By Scott Cerreta, BS, RRT Director of Education New Guidelines for COPD They keep changing... are you up to speed?

by Scott Cerreta, BS, RRTDirector of Education

www.copdfoundation.org

New Guidelines for COPD They keep changing. . . are you up to

speed?

http://www.copdfoundation.org/

Conflict of Interest Conflict of Interest

I have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.

ObjectivesObjectives

1. Discuss different definitions of COPD

2. Discuss current literature and research that warrants the need to change COPD Guidelines

3. Describe new features of the GOLD Guidelines

4. Describe how these changes will impact diagnosis and treatment recommendations

1. GOLD Definition1. GOLD Definition

• 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 severity in individual patients.

ATS / ERS DefinitionATS / ERS Definition

• Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.

• The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.

NHLBI DefinitionNHLBI Definition

• Chronic Obstructive Pulmonary Disease

• Serious lung disease that over time makes it hard to breathe– Emphysema– Chronic Bronchitis

• Blocked (obstructed) airways make it hard to get air in and out

COPD Foundation DefinitionCOPD Foundation Definition

• Chronic Obstructive Pulmonary Disease

• Serious lung disease that over time makes it hard to breathe– Emphysema– Chronic Bronchitis– Refractory Asthma and– Some forms of bronchiectasis

• Blocked (obstructed) airways make it hard to get air in and out

COPD: Definitions of 21st Century1COPD: Definitions of 21st Century1

• Preventable and treatable

• Airflow limitation that is not fully reversible

• Progressive disease• Abnormal inflammatory

response of the lungs• Subsets of patients

Chronic bronchitis Emphysema

Asthma

COPD

Bronchiectasis Alpha-1 D

eficiency

O2 Dependency

OSA, HTN, Others

Box = FEV1/FVC < 70% or < LLN

Spirometry is REQUIRED for diagnosis

2. Literature Review2. Literature Review

• COPD Gene Study – Dr. Crapo– Why some smokers get COPD & others

don’t– Using HRCT and identified a large

number of people with emphysema despite normal spirometry

• Spiromics – Dr. Rennard– Identifying subsets of people with COPD– collection and analysis of phenotypic,

biomarker, genetic, genomic, and clinical data from subjects with COPD

Observations from ExpertsObservations from Experts

• Not all forms of Emphysema or Chronic Bronchitis are COPD.

• Not all severities of COPD are the same– People with same FEV1 have different

health status, dyspnea scores, comorbidities, exacerbation history, etc.

Dr. Vesbo, Chair of GOLD states:Dr. Vesbo, Chair of GOLD states:

• “Spirometry is essential for the diagnosis of COPD, but it doesn’t fully capture the impact of the disease on individual patients”

• Example: Some patients with Moderate COPD may have severe breathlessness, while others may have Mild COPD but more prone to acute exacerbations

• Both groups require more aggressive therapy than past guidelines would recommend

“COPD HETEROGENEITY”PT # 158 yFEV1: 28 %MRC: 2/4PaO2: 70 mmHg6MWD: 540 mBMI: 30

PT # 262 yFEV1: 33%MRC: 2/4PaO2: 57 mmHg6MWD: 400 mBMI: 21



Cote & Celli

FEV1 / FVC < 70%

I: MildFEV1>80% pred

II:ModerateFEV1 50-80% pred

III: SevereFEV1 30-50% pred

IV: Very SevereFEV1 < 30% pred or FEV1 <50% predicted plus respiratory failure

Active Reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator when needed

Add regular treatment with one or more long-acting bronchodilators: ß2 agonists and anticholinergics

Add rehabilitation

Add ICS for repeated exacerbations

Add LTOT

Surgical interventions

GOLD Treatment of COPDGOLD Treatment of COPD

http://www.goldcopd.org/

3. New Features Added in Dec 20113. New Features Added in Dec 2011

• GOLD Spirometry Classification Stays

• NEW is Assessment Model – ABCD– mMRC dyspnea scale or COPD

Assessment Test (CAT) health status– Spirometry classification and– Exacerbation History

