Take My Breath Away: COPD Update - staabsymposium.com · Take My Breath Away March 26, 2018 l 2 •...

Take My Breath Away: COPD Update

Jason Henderson D.O.Warren Clinic Pulmonary & Critical Care

Take My Breath Away March 26, 2018 l 2

• 1. Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema.

• 2. Describe the workup involved in diagnosing obstructive airway disease.

• 3. Utilize COPD staging tools to determine disease classification and appropriate therapies.

• 4. Describe the treatment options for COPD including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers.

Objectives

Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema.

COPD

• Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.

COPD

Complaints

• COPD should be suspected in all patients who report any combination of the following: – chronic cough, – chronic sputum production,– dyspnea at rest or with exertion,– or a history of inhalational exposure to tobacco

smoke, occupational dust, or occupational chemicals

• These are the 3 cardinal complaints, they prevent in varying degrees, also can have people compensate but becoming increasing sedentary to compensate and down play dyspnea

COPD

COPD

• Most common cause depends on how your frame your patient population.

• In 1st world countries, it is tobacco use

• In rest of world, 3 billion people use wood or other biomass fuels (i.e. cow poop/coal/crop residuals) to cook, under ventilated, indoors….

• American Thoracic Society states ~20% of COPD is related to occupational exposures, coal dust, organic small particle dust, cotton textile workers, etc,

• Allegedly ~10% of COPD patients have Alpha-1 antitrypsin deficiency, in my experience, ~10% are carriers and ~1% have homozygous disease.

Cause of COPD

Stats on COPD

• 4th leading cause of death in the United States, responsible for 6% of all global deaths each year (2012 apprx 3,000,000)

• Estimated to be 3rd leading cause of death by 2020. some studies already ranking it 3rd

• 16 million adults with diagnoses of COPD

• Estimated 14 million who are undiagnosed

• Significant morbidity as well as mortality– In US, COPD 2nd most common cause of

decreased ADL tolerance

• Expensive to treat…….– Advair is apprx $300/month

COPD

From: Jemal A. et al. JAMA 2005

The incidence of COPD is on the Rise

Introduction of the Atari

Introduction of Nintendo

Introduction of Sega Genesis

COPD

Pack-years of smoking effect on FEV 1

Smoking is by far the largest risk factor for development of COPD, but not everyone who smokes heavily develops COPD as demonstrated by Burrows et al

Not everyone who smokes even heavily develops COPD

Describe the workup involved in diagnosing obstructive airway disease.

COPD

• First and foremost, smoking cessation is paramount regardless of diagnosis or workup.

• You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup.

• Stop smoking, stop smoking, stop smoking

STOP SMOKING

Key points of the Treating Tobacco Use and Dependence guidelines

• Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved

• Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments

• Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention

• There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness

• Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment

• Five first-line pharmacotherapies for tobacco dependence have shown efficacy

COPD

Spirometry,

• Spirometry is the Gold standard

• Yet only 32% of patients with a new diagnosis of COPD had undergone spirometry

– Spirometry Utilization for COPD How Do We Measure Up? CHEST August

2007 vol. 132 no. 2 403-409

• We are under utilizing Spirometry in the diagnosis of COPD

• Spirometry can help us – Confirm the diagnosis of COPD

– as many as 20 percent of individuals with severe airway obstruction will have no symptoms

– Determine the severity of COPD– And help guide treatment options

– Gives us prognostic information about survival rates– Lower FEV1 or FEV1/FVC means worse outcomes and worse

survival

COPD

Differential diagnosis of obstructive lung diseases

• COPD – strong history of tobacco use,

• Asthma – reversible obstruction, strong correlation with allergies (unless it’s not allergy mediated)

• Bronchiectasis – multiple different types, can be part of COPD, – Alpha-1 antitrypsin deficiency (hereditary COPD)– Ciliary dyskinesia – Rheumatoid arthritis ILD

• Cystic fibrosis – has significant amounts of bronchiectasis, rarely diagnosed as adult

• ILD– sarcoidosis, – pulmonary Langerhans cell histiocytosis, – LAM (lymphangioleiomyomatosis) – bronchiolitis obliterans

• And many other esoteric obstructive lung diseases

COPD


•How Severe is this patient’s COPD?

