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COPD: A Common Four Letter Word Chapter V‐‐ Toward a Better Understanding of Treatment Neil Waravdekar, MD, FCCP Frederick Medical & Pulmonary Associates

COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

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Page 1: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

COPD: A Common Four Letter WordChapter V‐‐Toward a Better Understanding of Treatment 

Neil Waravdekar, MD, FCCPFrederick Medical & Pulmonary Associates

Page 2: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Disclosures: None

Sign in for CME Credit for attendingRemember to complete CME evaluation also

Page 3: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Dr. Gough’s Assignment

CME lecture

Everything about COPD

Keep it understandable

1 hour

Page 4: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Dr. Koilpillai’s Amendment

No problem with time limitsAs much time as you need

We will cover many topics in the next three hours

Page 5: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Quick summary about me:Frederick Native / Local talentGrew up in IjamsvilleGraduated from TJ High SchoolU of MD, College Park

BS, MicrobiologyHahnemann University (Drexel), Philadelphia, PA

MA, PhysiologyMDInternship & Residency

Page 6: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Penn State / Hershey Medical CenterPulmonary / CC Fellowship Instructor of Medicine

Frederick Medical & Pulmonary Associates  1995

Page 7: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

When to refer to a Pulmonologist

Help needed in managing patientNew diagnosis of COPDModerate/Severe/Very Severe COPDPoor response to meds or failure of treatmentExacerbations in a year

2 or more – outpatientI or more inpatient

On oxygenCo‐morbidities

heart disease, arrhythmias, DM and steroidsOther

Page 8: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in
Page 9: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

COPD may be a four letter word, but so is

EXAM

Page 10: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q1.

A medication delivered by a nebulizer is better received at the alveolar level than one by metered dose inhaler.

A. TrueB. False

Page 11: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A1.

B. False

With proper inhaler technique both are approximately equal

Page 12: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Proper inhaler technique

MDIs are an issueCorrect use ensures delivery (or not)

Re‐educate for proper use

Demonstration

Spacers?

Page 13: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Nebulizers: balance of help and nuisance

Utility:very youngvery oldpoor inhaler techniquefrequent exacerbations

NW advice:  Never worship at the temple of the nebulizer when you should be in the ER

Page 14: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q2.Beginning in 2001 a consensus report has been developed by experts in science and industry throughout the world and has been released and  frequently updated to help in the diagnosis, treatment and management of COPD based on scientific and academic information. What is the name of that group?

A.  STARTB.  STOPC.  GOLDD.  BLU

Page 15: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A2.C. GOLD

START is what one does at the beginning of an exam or race and  STOP is what is done at completion. GOLD is

Global Initiative for Chronic Obstructive Lung Disease

Blu is an e cigarette and these are notrecommended.

Page 16: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

United StatesUnited States

United Kingdom

ArgentinaArgentina

AustraliaAustralia

BrazilBrazil

AustriaCanadaCanada

Chile

Belgium

ChinaChina

DenmarkDenmark

ColumbiaColumbia

CroatiaCroatia

EgyptEgypt

Germany

Greece

IrelandIreland

ItalyItaly

SyriaSyria Hong Kong ROC

Japan

Iceland

IndiaIndia

KoreaKorea

Kyrgyzstan

UruguayUruguay

MoldovaMoldova

NepalNepal

Macedonia

Malta

Netherlands

New Zealand

PolandPoland

NorwayNorway

Portugal

GeorgiaGeorgia

Romania

Russia

SingaporeSlovakia

Slovenia Saudi ArabiaSaudi Arabia

South AfricaSouth Africa

SpainSwedenSweden

ThailandThailand

SwitzerlandSwitzerland

UkraineUkraine

United Arab EmiratesUnited Arab Emirates

Taiwan ROC

VenezuelaVenezuela

Vietnam

Peru

Yugoslavia

Bangladesh

France

Mexico

Turkey Czech Republic

Pakistan

Israel

GOLD National Leaders

PhilippinesYeman

Kazakhstan

Mongolia

Albania

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Page 17: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

2001  annual reports/updates

www. GOLDCOPD.ORG

Very helpful

At times biased

Page 18: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q3.

