or more or
> 1 leadingto hospitaladmission
1 (not leadingto hospitaladmission)
COPD Treatment
Other Pharmacologic issues:NW summary ACCP/CTS guidelines LABAs and LAMAs preferred over SABAs and SAMAs Combined use of a short or long acting beta agonist and anticholinergic may be considered if sx not improved with single agents
In general theophylline not recommended Phosphodiesterase 4 Inhibitor, roflumilast, maybe used to decrease exacerbations in pts with severe or very severe COPD (FEV1 < 50%)
Q10.
Long term therapy with oral steroids would be recommended in the treatment of COPD.
A. TrueB. False
COPD Treatment
Other Pharmacologic issues:NW summary ACCP/CTS guidelines Long term use of oral corticosteroids is not recommended.
Oral steroid may be given to prevent hospitalization for subsequent AE COPD in the first 30 days following the AE
Using steroids to treat outpatient AE COPD is acceptable
COPD Treatment
Other NON‐PharmacologicNW summary GOLD and/or ACCP/CTS guidelines Smoking cessation
remember NW rule Pulmonary rehab
groups B, C, Dwithin 4 weeks of AE COPD
Daily physical exercise Pulmonary vaccines Palliative Care
COPD Exacerbations
Exacerbations are……..A. not just a hospitalizationB. “an event that increases dyspnea, cough and/or
sputum beyond day to day variance and may require a change in COPD medicines”
C. under reported by patientsD. a nuisance to you and the patientE. a cause of permanent loss of lung function
NW: think of AE COPD along the same line as an MI or a stroke but involving the lungs
COPD Exacerbations
Treatment modalities:Antibiotics Steroids Oxygen Bronchodilators
SABAsHospitalization
COPD Exacerbations
To reduce exacerbations be pre‐emptive Smoking cessation Pulmonary vaccines LABAs ICS/LABA LAMA PDE 4 I Macrolides NAC Pulmonary rehab
When to refer to a Pulmonologist
Help needed in managing patientNew diagnosis of COPDModerate/Severe/Very Severe COPDPoor response to meds or failure of treatmentExacerbations in a year
2 or more – outpatientI or more inpatient
On oxygenCo‐morbidities
heart disease, arrhythmias, DM and steroidsOther
Closing: one lap to go
I know you are thinking, “thank God!”
Ask your patients (because they don’t tell) about: Smoking
If they don’t get irritated, they started again Med use
All of them?Price is an issue
SOB Level of activity
“ok” is a non‐answer↑ SOB = ↓ Ac vity → Muscle loss → Death