18810 BI COPD CES(2) VM final designed slides 4-12-18 FOR PDF · Flow (L/sec) Volume (L) Normal COPD Graph created by Susan Corbridge. Used with permission. Hyperinflation in COPD

1

Disclosures

• Dr. Corbridge's spouse is an employee of GlaxoSmithKline pharmaceutical company (effective May 1, 2018).

• This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

Learning Objectives

• Review evidence-based strategies for screening, diagnosis, and assessment of COPD.

• Describe the most current guideline recommendations for the pharmacologic treatment of COPD, including agents discussed in the guidelines.

• Describe the most current guideline recommendations for the nonpharmacologic treatment of COPD.

• Recognize acute exacerbations of COPD.

• Discuss strategies for promoting patient adherence to COPD therapy.

2

COPD Guidelines

• Global Initiative for Chronic Obstructive Lung Disease (GOLD) – 2018 Global Strategy for Prevention, Diagnosis, and

Management of COPD

– 2018 GOLD Pocket Guide

– COPD Diagnosis and Management At-A-Glance Desk Reference

– Asthma, COPD, and Asthma-COPD Overlap Syndrome

– Spirometry Guidehttp://goldcopd.org/gold-reports/http://goldcopd.org/copd-diagnosis-management-glance-desk-reference-2016/http://goldcopd.org/asthma-copd-asthma-copd-overlap-syndrome/ http://goldcopd.org/gold-spirometry-guide/

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

COPD

• A common, preventable, and treatable disease

• Characterized by persistent airflow limitation – Typically progressive

– Associated with an enhanced chronic inflammatory response in the airways and lung due to noxious particles or gases

• Exacerbations and comorbidities contribute to the overall severity in individual patients

COPD

• Common symptoms:– Progressive dyspnea– Cough– Sputum production

• Symptoms are often underreported!• Associated with significant comorbidities

– Increase morbidity and mortality

• May have periods of worsening baseline symptoms– Important to prevent exacerbations


3

US Burden of COPD

Cause of Death Number*

Heart disease 165.5

Cancer 155.8

Unintentional injuries 47.4

Chronic lower respiratory diseases 40.6

Stroke 37.3

Alzheimer’s disease 30.3

Diabetes 21.0

Influenza and pneumonia 13.5

Kidney disease 13.1

Intentional Self Harm (Suicide) 13.5

Kochanek KD, et al. Mortality in the United States, 2016. NCHS Data Brief, no 293. Hyattsville, MD: National Center for Health Statistics. 2017.https://www.cdc.gov/copd/data.html (Data source: CDC Behavioral Risk Factor Surveillance System [BRFSS], 2014.)

Age-adjusted death rates for the 10 leading causes of death

in 2016: United States, 2015 and 2016

Prevalence of COPD among adults aged ≥ 18 years, 2014

*Deaths per 100,000 U.S. standard population

Global Burden of COPD

• Estimated global prevalence: 11.7%– 3 million deaths annually

• The prevalence of COPD is expected to rise over the next 30 years due to:– Increasing prevalence of smoking in developing

countries– Aging populations in high-income countries

• By 2030, a predicted 4.5 million COPD-related deaths will occur annually

• COPD imparts a significant economic burden


COPD is Underrecognized and Underdiagnosed!


4

Risk Factors for COPD

• Tobacco smoke– Greater exposure =

greater risk

• Air pollution– Indoor Biomass fuels/coal

– Outdoor

• Occupational dust and chemicals

• Genes

• Respiratory infections

• Asthma and airway hyperreactivity

• Socioeconomic status

• Gender

• Age


COPD in Women

• Women develop COPD at a younger age

• Are less likely to be diagnosed with COPD than men when presenting with the same symptoms

• Are more likely to die from COPD than men

American Lung Association. http://www.lung.org/assets/documents/research/rise-of-copd-in-women-full.pdf.Photo: University of Illinois at Chicago. Used with permission.

Pathology and Pathogenesis

Noxious particle

Susceptible host

Lung inflammation – structural changes

Oxidative stress

Inflammatory cells & mediators

Inflammatory mediators

Peribronchiolar and interstitial fibrosis

5

Hogg JC. Lancet. 2004;364(9435):709-721; Used with permission.

