take my breath away: copd update - staabsymposium.com · take my breath away march 26, 2018 l 2 •...
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Take My Breath Away: COPD Update
Jason Henderson D.O.Warren Clinic Pulmonary & Critical Care
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Take My Breath Away March 26, 2018 l 2
• 1. Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema.
• 2. Describe the workup involved in diagnosing obstructive airway disease.
• 3. Utilize COPD staging tools to determine disease classification and appropriate therapies.
• 4. Describe the treatment options for COPD including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers.
Objectives
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Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema.
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COPD
• Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.
COPD
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Complaints
• COPD should be suspected in all patients who report any combination of the following: – chronic cough, – chronic sputum production,– dyspnea at rest or with exertion,– or a history of inhalational exposure to tobacco
smoke, occupational dust, or occupational chemicals
• These are the 3 cardinal complaints, they prevent in varying degrees, also can have people compensate but becoming increasing sedentary to compensate and down play dyspnea
COPD
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COPD
• Most common cause depends on how your frame your patient population.
• In 1st world countries, it is tobacco use
• In rest of world, 3 billion people use wood or other biomass fuels (i.e. cow poop/coal/crop residuals) to cook, under ventilated, indoors….
• American Thoracic Society states ~20% of COPD is related to occupational exposures, coal dust, organic small particle dust, cotton textile workers, etc,
• Allegedly ~10% of COPD patients have Alpha-1 antitrypsin deficiency, in my experience, ~10% are carriers and ~1% have homozygous disease.
Cause of COPD
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Stats on COPD
• 4th leading cause of death in the United States, responsible for 6% of all global deaths each year (2012 apprx 3,000,000)
• Estimated to be 3rd leading cause of death by 2020. some studies already ranking it 3rd
• 16 million adults with diagnoses of COPD
• Estimated 14 million who are undiagnosed
• Significant morbidity as well as mortality– In US, COPD 2nd most common cause of
decreased ADL tolerance
• Expensive to treat…….– Advair is apprx $300/month
COPD
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From: Jemal A. et al. JAMA 2005
The incidence of COPD is on the Rise
Introduction of the Atari
Introduction of Nintendo
Introduction of Sega Genesis
COPD
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Pack-years of smoking effect on FEV 1
Smoking is by far the largest risk factor for development of COPD, but not everyone who smokes heavily develops COPD as demonstrated by Burrows et al
Not everyone who smokes even heavily develops COPD
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Describe the workup involved in diagnosing obstructive airway disease.
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COPD
• First and foremost, smoking cessation is paramount regardless of diagnosis or workup.
• You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup.
• Stop smoking, stop smoking, stop smoking
STOP SMOKING
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Key points of the Treating Tobacco Use and Dependence guidelines
• Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved
• Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments
• Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention
• There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness
• Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment
• Five first-line pharmacotherapies for tobacco dependence have shown efficacy
COPD
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Spirometry,
• Spirometry is the Gold standard
• Yet only 32% of patients with a new diagnosis of COPD had undergone spirometry
– Spirometry Utilization for COPD How Do We Measure Up? CHEST August
2007 vol. 132 no. 2 403-409
• We are under utilizing Spirometry in the diagnosis of COPD
• Spirometry can help us – Confirm the diagnosis of COPD
– as many as 20 percent of individuals with severe airway obstruction will have no symptoms
– Determine the severity of COPD– And help guide treatment options
– Gives us prognostic information about survival rates– Lower FEV1 or FEV1/FVC means worse outcomes and worse
survival
COPD
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Differential diagnosis of obstructive lung diseases
• COPD – strong history of tobacco use,
• Asthma – reversible obstruction, strong correlation with allergies (unless it’s not allergy mediated)
• Bronchiectasis – multiple different types, can be part of COPD, – Alpha-1 antitrypsin deficiency (hereditary COPD)– Ciliary dyskinesia – Rheumatoid arthritis ILD
• Cystic fibrosis – has significant amounts of bronchiectasis, rarely diagnosed as adult
• ILD– sarcoidosis, – pulmonary Langerhans cell histiocytosis, – LAM (lymphangioleiomyomatosis) – bronchiolitis obliterans
• And many other esoteric obstructive lung diseases
COPD
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•How Severe is this patient’s COPD?
