Claire Murphy NP-C

Clinical Director Allergy VISN1

Pulmonary

VA New England Healthcare

Instructor of Medicine

Boston University School of Medicine

COPD…CLEARLY AN OVERLOOKED PRACTICE DIAGNOSIS

OBJECTIVES

• Recognize presenting symptoms supporting COPD in the differential.

• Design an intervention to eliminate barriers in diagnosing and treating COPD.

• Identify the management of stable COPD vs. AECOPD.

FACULTY DISCLOSURE

Claire Murphy, RN, MSN, NP-C

No Disclosures

It would require a Primary Care Provider at least 21 hours a day to render all guidelines, recommendations, and provide care for acute, preventive, and chronic disease management requirements for their patients in a day of clinic.

• Yarnell et al. Family physicians as team leaders: “time” to share the care. Prev. Chronic Dis. 2009;6 (2):A59.

WHAT’S THE BIG DEAL?

• 3rd leading cause of death• Results in added co-morbidities:

• Cardiac, osteo, psychological, nutritional, etc• $$$$ Public health burden ($49 billion/yearly)• Early dx→→ primary and secondary interventions decrease

the assault on the lung• Employ →→ pharmacologics, pulmonary rehab, smoking

cessation, education• By the time YOUR PATIENT has been diagnosed by a

Pulmonary specialist, pulmonary function is markedly decreased (FEV1>50%)* (Cooper et al, 2008)

• CMS penalty for hospital readmissions.

RISK FACTORS…YOU ALREADY KNEW• Smoking

• Including “hookah” smoking (with byproducts exceeding those found in smoking)

• Environmental exposure/Occupational • Dust, gases, fumes, mill workers, farmers

• Genetic disorder “ Alpha 1 antitrypsin deficiency• Marijuana use

• Enhanced effect with cigarette smoking• Asthma

• Uncontrolled asthmatics with lung remodeling and chronic bronchoconstriction

MISSING THE BOAT…..• Jones et al, in a 20 yr retrospective study, (n=38K) reviewed diagnosed

COPD in patients.• Missed opportunities through

• Review of health care use• Presence of comorbidities• Visits for respiratory infections• Prescribed antibiotics and steroids• CXR

• Findings noted:• 85% missed opportunity to diagnose in 5 years immediately

preceding diagnosis of COPD• 58% 6–10 years before diagnosis • 42% 11–15 years before diagnosis• 8% 16–20 years before diagnosis.

Jones et al.Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a retrospective study of a clinical cohort. The LANCET, Volume 2, No. 4, p267–276, April 2014

WHY ARE WE MISSING IT?

• We need to look at:• Those patients we are chronically treating for

respiratory infection.• When is a “cough” just a “cough”• Missed opportunities for spirometry?• Look at the patient over time…is there a decline in

function?• Are we fooled by the “age” and sex of our patients?

HMMM…WHO YOU WORRIED ABOUT???

• Not always your middle-aged male• Think about women

• women continue to exceed men in mortality • In 2010, more than 70,000 females died

compared to more than 64,000 males.• Teenagers• Children

CHRONIC BRONCHITIS VS EMPHYSEMAOverproduction of mucous

http://www.nlm.nih.gov/medlineplus/chronicbronchitis.html

Irreversible damage to the parenchyma

Smoking Continues to Be the Primary Culprit

How Are You Diagnosing COPD?

1. Obtain a CXR and confirm if evidence of hyperinflation.2. Obtain a spirometry or pulmonary function test to confirm.3. Classic symptoms of cough, hx of smoking, and family hx of COPD will confirm.

www.radiologyinfo.org

MAKING THE DIAGNOSIS• Consider COPD in those patients reporting chronic cough, sputum

production, dyspnea, decline in function, previous exposure to risk factors.

• Pattern of symptoms, freq URI’s• Know the risk factors• Immunizations UTD?• Alpha 1 Anti- trypsin

• COPD population screener• http://www.drive4copd.org/AreYouAtRisk/TaketheScreener.aspx

• Spirometry is the Gold Standard for making the diagnosis:• FEV1/FVC <0.70 (post) confirms persistent airflow obstruction

with this clinical picture above

http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdf

ANOTHER TOOLSTAGE GRADE

HPI:

A brief review of her chart notes your former colleague, (before he left to find himself in Vegas), rx’ed her with a Z-Pak and tapering dose of Prednisone 6x in the last year.