Pathology and Pathogenesis

• Airway limitation and gas trapping

• Gas exchange abnormalities

• Mucus hypersecretion

• Pulmonary hypertension

Diagnosis

Diagnosing COPD

SymptomsBreathlessness

Cough

Sputum

Exposure to Risk FactorsTobacco

Pollution

Occupation

Physical Exam&

SpirometryRequired to establish diagnosis

6

Physical Exam

• Airflow obstruction:– Wheezing during auscultation – Prolonged expiration

• Severe emphysema indicated by:– Hyperinflation– Low diaphragmatic position– Decreased intensity of heart and breath sounds

• Severe disease suggested by:– Pursed-lip breathing– Use of accessory respiratory muscles– Retraction of intercostal spaces– Pulmonary hypertension

• No clubbing

Assessment of COPD

• Determine impact on patient’s health status– COPD Assessment Test (CAT)– Modified Medical Research Council (MMRC)

dyspnea/breathlessness scale– Clinical COPD Questionnaire (CCQ)

• Determine degree of airflow limitation– Spirometry

• Assess risk of exacerbations, hospitalizations– “Past predicts future”– Increases with worsening airflow limitations

• Identify and treat comorbidities

Modified MRC (mMRC) Dyspnea Scale

Grade

“I only get breathless with strenuous exercise.” 0

“I get short of breath when hurrying on the level or walking up a slight hill.”

1

“I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level.”

2

“I stop for breath after walking about 100 yards or after a few minutes on the level.”

3

“I am too breathless to leave the house.”or…“I am breathless when dressing.”

4

mMRC = Modified Medical Research Council Dyspnea Scale

7

www.catestonline.org/images/pdfs/CATest.pdf

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

I have no phlegm (mucus) in my chest at all

My chest is completely full of phlegm (mucus)

My chest does not feel tight at all

My chest feels very tight

When I walk up a hill or one flight of stairs I am not

breathless

When I walk up a hill or one flight of stairs I am

very breathlessI am not limited doing any

activities at homeI am very limited doing any activities at home

I am confident leaving my home despite my lung

condition

I am not at all confident leaving my home despite

my lung condition

0 1 2 3 4 5I sleep soundlyI don’t sleep soundly because of my lung

condition

0 1 2 3 4 5I have lots of energy I have no energy at all

Total Score:

COPD Assessment Test (CAT)

Diagnosis of COPD

• Spirometry is required to make the diagnosis of COPD.

Photo: University of Illinois at Chicago. Used with permission.

Spirometry

• FVC (forced vital capacity):– Maximum volume of air that can be exhaled

during a forced maneuver• FEV1 (forced expired volume in one second):

– Volume expired in the first second of maximal expiration after a maximal inspiration. This is a measure of how quickly the lungs can be emptied.

• FEV1/FVC:– FEV1 expressed as a percentage of the FVC,

gives a clinically useful index of airflow limitation

8

Obstruction by SpirometryFEV1 falls more than FVC

FEV1/FVC < 0.70

Volume (L)

Time (sec)1 3 5 8 2 6 7

1

2

3

4

5

FVC

TLC

0

FEV1 / FVC = .73FEV1 / FVC = .26

FEV1

COPD

Normal

Graph created by Tom Corbridge. Used with permission.

Hyperinflation in COPD

Flo

w (

L/s

ec)

Volume (L)

NormalCOPD

Graph created by Susan Corbridge. Used with permission.

Flo

w (

L/s

ec

)

Volume (L)

NormalCOPD

Graph created by Susan Corbridge. Used with permission.

Hyperinflation in COPD

9

Pulmonary Function Tests in COPD

• Post-bronchodilator FEV1/FVC ≤ 0.70 confirms irreversible obstruction

• Classically associated with increased lung volume and decreased diffusion capacity


GOLD Spirometric ClassificationBased on Post-Bronchodilator FEV1

GOLD 1: Mild • FEV1/FVC < .70• FEV1 ≥ 80% predicted

GOLD 2: Moderate • FEV1/FVC < .70• 50% ≤ FEV1 < 80% predicted

GOLD 3: Severe • FEV1/FVC < .70• 30% ≤ FEV1 < 50% predicted

GOLD 4: Very Severe • FEV1/FVC < .70• FEV1 < 30% predicted


GOLD “ABCD” Assessment Tool (Refined)

© 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. Used with permission. Do not reproduce in print. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

Patient example:FEV1 47% predictedCAT score 18No exacerbations

GOLD Grade 3, Group B=

10



Additional Investigations

• Chest X-ray– Chest CT imaging

• Lung volumes and diffusing capacity

• Oximetry and arterial blood gases

• Alpha-1 antitrypsin deficiency screening

• Exercise testing

• Composite scores


11

COPD and Comorbidities

• Common comorbidities of COPD:– Cardiovascular disease– Heart failure– Arrhythmias– Diabetes– Depression/Anxiety– Osteoporosis– Lung cancer– Sleep disorders– Anemia– GERD– Obstructive sleep apnea