•A. Mild
•B. Moderate
•C. Severe
•D. Very Severe
What not to do
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Take My Breath Away March 26, 2018 l 16
How Severe is this patient’s COPD?A. Mild
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•How Severe is this patient’s COPD?
•A. Mild
•B. Moderate
•C. Severe
•D. Very Severe
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Take My Breath Away March 26, 2018 l 18
How Severe is this patient’s COPD?D. Very Severe
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Take My Breath Away March 26, 2018 l 19
What’s the DiagnosisXR Chest PA and LatPA and lateral chest x-ray
FINDINGS:
Upper lung emphysematous changes are identified. Linear upper lobe scarring is seen. A few calcified granulomas are present. IMPRESSION:
Stable findings including parenchymal scarring, emphysematous changes.
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Take My Breath Away March 26, 2018 l 20
What’s the Diagnosis?
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Take My Breath Away March 26, 2018 l 21
What’s the Diagnosis?
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Take My Breath Away March 26, 2018 l 22
What’s the Diagnosis?
XR Chest PA and LatTWO VIEWS OF THE CHEST:
INDICATION: Chest pain
FINDINGS: No consolidation, effusion, or pneumothorax. Increased lung volumes consistent with obstructive lung disease. Stable left upper lobe scarring. Cardiomediastinal silhouette is normal.
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Take My Breath Away March 26, 2018 l 23
What’s the Diagnosis?
FEV1/FVC 41%FEV1 39%
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Take My Breath Away March 26, 2018 l 24
What’s the Diagnosis?
PA and lateral chest x-ray
Comparison: 10/1/2013
Findings: The cardiomediastinal silhouette and pulmonary vascular markings are normal. Mild basal scarring is seen. The costophrenic sulci and lungs are otherwise clear.
Impression: No acute findings.
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Take My Breath Away March 26, 2018 l 25
What’s the Diagnosis?
PA and lateral chest x-ray
Comparison: 10/1/2013
Findings: The cardiomediastinal silhouette and pulmonary vascular markings are normal. Mild basal scarring is seen. The costophrenic sulci and lungs are otherwise clear.
Impression: No acute findings.
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COPD
What NOT to do……..
Make diagnosis by radiology….Make diagnosis by history alone…Make diagnosis without spirometry…
Order a spirometry then mark out machine interpretation of probable restriction and relabel obstruction to fit your bias……
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What Not to do…..
• CXR: poor sensitivity. –Has sensitivity of less than 50% in detecting COPD
with moderate severity COPD
• ABG–The PaO2 usually remains near normal until the
FEV1 is decreased to ~50% of predicted, –PaCO2 elevation is not expected until the FEV1 is
<25% of predicted
• CT–Can give pathologic data, but nothing on the
functional data, no data on sensitivity or specificity
• And since other conditions can present with symptoms similar to COPD, don’t misread the test data
COPD
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70 %80 %
80 %
80 % 80 %
COPD
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COPD
FEV1/FVC ratio >70%
FVC >80%? FVC >80%?
Obstruction Get full PFTNormal Possible
restriction, get full PFT
yes
yes yes
no
nono
Look at FEV1 to determine severity
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COPD
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COPD
• Step 1 – FEV1/FVC ratio
• Step 2 – FVC
• Step 3 – FEV1
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Utilize COPD staging tools to determine disease classification and appropriate therapies.
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Classification of COPD per GOLD criteria
COPD
GOLD I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted
GOLD II: Moderate FEV1/FVC < 0.7050% < FEV1 < 80% predicted
GOLD III: Severe FEV1/FVC < 0.7030% < FEV1 < 50% predicted
GOLD IV: FEV1/FVC < 0.70Very Severe FEV1 < 30% predicted
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Choice of thresholds
© 2017 Global Initiative for Chronic Obstructive Lung Disease
► COPD Assessment Test (CAT TM )► Chronic Respiratory Questionnaire (CCQ® )► St George’s Respiratory Questionnaire (SGRQ)► Chronic Respiratory Questionnaire (CRQ)► Modified Medical Research Council (mMRC) questionnaire
COPD
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ABCD Assessment Tool
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Because FEV1 does not predict symptoms/progression
COPD
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Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease COPD
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You can not go just by FEV1
New guidelines treatment determined more by symptoms and exacerbations over FEV1, But……few of us actually calculate the GOLD classification based off new guidelines, important information is Severity of obstruction, how symptomatic and how frequently they’re exacerbating and have they quit smoking.
