Keeping Current with COPD Management in Family Practice

Keeping Current with COPD Management in

Family Practice

2

Friday 4:45 pm visit

• Nancy—56 yo with cc of bronchitis• Coughing >2 weeks, productive-yellow• ?Fever, some breathlessness climbing stairs• Does not want to go to the ED again• Does not want chest x-ray• Wants antibiotics before the weekend

– The last kind she received worked

What Will You Do?

A. Give her the prescription and have her return in 2 weeks for evaluation

B. Take more historyC. Explain that she has no fever, no purulent

sputum and does not need antibioticsD. Begin smoking cessation discussion—she

smells like tobacco smoke

3

4

What Should We Do?

• Take more history– Smoker 35 pack years– Third episode of “bronchitis” in past 2 years

• Colds last for weeks• Always worse than others

– Decrease in activities due to trouble breathing with walking. Now SOB with 6 stairs.

– Has “smoker’s cough” for past 3 years– Mother developed “asthma” at age 60 and died of CHF at

age 68

• Think chronic lung disease!

5

Definition of COPD

• Chronic Obstructive Pulmonary Disease (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 burden of disease in individual patients

Vestbo J et al. Am J Respir Crit Care Med 2013; 187: 347-65.

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Small Airways Disease• Airway inflammation• Airway fibrosis, luminal plugs• Increased airway resistance

Parenchymal Destruction• Loss of alveolar attachments• Decrease of elastic recoil

AIRFLOW LIMITATION

Mechanisms Underlying Airflow Limitation in COPD

7

Burden of COPD

• COPD is a leading cause of morbidity and mortality worldwide and third leading cause of death in the US

• The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the world’s population

• COPD is associated with significant economic burden

12

Why Is COPD Underdiagnosed?Clinicians Tell All

Yawn BP and Wollan PC. Int J COPD. 2008;3(2):311-317.

5

2220

22

50

64

0 10 20 30 40 50 60 70

Lack of effective treatment

Lacks access to spirometry

Patient lacks specific symptoms

Inadequate knowledge and training

Patient fails to report/recognize dyspnea

Patient has multiple chronic conditions

Perceived Barrier (%)

45

48

33

2129

7

MDsNPs/PAs

Survey of 278 Clinicians

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Key Barriers to COPD Diagnosis• COPD not in differential diagnosis• Failure of patients to notice and

report symptoms– Early symptoms often do not interfere with

activities of daily living– Symptom severity increases very slowly

• Failure of health professionals to inquire about respiratory issues– Tools to help– Be specific

• Misdiagnosis of COPD as asthma or bronchitis • Underuse of spirometry

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More about Nancy

• Need to treat acute episode but with what? Antibiotics, SABA, steroids?

• Diagnosis what she has—asthma, COPD or something else?

• Chest x-ray—little help?• Spirometry—can she do it now

with cough?• Stress test—maybe breathlessness

is CV in origin?• Smoking cessation—Never wrong,

time to try!

PMHHypertension—diureticOsteopenia—Ca and Vit DHysterectomy—age 5135 pack year historyMultiple ED visits—bronchitisNo asthmaFamily history—CVD, late asthma

COPD Population Screener (COPD-PS)

1 2 20

Martinez FJ, et al. COPD. 2008;5:85-95.

1. During the past 4 weeks, how much of the time did you feel short of breath?

2. Do you ever cough up any “stuff,” such as mucus or phlegm?

4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?

Yes

A little of the time

Some of the time

Most of the time

All of the time

None of the time

0 1 2 20

Only with occasional colds or chest infections

Yes, a few days a month

Yes, most days a week

No, never Yes, every day

0 1 1 20

Disagree Unsure Agree Strongly agree

Strongly disagree

0 0 10 2

5. How old are you?

Don’t knowNo

0 2 0

Age 35 to 49 Age 50 to 59 Age 60 to 69 Age 70 +

3. Please select the answer that best describes you in the past 12 months, I do less than I used to because of my breathing problems.

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Feature COPD Asthma

Onset Often in midlife Often in childhood

Family history Variable Often

Medical or social history

Smoking (often ≥20 pack-years)

Atopy(ie, allergy and/or eczema)

Patients report symptoms as . . .

Most notable during exercise

“Mostly bad days”

Most notable at night or early morning

“Mostly good days”

Airflow obstruction May be some reversibility with bronchodilation

Largely reversiblewith bronchodilation

Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. • Doherty DE. Am J Med. 2004;117(12A):11S-23S.

