Raising Awareness of COPD - UC San Diego School of ...

Activity DescriptionThe Raising Awareness of COPD: Diagnosis, Management, and Comorbid Con-ditions activity reviews the characteristics and diagnosis of COPD, current Global Initiative for Chronic Obstructive Lung Disease (GOLD) standards, and emerging treatment options in a brief, text-based format.

Target AudienceThis activity is designed for pulmonologists, respiratory therapists, internal medicine and primary care physicians, geriatricians, and other health care professionals involved in the treatment of patients with COPD.

Method of ParticipationThe estimated time to complete this activity is 1 hour. To obtain credit, participants should register for the activity at http://cme.ucsd.edu/copd, take the online pre-test, read the monograph, answer the multiple-choice post-test questions, and complete the evaluation form online to download a certificate immediately upon completion.

Educational ObjectivesFollowing completion of this educational activity, learners should be able to:

• Examine GOLD standards and incorporate proper staging and diagnostic exami-nation of COPD.

• Correctly administer and accurately interpret spirometry as a diagnostic tool for patients suspected of suffering from COPD.

• Integrate current and evolving treatment options into practice for patients with COPD, addressing patient adherence and psychosocial issues.

• Identify common comorbidities associated with COPD and discuss effective management options.

Statement of NeedChronic obstructive pulmonary disease (COPD) currently affects approximately 15 million people in the U.S. and was the third leading cause of death in the United States in 2011. An additional 12 million are estimated to be undiagnosed. While COPD is becoming increasingly common, it is also both preventable and treatable.

Accreditation StatementThe University of California, San Diego School of Medicine is accredited by the Ac-creditation Council for Continuing Medical Education to provide continuing medi-cal education for physicians.

Credit DesignationAMA: The University of California, San Diego School of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

AAPA: Accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit(s)™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 1.0 hour of Cat-egory 1 credit for completing this program.

BRN: For the purpose of recertification, the American Nurses Credentialing Cen-ter accepts AMA PRA Category 1 Credit(s)™ issued by organizations accredited by the ACCME. For the purpose of relicensure, the California Board of Registered Nursing accepts AMA PRA Category 1 Credit(s)™ (report up to 1 hour of credit and list “CME Category 1” as the provider number).

Release Date: October 8, 2013 Expiration Date: October 7, 2014

Course DirectorRebecca Sell, MD Assistant Professor of Clinical Medicine Associate Program Director, Internal Medicine Residency Program Division of Pulmonary & Critical Care Medicine University of California, San Diego

ReviewerNi-Cheng Liang, MD Associate Physician Division of Pulmonary & Critical Care Medicine University of California, San Diego

Staff WritersAngela Felker, PhD Continuing Medical Education University of California, San Diego

Christina Williams Continuing Medical Education University of California, San Diego

4 – Raising Awareness of COPD

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DisclosureThe faculty, CME staff, editorial staff, peer reviewer, and CME committee reviewers do not have any relevant financial relationships to disclose.

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Cultural CompetencyThis activity is in compliance with California Assembly Bill 1195 which requires CME courses with patient care components to include curriculum in the subjects of cultural and linguistic competencies. Cultural competency is defined as a set of integrated at-titudes, knowledge, and skills that enables health care professionals or organizations to care effectively for patients from diverse cultures, groups, and communities. Linguistic competency is defined as the ability of a physician or surgeon to provide patients who do not speak English or who have limited ability to speak English, direct communi-cation in the patient’s primary language. Cultural and Linguistic Competency was incorporated into the planning of this activity. Additional resources on cultural and linguistic competency and information about AB1195 can be found on the UC San Diego CME website at http://cme.ucsd.edu.

