by scott cerreta, bs, rrt director of education new guidelines for copd they keep changing... are...
TRANSCRIPT
by Scott Cerreta, BS, RRTDirector of Education
www.copdfoundation.org
New Guidelines for COPD They keep changing. . . are you up to
speed?
Conflict of Interest Conflict of Interest
I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.
ObjectivesObjectives
1. Discuss different definitions of COPD
2. Discuss current literature and research that warrants the need to change COPD Guidelines
3. Describe new features of the GOLD Guidelines
4. Describe how these changes will impact diagnosis and treatment recommendations
1. GOLD Definition1. GOLD Definition
• COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with 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.
ATS / ERS DefinitionATS / ERS Definition
• Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.
• The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
NHLBI DefinitionNHLBI Definition
• Chronic Obstructive Pulmonary Disease
• Serious lung disease that over time makes it hard to breathe– Emphysema– Chronic Bronchitis
• Blocked (obstructed) airways make it hard to get air in and out
COPD Foundation DefinitionCOPD Foundation Definition
• Chronic Obstructive Pulmonary Disease
• Serious lung disease that over time makes it hard to breathe– Emphysema– Chronic Bronchitis– Refractory Asthma and– Some forms of bronchiectasis
• Blocked (obstructed) airways make it hard to get air in and out
COPD: Definitions of 21st Century1COPD: Definitions of 21st Century1
• Preventable and treatable
• Airflow limitation that is not fully reversible
• Progressive disease• Abnormal inflammatory
response of the lungs• Subsets of patients
Chronic bronchitis Emphysema
Asthma
COPD
Bronchiectasis Alpha-1 D
eficiency
O2 Dependency
OSA, HTN, Others
Box = FEV1/FVC < 70% or < LLN
Spirometry is REQUIRED for diagnosis
2. Literature Review2. Literature Review
• COPD Gene Study – Dr. Crapo– Why some smokers get COPD & others
don’t– Using HRCT and identified a large
number of people with emphysema despite normal spirometry
• Spiromics – Dr. Rennard– Identifying subsets of people with COPD– collection and analysis of phenotypic,
biomarker, genetic, genomic, and clinical data from subjects with COPD
Observations from ExpertsObservations from Experts
• Not all forms of Emphysema or Chronic Bronchitis are COPD.
• Not all severities of COPD are the same– People with same FEV1 have different
health status, dyspnea scores, comorbidities, exacerbation history, etc.
Dr. Vesbo, Chair of GOLD states:Dr. Vesbo, Chair of GOLD states:
• “Spirometry is essential for the diagnosis of COPD, but it doesn’t fully capture the impact of the disease on individual patients”
• Example: Some patients with Moderate COPD may have severe breathlessness, while others may have Mild COPD but more prone to acute exacerbations
• Both groups require more aggressive therapy than past guidelines would recommend
“COPD HETEROGENEITY”PT # 158 yFEV1: 28 %MRC: 2/4PaO2: 70 mmHg6MWD: 540 mBMI: 30
PT # 262 yFEV1: 33%MRC: 2/4PaO2: 57 mmHg6MWD: 400 mBMI: 21
PT # 369 yFEV1: 35%MRC: 3/4PaO2: 66 mmHg6MWD: 230 mBMI: 34
PT # 472 yFEV1: 34%MRC: 4/4PaO2: 60 mmHg6MWD: 154 mBMI: 24
Cote & Celli
FEV1 / FVC < 70%
I: MildFEV1>80% pred
II:ModerateFEV1 50-80% pred
III: SevereFEV1 30-50% pred
IV: Very SevereFEV1 < 30% pred or FEV1 <50% predicted plus respiratory failure
Active Reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting bronchodilators: ß2 agonists and anticholinergics
Add rehabilitation
Add ICS for repeated exacerbations
Add LTOT
Surgical interventions
GOLD Treatment of COPDGOLD Treatment of COPD
http://www.goldcopd.org/
3. New Features Added in Dec 20113. New Features Added in Dec 2011
• GOLD Spirometry Classification Stays
• NEW is Assessment Model – ABCD– mMRC dyspnea scale or COPD
Assessment Test (CAT) health status– Spirometry classification and– Exacerbation History
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
Assess symptomsAssess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k (G
OLD
Cla
ssifi
catio
n of
Air
flo
w L
imit
atio
n)
Ris
k (E
xace
rbat
ion
hist
ory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score))
COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD(http://catestonline.org).
Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status
and predicts future mortality risk.
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Symptoms
Tools: COPD Assessment Test (CAT)Tools: COPD Assessment Test (CAT)
• Measures health status
– Based on 8 questions
– Score from 0 to 5
– High scores = symptoms
• May predict exacerbation
• May reveal improvement after
attending Rehab
http://www.catestonline.org/english/index.htm
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score))
If mMRC 0-1 or CAT < 10: Less Symptoms (A or C)
If mMRC > 2 or CAT > 10: More Symptoms (B or D)
Assess symptoms first
Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow Limitation in COPD*
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
*Based on Post-Bronchodilator FEV1
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations use history of exacerbations and spirometry:
Two or more exacerbations within the last year or an FEV1
< 50 % of predicted value are indicators of high risk.