She tells you Prednisone is the wonder drug..” I sure can breathe better”.. and if she could just have that ZZZZ Pack , she will be off and running…(not really…truth be told, she never exercises at all since she is so SOB…a symptom she blames on her recent weight gain…she weighs 112 lbs).

Let’s put her on the back burner for now……while you quietly think about taking a sabbatical yourself wondering if your colleague is hopefully now in the Witness Protection Program……..

“ I COULD SURE USE A ZZZZ PACK AND SOME NICE WHITE PILLS… I GOT THAT COLD AGAIN..”

48 y.o female, Karla Marlboro a former patient of your now retired colleague, presents again with hx of cough, productive of green, glow in the dark (her words) sputum x 7 days.She has been into clinic at least 6x in the last year with URI symptoms

YOUR FAVORITE PATIENT

Medical HistoryPMH +HTN, CHF, Bronchitis ,Asthma as child, +

Intubation as child2 ER visits in last 6 months per EMRSH

Social alcohol, no drugsSmokes 2.5 PPD x 30 yrs when she is not smoking the hookah (cutting down soon…maybe)Married with 4 children who sometimes live with her

EHGrew up on farmRecently quit factory job after 40 yrsNow living in first floor apt.+ second hand smoke exposure

FHFather+ hx of COPD

ROS

+ occ cough prod of white sputum+GERD+ DOE+nocturnal SOB-nasal congestion

-postnasal drip

MEDSAlbuterol 6-10 inhalations daily HCTZ 12.5 mg dailyMulti-Vitamins one tab dailyOTC Nyquil and Mucinex

IMMUNIZATIONSFlu 11/2010Pneumococcal declined

Rest of the review of systems was negative.

WORK UP

“I am allergic to the Flu shot. I get the Flu every

time I get the shot

I really don’t inhale

WORK UP (2)Physical Examination

BP, 165/95 mm Hg; HR, 72 beats per minute and regular; respiratory rate, 24 breaths per minute; T98, O2 91% RAPleasant female in NAD

Head, eyes, ears, nose and throat (HEENT): nasal mucosa without edema, erythema posterior pharynx + cobblestoning Neck: no stridor; no neck vein distention, thyromegaly, or tracheal deviationChest: decreased BS base; mod rhonchi, -rales,Heart: normal S1 and S2; no S3, S4, or murmurAbdomen: neg for HSMExtremities: neg for CCE, mod clubbing bilat digitsSkin: intactNodes: neg for LAN

* Endorses she was admitted x3 this last winter while “snow birding” in Fla but signed her self out since the food was “simply not up to my culinary expectations”.

Laboratory• Blood studies.

Alpha-1 antitrypsinCBC

• Exercise oximetry• Sleep oximetry• Pulmonary function tests.

(FVC): 60%(FEV1): 21%

FEV1/FVC ratio: 34%Post

No improvement in the FEV1

• Chest x-ray.Hyperinflation

WELL…WHAT NOW….

WHAT ELSE?• High risk vs low risk• Smoking cessation• Medication• Patient education• Functional assessment• Bone Density (just a thought)• Pulmonary Rehab• Case Management

• SABA (short-acting Beta-Agonists)• Albuterol• Levalbuterol

• LABA (long-acting Beta Agonists)• Formoterol (Foradil)• Salmeterol (Serevent)

• Anticholinergics (short-acting)• Ipratropium (Atrovent)

• Anticholinergics (long acting)• Tiotropium ( Spiriva)

• ICS (Inhaled Corticosteroids)• Beclomethasone (Qvar)• Budesonide (Pulmicort)• Fluticasone (Flovent)

• SABA/Anticholinergics• Albuterol/Impratropium

(Combivent)• (Combivent Respimat)

• Inhaled Corticosteroids/LABA• Formoterol/Budesonide

(Symbicort)• Salmeterol/Fluticasone (Advair)• Formoterol/Mometasone

(Dulera)

THE PHARMACOLOGICAL WEAPONRY

FreqExacerbations

First

Second

• Aclidinium (Tudorza Pressair)

• Long- Acting Anticholinergic Agent;

• Inhalation, oral: 400 mcg (one inhalation) twice daily

• Olodaterol (Striverdi Respimat)

• Beta2-Adrenergic Agonist, Long-Acting

• Two inhalations once daily

• Umeclidinium /vilanterol (Anoro Ellipta)