SupportSupported by an educational grant from Boehringer Ingelheim

ContactUC San Diego School of Medicine, Continuing Medical Education P: (619) 543-7602, E: [email protected], W: http://cme.ucsd.edu


OverviewChronic obstructive pulmonary disease (COPD) currently affects approximately 15 million people in the U.S. and was the third leading cause of death in 2011 (Engel & Vemulpad, 2009; Ferguson, 2011; Urbano & Pascual, 2005; Yohannes & Hardy, 2003; Hoyert et al., 2012). Moreover, roughly 12 million more people have COPD but remain undiagnosed. In 2000, approximately 120,000 people died due to COPD. The death rate for women has increased exponentially since 1980 (Urbano & Pascual, 2005). Costing approximately $53 billion dollars annually, COPD results in 8 million office and outpatient clinic visits, 1.5 million emergency room visits, and 725,000 hospitalizations (Burt & Corbridge, 2013; Urbano & Pascual, 2005). While COPD is becoming increasingly common, it is also both preventable and treatable, and is becoming more manageable with new diagnostic and treatment advances (Vestbo et al., 2013). This monograph will review the characteristics and diagnosis of COPD, current Global Initiative for Chronic Obstructive Lung Disease (GOLD) standards, and emerging treatment options.

COPD is characterized by shortness of breath and chronic cough caused by irrevers-ible airflow obstruction, and encompasses a range of diseases from chronic bronchitis to emphysema. Chronic bronchitis is defined as the presence of a chronic produc-tive cough for three of 12 months, over two consecutive years. Airway inflammation and mucus hypersecretion ultimately results in narrowed airways, productive cough and difficulty breathing (National Heart, Lung, and Blood Institute [NHLBI], 2012). Emphysema is permanent destruction of the distal airways and alveoli (air sacs) result-ing in loss of elastic recoil, gas exchange abnormalities and air trapping within the lung (Urbano & Pascual, 2005). Alpha-1 antitrypsin deficiency, a subtype of emphysema, is an inherited disorder that affects between 1:1,500-3,500 people of European ancestry and may present at an earlier age. Most COPD patients have some characteristics of both chronic bronchitis and emphysema (NHLBI, 2012).

Risk factors for the development of COPD include significant exposure to smoke (e.g., tobacco, fire, second-hand smoke inhalation, etc.), occupational dust and fumes, biomass fuel exposure, family history, gender (i.e., more women than men are now at risk of a COPD diagnosis), alpha-1 antitrypsin deficiency, socioeconomic status (i.e., lower status indicates a greater risk factor), poor nutrition, and chronic respiratory infections (Burt & Corbridge, 2013). However, the main risk factor in the potential development of COPD is tobacco use – smoking has been linked to a majority of cases of COPD (Heffner, 2011; Urbano & Pascual, 2005; Yohannes & Hardy, 2003).

COPD typically presents with subacute shortness of breath, frequently with exertion, and chronic cough. As the disease progresses, patients can be functionally limited and breathless even at rest. They may develop hypoxia and subsequent heart failure (cor pulmonale). Patients with COPD are at risk for respiratory infections and acute exacerbations. An acute COPD exacerbation is defined as increased breathlessness, cough and/or sputum production from baseline and may be severe enough to result in hospital admission. By detecting COPD in its early stages, it may be possible to reduce exacerbations and emergency treatment, and improve physical function. Exac-erbations may be preceded by common causes including viral and bacterial respiratory


tract infections and air pollution; however, some patients may simply be more prone to exacerbations than others. According to Fromer and colleagues (2010), COPD di-agnosis may not be considered due to characteristics of both physician and patient. For example, in women and younger patients, COPD is not often on a physician’s radar and may be missed in the early stages; similarly, patients may not seek medical treatment in the early stages of the disease and choose instead to self-treat by reduc-ing activity to avoid experiencing symptoms and/or neglecting to mention specific symptoms. COPD should be considered in patients over the age of 40 with progressive dyspnea, chronic cough, sputum production and exposure history (i.e. tobacco use). Specific diagnostic measures for COPD include history, physical examination, X-ray, and spirometry.

Diagnostic Tests for COPDThe goals of COPD assessment and diagnosis are three-fold: a) determining the impact of COPD on health status, b) evaluating severity of airflow limitation, and c) calculat-ing risk of future exacerbations, all of which can aid in guiding management options (Vestbo et al., 2013).

Since COPD is defined as airflow obstruction, pulmonary function testing is necessary for diagnosis and staging (Cooper, 2005). The most widely used diagnostic test and the current gold standard for arriving at a COPD diagnosis is spirometry (Coates et al., 2013; Cooper, 2005; Mapel et al., 2011; NHLBI, 2012). Spirometry is the measure of airflow limitation; this test is standardized and widely available. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) need to be measured via spirometry in order to arrive at a definitive diagnosis of COPD.

