copd: barriers to effective management - bu. · pdf filelearning objectives for copd: ... dr....

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COPD: Barriers to COPD: Barriers to Effective ManagementEffective Management

22

Learning Objectives for COPD: Learning Objectives for COPD: Barriers to Effective ManagementBarriers to Effective Management

•• Describe common problems in the Describe common problems in the management of COPD patients and management of COPD patients and cite possible office systems solutionscite possible office systems solutions

•• Describe clinical challenges in the Describe clinical challenges in the management of difficult COPD patients management of difficult COPD patients and cite possible solutions the referral and cite possible solutions the referral specialist can offerspecialist can offer

33

Accreditation StatementAccreditation Statement

Boston University School of Medicine is accredited by theBoston University School of Medicine is accredited by theAccreditation Council for Continuing Medical Education (ACCME)Accreditation Council for Continuing Medical Education (ACCME)to provide continuing medical education for physicians.to provide continuing medical education for physicians.

Boston University School of Medicine designates this educationalBoston University School of Medicine designates this educationalactivity for a maximum of 1 activity for a maximum of 1 AMA PRA Category 1 CreditAMA PRA Category 1 Credit™™..Clinicians should only claim credit commensurate with the extentClinicians should only claim credit commensurate with the extentof their participation in the activity.of their participation in the activity.

In order to receive CME/CE credit for this teleconference, complIn order to receive CME/CE credit for this teleconference, complete theete theProgram Evaluation and Claim for Credit forms that are on our WeProgram Evaluation and Claim for Credit forms that are on our Websitebsiteat at www.mentorqi.comwww.mentorqi.com.. Click on the EVENTS tab at the top and look for Click on the EVENTS tab at the top and look for

Teleconference #5. Teleconference #5.

Target AudienceTarget AudiencePrimary care physicians, nurse practitioners, and physician assiPrimary care physicians, nurse practitioners, and physician assistantsstants

Grant SupportGrant Support

This program is supported by an educational grant from BoehringeThis program is supported by an educational grant from Boehringer r Ingelheim and Pfizer Inc.Ingelheim and Pfizer Inc.

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Planning Committee Disclosures Planning Committee Disclosures

Julie White, MSJulie White, MSAdministrative DirectorAdministrative DirectorContinuing Medical EducationContinuing Medical EducationBoston University School of MedicineBoston University School of MedicineBoston, MassachusettsBoston, Massachusetts

Julie White has nothing to disclose.Julie White has nothing to disclose.

Lara Zisblatt, MALara Zisblatt, MAAssistant DirectorAssistant DirectorContinuing Medical EducationContinuing Medical EducationBoston University School of MedicineBoston University School of MedicineBoston, MassachusettsBoston, Massachusetts

Lara Zisblatt has nothing to disclose. Lara Zisblatt has nothing to disclose.

Elizabeth GiffordElizabeth GiffordProgram ManagerProgram ManagerContinuing Medical EducationContinuing Medical EducationBoston University School of Boston University School of MedicineMedicineBoston, MassachusettsBoston, Massachusetts

Elizabeth Gifford has nothing to Elizabeth Gifford has nothing to disclose.disclose.

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Faculty Disclosure InformationFaculty Disclosure Information

Roy C. Blank, MD Roy C. Blank, MD Southern Piedmont Primary CareSouthern Piedmont Primary CareMonroe, North CarolinaMonroe, North Carolina

Roy C. Blank, MD, is on the speakersRoy C. Blank, MD, is on the speakers’’ bureaus for Merck, Pfizer Inc., and bureaus for Merck, Pfizer Inc., and TakedaTakeda PharmaceuticalPharmaceutical Company Ltd. Company Ltd.

Dr. Blank does not plan to discuss offDr. Blank does not plan to discuss off--label/investigational uses of products. label/investigational uses of products.

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Faculty DisclosureFaculty Disclosure

Dennis E. Niewoehner, MD Dennis E. Niewoehner, MD

Professor of MedicineProfessor of MedicineUniversity of MinnesotaUniversity of MinnesotaMinneapolis, MinnesotaMinneapolis, Minnesota

Dennis E. Niewoehner, MD, serves as a consultant, receives grantDennis E. Niewoehner, MD, serves as a consultant, receives grantsupport, and is on the speakerssupport, and is on the speakers’’ bureau for Boehringer Ingelheim and bureau for Boehringer Ingelheim and for Pfizer Inc.; and serves as a consultant for Adams Respiratorfor Pfizer Inc.; and serves as a consultant for Adams Respiratory y Therapeutics, Forest Laboratories, and GlaxoSmithKline. Therapeutics, Forest Laboratories, and GlaxoSmithKline.