• COPD has significant extrapulmonary (systemic) effects including:– Weight loss/gain– Nutritional abnormalities– Skeletal muscle

dysfunction


Treatment

Treatment: Nonpharmacologic Approaches

• Smoking cessation • Avoidance of indoor and outdoor pollutants• Vaccinations• Optimizing nutrition • Pulmonary rehabilitation• Exercise training• Oxygen therapy• Surgical and bronchoscopic interventions• Education and self-management• End of life and palliative care


12

Smoking Cessation

• Brief counseling is effective; provide at every visit– Counseling and pharmacotherapy more effective together

than either alone

• First-line pharmacotherapies:– Oral: varenicline, bupropion

– Nicotine replacement therapy: gum, inhaler, nasal spray, patch, lozenges

5 A’sAsk, Advise, Assess,

Assist, Arrange

5 R’sRelevance, Risk,

Rewards, Roadblocks, Repetition

4 D’sDelay, Deep Breath, Drink Water, Do Something Else

Agency for Healthcare Research and Quality. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

Pulmonary Rehabilitation and Home Exercise

• Pulmonary rehab (PR) is the most effective therapeutic strategy to improve shortness of breath, health status and exercise tolerance– Reduces readmissions and

mortality

– Among the most cost-effective strategies

• Clinician “tips” for promoting exercise and activity in COPD– Take all meds as

prescribed

– Avoid prolonged sitting

– Make exercise routine

– Warm up, cool down, don’t over-do it

– Start slowly and increase speed or mileage daily

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report.

http://goldcopd.org/gold-reports/Corbridge SJ, Nyenhuis SM. J Nurse Pract. 2017;13(1):41-46.Photo: University of Illinois at Chicago. Used with permission.

COPD Inhaler Classes

• Short-acting beta-2 agonists (SABA)• Short-acting muscarinic receptor antagonists

(SAMA)• Combination SABA/SAMA• Long-acting beta-2 agonists (LABA)• Long-acting muscarinic receptor antagonists

(LAMA)• Inhaled corticosteroids (ICS)• Combination LAMA/LABA• Combination ICS/LABA• Combination ICS/LABMA/LABA

13

COPD Medications

For a complete list, please refer to the appendix provided in the activity materials:

https://www.aanp.org/copd.pdf

Bronchodilators in Stable COPDGOLD Recommendation Evidence

Level

Inhaled bronchodilators in COPD are central to symptom management and commonly given on a regular basis to prevent or reduce symptoms

A

Regular and as-needed use of SABA or SAMA improves FEV1 and symptoms

A

Combinations of SABA and SAMA are superior to either medication alone in improving FEV1 and symptoms

A

LABAs and LAMAs significantly improve lung function, dyspnea, health status, and reduce exacerbation rates

A

LAMAs have a greater effect on exacerbation reduction compared with LABAS

A

LAMAs have a greater effect decreased hospitalizations compared with LABAS

B

A = Randomized controlled trials, rich body of high quality evidence without any significant limitation or biasB = Randomized controlled trials with important limitations, limited body of evidenceGlobal Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

Bronchodilators in Stable COPD

GOLD Recommendation Evidence Level

Combination treatment with a LABA and LAMA increases FEV1 and reduces symptoms compared to monotherapy

A

Combination treatment with a LABA and LAMA reduces exacerbations compared to monotherapy or ISC/LABA

B

Tiotropium improves the effectiveness of pulmonary rehabilitation in increasing exercise performance

B

Theophylline exerts a small bronchodilator effect in stable COPD A

Theophylline is associated with modest symptom benefits in stable COPD

B

A = Randomized controlled trials, rich body of high quality evidence without any significant limitation or biasB = Randomized controlled trials with important limitations, limited body of evidenceGlobal Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

14

Pharmacologic Treatment Algorithms by GOLD Grade

© 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. Used with permission. Do not reproduce in print. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

Inhaler Technique is Key

• Patients frequently misuse inhalers1-4

• Health care providers misuse inhalers5-6

• Guidelines recommend review of technique at each visit 7

1.Batterink J, et al. CN J Hosp Pharm. 2012;65(2):111-118.2.Melani AS, et al. Respir Med. 2011;105(6):930-938.3.Press VG, et al. J Gen Intern Med. 2012;27(10):1317-1325.4.Sestini P, et al. J Aerosol Med. 2006;19(2):127-136.5.Lalani NS, et al. Health. 2012;3(1):16-18.6.De Tratto K, et al. 2014;28(3):156-160.7.Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report.