Once the FEV1/FVC ratio is obtained, the Global Initiative for Chronic Obstruc-tive Lung Disease (GOLD) criteria can be used to arrive at a patient severity classifica-tion. A post-bronchodilator FEV1/FVC ratio of less than 70% is diagnostic of COPD. GOLD stage I (mild) has a post-bronchodilator FEV1 > 80% with a reduced FEV1/FVC ratio. Stage II (moderate) is an FEV1 between 50 – 80%, Stage III (severe) has an FEV1 between 30% and 50% and Stage IV, very severe, has an FEV1 <30%. (Heffner, 2011; Urbano & Pascual, 2005; Yohannes & Hardy, 2003).

KEY POINTS:• COPD is a leading cause of mortality and morbidity, resulting in a significant

economic burden• COPD is a preventable and treatable condition that is typically progressive

and results in chronic inflammatory response in the airways and lungs• Exacerbations and comorbidities are common, contribute to disease severity,

and can impact management


FEV1 may be influenced by individual characteristics such as age, sex, height, and eth-nicity, but these common variables are controlled. After staging the severity of obstruc-tion, GOLD guidelines recommend individualizing risk assessment based on symp-toms and number of exacerbations. The MRC or CAT score is calculated to quantify symptoms and place patient to left (few symptoms) or right (many symptoms) side of the combined assessment box (see Figure 1 from Vestbo et al., 2013). The number of exacerbations per year places patients in the lower (≤ 1 per year) or higher (≥2 per year) boxes. Patient group A (GOLD 1 or 2, few symptoms, few exacerbations) will be treated differently than patient groups B (GOLD 1 or 2, low risk, more symptoms), C (GOLD 3 or 4, high risk, fewer symptoms) and D (GOLD 3 or 4, many symptoms, several exacerbations).

Figure 1. Combined COPD assessment. When assessing risk, choose the highest risk according to GOLD spirometric grade or exacerbation history. Vestbo et al., 2013

American journal of respiratory and critical care medicine: an official journal of the American Thoracic Society, medical section of the American Lung Association by AMERICAN LUNG

ASSOCIATION Reproduced with permission of AMERICAN THORACIC SOCIETY in the format Post in a course management system via Copyright Clearance Center.

Spirometry can effectively aid in diagnosing and assessing the severity of COPD, and periodically track lung function over time. Currently there are electronic desktop spirometers and hand-held spirometers used in clinical practice. Similarly, two trace graphs can be read in spirometers with real-time displays – volume exhaled versus time and flow (L/sec) versus volume (L), the latter of which is best used in identifying the common issue of airway obstruction in COPD. Patients should be seated when performing a spirometry test, and will be given specific instructions on breathing into the mouthpiece so as to accurately measure exhalations. Bronchodilator use may affect the results, as well as patients with chest pain and/or cough who may have difficulty properly completing the test. Thus, ensure that the patient is able to fully comply with

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instructions to ensure accurate results. Additionally, spirometry testing is not typi-cally recommended for use during a patient exacerbation due to performance difficulty (Burt & Corbridge, 2013; Vestbo et al., 2013).

Routine spirometry is beneficial in identifying patients with COPD who may be de-clining, and can improve quality of care. Further, the authors (Abramson et al., 2010) commented that when using spirometry, it is possible to detect COPD in its early stages, with a recent pre-/post-study design in the US which indicated that manage-ment changes occurred in 48% of patients with COPD or asthma who incorporated the use of spirometry testing in a family medical practice. However, Price et al. (2010) reported that less than one third of patients with COPD have received diagnostic confirmation via spirometry. Cooper (2005) reported that when a Swedish location utilized spirometry as a screening tool for all smokers over the age of 40, 27% of the sample aged 40-55 was found to have COPD, which may have gone undiagnosed until disease progression. Ultimately, the use of spirometry testing can be highly ben-eficial when making an initial COPD diagnosis as well as to continue further staging and disease progression.

Differential Diagnosis of COPDThe GOLD guidelines, in addition to reviewing disease staging and diagnostic testing recommendations, also highlight potential conditions that need to be ruled out when arriving at a differential diagnosis of COPD; namely, asthma, which is frequently mis-taken for COPD. Other conditions include bronchiectasis (similar symptoms mimic COPD), tuberculosis, bronchiolitis, diffuse panbronchiolitis, and congestive heart failure (Mapel et al., 2011; Price et al., 2010).