• Anticholinergic Agent, Long-Acting Beta2 Agonist

• 1 inhalation once daily

• Fluticasone/vilanterol(Breo Ellipta)• Long-Acting Beta2

Agonist/Corticosteroid• One inhalation once daily

• Albuterol inhalation powder (PROAIR RESPICLICK)• beta2-adrenergic agonist • 2 inhalations every 4-6 hours prn

• Tiotropium bromide (SPIRIVA®

RESPIMAT)Inhalation Spray • Long-acting Anticholinergic agent• 2 inhalations once daily

THE PHARMACOLOGICAL ARMORY UPDATES

TREATMENT CONSIDERATIONSFocus on Reducing Airway Resistance

1.SABA (short-acting beta agonist)Albuterol

2. LAMA (long-acting muscarinic antagonist aka long-acting anti-cholinergic)

Titotropium

3. ICS/LABA (inhaled corticosteroid/long-acting beta agonist)Budesonide/Formoterol

***LABA alone. Note incidence of increased mortality in asthmatic patients

PREVENTING AECOPD• Antibiotics• PDE-4 Inhibitors• Consider High-risk Case

Management

ROFLUMILAST• Phosphodiesterase-4 Inhibitors

*consider in patients with Gold 3-4 COPD demonstrating a chronic bronchitis component

• Reduce inflammation by inhibiting the breakdown of intracellular cyclic AMP.

• Once daily administration by mouth

• No direct bronchodilator effect but in combination with salmeterol or tiotropium, has shown improvement in FEV1.

• 15-20% reduction in exacerbations in chronic bronchitis and severe COPD

• Adverse effects• nausea,• Decreased appetite• Abd pain• Diarrhea• Headache• Sleep disturbances

Monitor wt during rxAvoid in underweight ptUsed with caution in depressed pt

CANNOT BE GIVEN CONCOMMITANTLY WITH THEOPHYLLINE

• Hahn in his study reviewed patients randomized to receive Azithromycin* vs. placebo• 27% reduction in exacerbation frequency• Antibiotic resistance monitored and found to have decreased growth of

bacteria but higher incidence of resistance

• Sethi et al evaluated patients enrolled in a randomized trial comparing intermittent Moxifloxacin* use to placebo• 20-25% reduction in exacerbation frequency• Well tolerated• No evidence of C-Difficile infections

* Monitor QT interval

Hahn DL. Azithromycin for prevention of exacerbations of COPD. N. Engl. J. Med.365(23), 2236–2236; author reply 2236–2237 (2011).

Sethi S, Jones PW, Theron MS et al. Pulsed moxifloxacin for the prevention of exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Respir. Res.11, 10(2010).

CONSIDER ANTIBIOTICS FOR PREVENTION

GOT OXYGEN?

FIRST treatment shown to decrease mortality in patients diagnosed with COPD* **

*Report of the Medical Research Council Working Party Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet. 1981;1(8222):681–686.

**Nocturnal Oxygen Therapy Trial Group Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93(3):391–398.

SUPPLEMENTAL OXYGEN

CONTINUOUS USE INTERMITTENT USE*

Resting Pao2 ≤ 55 mm Hg Desaturation (Spo2 ≤ 88%) with activity

Resting Pao2 of 56-59 mm Hg with:

Desaturation (Spo2 ≤ 88%) at night

Dependent edemaP pulmonale on the EKGPolycythemia (hematocrit, >

56%)

Chest. 2010 Jul; 138(1): 179–187.

*current criteria for medicare coverage of O2, but no evidence for benefit for exertional hypoxemia or nocturnal hypoxemia

• Reis and colleagues in their series case study looked at COPD patients enrolled a 96-wk exercise training program

• Pulmonary function tests, blood biochemistry, six-minute walking distance test and health-related quality of life were recorded at baseline and after completion of the 6th, 12th, 18th, 24th months.

• Results: Out of 41 patients, 36 completed the study with documentedimprovement in hemodynamics ,reduction of low density lipids and increase of the high density lipids levels. Also noted an increase in exercise tolerance, improvement in DOE, respiratory muscle strength and QOL.

Based on their data, they support a 24-month pulmonary rehabilitation program leads to significant improvement in physical conditioning resulting in improved QOL for COPD patients.