How to Use Inhalers: https://use-inhalers.com/ Used with permission.

How to Use Inhalers

15

• Phosphodiesterase-4 inhibitors• Azithromycin and erythromycin• Systemic corticosteroids• Alpha-1 antitrypsin augmentation therapy• Low dose long acting opioids• Methylxanthines• Bone sparing agents• Antidepressants

Additional Medications

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report.Laurin C, et al. Am J Respir Crit Care Med. 2012;185(9):918-923.Cafarella PA, et al. Respirology. 2012;17(4):627-638.

Adherence

• Adherence to COPD therapy is often poor1

– Fewer than half of treatments for COPD are taken as prescribed

– Nonadherence contributes to hospitalization, death, and healthcare costs

• Nonadherence or poor adherence can be caused by:2,3

– Inadequate patient knowledge of disease or treatments

– Side effects– Poor inhaler technique (unintentional)– Cost

1.Bender BG. Curr Opin Pulm Med. 2014;20(2):132-137.2.Spencer P and Hanania NA. J Multidiscip Healthc. 2013;6:53-63 3.Sriram KB and Percival M. Chron Respir Dis. 2016;13(1):13-22.

Assessing Adherence

Method Advantages Disadvantages

Clinician estimates Easy to obtain Unreliable

Patient self-report Easy to obtain Unreliable

Pill counts/weighing Easy to obtain Overestimates use

Pharmacy records Confirms prescription filling

Incomplete, biased estimates

Biologic measures Confirms ingestion

Expensive,invasive, insensitive to inhaled drugs, affected by pharmacokinetics and polypharmacy

Electronic monitoring Confirms patterns of use, ingestion

Expensive, limited availability and use, malfunctions

• Red flags for poor adherence– Denial

Patient beliefs about illness and treatment

– Disruption Personal and family

crises

– Depression Apathy and

withdrawal

– Dementia Psychiatric or related

to substance abuse

Lareau SC and Yawn BP. Int J Chron Obstruct Pulmon Dis. 2010;5:401-406.

16

Improving Adherence

Type of nonadherence Adherence intervention

Erratic • Simplify and tailor regimen• Implement behavioral strategies such as

cueing, reminders, and reinforcement• Self-monitoring and support, with monitoring

from others

Unwitting • Review of adherence behavior• Written or visual medication plans• Patient education in disease management

Intelligent • Patient education and counseling• Negotiate therapy• Link therapy with personal goals

Matching Adherence Interventions to the Type of Nonadherence

Lareau SC and Yawn BP. Int J Chron Obstruct Pulmon Dis. 2010;5:401-406.

Case

• MP: 55-year-old investment banker

• Presents with:– Shortness of breath and increased sputum production (2

teaspoons clear phlegm each morning)

– Dyspnea on exertion: 1-2 blocks/1 flight stairs

• No prior respiratory-related hospitalizations or ED visits but internist gave her albuterol several months ago – uses several times a week with some relief

• Started smoking age 15; smokes 2 packs per day

• No other significant past medical history


Case, cont’d.

• Vital signs– BP: 138/78 mmHg; HR: 88 beats per minute; RR:

22 breaths per minute; afebrile; BMI: 21; O2 saturation at rest: 94%

• No acute distress• Cardiac exam unremarkable• Lungs

– Diminished breath sounds– Prolonged expiratory phase– Scattered end-expiratory wheezing

• No peripheral edema; no clubbing

17

• Spirometry (post-bronchodilator):– FEV1/FVC: 0.65

– FEV1: 60% predicted

• COPD assessment test (CAT) score: 17

• 6 minute hall walk: 1000 feet with no desaturation

Case, cont’d.

Case: GOLD ABCD Assessment Tool

© 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. Used with permission. Do not reproduce in print. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report.

http://goldcopd.org/gold-reports/

© 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. Used with permission. Do not reproduce in print. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report.

http://goldcopd.org/gold-reports/

18

Additional Recommendations by Group

Patient Group Essential Recommended

A • Smoking cessation • Physical activity• Flu and pneumonia

vaccines

B-D • Smoking cessation• Pulmonary

rehabilitation

• Physical activity


Acute Exacerbations

Potential Causes of Exacerbations

• Respiratory viral infections or (less often) bacterial infections

• Environmental factors– Pollution

– Ambient temperature

• Short-term exposure to fine particulate matter


19

Prevention of Exacerbations

• Prevention of exacerbations is key– Lung function may never recover to baseline

• Frequent exacerbators have worse outcome and morbidity

• Available tools to help prevent exacerbations:– Pharmacotherapy– Patient education– Vaccinations– Pulmonary rehabilitation

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/ Corbridge S, et al. Am J Nurse. 2012;112(3):46-57.