Asthma is common in patients with a moderate to severe COPD staging diagnosis (40%), but has also been identified as fairly common (23%) among patients with a mild case of COPD (Mapel et al., 2011). While asthma typically strikes patients at a younger age and is related to airflow limitation and airway hyper-responsiveness, COPD is typically associated with older adults with a history of smoking and af-fects the airway and lung parenchyma (Price, et al., 2010). Up to 25% of patients aged 40 and older who were diagnosed with asthma in fact had COPD (Price et al., 2010). According to Tinkelman et al. (2006), “the strongest differential indicators were increasing age and pack-years of smoking, dyspnea that had worsened in recent years, breathing-related hospitalization, phlegm of more than 15 mL/d and tendency for colds to go to the chest” (p.1126). Exacerbation symptoms may seem similar to other conditions that need to be differentially diagnosed; specifically, pneumonia, pul-monary embolism, congestive heart failure, cardiac arrhythmia, pneumothorax and pleural effusion (Vestbo et al., 2013). Thus, it remains important to fully screen and evaluate patients to arrive at a differential diagnosis of COPD.


Comorbidities Commonly Associated with COPDIn addition to utilizing available diagnostic tools such as spirometry when diagnosing COPD, patients that have been newly diagnosed with COPD should have chest X-rays to rule out other potential conditions that are similar to COPD. Testing for alpha-1 antitrypsin deficiency should be considered in younger patients. Several studies have determined that comorbidities such as hypertension, musculoskeletal disease, cardio-vascular disease, chronic renal failure, diabetes, dementia, and cerebrovascular disease are more common in patients with COPD, which may in fact increase a patient’s risk of these conditions (Incalzi et al., 2010; Mapel et al., 2011; Terzano et al., 2010).

Cardiovascular DiseaseThe most common condition occurring alongside COPD is cardiovascular disease (Falk et al., 2008). Ischemic heart disease (IHD), heart failure, atrial fibrillation (AF), and hypertension are the four main cardiovascular comorbid conditions. While the risk of cardiovascular disease is increased in patients with COPD, it remains frequently underdiagnosed (Falk et al., 2008; Vestbo et al., 2013). Though cardiovascular comor-bidities are common, each condition should be treated separately according to stan-dard guidelines, although high doses of beta-agonists for treatment COPD should be avoided in patients with concomitant IHD (Vestbo et al., 2013).

Terzano and colleagues (2010) reported that hypertension appeared to be the most common comorbidity present in their sample of patients with COPD at 64.2%, while chronic renal failure, diabetes, peptic ulcers and other cardiovascular problems fol-lowed close behind. Specifically, atrial fibrillation and heart failure were found among the study sample to be higher among patients with COPD when compared to the gen-eral population, frequently accompanied by increased stroke rates. Additionally, since smoking is a common precursor to COPD, the prevalence of patients with COPD who smoke and have resultant cardiovascular disease is also quite high among this group. The authors examined hospitalizations of these patients with COPD and noted that aside from exacerbations that required hospitalization, cardiovascular disease was the main cause of hospitalization and mortality among patients with COPD (Terzano et al., 2010).

Anxiety and DepressionDifferences in physiological and psychological health are present between patients with mild, moderate and severe stages of COPD (Hajiro et al., 2000). While patients with mild COPD are typically encouraged to remain active and engaged in activity, moder-ate to severe COPD cases have reported higher rates of anxiety and dyspnea, which can negatively impact perceived ability to be active.

Depression prevalence rates in patients with COPD are between 10 – 42% for a clini-cal depression diagnosis and 10 – 19% for anxiety disorder (Maurer et al., 2008). The risk of depression is higher (62%) in patients with severe COPD who are reliant on oxygen therapy, while patients with COPD who have recently experienced an acute exacerbation also have high prevalence ranges for depression (19 – 50%) and anxiety (9 – 58%). These figures are similar to that of patients with other advanced diseases such as cancer, heart disease, and AIDS (Maurer et al., 2008). Since patients who are


depressed or anxious typically have lower rates of treatment adherence and additional problems with fatigue and disability, treating both depression/anxiety and COPD re-mains paramount to improving overall quality of life. Current research suggests that treatment for both anxiety and depression should continue as normal for patients with COPD (Maurer et al., 2008).