Dr. Niewoehner plans to discuss offDr. Niewoehner plans to discuss off--label/investigational uses of label/investigational uses of formoterol, salmeterol, tiotropium, or theophylline for managingformoterol, salmeterol, tiotropium, or theophylline for managingexacerbations of COPD. exacerbations of COPD.

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COPD Performance COPD Performance Improvement Initiative:Improvement Initiative:

Chart ReviewsChart ReviewsJulie White, MSJulie White, MS

Administrative DirectorAdministrative DirectorContinuing Medical EducationContinuing Medical Education

Boston University School of MedicineBoston University School of MedicineBoston, MassachusettsBoston, Massachusetts

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Participants in the ProgramParticipants in the Program

•• 205 people registered205 people registered

•• 142 people started the program142 people started the program

•• 74 people started their initial chart review74 people started their initial chart review

•• 20 people completed their initial chart review20 people completed their initial chart review

•• 19 people submitted their action plans and 19 people submitted their action plans and are awaiting their followare awaiting their follow--up chart reviewup chart review

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Performance ImprovementPerformance Improvement

•• Enrolling in this PI program is the Enrolling in this PI program is the 11stst step in improving care for your step in improving care for your patientspatients

•• Key component to improvement is Key component to improvement is chart reviewchart review•• Simple way to look at baseline measures of your Simple way to look at baseline measures of your

practicepractice

•• Very act of reviewing charts can be illuminatingVery act of reviewing charts can be illuminating

1010

Chart Review ChallengeChart Review Challenge

•• Biggest Challenge = TimeBiggest Challenge = Time

•• Ways to overcome this barrier:Ways to overcome this barrier:

•• Ask support staff to review patients seen in the past Ask support staff to review patients seen in the past month with any ICD 9 code for COPD and pull charts month with any ICD 9 code for COPD and pull charts or review EMRor review EMR

•• Complete the chart review with another member of Complete the chart review with another member of your teamyour team

•• Make a plan to complete this chart reviewMake a plan to complete this chart review

•• Schedule 2 oneSchedule 2 one--hour sessions over the next week hour sessions over the next week using administrative time or your lunch hourusing administrative time or your lunch hour

1111

COPD ProjectCOPD Project

•• Make a commitment to yourself and your patients Make a commitment to yourself and your patients to work toward improving care!to work toward improving care!

•• Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement

•• If you are having trouble completing the chart If you are having trouble completing the chart reviews, please let us know. We can help!reviews, please let us know. We can help!

•• If you have any questions, please email us at If you have any questions, please email us at [email protected]@bu.edu or call us at or call us at 617.638.4605617.638.4605

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Barriers to the Management Barriers to the Management of COPDof COPD: A Practical : A Practical

OfficeOffice--Based ApproachBased ApproachRoy C. Blank, MD Roy C. Blank, MD

Southern Piedmont Primary CareSouthern Piedmont Primary CareMonroe, North CarolinaMonroe, North Carolina

1313

Case Study: Patient PresentationCase Study: Patient Presentation

•• Mr. T is a 68Mr. T is a 68--yearyear--old man with a history of old man with a history of COPD who presents to his physicianCOPD who presents to his physician’’s office s office with worsening of his exertional dyspnea with worsening of his exertional dyspnea

•• The symptoms have occurred over several The symptoms have occurred over several days, accompanied by cough and purulent days, accompanied by cough and purulent sputum productionsputum production

1414

Case Study: Patient HistoryCase Study: Patient History

•• Mr. T has missed several appointments and Mr. T has missed several appointments and has not visited the office for more than a year. has not visited the office for more than a year. He has been hospitalized once and had 2 ED He has been hospitalized once and had 2 ED visits since his last office visitvisits since his last office visit

•• MedicationsMedications–– Uses a shortUses a short--acting betaacting beta2 2 agonist as neededagonist as needed

–– Does not use the previously prescribed inhaled Does not use the previously prescribed inhaled tiotropiumtiotropium

ED = emergency department.