Recognizing Acute Exacerbations

• Defined as an acute worsening of respiratory symptoms that result in additional therapy– Associated with increased airway inflammation, increased

mucus production, and marked gas trapping• Symptoms include:

– Dyspnea– Increased sputum purulence and volume– Increased cough and wheeze

• Symptoms typically last 7-10 days, but may last longer– 20% of patients have not recovered to their pre-

exacerbation state at 8 weeks

When to Hospitalize

• Potential indications for hospital assessment:– Severe symptoms Sudden worsening of resting dyspnea High respiratory rate Decreased oxygen saturation Confusion and/or drowsiness

– Acute respiratory failure– Onset of new physical signs (eg, peripheral edema)– Failure of an exacerbation to respond to initial medical

management– Presence of serious comorbidities (eg, heart failure,

newly occurring arrhythmias, etc.)– Insufficient home support

20

Management of Exacerbations

• Pharmacotherapy and optimizing oxygenation and ventilation are cornerstones of management

• More than 80% of patients can be treated at home

• Treatment options:– Bronchodilators– Glucocorticoids– Antibiotics– Respiratory support

GOLD Recommendations for Management of Exacerbations

GOLD Recommendation Evidence Category

SABA with or without short-acting anticholinergics are recommended as the initial bronchodilators to treat an acute exacerbations

C

Systemic corticosteroids can improve lung function (FEV1),oxygenation, and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days

A

Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should not be more than 5-7 days

B

Methylxanthines are not recommended due to increased side effect profiles

B

Non-invasive mechanical ventilation (NIV) should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication

A

A = Randomized controlled trials, rich body of high quality evidence without any significant limitation or bias; B = Randomized controlled trials with important limitations, limited body of evidence; C = non-randomized trials, observational studiesGlobal Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2018 Report. http://goldcopd.org/gold-reports/

Summary

• COPD is a major source of morbidity and mortality in the US and worldwide– Chronically underreported– Exacerbations and comorbidities negatively

impact prognosis

• Diagnose by symptoms and exposure– Use spirometry to confirm– Assess patient impact CAT, MMRC, CCQ

• Use the GOLD ABCD assessment tool

21

Summary

• Use both pharmacological and nonpharmacological treatment options to manage COPD– Prevent exacerbations– Assess inhaler technique– Assess patient adherence

• Most acute exacerbations can be managed at home– Know when to hospitalize patients

Comprehensive Care in COPD: Strategies for Nurse Practitioners References

Asthma, COPD, and Asthma-COPD Overlap Syndrome. The Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/asthma-copd-asthma-copd-overlap-syndrome. Published 2015.

Batterink J, Dahri K, Aulakh A, Rempel C. Evaluation of the use of inhaled medications by hospital in patients with chronic obstructive pulmonary disease. Can J Hosp Pharm. 2012 Mar;65(2):111-118.

Bender B G. Nonadherence in chronic obstructive pulmonary disease patients: what do we know and what should we do next? Curr Opin Pulm Med. 2014 Mar;20(2):132-137.

Cafarella PA, Effing TW, Usmani ZA, Frith PA. Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: a literature review. Respirology. 2012 May;17(4):627-638.

Corbridge SJ, Nyenhuis SM. Promoting Physical Activity and Exercise in Patients with Asthma and Chronic Obstructive Pulmonary Disease. J Nurse Pract. 2017;13(1):41-46.

Corbridge S, Wilken L, Kapella MC, Gronkiewicz C. An evidence-based approach to COPD: part 1. Am J Nurs. 2012 Mar;112(3):46-57; quiz 59,58.

COPD Assessment Test. COPD Assessment Test Website. www.catestonline.org/images/pdfs/CATest.pdf. Published February 24,2012. Updated October 2016.

COPD Diagnosis and Management At-A-Glance Desk Reference – 2016. The Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/copd-diagnosis-management-glance-desk-reference-2016.

Deaths and Mortality-National Center for Health Statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/deaths.htm. Published May 3, 2017.

