Diagnosing and Managing COPD · Diagnosis and Assessment: Key Points • COPD dx should be...

Diagnosing and Managing COPD

Douglas ArenbergUniversity of Michigan

Division of Pulmonary & Critical Care Medicine

• Session Objectives: By the end of this session, participants will be able to…

• Understand the characteristic subjective and objective findings in patients with COPD, when to perform, and how to interpret spirometry in COPD

• Understand the goals of managing patients with COPD and the treatments aimed at achieving these goals

COPD

• Diagnosis• You can’t diagnose if you don’t look, because most people with COPD won’t

come in talking about being out of breath.

• Treatment Goals: improve quality-of-life, prevent exacerbations, treat exacerbations, preserve lung function

• Drugs that improve symptoms, drugs that prevent exacerbations, and drugs that reduce decline in FEV1.

• Flu vaccine, pneumococcal vaccine. Stand your ground, be firm, be right, but vaccinate your patients with COPD.

• Supplemental oxygen Do’s and Don’t’s

Global Strategy for Diagnosis, Management and Prevention of COPD

Diagnosis and Assessment: Key Points

• COPD dx should be considered in any patient with dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for the disease.

• Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis, Management and Prevention of COPD

Risk Factors for COPD

Genes

Infections

Socio-economic status

Aging Populations© 2015 Global Initiative for Chronic Obstructive Lung Disease

!!Second Hand Smoke!!

SYMPTOMS

chronic coughshortness of breath

EXPOSURE TO RISKFACTORS

tobaccooccupation

indoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis

Global Strategy for Diagnosis, Management and Prevention of COPD

Diagnosis of COPD

sputum

© 2015 Global Initiative for Chronic Obstructive Lung Disease

USPSTF. JAMA 2016; 315: 1372-7

Symptoms are not always obvious!!

• Assess symptoms• Assess degree of airflow limitation using spirometry

• The goals of assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact on the patient’s health status, and the risk of exacerbations

• Comorbidities (CAD, DM, CVD) occur frequently in COPD patients, and should be actively looked for and treated appropriately if present.

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Use spirometry for grading severity according to spirometry, using four grades split at 80%, 50% and 30% of predicted

http://www.catestonline.org/english/indexEN.htm CAT score Impact

>30 • Referral to specialistAlso consider:• Additional pharmacological treatments• Pulmonary rehabilitation• Focus on preventing exacerbations

20-29

10-19 • Reviewing maintenance rx – is it optimal?•Pulmonary rehabilitation• Prevent exacerbations • Aggravating factors; still smoking?

<10 Smoking cessation• Annual flu vaccination• Reduce exposure to exacerbation risk factors• Symptom management

• Assess symptoms• Assess degree of airflow limitation using spirometry

• The goals of assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact on the patient’s health status, and the risk of exacerbations

• Comorbidities (CAD, DM, CVD) occur frequently in COPD patients, and should be actively looked for and treated appropriately if present.

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Use spirometry for grading severity according to spirometry, using four grades split at 80%, 50% and 30% of predicted

GOLD Grading System: FEV1 Airflow Limitation (80-50-30)

12Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD COPD web site. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2015_Apr2.pdf. Accessed June 18, 2015.

Postbronchodilator FEV1/FVC <.70 • Confirms presence of persistent airflow limitation

• Supports diagnosis of COPD

GOLD Grade 4

GOLD Grade 1

GOLD Grade 2

GOLD Grade 3

• Mild• FEV1 ≥80% predicted

• Moderate• 50% ≤FEV1 <80%

predicted

• Severe• 30% ≤FEV1 <50% predicted

• Very severe• FEV1 <30% predicted

Assess symptoms Assess degree of airflow limitation using

spirometry Assess risk of exacerbations

Assess comorbiditiesUse history of exacerbations and spirometry. Two exacerbations or more within the last year

or an FEV1 < 50 % of predicted value areindicators of high risk. Hospitalization for a COPD

exacerbation associated with increased risk of death.

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis, Management and Prevention of COPD

Assess Risk of Exacerbations

• Unlike stock market, past performance probably predicts future results:

• Past exacerbations often predict future risk• Two or more exacerbations within the last year or an FEV1 < 50 % of predicted indicate higher risk

• One or more hospitalizations for COPD exacerbation should be considered highrisk.