1515

Case Study: Patient History (Case Study: Patient History (contcont’’dd))

•• Social historySocial history–– Smokes 1 pack of cigarettes dailySmokes 1 pack of cigarettes daily

–– No excess alcohol intakeNo excess alcohol intake

•• Review of symptomsReview of symptoms–– FatigueFatigue

–– Loss of interest in activitiesLoss of interest in activities

–– Prefers to remain at home alone rather than Prefers to remain at home alone rather than participate in social activitiesparticipate in social activities

1616

Case Study: Chart ReviewCase Study: Chart Review

•• Despite the diagnosis of COPD, there is no Despite the diagnosis of COPD, there is no record of spirometryrecord of spirometry

•• No documentation of education/pulmonary No documentation of education/pulmonary rehabilitation for pulmonary diseaserehabilitation for pulmonary disease

•• No documentation of influenza or No documentation of influenza or pneumococcal vaccinationspneumococcal vaccinations

•• No pulse oximetry or arterial blood gases No pulse oximetry or arterial blood gases (ABGs)(ABGs)

1717

Case Study: Physical ExaminationCase Study: Physical Examination

•• Temp 98.7Temp 98.7°° F; pulse 72/min; resp 16/min; BP F; pulse 72/min; resp 16/min; BP 124/70124/70

•• Mild dyspnea at rest Mild dyspnea at rest •• Cardiovascular: no evidence of congestive Cardiovascular: no evidence of congestive

heart failureheart failure•• Pulmonary: prolonged expiratory phase of Pulmonary: prolonged expiratory phase of

respiration; scattered expiratory wheezes; respiration; scattered expiratory wheezes; decreased breath soundsdecreased breath sounds

BP = blood pressure.

1818

Case Study: Laboratory FindingsCase Study: Laboratory Findings

•• Pulse oximetry: 92%Pulse oximetry: 92%•• Chest XChest X--ray: findings of COPD with no ray: findings of COPD with no

congestive heart failure or pulmonary congestive heart failure or pulmonary infiltratesinfiltrates

•• White blood cell count: normal with a normal White blood cell count: normal with a normal differentialdifferential

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Case Study: TreatmentCase Study: Treatment

•• AcuteAcute–– Provide appropriate treatment for an acute Provide appropriate treatment for an acute

exacerbation of COPDexacerbation of COPD

•• ChronicChronic–– Explore reasons for possible noncompliance Explore reasons for possible noncompliance

and lack of adequate longand lack of adequate long--term management term management for COPDfor COPD

2020

Chronic Disease ManagementChronic Disease Management

•• Problem:Problem:–– Missed Missed

appointmentsappointments

–– Hospitalizations; Hospitalizations; ED or urgentED or urgent--care care visits

•• Possible solutions:Possible solutions:–– Use office system to identify Use office system to identify

missed appointmentsmissed appointmentsPromote support staff awareness Promote support staff awareness of the importance of followof the importance of follow--upup

–– Use system approach for Use system approach for notification of hospitalizations; ED notification of hospitalizations; ED or urgentor urgent--care visitscare visits

–– Provide initial education Provide initial education emphasizing the importance emphasizing the importance of regular medical followof regular medical follow--up up for chronic disease management

visits

for chronic disease management

2121

Chronic Disease Management Chronic Disease Management ((contcont’’dd))

•• Problem:Problem:–– Noncompliance Noncompliance

with longwith long--acting acting bronchodilatorbronchodilator

Mr. T did not have Mr. T did not have any immediate any immediate effect from the effect from the inhalation of inhalation of tiotropium

•• Possible solutionsPossible solutions–– Provide initial education regarding Provide initial education regarding

the expectations of treatment with the expectations of treatment with tiotropium or any prescribed tiotropium or any prescribed medicationmedication

–– Ask questions regarding possible Ask questions regarding possible economic issueseconomic issues

–– Ask questions regarding possible Ask questions regarding possible side effectsside effects

–– Review all prescribed medications Review all prescribed medications and attempt to simplify regimens

tiotropium

and attempt to simplify regimens

2222

Chronic Disease Management Chronic Disease Management ((contcont’’dd))

•• Problem:Problem:–– Continued Continued

tobacco abuse

•• Possible solutionsPossible solutions–– Provide additional education Provide additional education

regarding smoking cessationregarding smoking cessation

–– Review therapeutic optionsReview therapeutic optionsPharmacologicPharmacologic

–– Provide referral for smoking Provide referral for smoking cessation programcessation program

–– Use system solution for tobacco Use system solution for tobacco cessation educationcessation education