Characteristics That Help Distinguish COPD From Asthma

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Key Indicators of COPD

• Chronic cough– Present intermittently or every day– Often present throughout the day;

seldom only nocturnal

• Chronic sputum production– Any pattern chronic sputum production

may indicate COPD

• Dyspnea that is– Progressive (worsens over month/years)– Persistent (present every day)– Worse with exercise– Worse during respiratory infections

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Key Indicators of COPD

• Presence of risk factors– Host factors

• Genetics (alpha-antitrypsin)• Hyperresponsiveness• Lung growth

– Exposure to• Tobacco smoke• Smoke from home cooking

and heating fuels• Occupational dusts and chemicals

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COPD Missed Diagnoses

Miravitlles et al. Arch Bronconeumol. 2006;42:3-8.

Hypothetical male patient with COPD symptoms

Hypothetical female patientwith COPD symptoms

42% diagnosed as COPD by physicians

32% diagnosed as COPDby physicians

32%

COPD symptoms in women were most commonly

misdiagnosed as asthma

42%

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Nancy Needs Spirometry!

• Often have to wait 4 to 6 weeks to return to baseline after acute event (exacerbation)

• See her before you obtain test or at least evaluate over the phone

• Needs pre and post bronchodilator to see about reversibility and if she meets obstruction definition

• Need FEV1 and FVC to determine severity and how to begin maintenance therapy

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Spirometry: Normal Trace Showing FEV1 and FVC

1

1

Volu

me,

lite

rs

Time, seconds

FVC

2 3 4 5 61

FEV1 = 4L

FVC = 5L

FEV1/FVC = 0.82

3

4

5

Spirometry: Obstructive DiseaseVo

lum

e, li

ters

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Normal

Obstructive

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Prebronchodilator andPostbronchodilator Testing• Bronchodilator reversibility testing can help rule out asthma

diagnosis and guide initial treatment decisions– Complete or very nearly complete reversibility (return to normal lung

function metrics) suggests asthma, whereas partial reversibility (not returning to normal or near normal) suggests COPD1

– Some reversibility is possible in people with COPD2

– Basic Protocol• Give 1 puff, wait 1 minute, then administer the second dose• Wait 20 minutes for the inhaler to take effect• Repeat the pulmonary function study • Compare post results to pre results

1. Doherty DE. Am J Med. 2004;117(12A):11S-23S. 2. Celli BR et al.Resp Med.2011;105(8):1176-1188

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Algorithm for Interpreting Spirometry Results

Petty TL. Spirometry made simple. National Lung Health Education Program website. http://www.nlhep.org/resources/SpirometryMadeSimple.htm. Published January 1999.

Acceptable spirogram

Restrictivedefect

Is FVC low?

Yes

Furthertesting

Normal

Yes

Obstructive defect

Is FVC low?

Near-total reversal with use of beta agonist?

Yes

Mixed obstructive/ restrictive defect or hyperinflation

No

Pure obstruction

No

Is FEV1/FVC ratio low?

No

Yes No

Asthma COPDFurther testing

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Nancy’s Numbers

• You do spirometry on Nancy and get the following results – Good quality tracing—rated B

Pre-bronchodilator Post-bronchodilator

FEV1 2.2 L 65% pred FEV1 2.7 L 68% pred

FVC 4.0 L FVC 4.1 L

FEV1/FVC 0.55 FEV1/FVC 0.66

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What is Your Spirometry-Confirmed Diagnosis?1. Normal spirometry2. Poor quality can’t interpret3. Asthma4. Obstructive lung disease consistent with COPD5. Restrictive lung disease

Avoid Interpretation Pitfalls

Common Interpretation Errors Among Family Physicians

(N = 12) New to Interpreting Spirometry

Interpreting a normal result as an obstructive pattern

Interpreting a poor effort as a restrictive pattern

Diagnosing COPD in the absence of an FEV1/FVC ratio <70%

Yawn BP et al. Chest. 2007;132(4):1162-1168. 27

Spirometry Reimbursement

• Billing codes and reimbursement for simple spirometry vary by state

Final rule Medicare program’s fee schedule for physician’s services for calendar year 2007 and the Tax Relief and Health Care Act of 2006. Fed Reg. November 2006;70(216):68132-68215.