De Tratto K, Gomez C, Ryan C, Bracken N, et al. Nurses’ Knowledge of Inhaler Technique in the Inpatient Hospital Setting. Clin Nurse Spec: May/June 2014 May/June;28 (3):156–160.

GOLD Spirometry Guide. The Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/gold-spirometry-guide. Published 2010.

Lalani NS. A study of knowledge assessment and competence in asthma and inhaler technique of nurses employed at university teaching hospital. theHealth. 2012;3(1):16-18.

Lareau SC, Yawn BP. Improving adherence with inhaler therapy in COPD. Int J Chron Obstruct Pulmon Dis. 2010 Nov 24;5:401-406.

Laurin C, Moullec G, Bacon SL, Lavoie KL. Impact of anxiety and depression on chronic obstructive pulmonary disease exacerbation risk. Am J Respir Crit Care Med. 2012 May 1;185(9):918-923.

Melani A, Bonavia M, Cilenti V, Cinti C, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011 Jun;105(6):930-938.

Pocket Guide to COPD Diagnosis, Management, and Prevention -2018. The Global Initiative for Chronic Obstructive Lung Disease. http://goldcopd.org/wp-content/uploads/2018/02/WMS-GOLD-2018-Feb-Final-to-print-v2.pdf. Published December 2017.

Press V G, Arora V M, Shah L M, Lewis S L, et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial. J Gen Intern Med. 2012 Oct;27(10):1317-1325.

Sestini P, Cappiello V, Aliani M, Martucci P, et al. Prescription bias and factors associated with improper use of inhalers. J Aerosol Med. 2006 Summer;19(2):127-136.

Spencer P, Hanania NA. Optimizing safety of COPD treatments: role of the nurse practitioner. J Multidiscip Healthc. 2013;6:53-63.

Sriram KB, Percival M. Suboptimal inhaler medication adherence and incorrect technique are common among chronic obstructive pulmonary disease patients. Chron Respir Dis. 2016 Feb;13(1):13-22.

Taking Her Breath Away: The Rise of COPD in Women. American Lung Association. http://www.lung.org/assets/documents/research/rise-of-copd-in-women-full.pdf. Published June 2013.

Treating Tobacco Use and Dependence: 2008 Update. Agency for Healthcare Research and Quality. https://www.lib.jmu.edu/citation/amaguide.pdf. Published August 2008. Updated January 2018.

Developed by Lori Wilken, PharmD. Used with permission.

Appendix: COPD Medication Table

SHORT-ACTING BRONCHODILATORS

Short-Acting Beta2-Agonists (SABA) Short-Acting Muscarinic

Antagonists (SAMA) Combination SABA/SAMA

Drug Albuterol Levalbuterol Ipratropium Albuterol/Ipratropium

Product

Ventolin HFA ProAir HFA

Proventil HFA MDI

90 mcg

Nebulizer Solution

2.5 mg/3 mL (0.083%) vial

Xopenex HFA MDI

45 mcg

Nebulizer Solution

1.25 mg/3mL vial

Atrovent HFA

17 mcg/puff

Nebulizer Solution

500 mcg (2.5 mL) per vial

Combivent SMI Respimat

Albuterol 100

mcg/ Ipratropium 20

mcg

DuoNeb Nebulizer Solution

Albuterol 3mg/

Ipratropium 0.5mg vial

Image

Dosing 1-2 puffs Q4-

6h PRN

2.5 mg Q4-6h PRN

1-2 puffs Q4-6h PRN

1.25 mg Q4-6h PRN

2 puffs Q6-8h PRN

500 mcg Q6-8h PRN

1 inhalation Q6h PRN

3 mL Q6h

Use Preferred use

• Group A without persistent dyspnea • Treatment of an exacerbation

Adverse Effects Tremor, nervousness, palpitations, tachycardia, hypokalemia,

insomnia, hyperglycemia

Dry mouth, metallic taste, constipation, urinary retention,

tachycardia, blurred vision, precipitation of narrow angle

glaucoma, increased CV events

See Individual SEs

Advantages Reduces symptoms, temporary increase in FEV1, increased exercise endurance Combo provides greater change in spirometry than either agent alone.

