An Update on Chronic Obstructive Pulmonary

Disease

No Company Affiliations Graduated from Medical University of South

Carolina in Charleston, 2000 Experience-14+ Years in Cardiology and

Pulmonary Practice in Coastal South Carolina

Now Back in Primary Care for past 9 months. What was I thinking!

80-100 patients per week (60% practice is Pulmonary medicine-40% Cardiology)

Discuss the pathophysiology of COPD, manifestations of disease process and diagnosis of COPD

Name the financial and Social Impact of COPD on U.S. and South Carolina population

Interpret and review effective diagnostic testing for COPD

Discuss current Pharmacologic Treatments of COPD

Discuss Non-Pharmacologic Treatments options

Defined as a common preventable and treatable disease, it is characterized by persistent airflow limitation that is also accompanied by chronic inflammation from exposure to noxious particles or gases

Causes include tobacco smoking, second hand smoke exposure, air pollution and occupational exposure

Clinical Diagnosis of COPD should be considered with patients who have dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors. Spirometry is required to make diagnosis.

Assessment of COPD is based on the patients symptoms, risk of exacerbations, severity of COPD (bases on spirometry) and comorbid conditions.

COPD is the 3rd leading cause of death in the United States

Many are not even aware they have it……

COPD was the 3rd leading cause of Death in the US in 2008

Approximately 13 million adults in US have COPD, however, estimated 24 million have evidence of impaired lung function=under diagnosis of disease

A retrospective analysis of HMO database showed that 81% of patients with COPD were not diagnosed until disease was moderate to severe

The projected annual cost for COPD in the US for 2010 was $50 billion (not million, yes billion!!!!)

Estimated related to cost-between 50% and 75% of all COPD cost are related to exacerbations

Frequency of exacerbations: 2 or more exacerbations in the first year of observational study showed ◦ 22% of patients with stage 2 disease◦ 33% of patients with stage 3 disease◦ 47% of patients with stage 4 disease

COPD Asthma CHF Bronchectasis TB Obliterative Bronchiolitis Diffuse Panbronchiolitis Bronchitis

Chronic Cough (smoker cough) Chronic Phlegm Production Shortness of Breath (limits activity) Not able to take deep breath Wheezing Recurrent Respiratory Infections/Bronchitis Hypoxemia

Goals of assessment to determine severity of disease and it’s impact on patients health to guide treatment therapy◦ Symptoms◦ Degree of airflow limitation (using spirometry)◦ Risk of exacerbations◦ Co-morbidities

May use tools such as CAT-COPD Assessment Tool

In 2015-Updates to Gold Guidelines Spirometry is required to make clinical

diagnosis of COPD Clinical Diagnosis should be considered in

any patient over age 40 who has dyspnea, chronic cough or sputum production, history of exposure to risk factors for disease and/or family history of COPD

In Patients with FEV1/FEC <70

(Based on post-bronchodilator FEV1)

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

Measure how well the lungs take in and release air

Measure how well the lungs move gases such as oxygen from the air into the body’s circulation

PFTs add additional information including Lung volume and diffusion capacity

Longer test and more expensive, however helpful in treatment

Use spirometry to make initial diagnosis and Full PFTs to guide therapy

Well trained staff-Does not have to be RT but need to do test well for accurate results.

Patient cooperation-If patient is not following direction and you don’t have good loop, less accurate results (May need full PFT to help make diagnosis)

Patient should not have had any respiratory medications within 4 hours of test and preferable that am (if possible).

Non-PharmacologicPharmacologicManagement of Stable COPDManagement of COPD exacerbations

Symptom relief Increase exercise tolerance Improve health Decrease disease progression Prevent exacerbations Treat exacerbations Decrease Mortality

Smoking Cessation!!!!!!◦ Counseling does help, counseling by physicians

and other health care professionals significantly increases quit rates over self-initiated strategies

◦ Nicotine replacement Therapy-gum, patches◦ Pharmacotherapy-varenicline, bupropion or

nortriptyline are more effective than placebo◦ Smoking prevention-once quit need to stay QUIT,

keep smoke free homes◦ Don’t Give Up! Keep on trying each and every

time you see them.