Procedure CPT Code 2006 National Average Medicare Reimbursement

Simple spirometry 94010 $33.32

Prebronchodilator and postbronchodilator 94060 $56.61

Smoking cessation counselinga 99406b

99407c$12.13$23.12

Inhaler traininga 94664 $14.02

a Append Modifier -25 code to CPT code in order to be reimbursed for these procedures. b 3 to 10 minutes.c >10 minutes.

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COPD ManagementSuspect COPD

Select Rx based on:Symptoms FEV1

Exacerbations

Modifications

Whyinadequate?

Inadequate response Adequate

responseAdherenceTriggersCo-morbiditiesPsycho-socialInhaler techniqueExacerbationsDisease progression

Spirometery

Using the Global Initiative for Chronic Obstructive Lung

Disease™ (GOLD) Guidelines

A Discussion

See full 2014 GOLD guidelines at www.goldcopd.org

32

Assessment of COPD: Goals

See full 2014 GOLD guidelines atwww.goldcopd.org

33

Assessment of COPD


34

Symptoms of COPD


Modified MRC (mMRC) Questionnaire

35

36

Assessment of COPD


Classification of Severity of Airflow Limitation in COPD*: 2013


38

Assessment of COPD


39

Assess Risk of Exacerbations


40

Nancy Again

• MMRC is 2• Exacerbations? Probably 2 per year• FEV1—68% of predicted• On no therapy until you treated “bronchitis”

and began SABA.

Combined Assessment of COPD

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42

Combined Assessment of COPD


Additional Investigations

43


Manage Stable COPD:Goals of Therapy

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45

Therapeutic Options: Key Points


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Cigarette Smoking in the US: The Epidemic Continues (2002 Data)*

*The percentage of all adults in each state/area who reported having smoked 100 cigarettes during their lifetime and who currently smoke every day or some days.Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2004;52:1277-1280.

9.5%-22.0%22.1%-23.0%24.0%-32.6%

DCGUPRUSVI

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Addressing Smoking Cessation

• Best thing parents can do for themselves and their children

• Clinician intervention is effective and cost effective

• Nicotine is addictive, relapse is prevalent

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Smoking Cessation Interventions

Intervention Studies evaluated (n) Absolute Increase in Cessation Rate

Brief physician contact 16 (Cochrane)7 (US DHHS)

2%2.3%

Group counseling 6 (Cochrane)58 (US DHHS)

10%3.1%

Nicotine gum 51 (Cochrane)13 (US DHHS)

8%6.6%

Nicotine nasal spray 4 (Cochrane)3 (US DHHS)

12%16.6%

Bupropion(300 mg/day SR)

7 (Cochrane)2 (US DHHS)

10%13.2%

Marlow SP et al. Resp Care 2003;48:1238-1256

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Therapeutic Options for COPD: Formulations and Duration of Action

Drug Class Inhaled Nebulizer Solution Oral Duration of Action,

Hours

β2-agonists

Short acting X X X 4-8

Long acting X X X (transdermal) 12-24

Anticholinergics

Short acting X X 6-9

Long acting X 12-24

Combination short-acting β2-agonists plus anticholinergic X X 6-8

Methylxanthines X Up to 24

Inhaled corticosteroids X X

Combination long-acting β2-agonists plus inhaled steroid X

Combination long-acting β2-agonists plus anticholinergic X

Systemic corticosteroids X

Phosphodiesterase-4 inhibitors X 24

Global Strategies for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2011.

50

Hierarchy

Short-acting beta2-agonists or Short acting anticholinergics or Combination

Long-acting beta2-agonists or Long-acting anticholinergics or Combination

Inhaled corticosteroids usually in combination with LABA or LAMA or both

Phosphodiesterase-4 inhibitors

Methylxanthines

Systemic corticosteroids

Therapeutic Options: COPD Medications

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Pharmacotherapy Overview

Minimal SymptomsMild-Moderate &

Exacerbations (0-1/yr)

Severe symptomsMild-Moderate &


Minimal SymptomsSevere-Very Severe &/or

Exacerbations( ≥2/yr)

Severe SymptomsSevere-Very Severe &/or

Exacerbations (≥2/yr)

Short-acting bronchodilator (prn)

Scheduled: Long-acting bronchodilator

A B C D

Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

Consider adding other agents**

Scheduled: *Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist

*Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator)** Other possible agents: PDE-4 inhibitor = phosphodiesterase-4 inhibitor and/or theophylline