Office education programs

tobacco abuse

Office education programs

2323

Smoking Cessation OptionsSmoking Cessation Options•• IIndividual, groupndividual, group,, and telephone counselingand telephone counseling

•• 2 components enhance effectiveness of counseling2 components enhance effectiveness of counseling

•• Practical counseling (problem solving/skills training)Practical counseling (problem solving/skills training)

•• Social support (as part of treatment)Social support (as part of treatment)

•• FirstFirst--line line medications (except when medicallymedications (except when medicallycontraindicated)contraindicated)

Nicotine nasal Nicotine nasal sprayspray

Nicotine patchNicotine patch

VareniclineVarenicline

Bupropion SRBupropion SR

Nicotine gumNicotine gum

Nicotine inhalerNicotine inhaler

Nicotine lozengeNicotine lozenge

AHCPR (Agency for Health Care Policy and Research) Supported Clinical Practice Guidelines 2008 Update. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.part.4408.

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•• Problem:Problem:–– DepressionDepression

Possible cause Possible cause of noncomplianceof noncompliance

Possible cause Possible cause of unwillingness of unwillingness to leave home for to leave home for appointments

•• Possible solutions:Possible solutions:–– Screen all patients with chronic Screen all patients with chronic

disease for depressiondisease for depression

–– Provide appropriate treatment or Provide appropriate treatment or referralreferral

–– Maintain high level of suspicion Maintain high level of suspicion for the diagnosis of depressionfor the diagnosis of depressionappointments

2525

Depression Common in Patients Depression Common in Patients With COPDWith COPD

•• Of 1,736 participants with COPD, 40% had Of 1,736 participants with COPD, 40% had ≥≥3 3 depressive symptoms. Depressive symptoms depressive symptoms. Depressive symptoms were more common in COPD than in coronary were more common in COPD than in coronary heart disease, stroke, diabetes, arthritis, heart disease, stroke, diabetes, arthritis, hypertension, and cancerhypertension, and cancer1 1

•• Patients with frequent exacerbations are more Patients with frequent exacerbations are more depressed than those with infrequent depressed than those with infrequent exacerbationsexacerbations22

1. Schane RE, et al. J Gen Intern Med. 2008 Aug 9. [Epub ahead of print]. 2. Quint JK, et al. Eur Respir J. 2008;32(1):53-60. Epub 2008 Mar.

2626


•• Problem:Problem:–– Spirometry not Spirometry not

performed

•• Possible solutionsPossible solutions–– Provide spirometry in the officeProvide spirometry in the office

–– Promote increased provider Promote increased provider awareness of guidelines for the awareness of guidelines for the management of COPDmanagement of COPD

Obtain necessary information to Obtain necessary information to stratify the severity of COPD and stratify the severity of COPD and offer appropriate therapyoffer appropriate therapy

–– Use flowsheet for chronic disease Use flowsheet for chronic disease managementmanagement

Facilitates data management

performed

Facilitates data management

2727

Treatment of COPD According Treatment of COPD According to Spirometric Stage of Diseaseto Spirometric Stage of Disease

Add long-term oxygen if chronic respiratory failure.Consider surgical treatments.

Add inhaled glucocorticosteroids if repeated exacerbations.

Add regular treatment with one or more long-acting bronchodilators (when needed). Add rehabilitation.

Active reduction of risk factor(s); influenza vaccination.Active reduction of risk factor(s); influenza vaccination.AddAdd shortshort--acting bronchodilator (when needed).acting bronchodilator (when needed).

COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume (in liters) in 1 second; FVC = forced vital capacity.NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. November 2006.

• FEV1/FVC <0.70• FEV1 ≥80% predicted

• FEV1/FVC <0.70• 50% ≤FEV1

<80% predicted

• FEV1/FVC <0.70• 30% ≤FEV1 <50%

predicted

• FEV1/FVC <0.70• FEV1 <30%

predicted plus chronic respiratory failure

I: MildI: Mild II: ModerateII: Moderate III: SevereIII: Severe IV: Very SevereIV: Very Severe

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•• Problem:Problem:–– Lack of vaccinationsLack of vaccinations

–– Lack of pulse Lack of pulse oximetry or ABGsoximetry or ABGs

•• Possible solutions:Possible solutions:–– Use system approach for Use system approach for

vaccinations of all patients with vaccinations of all patients with chronic illnesschronic illness