Improved adherence

Disadvantages Lack of clinical studies to support use in Group A Response varies

by patient and may be less than SAMA Lung Health Study showed no

effect on decline in FEV1 See Individual SEs


LONG-ACTING BRONCHODILATORS

Long-Acting Muscarinic Antagonists (LAMA)

Drug Tiotropium Aclidinium Umeclidinium Glycopyrrolate

Product Spiriva Respimat

2.5 mcg

Spiriva Handihaler DPI

18 mcg

Tudorza Pressair DPI

400 mcg

Incruse Ellipta DPI

62.5 mcg

Seebri Neohaler

15.6 mcg

Image

Dosing 2 inhalations DAILY

1 capsule for inhalation DAILY

1 inhalation BID

1 inhalation DAILY

1 capsule for inhalation BID

Use Preferred use • Alone in Group A, Group B, or Group C

• Use with LABA in Group D Step up

• With LABA in Groups B and C • With LABA and ICS in Group D

Adverse Effects Dry Mouth, blurred Vision, constipation, urinary retention, worsening glaucoma

Advantages Decreases exacerbations and hospitalizations

Improves symptoms Dosed once daily

Gold standard COPD medication Approved for asthma

Locking mechanism after last dose Propellant free (Respimat)

Decreases hospitalizations

Improves symptoms

Indicator window for proper dose

delivery

Improved QOL and FEV1

Quick onset

Decreases exacerbations

and hospitalizations

Improves symptoms

Disadvantages Difficult to assemble

Twisting may be difficult for patients with low dexterity More side effects

with CrCl <60

Capsule for inhalation may be confusing

and/or challenging, especially with poor

dexterity Product phasing out

Difficulty with using unique inhaler

Lacks evidence for use Capsule for inhalation may be confusing

and/or challenging, especially with poor

dexterity


LONG-ACTING BRONCHODILATORS

Ultra-Long-Acting Beta2-Agonists (LABA)

Long-Acting Beta2-Agonists (LABA)

Drug Indacaterol Olodaterol Salmeterol Formoterol Arformoterol

Product Arcapta Neohaler DPI

75 mcg

Striverdi Respimat

2.5 mcg

Serevent Diskus DPI

50 mcg

Perforomist

20 mcg/2mL

Brovana Nebulization Solution

15 mcg/2mL

Image

Dosing 1 capsule for inhalation DAILY

2 inhalations DAILY

1 inhalation BID

1 vial BID

1 vial BID

Use

Preferred use • Alone in Group A or Group B

• Use with LAMA or ICS in Group D Step up

• With LAMA in Groups B and C • With LAMA and ICS in Group D

• Group C/D: combined with ICS or with LAMA

Adverse Effects

Dry Mouth Tremor

Chest pain Blurry vision Sore throat Headache

Cough Nasopharyngitis

Hypokalemia Hyperglycemia

Nasopharyngitis Back pain Bronchitis

Cough QTc prolongation

Upper respiratory tract infection


Cough Headache Pharyngitis

Upper respiratory tract infections

Musculoskeletal pain Throat irritation Hypokalemia

Hyperglycemia

Nausea Diarrhea

Dry mouth Tremor


Pain Chest pain Skin rash Diarrhea

Nonspecific pain Sinusitis

Backache Hypokalemia

Hyperglycemia

Individual Advantages

Improves breathlessness, health status, and exacerbation rates

Studied at higher doses of

150 and 300 mg daily

Improves FEV1 and symptoms

Improves FEV1, dyspnea, QOL,

Decreases hospitalizations and

exacerbations

Improves FEV1, dyspnea, QOL,

Decreases hospitalizations and

exacerbations No coordination

Covered by Medicare

Improved FEV1 No coordination

Covered by Medicare

Overall precaution

Avoid use alone in asthma


Long-Acting Muscarinic Antagonist (LAMA)/ Long Acting Beta2-Agonists (LABA)

Drug Umeclidinium/Vilanterol Indacaterol/Glycopyrrolate

Tiotropium/Olodaterol Glycopyrrolate/Formoterol

Product Anoro Ellipta DPI

62.5 mcg/25 mcg

Utibron Neohaler

27.5 mcg/15.6 mcg

Stiolto Respimat

2.5 mcg/2.5 mcg

Bevespi Aerosphere

9 mcg/4.8 mcg

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Dosing 1 inhalation DAILY

1 inhalation BID

2 inhalations DAILY

2 inhalations BID

Use

Preferred use • Group D Step up

• Group B, Group C • In combination with ICS for Group D

Adverse Effects Pharyngitis Sinusitis

Upper respiratory tract infection

Nasopharyngitis Hypertension

Headache

Nasopharyngitis Back pain Backache

Cough Urinary tract infection


Improved FEV1 at 6 months Umeclidinium reversibly

inhibits M3 receptor

Best evidence Improved FEV1 at 52 weeks. Improved QOL

Decreases exacerbations

Improved FEV1 at 52 weeks Tiotropium inhibits M1 to M5

receptors

Improved FEV1, QOL and decreased albuterol use at 6

months Glycopyrrolate inhibits M1 to

M5 receptors

Overall precautions

Worsening narrow angle-glaucoma, BPH, arrhythmias, hypertension, seizures, hyperglycemia and hypokalemia