52

Patients often do NOT progress through the Grades of COPD Sequentially











A B C D

Consider adding other agents

Scheduled: Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist


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A B C D




54












A B C D




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Recommended Pharmacotherapy



SABA (prn) Albuterol: ProAir®

Proventil®

Ventolin®

Levalbuterol: Xopenex® Pirbuterol: Maxair®

OR

SAMA (prn)Ipratropium: Atrovent®







SABA = short-acting beta2-agonistSAMA = short-acting muscarinic antagonist

(anticholinergic)


A B C D


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SABA or SAMA (prn)



LABA (scheduled) Arformoterol: Brovana®

Formoterol: Foradil® Perforomist®

Indacaterol: Arcapta®

Salmeterol: Serevent®

OR

LAMA (scheduled)Tiotropium: Spiriva®

Aclidinium: Tudorza® Pressair®





LABA = long-acting beta2-agonistLAMA = long-acting muscarinic antagonist

(anticholinergic)

A B C D






SABA or SAMA (prn)



LABA or LAMA(scheduled)



ICS/LABABudesonide/Formoterol

(Symbicort®)Fluticasone/Salmeterol

(Advair®)Fluticasone/Vilanterol

(Breo®)

OR

LAMATiotropium: Spiriva®




ICS = inhaled corticosteroidLABA = long-acting beta2-agonistLAMA = long-acting muscarinic antagonist

(anticholinergic)

A B C D

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SABA or SAMA (prn)



LABA or LAMA(scheduled)



ICS/LABA or LAMA(scheduled)



ICS/LABABudesonide/Formoterol

(Symbicort®)Fluticasone/Salmeterol

(Advair®)Fluticasone/Vilanterol

(Breo®)

AND/OR

LAMATiotropium: Spiriva®


ICS = inhaled corticosteroidLABA = long-acting beta2-agonistLAMA = long-acting muscarinic antagonist

(anticholinergic)

A B C D

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Pharmacotherapy (Summary)



First choice:SABA or SAMA (prn)

Alternative choice:LABA

or LAMA

orSABA + SAMA

(scheduled)

Consider Theophylline



First choice:LABA or LAMA

Alternative choice:

LABA & LAMA




First choice:ICS/LABA or LAMA

Alternative choice:LABA + LAMA

orLABA + PDE-4 inhibitor

orLAMA + PDE-4 inhibitor




First Choice:ICS/LABA &/or LAMA

Alternative choice:ICS/LABA + LAMA

orICS/LABA + PDE-4 inh

orLABA + LAMA

orLAMA + PDE-4 inh


A B C D

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60

Therapeutic Options: Phosphodiesterase-4 Inhibitors


61

What Will Be Nancy’s Initial Therapy?She is a “C”1. SABA or SAMA2. LABA or LAMA3. LABA + LAMA4. LABA or LAMA + ICS

Therapeutic Options: Other Pharmacologic Treatment


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63

Manage Stable COPD: Non-pharmacologic


64

Activity in People with COPD

• COPD patients are very inactive

• This inactivity is present in all GOLD-stagesFEV1 65%

FEV1 38%FEV1 25%

0

10

20

30

40

50

60

70

80

90

100

Walking

HealthyGOLD I & IIGOLD IIIGOLD IV

min

utes

Pitta et al., AJRCCM 2005; 171: 972-977

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Therapeutic Options: Rehabilitation


COPD: The Vicious Circle

Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.

Chronic Pulmonary Disease

Physical Deconditioning

Physical Reconditioning

Decreased Exercise Capacity

Increased Exercise Capacity

Increased Breathlessness

Decreased Breathlessness

Immobility Pulmonary Rehabilitation

Increased VE Requirements

Decreased VE

Requirements

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Pulmonary Rehabilitation Improves CRQ Dyspnea

Lacasse et al, Cochrane Database of Systematic Reviews 2006; Issue 4; Art. No.: CD003793

4 2 2 4

Behnke 2000a

Cambach 1997

Favors Control Favors treatment

Goldstein 1994

Mean Difference(95% CI)

2.26 (1.34, 3.18)

1.20 (0.36, 2.04)0.66 (0.12, 1.20)

0

Gosselink 2000

Griffiths 2000Gell 1995

0.82 (0.17, 1.47)

1.18 (0.85, 1.51)1.30 (0.64, 1.96)

Gell 1998Hernandez 2000Simpson 1992

1.00 (0.20, 1.80)0.78 (0.02, 1.54)1.20 (0.37, 2.03)