Very cumbersome system, so the more they are exacerbating and more symptomatic they are, and the worse the FEV1 is, the more medications they get.
COPD
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Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease COPD
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Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Education and self-management
► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system.
► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease.
COPD
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COPD
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COPD
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Monitoring and Follow-up
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Monitoring disease progression and development of complications and/or comorbidities
► Measurements. Decline in FEV1 can be tracked by spirometry performed at least once a year.
► Symptoms. At each visit, information on symptoms since the last visit should be collected, including cough and sputum, breathlessness, fatigue, activity limitation, and sleep disturbances.
► Exacerbations. The frequency, severity, type and likely causes of all exacerbations should be monitored.
► Imaging. If there is a clear worsening of symptoms, imaging may be indicated.
► Smoking status. At each visit, the current smoking status and smoke exposure should be determined followed by appropriate action.
COPD
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Useful Guidelines and resources
• The Global Initiative for Chronic Obstructive Lung Disease– www.goldcopd.com
COPD
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Describe the treatment options for COPD including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers.
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COPD
• First and foremost, smoking cessation is paramount regardless of diagnosis or workup.
• You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup.
• Stop smoking, stop smoking, stop smoking
STOP SMOKING
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Key points of the Treating Tobacco Use and Dependence guidelines
• Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved
• Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments
• Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention
• There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness
• Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment
• Five first-line pharmacotherapies for tobacco dependence have shown efficacy
COPD
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Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease
SABA - short acting beta agonistLABA – long acting beta agonistSAMA – short acting muscarinic antagonistLAMA – long acting muscarinic antagonist ICS – inhaled corticosteroidPDE4 - Phosphodiesterase 4 inhibitor
COPD
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Current medications LABA
Arcapta (indacaterol)Serevent (Salmeterol)Striverdi (olodaterol)
ICSAerospan (flunisolide)Alvesco (ciclesonide)Arnuity (fluticasone furoate)Asmanex (mometasone)FLovent (fluticasone propionate)Pulmicort (budesonide)Qvar (beclomethasone)
Presentation Title l March 26, 2018 l 48
ICS/LABAAdvair (fluticasone/salmeterol)Breo (fluticasone/vilanterol)Dulera (mometasone/formoterol)Symbicort (Budesonide/formoterol)
LABA/LAMAAnoro (umeclidinium/vilaterol)Stiolto (tiotroprium/olodaterol)Utibron (glycopyrrolate/indacaterol)
LAMASeebri (glycopyrrolate)Incruse (umeclidinium)Spiriva (tiotropium)Tudorza (aclidinium)
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Treatment of Stable COPD
© 2017 Global Initiative for Chronic Obstructive Lung Disease COPD
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ABCD Assessment Tool
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Because FEV1 does not predict symptoms/progression
COPD
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COPD
• Everyone w/ COPD should have a rescue SABA on hand,
• Inhalers don’t work if they aren’t being used properly,
• Check technique
• Spacer chamber
Other treatment considerations
Other treatment considerations
• Possible Lung volume reduction surgery• Lung transplant• ??? Endobronchial 1-way valves???• Anti-IL5 for eosinophilic asthmatic overlap
syndromes
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Updates and likely changes in recommendations- The use of combination therapy with LAMA/LABA is
newly emphasized within last year as first line therapy,
- Monotherapy with LABA or use w/o ICS previously discouraged due to SMART study in asthma,
- Moderate hypoxemia treatment does not improve mortality,
COPD
Old recommendations
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Beware the combo products……
Very easy to over medication with many different ICS/LABA and LABA/LAMA combinations.
COPD
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Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Education and self-management
► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system.
► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease.
COPD
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Non-Pharmacologic Treatment
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Oxygen therapy
Long-term oxygen therapy is indicated for stable patients who have:
► PaO2 at or below 55 mmHg or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or
► PaO2 between 55 mmHg and 60 mmHg, or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
► Resting sats >89% but desats on ambulation no benefit in mortality, ? Insurance changes in coverage for this in coming years.
COPD
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Questions?