Disadvantages

Breath actuated Good for only 6 weeks

after opening the foil packaging

Requires capsules - may be difficult for patients with low dexterity

Twisting may be difficult for patients with low dexterity

Moderate-severe renal

impairment may worsen side effects

Prime after 3 days of

not using inhaler

Coordinated actuation and inhalation required

Prime inhaler after 7 days of

not using the inhaler


ANTI-INFLAMMATORY AND BRONCHODILATOR

Inhaled Corticosteroids (ICS)/ Long Acting Beta2-Agonists (LABA)

Drug Budesonide/ Formoterol Fluticasone Propionate/

Salmeterol

Fluticasone Propionate/ Salmeterol

Fluticasone Furoate/ Vilanterol

Product Symbicort HFA MDI

160/4.5 mcg

Advair Diskus DPI

250/50 mcg

Advair HFA MDI

115/21 mcg

Breo Ellipta DPI

100/25 mcg

Image

Dosing 2 inhalations

BID 1 inhalation

BID 2 inhalations

BID 1 inhalation

DAILY

Use

Preferred Use • Asthma + COPD

• Group D Step-up

• Group C or with LAMA in Group D

Adverse Effects Candidiasis (thrush): counsel patient to rinse out mouth; dysphonia; pneumonia; skin bruising; osteoporosis; cataracts; TB

Overall Advantages Decreases exacerbations and hospitalizations and improves QOL

Overall Disadvantages

Increased risk of mortality and pneumonia reported in the TORCH trial (fluticasone propionate alone) Increased risk of pneumonia with fluticasone propionate/salmeterol TORCH trial

Risk factors for pneumonia not dose dependent (current smokers, prior pneumonia, BMI <25 kg/m2, FEV1≥30%-<50%, poor MRC

dyspnea score)

Check for drug interactions


ALTERNATIVE STEP-UP MEDICATIONS

Drug Azithromycin Erythromycin Roflumilast

Product Azithromycin 250

mg Erythromycin Stearate

250 mg

Daliresp Tablets

500 mcg

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Dosing 250 mg/day or

500 mg 3X/week 250 mg

BID 500 mcg PO

DAILY

Use Step-up

Group D added to LAMA+LABA+ICS

Step-up Group D added to LAMA+LABA+ICS

Step-up Group D added to LAMA+LABA+ICS

Adverse Effects

Bacterial resistance and hearing test

impairments

QT prolongation Hepatotoxic N/V,

diarrhea

C. difficile, diarrhea nausea, vomiting, cramps

Hearing loss

QT prolongation

Diarrhea, weight loss, nausea,

headache, abdominal pain,

sleep disturbances


Decreases exacerbations Decreases exacerbations

Decreases exacerbations Prevents hospitalizations

Improves symptoms and QOL

Disadvantages Not effective in current smokers

Limited studies

Contraindicated: Moderate/severe liver impairment Not used in emphysema

Avoid use with theophylline CYP 3A4 substrate Caution In: Cancer patients, latent infections, immunologic

disorders/ immunosuppressant medications, depression or SI


COPD Severity Group

COPD SEVERITY Exacerbations in the

Past 12 Months

C

LAMA

D

LAMA + LABA

>2 or any COPD

related hospitalizations

A

SAMA or SABA or LAMA or LABA

B

LAMA or LABA

1 or less and not

leading to hospitalization

CAT <10 or mMRC 0-1

Few symptoms

CAT <10 or mMRC >2

Many symptoms

Group Recommended

First Choice Step Up Step Up

A

SAMA prn, SABA prn, LABA, LAMA

or SABA and SAMA prn

LAMA or LABA

Alternative Class

B LAMA or LABA LAMA and

LABA Alternative

Class

C LAMA LAMA + LABA or LABA+ICS

LAMA and Roflumilast LABA and Roflumilast

LAMA + LABA + ICS

D LAMA + LABA or LABA+ICS

LAMA and LABA and ICS

Roflumilast Azithromycin ICS Withdraw

Documents

18810 BI COPD CES(2) VM final designed slides 4-12-18 FOR PDF · Flow (L/sec) Volume (L) Normal COPD Graph created by Susan Corbridge. Used with permission. Hyperinflation in COPD