Singh 2003Wijkstra 1994Total

0.88 (0.35, 1.41)0.90 (0.13, 1.67)1.06 (0.85, 1.26)

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Cardiovascular Disease

Lung CancerAnxiety, Depression

Peripheral Muscle Wasting & Dysfunction

Osteoporosis

Cachexia

Peptic Ulcers

GI complications

Anemia

Pulmonary Hypertension

Diabetes

Metabolic Syndrome

Address Comorbidities of COPD

Kao C, Hanania, NA. Atlas of COPD, 2008

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Risk of Lung Cancer in COPD: Meta-analysis• 4 large population-based prospective studies that used standardized

methods & did not select population on basis of disease.• Highest quintile of FEV1 had lowest risk of lung cancer; lowest quintile had

highest risk. For same marginal decrease in FEV1, adj. for smoking, women are ~2X more likely to develop lung cancer than men

Wasswa-Kintu et al Thorax 2005;60:570

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Anxiety in COPD

• Anxiety is independently associated with:– poorer exercise performance– greater disability– greater hospitalizations for acute exacerbations– decreased quality of life

• Independent of lung function, dyspnea ratings, and other chronic diseases

0%

20%

40%

60%

80%

100%

GOLD I GOLD II GOLD III-IV

Normal Osteopenia Osteoporosis

Patie

nts

(%)

Severity of COPD

Sin et al. Am J Med. 2003; 114: 10-14.

Osteoporosis

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From What Do COPD Patients Die?

ASCVD=arteriosclerotic cardiovascular disease.Mannino et al. Thorax. 2003;58:388-393.Executive Summary: Global Strategy for the Diagnosis, Management and Prevention of COPD. Updated 2005. Available at: http://www.goldcopd.com/Guidelineitem.asp?l1=intId=996. Accessed June 6, 2006 (A).

COPD ASCVD Lung cancer Pneum/Inf Other

1000 20 40 60 80

Severe COPDGOLD Stage III

Patients (%)

72

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Kurt

• Kurt is 58-year-old retired man with COPD diagnosed 3 years ago during hospitalization for “pneumonia”

• Today he comes in for follow up of visit to the ED for “bronchitits”• He has a 40-year pack history of smoking cigarettes, stopped smoking

3 years ago, 2 years ago and last year • Spirometry FEV1/FVC = 0.55, FEV1 is 61, 1 “exacerbation” past

3 years• MMRC-”2”—walks slower than others his age• He has moderate COPD and has been prescribed tiotropium

once daily • Additional medications include a diuretic for his hypertension, calcium and

vitamin D for his osteopenia (had non-traumatic FX) and escitalopram oxalate (Lexapro) for his “mood”

74

Kurt’s Comorbidities?

• Depression: very common in COPD– Decreases adherence– Antidepressant stopped in 1 to 2 months– Not followed like the chronic disease it is– Considered PHQ-9 to reassess

• Osteopenia– Unusual for a relatively young man– Good workup after FX

• What about CVD?– Stress test?

• What about his recurrent attempts at smoking cessation?

75

Kurt’s Management Program

1. Smoking cessation2. Pulmonary rehabilitation/activity3. May need CV evaluation4. Tiotropium and SABA5. Plan and education for exacerbation recognition6. Monitoring and managing comorbidities7. Regular visits

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An exacerbation of COPD is:

“an acute event characterized by a worsening of the patient’s respiratory

symptoms that is beyond normal day-to-day variations and leads to a

change in medication.”

Manage Exacerbations

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Manage Exacerbations: Key Points


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Impact on symptoms

and lungfunction

Negativeimpact on

quality of life

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

Consequences of COPD Exacerbations

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Manage Exacerbations: Treatment Options

81

Manage Exacerbations: Treatment Options


82

Must Haves for COPD

• Spirometry• Smoking cessation• Pulmonary rehabilitation• Pharmacotherapy• Assessment and therapy of co-morbidities• Good across group communications• Team approach

83

Question

Joel’s COPD was diagnosed 5 years ago. Hislatest FEV1 was 62% last year and his MRC todayis 2. He is taking Tiotropium once a day. He hashad 1 exacerbation (outpatient RX) last year.

Which COPD control square is Joel in?• A• B• C• D

84

Question

• Why is Joel not a candidate for ICS?– Only 1 exacerbation past 2 years– His FEV1 is too high– His insurance company won’t pay– His is afraid of ICS

• Evaluate the risk and benefits!

85

Documents

Keeping Current with COPD Management in Family Practice