Tease Out All ExacerbationsTease Out All Exacerbations
• Must assess all exacerbations – increase in symptoms that requires change in tx– Hospitalizations– ER / Urgent Care visits– PCP / Pulmonologist visit
• Ask about infection or use of antibiotics, the most common cause of exacerbation
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k (G
OLD
Cla
ssifi
catio
n of
Air
flo
w L
imit
atio
n)
Ris
k (E
xace
rbat
ion
hist
ory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score))
If GOLD 1 or 2 and only 0 or 1 exacerbations per
year: Low Risk (A or B)
If GOLD 3 or 4 or two ormore exacerbations per
year: High Risk (C or D)
Assess risk of exacerbations next
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k (G
OLD
Cla
ssifi
catio
n of
Air
flo
w L
imit
atio
n)
Ris
k (E
xace
rbat
ion
hist
ory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score))
Patient is now in one offour categories:
A: Less symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high risk
Use combined assessment
Patient Characteristic Spirometric Classification
Exacerbations per year
mMRC CAT
ALow Risk
Less SymptomsGOLD 1-2 ≤ 1 0-1 < 10
BLow Risk
More SymptomsGOLD 1-2 ≤ 1 > 2 ≥ 10
CHigh Risk
Less SymptomsGOLD 3-4 > 2 0-1 < 10
DHigh Risk
More SymptomsGOLD 3-4 > 2 > 2
≥ 10
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPDWhen assessing risk, choose the highest risk according to GOLD grade or exacerbation history
Maintenance Care vs. Acute CareMaintenance Care vs. Acute Care
• Typical hospitalization requires aggressive medication management
• Goal is to return patient to baseline treatment recommendations
• Maintenance Therapy requires the least amount of medication to control patient symptoms and health status
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)
Patient First choice Second choice Alternative Choices
ASAMA prn
or SABA prn
*LAMA or
LABA or
SABA and SAMA
Theophylline
B*LAMA
or LABA
*LAMA and LABA SABA and/or SAMATheophylline
C
*ICS + LABAor
*LAMA *LAMA and LABA*PDE4-inh.
SABA and/or SAMATheophylline
D
*ICS + LABAor
*LAMA
ICS and *LAMA or*ICS + LABA and *LAMA or
*ICS+LABA and *PDE4-inh. or*LAMA and LABA or
*LAMA and *PDE4-inh.
CarbocysteineSABA and/or SAMA
Theophylline
Impact on symptoms
and lungfunction
Negativeimpact on
quality of life
Consequences Of COPD Exacerbations
Increasedeconomic
costs
Acceleratedlung function
decline
IncreasedMortality
EXACERBATIONS
Scenario 1Scenario 1
Step 1: assess mMRC or CAT. mMRC=1– Left side, less symptoms
Step 2: assess spirometry = FEV1 43%
assess exacerbation hx = 2– Upper side, high risk
• Assessment Score = C
Scenario 1Scenario 1
• Old GOLD
– FEV1 = 43%
– Severe Stage 3
• Recommended Tx
– LABA or LAMA or LABA + LAMA
– ICS
• New GOLD
– FEV1 = 43%, Group C Less symp, Hi risk
• Recommended Tx
– ICS + LABA or LAMA
– PDE4 inh.
Scenario 2Scenario 2
Step 1: assess mMRC or CAT. CAT=12– Right side, more symptoms
Step 2: assess spirometry = FEV1
81%assess exacerbation hx = 0
– Lower side, Low risk
• Assessment Score = B
Scenario 2Scenario 2
• Old GOLD
– FEV1 = 81%
– Mild Stage 1
• Recommended Tx
– SABA prn
• New GOLD
– FEV1 = 81%, Group B More symp, Low risk
• Recommended Tx
– LAMA or LABA
Scenario 3Scenario 3
Step 1: assess mMRC or CAT. mMRC=4– Right side, more symptoms
Step 2: assess spirometry = FEV1
56%assess exacerbation hx = 5
– Upper side, High risk
• Assessment Score = D
Scenario 3Scenario 3
• Old GOLD
– FEV1 = 56%
– Moderate Stage 2
• Recommended Tx
– SABA prn
– LABA or LAMA or LABA + LAMA
• New GOLD
– FEV1 = 56%, Group D More symp, Hi risk
• Recommended Tx
– ICS + LABA or LAMA
– PDE4 inh.
– Add everything else
Prevention of COPD is to a large extent possible and should have high priority
Spirometry is required to make the diagnosis of COPD; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of
persistent airflow limitation and thus of COPD
The beneficial effects of pulmonary rehabilitation and physical activity cannot be overstated
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Summary
“COPD HETEROGENEITY”PT # 158 yFEV1: 28 %MRC: 2/4PaO2: 70 mmHg6MWD: 540 mBMI: 30
PT # 262 yFEV1: 33%MRC: 2/4PaO2: 57 mmHg6MWD: 400 mBMI: 21
PT # 369 yFEV1: 35%MRC: 3/4PaO2: 66 mmHg6MWD: 230 mBMI: 34
PT # 472 yFEV1: 34%MRC: 4/4PaO2: 60 mmHg6MWD: 154 mBMI: 24
Cote & Celli
All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results.
If exercise training is maintained at home the patient's health status remains above pre-rehabilitation levels.
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
COPD Pocket ConsultantCOPD Pocket Consultant
Mobile App – Coming SoonMobile App – Coming Soon
SummarySummary
• Dx of COPD requires Spirometry but definitions vary and change with new evidence
• Tx of COPD requires new assessment– Spirometry, dyspnea score, exacerbation
hx and consider comorbidities
• New ABCD assessment model is more accurate and will improve pt outcomes
• Learn how you can implement this model into your system to decrease hospitalization rates
COPD is:Almost Always Preventable.
Almost Always Treatable.Someday Curable.
Thank You !
ReferencesReferences
ReferencesReferences
1. GOLD Guidelines http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html
2. COPD Gene Study http://www.copdgene.org/
3. Spiromics http://www.cscc.unc.edu/spir/
4. COPD Foundation http://www.copdfoundation.org