© 2015 Global Initiative for Chronic Obstructive Lung Disease

(C) (D)

(A) (B)

Combined Assessment of COPD requires 3 ‘axes’ to determine severity

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Exac

erba

tions

per

yea

r

CAT < 10mMRC 0-1

CAT > 10 mMRC > 2

GOLD 3-4

GOLD 1-2

2 or more or

1 with hospitaladmission

0-1 (without hospital admission)

Spiro

met

ricSe

verit

y

High risk Less symptoms

Low risk Less symptoms

High risk More symptoms

Low risk Less symptoms

Most COPD Patients Do Not Receive Recommended Treatment

LACC, long-acting anticholinergic; SACC, short-acting anticholinergic Make B et al. Int J Chron Obstruct Pulmon Dis. 2012;7:1-9.

Patients not receivingrecommended

maintenance therapy

16

Exac

erba

tions

per

yea

r

CAT < 10mMRC 0-1

CAT > 10 mMRC > 2

GOLD 3-4

GOLD 1-2 SAMA prn

orSABA prn

LABA or

LAMA

ICS* + LABAor

LAMA

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Pharmacologic TherapyRECOMMENDED FIRST CHOICE

A B

DC

ICS* + LABAand/orLAMA

© 2015 Global Initiative for Chronic Obstructive Lung Disease

2 or more or

1 with hospitaladmission

0-1 (without hospital admission)

Spiro

met

ricSe

verit

y

Exac

erba

tions

per

yea

r

0

CAT < 10mMRC 0-1

GOLD 4

CAT > 10 mMRC > 2

GOLD 3

GOLD 2

GOLD 1

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Pharmacologic TherapyALTERNATIVE CHOICE

A B

DC

© 2014 Global Initiative for Chronic Obstructive Lung Disease

2 or more or

> 1 leadingto hospitaladmission

1 (not leadingto hospitaladmission)

LAMA and LABA or

LAMA and PDE4-inh or

LABA and PDE4-inh

ICS + LABA and LAMA or

ICS + LABA and PDE4-inhor

LAMA and LABA or

LAMA and PDE4-inh.

LAMA or

LABAor

SABA and SAMA

LAMA and LABA

Relieve symptoms Improve exercise tolerance Improve health status

Prevent disease progression Prevent and treat exacerbations Reduce mortality

Reducesymptoms

Reducerisk

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: Goals of Therapy

© 2015 Global Initiative for Chronic Obstructive Lung Disease

• Avoidance of risk factors• Smoking cessation!!!!!! (there are not enough exclamation points on my keyboard)

- Avoid/Reduce of indoor pollution- Reduce occupational exposure

• Influenza vaccination• Pneumococcal Vaccine

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: All COPD Patients

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Pulmonary Rehabilitation: What does it do?

Lacasse Y et al. Lancet. 1996;348:1115-1119.

-2 -1 0 1 2 3 4Effect Size (SD units)

McGavin, 1977

Cockcroft, 1981Booker, 1984

Jones, 1985

Lake, 1990

Simpson, 1992

Weiner, 1992

Goldstein, 1994

Wijkstra, 1994

Guell, 1995

Strijbos, 1996

Overall effect

Study Favors control Favors treatment

• Dyspnea as a function of O2 consumption• The muscles lose their mitochondrial machinery from

inactivity• Rehab gradually recovers the function of this “cog”

O2 in

CO2 outO2 delivery

(Don’t forget

Hemoglobin and

vascular diseaseOxidative respiration

(This is costly to

maintain)

Pulmonary Rehabilitation: Outcomes

Outcome Control Rehab PDeaths (n) 12 6 NSHospitalized (n) 41 40 NSRespiratory admissions/pt 1.9 1.4 .04All-cause admissions/pt 2.2 1.7 .048Hospital days

(respiratory) 18.1 9.4 .021Hospital days

(all causes) 21.0 10.4 .022

Griffiths TL et al. Lancet. 2000;355:362-368.