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

Assess symptomsAssess degree of airflow limitation using spirometry

Assess risk of exacerbations

Assess comorbidities


Combined Assessment of COPD

Ris

k (G

OLD

Cla

ssifi

catio

n of

Air

flo

w L

imit

atio

n)

Ris

k (E

xace

rbat

ion

hist

ory)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1CAT < 10

4

3

2

1

mMRC > 2CAT > 10

Symptoms(mMRC or CAT score))

COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD(http://catestonline.org).

Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status

and predicts future mortality risk.


Assessment of Symptoms

Tools: COPD Assessment Test (CAT)Tools: COPD Assessment Test (CAT)

• Measures health status

– Based on 8 questions

– Score from 0 to 5

– High scores = symptoms

• May predict exacerbation

• May reveal improvement after

attending Rehab

http://www.catestonline.org/english/index.htm


Modified MRC (mMRC)Questionnaire



(C) (D)

(A) (B)

mMRC 0-1CAT < 10

mMRC > 2CAT > 10


If mMRC 0-1 or CAT < 10: Less Symptoms (A or C)

If mMRC > 2 or CAT > 10: More Symptoms (B or D)

Assess symptoms first


Classification of Severity of Airflow Limitation in COPD*

In patients with FEV1/FVC < 0.70:

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1


Assess Risk of Exacerbations

To assess risk of exacerbations use history of exacerbations and spirometry:

Two or more exacerbations within the last year or an FEV1

< 50 % of predicted value are indicators of high risk.

Tease Out All ExacerbationsTease Out All Exacerbations

• Must assess all exacerbations – increase in symptoms that requires change in tx– Hospitalizations– ER / Urgent Care visits– PCP / Pulmonologist visit

• Ask about infection or use of antibiotics, the most common cause of exacerbation



Ris

k (G

OLD

Cla

ssifi

catio

n of

Air

flo

w L

imit

atio

n)

Ris

k (E

xace

rbat

ion

hist

ory)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1CAT < 10

4

3

2

1

mMRC > 2CAT > 10


If GOLD 1 or 2 and only 0 or 1 exacerbations per

year: Low Risk (A or B)

If GOLD 3 or 4 or two ormore exacerbations per

year: High Risk (C or D)

Assess risk of exacerbations next



Ris

k (G

OLD

Cla

ssifi

catio

n of

Air

flo

w L

imit

atio

n)

Ris

k (E

xace

rbat

ion

hist

ory)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1CAT < 10

4

3

2

1

mMRC > 2CAT > 10


Patient is now in one offour categories:

A: Less symptoms, low risk

B: More symptoms, low risk

C: Less symptoms, high risk

D: More symptoms, high risk

Use combined assessment

Patient Characteristic Spirometric Classification

Exacerbations per year

mMRC CAT

ALow Risk

Less SymptomsGOLD 1-2 ≤ 1 0-1 < 10

BLow Risk

More SymptomsGOLD 1-2 ≤ 1 > 2 ≥ 10

CHigh Risk

Less SymptomsGOLD 3-4 > 2 0-1 < 10

DHigh Risk

More SymptomsGOLD 3-4 > 2 > 2

≥ 10


Combined Assessment of COPDWhen assessing risk, choose the highest risk according to GOLD grade or exacerbation history

Maintenance Care vs. Acute CareMaintenance Care vs. Acute Care

• Typical hospitalization requires aggressive medication management

• Goal is to return patient to baseline treatment recommendations

• Maintenance Therapy requires the least amount of medication to control patient symptoms and health status


Manage Stable COPD: Pharmacologic Therapy(Medications in each box are mentioned in alphabetical order, and

therefore not necessarily in order of preference.)

