COPDDiagnosis, Management and ProgramRYAN MARTIN, MDNEBRASKA PULMONARY SPECIALTIES

Initial diagnosis

Setting matters: Inpatient. Usually sicker, oftentimes avoiding healthcare.

Outpatient. Often seeking treatment before significant decompensation

Symptoms Cough

Sputum production

Shortness of breath

Cyanosis

Hypoxia.

WheezingClubbing

Diagnosis

Setting matters… Outpatient

Symptom assessment

CXR – usually shows hyperinflation and more translucent lung fields, flattened diaphragm.

PFTs – Show obstructive pattern. Severity varies. DLCO may be altered.

ABG May show either hypoxia, hypercapnia, both or neither

Alternate diagnosis?

Elevated total CO2 on BMP

Polycythemia

1. Hyperinflation.2. Hyperlucency3. Increased

retrocardiacairspace

4. Diaphragmatic flattening

Vs NORMAL.

Diagnosis

Inpatient. Usually arrive during acute exacerbation. Many of the above findings are present. Often times more prevalent

even.

Stage of disease is not determinate during the acute exacerbation

ABGs are usually worse acutely.

I avoid doing complete PFTs during acute exacerbation. Spiro or peak flow give enough information.

Cyanosis and hypoxia may be initially present, often reverse with treatment.

CXR findings are usually not appreciably different from acute to chronic settings

Obstructive PFTs. Above the X axis is EXPIRATION,

below it is INSPIRATION Dotted line indicates the expected

expiratory flow limb. COPD/Asthma will have the typical

spike, but then the obstruction takes over

Pursed lip breathing will move the obstruction to the more proximal part of the airway (Mouth) and help stent the smaller, distal airways open.

Reference ranges

Very important to PFT interpretation Determinants are Age, Gender and

Height. Ethnicity plays a smaller role

ABG

7.40/40/90/24 is the normal pH / PCO2 / PO2 / Bicarb Numbers can change both acutely AND chronically. Look to the pH to help direct your acuity.

COPD

It, at cellular level, is the destruction of the alveoli This includes loss of capillaries (where O2 and CO2 exchange occur) Predominantly caused by inhalation. Hyperinflation occurs due to loss of multiple alveoli As the lung becomes over-inflated, the airways become more

collapsible. Forced expiration will exacerbate wheezing.

GOLD 2017

Stages 1-4 derived by FEV1 Classes ABCD are combination based upon the :

Stage + Symptoms.

GOLD A is Stage 1 or 2 without exacerbations

GOLD B is Stage 1 or 2 WITH exacerbation

GOLD C is Stage 3 or 4 without exacerbations

GOLD D is Stage 3 or 4 WITH exacerbations

Treatment

Mainstays of therapy are derived by severity Can be as simple as Albuterol alone/as needed. Most commonly people use 1-2 daily inhalers PLUS a rescue inhaler. Our practice uses the 2017 GOLD guidelines LAMA/LABA preferred medication (for initial start of medication) LAMA/LABA/ICS (for Frequent Exacerbations) PDE inhibitors (Daliresp and Theophylline) Antibiotics (occasionally in Severe patients) Steroids

New DataIMPACT trial

GSK funded study that did a 3 arm trial Focused on the EXACERBATING patient. The arms are

1. Fluticasone/Vilanterol (LAMA/LABA class)

2. Umeclidinium/Vilanterol

3. Fluticasone/Umeclidinium/Vilanterol

Results showing that in the multiple exacerbating patients, triple therapy was most successful

PDE inhibitors

Falls into the classification of Daliresp specifically. Major SE is the GI distress/upset.

Typically lasts about 1 week

New starter pack that uses smaller dose.

Take a week off.

Not suited for all COPD’ers Typically the patients with Chronic Bronchitis

Acute Management of the Exacerbating Patient.

Nebulized medicaitons available and routinely used include Brovana (Afomoterol) or Perforomist (Afomoterol) Pulmicort (Budesonide) Xopenex (Levalbuterol Duonebs (Ipratropium and Albuterol) Albuterol Atrovent (Ipratropium) Lonhala

Acute Management of the Exacerbating Patient.

Steroids Oral meds

Prednisone

IV meds Solu-Medrol (methylprednisolone)

Antibiotics. Do not often require CAP or HCAP coverage.

Acute Management of the Exacerbating Patient.

Antibiotics Selection depends on comorbid conditions

Bronchiectasis

Concurrent PNA

Recent hospitalizations.

Allergies

Immune status

GOLD guidelines update

Transitioned to a LAMA/LABA for initial start of COPD GOLD 2 and 3

Bevespi, Anoro, Stiolto and Utibron

LAMA/LABA/ICS reserved for the more severe categories GOLD 4, or c/d

Trelegy

Some Combination of LABA/ICS + LAMA

Device decisions

Inhalers/MDI require typically about 30cc/sec to get medication delivery to the smaller airway where the mechanism of action can be achieved.

Hand-eye coordination matters. MDI vs Elipta vs Respimat device.

Activity level Extremely poor inspiratory capacity

should dictate usage of NEBs.

Program for Preventing Readmissions

Centers around Transition of care from Acute to Chronic. Withdrawal of acute therapies to something that can be readily

delivered at home. Devices such as Non-Invasive ventilation (BIPAP) can be life-saving

in the hospital but may not always have a role as an outpatient. Nebulized therapy IV medications

Program for Preventing Readmissions

Medication reconciliation is probably the single most important step Medication cost analysis Follow up appointment Home Health Care Durable medical equipment Pulmonary rehab Sleep disorders

Program for Preventing Readmissions

Constant self assessment. Routine analysis of data Iterative process to evaluate which steps are troublesome for

patients Predictive analysis of our patient population.

PNA, CHF, Aspiration and Hypercapnia predict readmission.

Oxygen Assessments

Walking Oximetry is indicated when the DLCO drops below 55% predicted.

6MWT is better used in Prognostic implications High Altitude Simulation Testing can be done if patients concerned.

Rule of thumb is if Dx of COPD/ILD and has exertional dyspnea, I would do one prior to significant elevation exposure…>2 hours.

Lung Cancer Screening

Lung Cancer Screening Must be done at a screening center/registry Annual lung cancer screening CTs even if negative initial scan Simplest minimum requirements:

30 pack years

Over the age 55, under the age of 80

Must have been a daily smoker within the last 15 years.

CT Lung Cancer Screening

False positive rate may be as high as 97% New Fleischner Society guidelines for follow up of the pulmonary

nodule Less concern for nodules < 6mm Ground glass lesions require longer follow up. Majority of the false positive tests simply end up as ongoing

monitoring with LD CTs.

Cases

82 yo male, retired farmer 55 pack years history, quit in 2009 Exertional dyspnea, Wheezing. CXR with hyperinflation, no evidence of nodule FEV1 58% predicted, FVC 89% predicted. No Sputum No weight loss Never hospitalized. Annual flu shot, has had Pneumovax.