•A. Mild

•B. Moderate

•C. Severe

•D. Very Severe

What not to do


How Severe is this patient’s COPD?A. Mild


•How Severe is this patient’s COPD?

•A. Mild

•B. Moderate

•C. Severe

•D. Very Severe


How Severe is this patient’s COPD?D. Very Severe


What’s the DiagnosisXR Chest PA and LatPA and lateral chest x-ray

FINDINGS:

Upper lung emphysematous changes are identified. Linear upper lobe scarring is seen. A few calcified granulomas are present. IMPRESSION:

Stable findings including parenchymal scarring, emphysematous changes.


What’s the Diagnosis?



XR Chest PA and LatTWO VIEWS OF THE CHEST:

INDICATION: Chest pain

FINDINGS: No consolidation, effusion, or pneumothorax. Increased lung volumes consistent with obstructive lung disease. Stable left upper lobe scarring. Cardiomediastinal silhouette is normal.



FEV1/FVC 41%FEV1 39%



PA and lateral chest x-ray

Comparison: 10/1/2013

Findings: The cardiomediastinal silhouette and pulmonary vascular markings are normal. Mild basal scarring is seen. The costophrenic sulci and lungs are otherwise clear.

Impression: No acute findings.

COPD

What NOT to do……..

Make diagnosis by radiology….Make diagnosis by history alone…Make diagnosis without spirometry…

Order a spirometry then mark out machine interpretation of probable restriction and relabel obstruction to fit your bias……

What Not to do…..

• CXR: poor sensitivity. –Has sensitivity of less than 50% in detecting COPD

with moderate severity COPD

• ABG–The PaO2 usually remains near normal until the

FEV1 is decreased to ~50% of predicted, –PaCO2 elevation is not expected until the FEV1 is

<25% of predicted

• CT–Can give pathologic data, but nothing on the

functional data, no data on sensitivity or specificity

• And since other conditions can present with symptoms similar to COPD, don’t misread the test data

COPD

70 %80 %

80 %

80 % 80 %

COPD

COPD

FEV1/FVC ratio >70%

FVC >80%? FVC >80%?

Obstruction Get full PFTNormal Possible

restriction, get full PFT

yes

yes yes

no

nono

Look at FEV1 to determine severity

COPD

• Step 1 – FEV1/FVC ratio

• Step 2 – FVC

• Step 3 – FEV1

Utilize COPD staging tools to determine disease classification and appropriate therapies.

Classification of COPD per GOLD criteria

COPD

GOLD I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted

GOLD II: Moderate FEV1/FVC < 0.7050% < FEV1 < 80% predicted

GOLD III: Severe FEV1/FVC < 0.7030% < FEV1 < 50% predicted

GOLD IV: FEV1/FVC < 0.70Very Severe FEV1 < 30% predicted

Choice of thresholds

© 2017 Global Initiative for Chronic Obstructive Lung Disease

► COPD Assessment Test (CAT TM )► Chronic Respiratory Questionnaire (CCQ® )► St George’s Respiratory Questionnaire (SGRQ)► Chronic Respiratory Questionnaire (CRQ)► Modified Medical Research Council (mMRC) questionnaire

COPD

ABCD Assessment Tool


Because FEV1 does not predict symptoms/progression

COPD

Treatment of Stable COPD

© 2017 Global Initiative for Chronic Obstructive Lung Disease COPD

You can not go just by FEV1

New guidelines treatment determined more by symptoms and exacerbations over FEV1, But……few of us actually calculate the GOLD classification based off new guidelines, important information is Severity of obstruction, how symptomatic and how frequently they’re exacerbating and have they quit smoking.