Patient First choice Second choice Alternative Choices

ASAMA prn

or SABA prn

*LAMA or

LABA or

SABA and SAMA

Theophylline

B*LAMA

or LABA

*LAMA and LABA SABA and/or SAMATheophylline

C

*ICS + LABAor

*LAMA *LAMA and LABA*PDE4-inh.

SABA and/or SAMATheophylline

D

*ICS + LABAor

*LAMA

ICS and *LAMA or*ICS + LABA and *LAMA or

*ICS+LABA and *PDE4-inh. or*LAMA and LABA or

*LAMA and *PDE4-inh.

CarbocysteineSABA and/or SAMA

Theophylline

Impact on symptoms

and lungfunction

Negativeimpact on

quality of life

Consequences Of COPD Exacerbations

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

Scenario 1Scenario 1

Step 1: assess mMRC or CAT. mMRC=1– Left side, less symptoms

Step 2: assess spirometry = FEV1 43%

assess exacerbation hx = 2– Upper side, high risk

• Assessment Score = C


• Old GOLD

– FEV1 = 43%

– Severe Stage 3

• Recommended Tx

– LABA or LAMA or LABA + LAMA

– ICS

• New GOLD

– FEV1 = 43%, Group C Less symp, Hi risk

• Recommended Tx

– ICS + LABA or LAMA

– PDE4 inh.


Step 1: assess mMRC or CAT. CAT=12– Right side, more symptoms

Step 2: assess spirometry = FEV1

81%assess exacerbation hx = 0

– Lower side, Low risk

• Assessment Score = B


• Old GOLD

– FEV1 = 81%

– Mild Stage 1

• Recommended Tx

– SABA prn

• New GOLD

– FEV1 = 81%, Group B More symp, Low risk

• Recommended Tx

– LAMA or LABA


Step 1: assess mMRC or CAT. mMRC=4– Right side, more symptoms

Step 2: assess spirometry = FEV1

56%assess exacerbation hx = 5

– Upper side, High risk

• Assessment Score = D


• Old GOLD

– FEV1 = 56%

– Moderate Stage 2

• Recommended Tx

– SABA prn

– LABA or LAMA or LABA + LAMA

• New GOLD

– FEV1 = 56%, Group D More symp, Hi risk

• Recommended Tx

– ICS + LABA or LAMA

– PDE4 inh.

– Add everything else

Prevention of COPD is to a large extent possible and should have high priority

Spirometry is required to make the diagnosis of COPD; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of

persistent airflow limitation and thus of COPD

The beneficial effects of pulmonary rehabilitation and physical activity cannot be overstated

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Summary

“COPD HETEROGENEITY”PT # 158 yFEV1: 28 %MRC: 2/4PaO2: 70 mmHg6MWD: 540 mBMI: 30




Cote & Celli

All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results.

If exercise training is maintained at home the patient's health status remains above pre-rehabilitation levels.


Therapeutic Options: Rehabilitation

COPD Pocket ConsultantCOPD Pocket Consultant

Mobile App – Coming SoonMobile App – Coming Soon

SummarySummary

• Dx of COPD requires Spirometry but definitions vary and change with new evidence

• Tx of COPD requires new assessment– Spirometry, dyspnea score, exacerbation

hx and consider comorbidities

• New ABCD assessment model is more accurate and will improve pt outcomes

• Learn how you can implement this model into your system to decrease hospitalization rates

COPD is:Almost Always Preventable.

Almost Always Treatable.Someday Curable.

Thank You !

ReferencesReferences

ReferencesReferences

1. GOLD Guidelines http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html

2. COPD Gene Study http://www.copdgene.org/

3. Spiromics http://www.cscc.unc.edu/spir/

4. COPD Foundation http://www.copdfoundation.org

http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html

http://www.copdgene.org/

http://www.cscc.unc.edu/spir/

http://www.cscc.unc.edu/spir/



Documents

By Scott Cerreta, BS, RRT Director of Education New Guidelines for COPD They keep changing... are you up to speed?