Lung CancerLung cancer is frequently found in patients with COPD and is often the cause of death in patients with more moderate cases of COPD (Vestbo et al., 2013). Of 2,507 patients with COPD followed for a median of 60 months, 215 developed lung cancer, with the most common type of lung cancer indicated as squamous cell carcinoma in 44% of patients (de Torres et al., 2011). Interestingly, lung cancer was less common among patients with COPD whose airflow obstruction was more severe. Increased age, low body mass index, and GOLD criteria at stages I and II were identified with a diagnosis of lung cancer by the end of the study. Similar to other comorbid condi-tions, lung cancer and COPD can be treated individually while occurring simultane-ously; however, if lung function is decreased due to COPD, this may negatively affect the potential for the surgical treatment of lung cancer.

Obstructive Sleep ApneaUp to 20% of patients with severe COPD may have coexisting obstructive sleep apnea (OSA) (Brander et al., 1992). This overlap syndrome results in gas exchange abnormalities, sleep disturbances and symptoms out of proportion to the degree of air-way obstruction (Flenley, 1985). OSA should be suspected in a patient with COPD who has daytime hypersomnolence, snoring, obesity or significant weight gain and witnessed apneas. Polysomnography should be done to evaluate for concomitant ob-structive sleep apnea. Obesity hypoventilation syndrome (OHS) should also be con-sidered if there is hypercapnia out of proportion to the severity of airflow obstruction, as patients with OHS may require nocturnal ventilator support. Those with COPD and OSA are at an increased risk of development of cor pulmonale or heart failure and have a worse prognosis than patients with OSA alone (Weitzenblum, 1992). Thus treatment of OSA with positive airway pressure therapies in patients with COPD is of paramount importance.

OsteoporosisOsteoporosis is a common systemic effect in COPD and may be due in part to the extended or recurrent use of corticosteroids for COPD exacerbations. Osteoporosis risk factors include genetics, endocrine abnormalities, body composition and periph-eral skeletal muscle structure (Ionescu & Schoon, 2003). Fractures are common in pa-tients with COPD and osteoporosis, which can add recovery time and economic bur-den to the cost of treating patients with these comorbid conditions. The EUROSCOP trial and TORCH trial found that inhaled corticosteroids budesonide and fluticasone propionate, respectively, were associated with decreased bone mass, which in turn can increase the risk of osteoporosis development and ultimately, fractures. Patients with COPD and fracture may have a difficult time recovering as the restrictions already facing patients with decreased lung function are amplified when dealing with fracture simultaneously (Ionescu & Schoon, 2003; Vestbo et al., 2013). Thus, it is imperative that clinicians be aware of the association between osteoporosis and COPD and the


implications that certain management options for COPD may be more likely to con-tribute to osteoporosis. Routine screening with a dual-energy X-ray absorptiometry scan (DXA) is not yet recommended for COPD patients, but may be considered.

InfectionBacterial and viral infections are common in patients with COPD who have com-promised lung function. Recurrent infections increase the risk of repeated acute ex-acerbations and impact long-term recovery (Sethi, 2010). Similarly, development of pneumonia is more common among patients with COPD than in healthy adults, and negatively impacts overall health of the patient with COPD. Patients with COPD who require extended use of inhaled corticosteroids may be more likely to develop pneumo-nia than those who do not use inhaled corticosteroids (Vestbo et al., 2013).

Treatment Options for Managing COPDThe treatment goals of COPD typically include slowing lung function decline, treating acute exacerbations, and improving symptoms. Smoking cessation is widely consid-ered as the only treatment able to improve lung function (Ferguson, 2011; Heffner, 2011; Urbano & Pascual, 2005; Yohannes & Hardy, 2003). Despite both clinician and patient knowledge that smoking cessation is imperative to lung function, rates of smoking cessation remain quite poor in patients with COPD. Nicotine replace-ment, behavioral counseling, and office visits have been utilized in attempts to im-prove smoking cessation rates. Smoking cessation is an important piece of COPD treatment strategies, as this is the most effective method to reducing disease risk and progression. While cognitive behavioral therapy is often useful as the main behavioral modification technique for smoking cessation, pharmacotherapeutic options have also continued to evolve and now include nicotine gum, patch and nasal spray, bupropion and varenicline in the arsenal of approved prescription strategies to aid in smoking cessation (Fiore et al., 2008).