PULMONARY REHAB

Reis et al. A long-term pulmonary rehabilitation program progressively improves exercise tolerance, quality of life and cardiovascular risk factors in patients with COPD. Eur J Phys Rehabil Med. 2013 Mar 13

AECOPDAcute Exacerbation of COPD• Steroids• Antibiotics• Treat at home vs admission

ORAL STEROIDS

Dependent on Severity of Exacerbation• Range 40 mg-60 daily 5- 14 days

• Individualize tapering doses, again depending on severity

• SCCOPE (Systemic Corticosteroids in COPD Exacerbations) Trial support a 14 day course of 40 mg daily. Comparison of two week vs eight week trials did not support additional efficacy with longer eight week trial. But did note a greater frequency of steroidal related side effects.*

• REDUCE (Reduction in the Use of Corticosteroids in Exacerbation COPD compared five to 14 day trials of 40 mg daily and found no evidence to support decreasing time to next exacerbation, or improvement in lung function. The authors suggest further study and some consideration in noting some patients may need longer than five days of treatment.**

*Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med 1999; 340:1941.**Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA 2013; 309:2223.

http://www.uptodate.com/contents/image?imageKey=ID%2F66357&topicKey=ID%2F7019&source=see_link&utdPopup=trueReproduced with permission from: Sethi S, Murphy TF. Acute exacerbations of chronic bronchitis: New developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy. Infect Dis Clin N Am 2004; 18:861. Illustration used with permission of Elsevier Inc. All rights reserved. Copyright © 2004 Elsevier Inc.Graphic 66357 Version 6.0

ARE THERE CLUES FOR US??Montserrat-Capdevila et al in their restrospective study of 2501 patients diagnosed with various stages of COPD, ranging from mild to severe and over 3 years, attempted to identify predictive factors in COPD patients, and noted the following:• 83.17% of patients experienced at least one exacerbation• Predictive factors identified were:

• Age( older in age)• Gender (male)• Previous hx of exacerbations• Documentation of Flu vaccinations• Documentation of Pneumococcal vaccinations• # of visits to PCP(Due to comorbidities)• smoking• GOLD severity

In summary, this model is effective in practice in identifying high risk patients.

Montserrat-Capdevilla et al. Risk of exacerbation in chronic obstructive pulmonary disease; a primary care retrospective cohort study. BMC Family Practice 2015 Dec 8;16 (1):173.

SOMETHING AS SIMPLE AS A FEW QUESTIONS

WHAT CAN YOU IMPLEMENT IN YOUR PRACTICE TO CAPTURE COPD?

• Know the risk factors • Provide COPD questionnaires to assess for early dx• Is there a pattern?• Smoking inquiries at every visit• Collaborate with ER and Hospital Nurse Discharge Planners

• Patients at risk 48 hours s/p discharge• Early f/u on patients post ER visit or admission• Consider on call steroids and antibiotic • Case Management for High Risk• Med Instruction/Nurse Educator• Research available Pulmonary Rehab• Office spirometry• When in doubt…refer to Pulmonary

ADDITIONAL SITES OF REFERENCE• Spencer, P. and Hanania, N. Optimizing safety of COPD treatments: role of the nurse practitioner. Journal of

Multidisciplinary Healthcare 2013:6 53-63• Blair et al. COPD: Overview and survey of NP knowledge. Nurse Pract. 2013 Jun 10;3• Blair et al. Risk factors for COPD: What do NP’s know? Journal of the American Association of Nurse

Practitioners 26 (2014) 123-130.• Miller et al. Chronic obstructive pulmonary disease: missed diagnosis versus misdiagnosis. BMJ

2015;351:h3021.• Yawn et al. The Impact of Screening Tools on Diagnosis of Chronic Obstructive Pulmonary Disease in Primary

Care. Am J Prev Med 2014;47(5):563–575).• Jones et al. Opportunities to diagnose chronic obstructive pulmonary disease in routine care in the UK: a

retrospective study of a clinical cohort. The LANCET, Volume 2, No. 4, p267–276, April 2014• Cooper, C.B.,and Dansfield, M. (2008). Primary Care of the patient with chronic obstructive lung disease-Part 4.

Understanding the clinical manifestations of a progressive disease. American Journal of Medicine,121 (7A), S33-S45.

• http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html#Mortality• Mapel et al. A clinical study of COPD severity assessment by primary care physicians and their patients

compared with spirometry. American Journal of Medicine 2015 Jun; 128 (6): 629-37• http://www.hfma.org/leadership/COPD/ L. Hegwer. Reducing COPD Readmissions with a Cross-Continum

Approach.HFMA April 2014. • Chung et al. Profile of fluticasone furoate/vilanterol dry powder inhaler combination therapy as a potential

treatment for COPD. International Journal of COPD. Feb. 2014 pp249-256.