Occupational Exposure Indoor and Outdoor Air Pollution Vaccination Pneumococcal and FLU Physical Activity

◦ Which leads to PULMONARY REHABILITATON◦ The more you do the more you can do is so true

for COPD

Defined as evidence –based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities

Pulmonary rehab is designed to reduce symptoms, optimize functional status, increase participation and reduce health-care cost through stabilization

Utilized various healthcare disciplines Individualized plan of care with realistic

goals for patient Attention to physical and social function Each patient plan includes

◦ Patient assessment◦ Exercise training◦ Education◦ Psychosocial support

Medicare has a maximum life-time visits Private Insurance-Co pays Maintenance programs Patient Compliance Exacerbations Access to programs

Abbreviations: SA-short acting LA-long acting AC-anticholinergic BA-beta agonist ICS-inhaled corticosteroid PDE-4-phosphodiesterase-4

Patient Types:◦Type A-Low risk, Low symptoms◦Type B-Low risk, Increased symptoms◦Type C-High risk, Low symptoms◦Type D-High risk, High symptoms

Patient Type 1st 2nd Other

Type A-LR,LS SA AC or SA BA LA AC or LA BAOrSA AC or SA BA

Theophylline

Type B-LR, IS LA AC or LA BA LA AC & LA BA SA AC &/or SA BATheophylline

Type C-HR, LS ICS &

LA BA or LA AC

LA AC & LA BA or LA AC & PDE4OrLA BA & PDE4

SA BA &/or SA AC

Theophylline

Type D-HR, IS ICS &

LA BA

&/or LA AC

ICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4

Carbocystiene

N-acetylcysteine

SA BA &/or SA AC

Theophylline

Does anything Go?

Proair HFA-Albuterol Ventolin HFA-Albuterol Proventil HFA-Albuterol Xopenex HFA-Salbuterol Xopenex nebulizer Albuterol nebulizer

Arcapta Neohaler (Indacterol)-1 cap inhalation daily

Foradil Aerolizer (Formoterol)-1 inhalation BID

Serevent Diskus (Salmeterol)-1 inhalation BID

Striverdi Respimat (Olodaterol)-2 inhalations daily

Performist Nebulizer (Formoterol)-1 neb BID Brovana Nebulizer (Arformoterol)- 1 neb BID

Aerospan (Flunisolide) 80mcg 2-4 puffs BID Asmanex Twisthaler (Mometasone)110mcg and 220mcg

1-2 puffs daily-BID (max 440mcg/day) Asmanex HFA (Mometasone) 100,200mcg 2 puffs BID

(max 800mcg/day) Alveso (Ciclesonide) 80mcg and 160mcg-1 puff BID (max

320mcg/day) Pulmicort Flexhaler (Budesonide)90mcg and 180mcg-2

puffs BID Flovent Diskus (Fluticasone propionate) 50mcg, 100mcg

and 250mcg- 1-2 puffs BID (max 1000mcg/day) Flovent HFA (Fluticasone propionate) 44mcg, 110mcg,

220mcg-2 puffs BID (max 880mcg/day) Qvar HFA (Beclomethasone dipropionate)40mcg, 80mcg-

1-4 puffs BID (max 640mcg/day) Arnuity Ellipta (Fluticasone furoate)-1 inhalation daily

LA BA and Corticosteroid◦ Advair Diskus, (Fluticasone Propionate/salmeterol)

100/50, 250/50, 500/50-1 inhalation BID◦ Advair HFA (Fluticasone Propionate/salmeterol)

45/21, 115/21, 230/21-2 puffs BID◦ Symbocort HFA (Budesonide/Formoterol) 80/4.5,

160/4.5-2 puffs BID◦ Breo Elipa (Fluticasone furoate/vilanterol)100/25-1

inhalation Daily◦ Dulera (Mometasone/formoterol) 100/5, 200/5-2

puffs BID

Atrovent HFA (Ipratropium bromide)-2 puffs qid Atrovent Nebulizer (Ipratropium)-1 neb qid Spiriva Handihaler (Tiotropium)-1 inhalation

Daily Spiriva Respimat (Tiotropium)-2 puffs Daily Tudorza Pressair (Aclidinium bromide)-1 puff

BID Incruse Ellipta (Umeclidinium)-1 puff Daily Combivent Respimat (ipratropium

bromide/albuterol)-1 inhalation QID Anoro Elipta (Umeclidinium/vilanterol)-1

inhalation daily

LA BA and AC Combivent Respimat (ipratropium

bromide/albuterol)-1 inhalation QID Anoro Elipta (Umeclidinium/vilanterol)-1

inhalation daily Duonebs (ipratropium/albuterol) Nebulizer-1

QID

PDE-4 Phosphidiesterase-4 (roflumilast- Daliresp)

Mexthylxanthines-Theophylline/aminophylline

Mucolytic-Carbocystiene (not available in US) Mucolytic-N-acetylcysteine (Mucomist)