Pharmacologic management of COPD depends on GOLD class and symptom se-verity. A short-acting bronchodilator is recommended for all patients to improve lung function and decrease breathlessness. As symptom severity increases, a long-acting beta-agonist or anticholinergic is preferred over short-acting inhalers. While long-act-ing beta agonist use without concurrent corticosteroid use has been associated with increased mortality in patients with asthma and is not recommended, it is considered safe and standard of care for patients with COPD (Nelson et al., 2006). With frequent

KEY POINTS:• Comorbidities should not alter treatment of COPD and should be evaluated and treated• Cardiovascular disease is the most frequent comorbid condition associated with COPD• Osteoporosis and depression/anxiety are common comorbidities but are underdiagnosed

in patients with COPD• Lung cancer has been noted as the most frequent cause of death in patients with mild to

moderate COPD


exacerbations, an FEV1 <50%, or chronic bronchitis, the addition of an inhaled cor-ticosteroid to a long acting beta-agonist has been shown to decrease inflammation and reduce exacerbation frequency while improving quality of life (Calverley et al., 2003).

There are several oral agents that may be used in the management of COPD. Methyl-xanthines such as theophylline may promote mucus clearance in patients with chronic bronchitis, however the narrow therapeutic window may promote toxicities and limits use (Kim et al 2013). Phosphodiesterase-4 (PDE-4) inhibitors act by decreasing airway inflammation and promoting airway muscle relaxation via the cyclic adenosine mono-phosphate pathway. Roflumilast is a new oral PDE-4 inhibitor approved for patients with COPD. In a trial of over 3,000 patients with COPD, roflumilast improved pre-bronchodilator FEV1 and decreased the rate of exacerbations (Calverley et al., 2009). Antioxidants, such as N-acetylcysteine, may have some effect on exacerbation rate, but data is conflicting (Decramer et al., 2005).

Recent studies have suggested a benefit in patients with COPD and frequent exacer-bations treated with long term macrolide antibiotics. Patients with COPD who were treated with daily azithromycin have a longer time to next exacerbation than those treated with placebo in addition to standard therapy (Albert et al., 2011). Unfortu-nately, there was a significant increase in hearing loss in the azithromycin group, and with concerns about cardiac disease in those taking azithromycin, the risks and benefits for azithromycin treatment should be weighed carefully. For patients found to have COPD and alpha-1 antitrypsin deficiency, intravenous (or inhaled) alpha-1 antitryp-sin replacement may slow the rate of FEV1 decline.

Acute COPD exacerbations, defined as increased cough, sputum production and shortness of breath, should be treated with systemic steroids, antibiotics, standard in-haler therapy and increased frequency of bronchodilators. Exacerbations can negatively impact patient quality of life, increase recovery time, rate of lung function decline and mortality, and are associated with a high socioeconomic cost (Vestbo et al., 2013). Be-ginning in 2015, hospitals with high rates of readmission for COPD exacerbations will be penalized with reimbursement penalties (Centers for Medicare & Medicaid Ser-vices, 2013). The goal of treating exacerbations is to decrease the frequency of future episodes and minimize the impact of the current exacerbation. Thus, treatment should include a course of oral corticosteroids. Recent studies suggest that a 5 day course of 40 mg of prednisone is not inferior to the traditional 2 week taper (Leuppi, 2013). In addition, antibiotics are recommended for the treatment of those with acute COPD exacerbations, especially with purulent sputum production and/or requiring admis-sion to the hospital, despite conflicting data (Woodhead et al., 2005). For patients hos-pitalized with exacerbations complicated by hypercapnic acidosis (PaCO2 >45mm Hg or pH of <7.3), non-invasive positive pressure ventilation (NPPV) should be initiated. Use of NPPV reduces hospital length of stay, decreases mortality, intubation rate, and treatment failure (Ram et al., 2004). Vestbo and colleagues (2013) noted that inter-ruption of maintenance therapy may lead to an increase in exacerbations, so monitor-ing treatment adherence is imperative. COPD exacerbations are preventable by utiliz-ing some of the therapies discussed above. Importantly, communication between the inpatient treatment team and outpatient primary and specialty care providers during the transition from inpatient admission to the outpatient setting is crucial for success.