Quality indicator for chart auditsQuality indicator for chart audits

Vaccination record or flowsheetVaccination record or flowsheet

–– Provide pulse oximetry in the Provide pulse oximetry in the officeoffice

Nocturnal pulse oximetryNocturnal pulse oximetry

Determine the need for home ODetermine the need for home O22

2929

Mortality Benefit of Continuous OMortality Benefit of Continuous O2 2 in Patients With Resting Hypoxiain Patients With Resting Hypoxia

•• Taken together, the MRC trialTaken together, the MRC trial1 1 and NOTTand NOTT22

demonstrated a relationship between survival demonstrated a relationship between survival and the average daily duration of oxygen useand the average daily duration of oxygen use3 3

in patients with a clinical diagnosis of severe in patients with a clinical diagnosis of severe COPD and severe resting arterial hypoxemia COPD and severe resting arterial hypoxemia

•• Median survival in patients using oxygen for Median survival in patients using oxygen for 18 h per day was approximately twice as long 18 h per day was approximately twice as long as those receiving no oxygen as those receiving no oxygen

MRC = Medical Research Council; NOTT = Nocturnal Oxygen Treatment Trial.1. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-398. 2. Report of the Medical Research Council Working Party. Lancet. 1981;1:681-686. 3. Croxton TL, Bailey WC. Am J Respir Crit Care Med. 2006;174:373-378.

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•• Possible solutions:Possible solutions:–– Provide inProvide in--office educationoffice education

Nurse practitioner/PANurse practitioner/PA

–– Provide referral for pulmonary Provide referral for pulmonary rehabilitationrehabilitation

–– Use flowsheet to track Use flowsheet to track appropriate referrals

•• Problem:Problem:–– Lack of patient Lack of patient

education or education or pulmonary pulmonary rehabilitationrehabilitation

appropriate referrals

3131

Chronic Disease Management Chronic Disease Management FlowsheetFlowsheet

3232

Overcoming Barriers to the Overcoming Barriers to the Management of COPDManagement of COPD: : SummarySummary

•• Implement a systems approach to chronic Implement a systems approach to chronic disease managementdisease management

•• Promote awareness of guidelinesPromote awareness of guidelines•• Provide education of office support staffProvide education of office support staff•• Institute a means of recording and tracking Institute a means of recording and tracking

appropriate dataappropriate data

3333

Clinical Questions on ManagingClinical Questions on Managingthe Difficult COPD Patient:the Difficult COPD Patient:

What the Referral What the Referral Specialist Can OfferSpecialist Can Offer

Dennis E. Niewoehner, MDDennis E. Niewoehner, MDVeterans Affairs Medical CenterVeterans Affairs Medical Center

University of MinnesotaUniversity of MinnesotaMinneapolis, MNMinneapolis, MN

3434

OverviewOverview

• Case Study: The Challenging COPD Patient• Use of combination inhalers• Use of theophylline by specialists• Ambulatory oxygen: uses and misperceptions• Unproven or not recommended drug therapies for COPD• Self-management/Disease management: the importance of patient education

• Surgical options

3535

The Challenging COPD Patient:The Challenging COPD Patient:Case DescriptionCase Description

• A 68-year-old man was referred by his primary care provider with a request for assistance in COPD management

• Dyspnea, which had first occurred about 10 years before, had progressed to the point where he could walk only about 100 feet without stopping

• He had had 3 exacerbations in the past year that required hospitalization or an ED visit

• He had smoked heavily for 50 years but had stopped 2 years previously

3636

The Challenging COPD Patient:The Challenging COPD Patient:Case Description (Case Description (contcont’’dd))

• Regular medications included an inhaled long-acting beta-agonist, an inhaled corticosteroid, and a short-acting beta-agonist

• He was current with recommended immunizations• Most recent spirometry showed an FEV1 of 0.65 L, an FVC of 1.93 L, and an FEV1/FVC of 0.34

• Oxygen saturation was 92% when sitting at rest while breathing room air but it dropped to 85% after walking up and down the hallway

• Chest X-ray demonstrated hyperinflation and emphysema• Comorbidities included hypertension, peripheral vascular disease, and diabetes mellitus

3737

The Challenging COPD Patient:The Challenging COPD Patient:Some ConsiderationsSome Considerations