Very cumbersome system, so the more they are exacerbating and more symptomatic they are, and the worse the FEV1 is, the more medications they get.

COPD

Non-Pharmacologic Treatment


Education and self-management

► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system.

► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease.

COPD

Monitoring and Follow-up


Monitoring disease progression and development of complications and/or comorbidities

► Measurements. Decline in FEV1 can be tracked by spirometry performed at least once a year.

► Symptoms. At each visit, information on symptoms since the last visit should be collected, including cough and sputum, breathlessness, fatigue, activity limitation, and sleep disturbances.

► Exacerbations. The frequency, severity, type and likely causes of all exacerbations should be monitored.

► Imaging. If there is a clear worsening of symptoms, imaging may be indicated.

► Smoking status. At each visit, the current smoking status and smoke exposure should be determined followed by appropriate action.

COPD

Useful Guidelines and resources

• The Global Initiative for Chronic Obstructive Lung Disease– www.goldcopd.com

COPD

http://www.goldcopd.com/

Describe the treatment options for COPD including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers.

COPD

• First and foremost, smoking cessation is paramount regardless of diagnosis or workup.

• You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup.

• Stop smoking, stop smoking, stop smoking

STOP SMOKING

Key points of the Treating Tobacco Use and Dependence guidelines

• Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved

• Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments

• Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention

• There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness

• Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment

• Five first-line pharmacotherapies for tobacco dependence have shown efficacy

COPD



SABA - short acting beta agonistLABA – long acting beta agonistSAMA – short acting muscarinic antagonistLAMA – long acting muscarinic antagonist ICS – inhaled corticosteroidPDE4 - Phosphodiesterase 4 inhibitor

COPD

Current medications LABA

Arcapta (indacaterol)Serevent (Salmeterol)Striverdi (olodaterol)

ICSAerospan (flunisolide)Alvesco (ciclesonide)Arnuity (fluticasone furoate)Asmanex (mometasone)FLovent (fluticasone propionate)Pulmicort (budesonide)Qvar (beclomethasone)

Presentation Title l March 26, 2018 l 48

ICS/LABAAdvair (fluticasone/salmeterol)Breo (fluticasone/vilanterol)Dulera (mometasone/formoterol)Symbicort (Budesonide/formoterol)

LABA/LAMAAnoro (umeclidinium/vilaterol)Stiolto (tiotroprium/olodaterol)Utibron (glycopyrrolate/indacaterol)

LAMASeebri (glycopyrrolate)Incruse (umeclidinium)Spiriva (tiotropium)Tudorza (aclidinium)

ABCD Assessment Tool


Because FEV1 does not predict symptoms/progression

COPD

COPD

• Everyone w/ COPD should have a rescue SABA on hand,

• Inhalers don’t work if they aren’t being used properly,

• Check technique

• Spacer chamber

Other treatment considerations

Other treatment considerations

• Possible Lung volume reduction surgery• Lung transplant• ??? Endobronchial 1-way valves???• Anti-IL5 for eosinophilic asthmatic overlap

syndromes

Updates and likely changes in recommendations- The use of combination therapy with LAMA/LABA is

newly emphasized within last year as first line therapy,

- Monotherapy with LABA or use w/o ICS previously discouraged due to SMART study in asthma,

- Moderate hypoxemia treatment does not improve mortality,

COPD

Old recommendations

Beware the combo products……

Very easy to over medication with many different ICS/LABA and LABA/LAMA combinations.

COPD



Education and self-management

► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system.

► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease.

COPD



Oxygen therapy

Long-term oxygen therapy is indicated for stable patients who have:

► PaO2 at or below 55 mmHg or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or

► PaO2 between 55 mmHg and 60 mmHg, or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).

► Resting sats >89% but desats on ambulation no benefit in mortality, ? Insurance changes in coverage for this in coming years.

COPD

Questions?

Take My Breath Away: COPD Update - staabsymposium.com · Take My Breath Away March 26, 2018 l 2 •...

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