Early outpatient pulmonary rehabilitation, physical activity, and proactive discussion of anxiety, depression, and the potential social impact of exacerbation setbacks can improve patient outcomes (Vestbo et al., 2013).

Nonpharmacologic therapies are useful in the treatment of COPD. Some include exercise and maneuvers that may improve mucus clearance. Pulmonary rehabilitation programs improve exercise tolerance and decrease symptoms. Vaccinations to prevent influenza and pneumococcus infections may also benefit patients with COPD. Smok-ing cessation cannot be emphasized enough. Continuous oxygen supplementation in those who are hypoxic or have cor pulmonale decreases mortality (Nocturnal Oxyen Therapy Trial Group et al., 1980). Hypercapnic patients with COPD who have recur-rent oxygen desaturation episodes while sleeping with supplemental oxygen should be evaluated for concurrent obstructive sleep apnea, and nocturnal NPPV may be initiated. Patients who have moderate to severe COPD with hypercapnea, chronic bronchitis, or desaturation during exercise should be tested for nocturnal desaturation, and assessed for nocturnal supplemental oxygen (Calverley et al., 1982; Fletcher et al., 1983; Mulloy et al., 1995).

Table 1. Therapy by COPD Disease Stage. Adapted from Global Initiative for Chronic Obstructive Lung Disease (GOLD) Executive Summary; 2013 update.

At Risk A B C D

Avoidance of risk factors; influenza vaccination X X X X X

Add short-acting bronchodilator when needed X X X X

Add regular treatment with long-acting bronchodilator (beta-agonist and/or anticholinergic)

X X X

Add pulmonary rehabilitation

X X X

Add inhaled steroids

X X

Add PDE-4 inhibitors

X X

Add oxygen; consider surgery

X


Lung volume reduction surgery (LVRS) is a surgical procedure that involves bilateral thoracotomy and resection of upper lobe emphysematous lung tissue. This removes areas of the lung that are full of air but not being ventilated, allowing healthier com-pressed lung tissue to re-expand and improve ventilation and perfusion matching. The NETT trial demonstrated that in a subgroup of patients with upper lobe predominant emphysema and low exercise capacity as measured on cardiopulmonary exercise test-ing, LVRS improved survival (Edwards et al., 2009). Morbidity and mortality (up to 5%) related to the surgery, however, limits patient selection. New endobronchial techniques of lung volume reduction, such as using a bronchoscope to insert endo-bronchial one-way valves or airway bypass stents are being studied. Lung transplant surgery may improve quality of life in patients with severe COPD. Five year survival is around 51% (NHLBI, 2011). Refer to Table 1 on previous page for an overview of the treatment options based on defined patient groups (Vestbo, et al., 2013).

Improving Recognition and Care of the Patient with COPD “Recognition of COPD is often missed or delayed in primary care. Once recognized, COPD is often undertreated or episodically treated without establishing maintenance control” (Fromer et al., 2010; p. 150). Due to the high cost of treatment and impor-tance of patient engagement, treating patients with COPD can be difficult. Patient education programs are encouraged, and can aid clinicians in delivering important health news to patients with COPD, formulating action plans and setting achievable goals (Urbano & Pascual, 2005).

Patients with COPD have experienced significant gains in long-term outcomes, thanks in part to diagnostic tools and treatment regimens that continue to evolve. However, despite the continued advances in COPD awareness and understanding by clinicians, barriers still exist in treatment adherence and diagnostic testing usage.

The current GOLD standards highlight the importance of standardized testing for COPD in an effort to arrive at a diagnosis. Ultimately, a proactive diagnosis and timely management can decrease the negative impact of COPD. Fromer et al. (2010) also have suggested that patient care needs to focus more on maintenance than rescue strategies, which will potentially help clinicians be more aware of presenting symptom-atology and will assist in arriving at an early and accurate diagnosis. An earlier diagno-sis coupled with a maintenance treatment strategy and efforts targeting reductions in COPD exacerbations using a multi-disciplinary team approach will improve quality of life and overall patient outcomes.

KEY POINTS:• Treatment goals of stable COPD include relieving symptoms and improving

exercise tolerance and health status• Treatment is also intended to reduce disease progression rates, exacerbations

and mortality• Treatment needs to be patient-guided based on symptom severity, comorbidities,

and patient response


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