• Emphysema by Hx/PE/HRCT

• FEV1 ≤ 45%; TLC > 100%; RV ≥ 150%

• pCO2 ≤ 60, pO2 ≥ 45• BMI ≤ 31.1 males, ≤ 32.3 females

• Exclusion• Previous thoracic

surgery• Significant CV disease

• Exclusionary pulmonary disease

• Unsuitable HRCT• Unplanned weight loss

• Life-threatening systemic disease

• No consentThe National Emphysema Treatment Trial Research Group. Chest. 1999;116:1750-1761.The National Emphysema Treatment Trial Research Group. NEJM 2001; 345: 1075-83

Lung Volume Reduction Surgery‘NETT; inclusion and exclusion criteria

Years after randomization0 1 2 3 4 5 6 7 8

Prob

abilit

y of d

eath

0.0

0.2

0.4

0.6

0.8

1.0

Medical

LVRS

608 526 496 454 352 227 122 29 LVRS 610 564 507 441 335 210 99 29 Medical

Overall P=0.02

P2 yr=0.48

P5 yr=0.02

Lung volume reduction surgery reduces mortality compared with medical management in selected patients with severe emphysema

RR = 0.85

Naunheim et al. Ann Thorac Surg 2006; 82: 431-43

Emphasys Endobronchial Valve TM

• Stent-like retainer

• Flexible seals

• One-way valve

• Removable

Key Features

Investigational device only. Not currently approved for sale.

Lung Transplantation

- Survival following transplant:

- 2 years, 60-65%; 40% at 5 years

- Average waiting time for Tx: 2 y

J Heart Lung Transplant 1998:17;703

Oxygen therapy

- Survival benefit for resting hypoxia

- NO benefit for exercised induced hypoxia

- Oxygen does NOT relieve dyspnea better than placebo

Oxygen in COPDIn the 1980s, two landmark trials, (NOTT) (1980) and the MRC (1981), showed that long-term oxygen therapy (LTOT, ≥ 18 hr/day) was the sole treatment that improved survival in patients with COPD.

Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980;93:391–398.

Medical Research Council Working Party. Lancet 1981;1:681–686.

Indications for Long-term Oxygen Therapy (LTOT) in COPDPaO2 <55 mmHg or SaO2 < 88% (room air)PaO2 56–59 mmHg or SaO2 89%–90%, with (one or more):

Pulmonary hypertensionEvidence of cor pulmonale or edema due to heart failureElevated hematocrit (>56%)

NEJM 2016;375(17):1617-27

• After seven months and the randomization of only 34 patients, the trial was redesigned to also include patients with moderate exercise-induced desaturation (SpO2 ≥ 80% for ≥5 minutes and <90% for ≥10 second during 6-minute walk test)

• Ultimately 738 patients were randomized to receive long-term supplemental oxygen versus (24-hour oxygen for those with resting desaturation and during exercise and sleep for those with exercise desaturation) no long-term supplemental oxygen.

NEJM 2016;375(17):1617-27

• No difference between groups in time to death or first hospitalization (hazard ratio 0.94; 95% CI 0.79-1.12; p=0.52).

• No difference in rates of hospitalization, COPD exacerbations, quality of life, lung function or 6 MW distance

GOLD Grading System:FEV1 Airflow Limitation

30Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD COPD web site. http://www.goldcopd.org/uploads/users/files/GOLD_Report_2015_Apr2.pdf. Accessed June 18, 2015.

Postbronchodilator FEV1/FVC <.70 • Confirms presence of persistent airflow limitation

• Supports diagnosis of COPD

GOLD Grade 4

GOLD Grade 1

GOLD Grade 2

GOLD Grade 3

• Mild• FEV1 ≥80% predicted

• Moderate• 50% ≤FEV1 <80%

predicted

• Severe• 30% ≤FEV1 <50% predicted

• Very severe• FEV1 <30% predicted

COPD: Summary• Diagnosis

• You can’t diagnose if you don’t look (40% rule)• Ask patients at risk about exercise tolerance (Are you able to do

everything you like to do without worrying about your breathing?”, cough, sputum production

• Treatment Goals: reduce symptoms, prevent exacerbations, manage risk factors (SMOKING!)

• Flu vaccine, pneumococcal vaccines. • Supplemental oxygen should be reserved for treating hypoxia, not

dyspnea

Questions/Discussion…