10% /ml solution, 6-10 ml nebulized and 20%ml solution, 3-5ml nebulized. Q 2 hours, max dose 10% 20ml and 20% 10ml

***must give with albuterol !!!!!**** Due to bronchospasms

Therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance◦ Bronchodilators

Inhaled therapy is preferred prescribed on as-needed or on a regular basis to

prevent or reduce symptoms Long-acting inhaled bronchodilators are convenient,

and maintaining symptoms relief compared to short acting bd

Combining bronchodilators (short and long) may improve efficacy and decrease risk of side effects

Inhaled Corticosteroids◦ In patients with FEV1 < 60% predicted, regular tx

with inhaled corticosteroids improves symptoms lung function quality of life reduces frequency of exacerbations

There is associated increased risk of pnemonia, withdrawal may lead to exacerbation.

Long-term monotherapy not recommended

Combined Inhaled Corticosteriod/ Bronchodilator Therapy◦ The IC/LBD is more effective than either individual

therapy in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD

Oral Corticosteroids-Long term not recommended

Phosphodiesterase-4 inhibitors- In Gold 3 and 4 patients with history of exacerbations and chronic bronchitis.

PD4 inhibitor is roflumilast or Daliresp Your experience? Our practice…

Mexthylxanthines◦ Less effective◦ Less well tolerated than LBD◦ Available and affordable◦ Evidence of modest BD effect◦ Aminophylline or Theophylline◦ Theophylline with salmeterol produces a greater

increase in FEV1 and relief of breathlessness than salmeterol alone.

◦ Low dose theophylline reduce exacerbations but does not improve post-bronchodilator lung function.

◦ Therapeutic values 10-20 (patient may get benefit and tolerate better at subtherapeutic levels of approx 8-12)

Vaccines including: Influenza and Pneumococcal vaccines can reduce serious illness and death

Alpha 1 Antitrypsin Therapy-For COPD related to Alpha 1 Defiency

Mucolytic Agents-for patient with excessive sputum, overall benefits small

Antitussive-use not recommended (however*)

Vasodilators-stable COPD with Pulmonary HTN

Pulmonary Rehabilitation Oxygen Therapy Ventilatory Support Surgical Treatments

◦ Lung Volume Reduction Surgery (LVRS)-need to qualify, emphysema upper lobe

◦ Lung Transplant, costly, need to live near transplant facility for at least 1 year and age requirements

Look at you patient type Look at spirometry and/or PFTs Mild/Moderate-start simple and work up Severe/Very Severe-be aggressive and get

symptoms under control then remember to back down (if able)

Symptom control/Quality of Life/Reduce Exacerbations & Mortality are key GOALS

Cost of meds does influence treatment

Patient Type 1st 2nd Other

Type A-LR,LS SA AC or SA BA LA AC or LA BAOrSA AC or SA BA

Theophylline

Type B-LR, IS LA AC or LA BA LA AC & LA BA SA AC &/or SA BATheophylline

Type C-HR, LS ICS &

LA BA or LA AC

LA AC & LA BA or LA AC & PDE4OrLA BA & PDE4

SA BA &/or SA AC

Theophylline

Type D-HR, IS ICS &

LA BA

&/or LA AC

ICS &LA BA & LA ACOr ICS &LA BA & PDE4Or LA BA & LA ACOrLA AC and PDE4

Carbocystiene

N-acetylcysteine

SA BA &/or SA AC

Theophylline

Defined as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication

Assess the severity◦ ABGs◦ CXR◦ CBC◦ Presence of purulent sputum◦ Sputum C&S◦ Spirometry NOT RECOMMENDED

Oxygen for hypoxemia with target saturation of 88-92%

SBD Systemic Corticosteroids

◦ 30-40mg for 10-14 days◦ Optional tx tapering dose◦ Patients with DM may have problems with

elevated glucose◦ Side effects of steroids

Antibiotics given to patients with◦ 3 symptoms of increased dyspnea, increased

sputum volume, increased sputum purulence

◦ Increased sputum purulence and one other cardinal symptoms

◦ Who require mechanical ventilation

CDC – www.cdc.gov/copd/data.htm Global Initiative for Chronic Obstructive Lung

Disease Pocket Guide (GOLD) 2015 Respiratory Care Connection-GSK Education

connection U.S. Department of health and human services,

Agency for Healthcare Research and Quality-www.ahrq.gov and www.guideline.gov and type in pulmonary rehabilitation

Aanma.org Mayoclinic.org

Thank You