• Confirm diagnosis of COPD• Exclude comorbidities as cause of worsening dyspnea

• Additional pharmacologic interventionsCombinations of inhaled steroids and long-acting

bronchodilatorsTheophyllineOxygen

• Nonpharmacologic interventionsDisease managementSurgical options

3838

Combined ICS and LABA: Combined ICS and LABA: TORCHTORCH

00

0.20.2

0.40.4

0.60.6

0.80.8

11

1.21.2

1.41.4

PlaceboPlacebo SalmeterolSalmeterol FluticasoneFluticasone SalmeterolSalmeterol++

FluticasoneFluticasone

Exacerbations/Exacerbations/PatientPatient--YearYear

**P P <<.05 compared with placebo.05 compared with placebo

**** **

‡‡P P <<.05 compared with salmeterol or fluticasone.05 compared with salmeterol or fluticasone

‡‡

ICS = inhaled corticosteroids; LABA = long-acting beta-agonists. TORCH = TOwards a Revolution in COPD Health. Calverley PM, et al. N Engl J Med. 2007;356:775-789.

3939

Combination Inhalers: Combination Inhalers: OPTIMA TrialOPTIMA Trial

PP <.05<.05

OPTIMA = OPTions In Management with Antiretrovirals.Aaron SD, et al. Ann Intern Med. 2007;146:545-555.

No. COPDNo. COPDHospitalizationsHospitalizations

00

1010

2020

3030

4040

5050

6060

TiotropiumTiotropium TiotropiumTiotropium++

SalmeterolSalmeterolTiotropiumTiotropium

++SalmeterolSalmeterol

++FluticasoneFluticasone

NSNS

4040

Theophylline: Therapeutic IndexTheophylline: Therapeutic Index

00 25251515101055 2020

Theophylline (Theophylline (µµg/mL)g/mL)

ResponseResponse

Therapeutic Therapeutic rangerange

IntoleranceIntoleranceEfficacyEfficacy

SevereSevereadverse adverse eventsevents

Jenne JW. Chest. 19897; 92(1 Suppl):7S-14S.

4141

Effect of Theophylline on COPD Effect of Theophylline on COPD ExacerbationsExacerbations

00

55

1010

1515

2020

2525

3030

3535

PlaceboPlacebo FormoterolFormoterol12 12 µµgg

FormoterolFormoterol24 24 µµgg

TheophyllineTheophylline

n =220

n =211

n =214

n =209

PP = .02= .02

PP = .04= .04

% Patients With % Patients With ≥≥1 Level 21 Level 2

ExacerbationsExacerbations

Rossi A, et al. Chest. 2002:121:1058-1069.

4242

Prescribing of Theophylline Prescribing of Theophylline for COPDfor COPD

• Aim for blood level of 8-12 µg/mL• Start with 300-400 mg daily in older men and 200-300 mg daily in older women

• Much individual variation in pharmacokinetics• Numerous drug-drug interactions• Check blood level in 7-10 days• Theophylline metabolism is first order; in given individual, average blood level is proportional to daily dose

• Recheck blood level annually and more frequently if there is change in clinical condition

4343

Ambulatory Oxygen: Ambulatory Oxygen: Uses and MisperceptionsUses and Misperceptions

• Proven mortality benefit in COPD patients with persistent hypoxemia who are in a stable clinical state (eg, O2 sat ≤88% or pO2 ≤55 mm Hg)*

• Ambulatory oxygen is commonly prescribed for patients who desaturate only with exercise, as is the case with outpatients. Medicare and most insurance plans allow this indication

* Nocturnal Oxygen Therapy Trial Group Group. Ann Intern Med. 1980;93:391.

4444

Ambulatory Oxygen: Ambulatory Oxygen: Uses and Misperceptions (Uses and Misperceptions (contcont’’dd))

• Clinical benefit for this indication remains unproven. Dyspnea severity correlates very poorly with exercise desaturation

• Ambulatory oxygen may be offered to such patients as a therapeutic trial, but discontinue if no symptomatic benefit

• Many patients do not wish to use oxygen because of nuisance factors and social stigma

4545

Unproven or Not Recommended Unproven or Not Recommended Drug Therapies in COPDDrug Therapies in COPD

• Leukotriene antagonistsMontelukastZafirlukastZileuton

• Levalbuterol• N-acetylcysteine• Chronic prednisone

4646

Erythromycin Prophylaxis Erythromycin Prophylaxis to Prevent COPD Exacerbationsto Prevent COPD Exacerbations

00

5050

100100

150150

200200

250250

PlaceboPlacebo ErythromycinErythromycin

N = 56 N = 53

PP = .004= .004

Exacerbations Exacerbations in 1 Yearin 1 Year

Seemungal TAR, et al. Am J Respir Crit Care Med. 2007;175:A764.

4747

MACRO Trial Study DesignMACRO Trial Study Design

• Randomized, double-blind, placebo-controlledActive arm: azithromycin, 250 mg qd

• Duration: 1 year• “High-risk” patients• Powered to show 20% relative reduction (1,130 patients) in COPD exacerbations

• Close monitoring of bacterial resistance patterns

http://clinicaltrials.gov/ct2/show/NCT00325897.

4848

Quebec SelfQuebec Self--Management Trial: Management Trial: The Importance of Patient EducationThe Importance of Patient Education

• Patient education program (8 weeks)Basic information about COPDMedicine compliance, immunizationsBreathing techniquesAction planHealthy lifestyleLeisure activitiesHome exerciseOxygen therapy (if appropriate)

• Monthly reinforcing phone calls• Ready availability of case manager

Bourbeau J, et al. Arch Intern Med. 2003;163:585-591.

4949

Quebec SelfQuebec Self--Management Trial:Management Trial:Prevention of COPD HospitalizationsPrevention of COPD Hospitalizations

00

1010

2020

3030

4040

5050

6060

Usual CareUsual Care InterventionIntervention

n = 95 n = 96

PP <.01<.01

% Subjects% SubjectsWith With >>1 COPD1 COPD

HospitalizationsHospitalizations


5050

VISN 23 COPD Disease VISN 23 COPD Disease Management Trial: Management Trial: The InterventionThe Intervention

• 1- to 1.5-hour group education sessionGeneral information about COPDProper inhaler techniquesOptimization of chronic COPD medicationsSmoking cessation, if neededVaccinationsEvaluation for long-term home oxygenEncourage regular exerciseExacerbation education

• Written action plan with refillable antibiotic and prednisone Rx• Availability of case manager (respiratory therapist) for questions with regularly scheduled phone calls at 4-week intervals

VISN = Veterans integrated Service Network.Rice KL, et al. Am J Respir Crit Care Med. 2008;177:A868.

5151

VISN 23 COPD Disease Management VISN 23 COPD Disease Management Trial: ResultsTrial: Results

COPD ED visits or hosp admitsCOPD ED visits or hosp admits(Events/100 pt(Events/100 pt--yrs)yrs)

100100

UsualUsualcarecare

InterventionIntervention

PP <.0001<.00018080

002020

40406060

00101020203030404050506060

UsualUsualcarecare


COPD Hosp admitsCOPD Hosp admits(Events/100 pt(Events/100 pt--yrs)yrs)

PP <.01<.01

COPD ED visitsCOPD ED visits(Events/100 pt(Events/100 pt--yrs)yrs)

6060

UsualUsualcarecare


PP <.0001<.00015050404030302020

001010

Rice KL, et al. Am J Respir Crit Care Med. 2008;177:A868.

5252

BrBronchitis and onchitis and EEmphysema mphysema AAdvice and dvice and TTraining to Reduce raining to Reduce HHospitalization (BREATH)ospitalization (BREATH)

• Randomized, 2-arm trial (VA Cooperative trial)Usual careComprehensive case management

• Duration: 1 year• “High-risk” patients (COPD hospitalization in past year)• Primary outcome: time to first COPD hospitalization• Powered to show 8% absolute reduction from 35% to 27% (960 patients)

http://clinicaltrials.gov/ct2/show/NCT00395083=591.

5353

Common Surgical OptionsCommon Surgical Options

• Lung transplantation• Lung volume reduction surgery


5454

Survival After Lung TransplantationSurvival After Lung Transplantation

Trulock EP, et al. J Heart Lung Transplant. 2007;26:782-795.

5555

Severe Emphysema:Severe Emphysema:Upper Lobe DominanceUpper Lobe Dominance

Courtesy of Dr. Dennis Niewoehner.

5656

Lung Volume Reduction Surgery:Lung Volume Reduction Surgery:NETT NETT -- Survival DataSurvival Data

NETT = National Emphysema Treatment Trial.Fishman A, et al. N Engl J Med. 2003;348:2059-2073. Epub 2003 May 20.

5757

Discussion/QuestionsDiscussion/Questions

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