What sport has participants such as Dale Jr., Danica Patrick and the Busch brothers? (My favorite sport)

A. SoccerB. TennisC. NASCARD. Golf

Page 19: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A3.

C. NASCAR

National Association for Stock Car Auto Racing

Page 20: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

IF someone mentions NASCAR,

THEN the question that follows is:

Who is your driver?

Page 21: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Nickname:    SMOKE

Page 22: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Old notion:10‐15% of smokers develop COPD“a minority of those who smoke get COPD”not correct

Newer concept:50% of smokers followed longitudinally in 

studies develop COPD

Lundback, Resp. Med. 97: 115‐22, 2003

Page 23: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk factors for developing COPD

1. Smokinga.  Cigaretteb.  Pipe/cigarc.  MJd.  Passive:  second hand smokee.  Pregnancy

risk to fetus in uterodecreased lung development

Page 24: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk factors for developing COPD

2. Occupationaldusts fumesparticles

4. Air pollution              

Page 25: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk factors for developing COPD

5. Smoke exposure in non‐smokersbiomass fuels

wooddungcrop wastecoal

poorly ventilated structure3 billion people in world

Page 26: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk factors for developing COPD6. Age7. Sex

M = Fmore females are smokingsome studies females more susceptible,

others not (?)8. Asthma

poorly controlled asthma leads to irreversible airway obstruction

Page 27: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk factors for developing COPD

9. Excessive mucus production10.  Family history of COPD

Page 28: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

For your practice:We just  identified who may be at risk for COPD:‐ Smoker‐ Dust/particle/fume exposure‐ Chronic cough/sputum production‐ SOB‐ Older patient‐ Poorly controlled asthmatic‐ Family history of COPD

Page 29: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

GOLD 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 a 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.”

Page 30: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Things to notePreventableTreatablePersistent airflow limitationProgressiveInflammatory response

No specific mention of:

Page 31: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Our specific old friends

Emphysema Chronic Bronchitis

Page 32: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

New concepts since I got in the game

Use of single agent LABAs(COPD not Asthma)

LAMAsICS use in COPD (ICS/LABA)Reversibility in not just asthma but also COPDProgressive nature of COPD even after the 

offending insult ceases‐running theme

Page 33: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q4.Josephine Kamal is a 54 YO F heavy equipment operator and mechanic who is a smoker, has frequent cough with sputum production and SOB. Mom and Dad (also smokers) had COPD. Which test will help you in determining the severity of COPD?

A.  WBCB.  SpirometryC.  Cholesterol profileD.  Serum porcelain level

Page 34: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A4.B. Spirometry

Assesses airway obstruction

(FYI: use of statins to prevent  AE COPD showed no positive effect.)

Grinder, NEJM 374: 685‐94,  2013

Page 35: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Spirometry

Normal

53 YO M

FVC  4.24L , 102%FEV1  3.46L, 106%FEV1/FVC  82% 

Effort is key!Coaching is allowed.

Page 36: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

SpirometryAbnormalObstruction“Moderate obstruction”

71 YO M with COPD

FVC  2.74L, 58%FEV1  1.59L, 46%FVC1/FVC  58%

Page 37: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Spirometry

By GOLD Criteria:FEV1/FVC ratio < 0.70 (70%)

FVCFEV1FEV1/FVC

Page 38: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

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

NOTE: Based on Post-Bronchodilator FEV1

GOLD

GOLD Stage of COPD by FEV1

Page 39: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

NW hint:

How I remember this:≥80<80 – ≥50<50 – ≥30<30

Page 40: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

SpirometryAbnormalObstruction“Moderate obstruction”

71 YO WM with COPD

FVC  2.74L, 58%FEV1  1.59L, 46%FVC1/FVC  58%GOLD 3Severe COPD

Page 41: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q5.

Does the stage of COPD help us define patients at risk and patients with higher mortality?

A.  YesB.  No

Page 42: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A5.

A.  Yes

Page 43: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Assessing  RiskFEV1 < 50 %, Gold 3 or Gold 4 = High risk patients

Also

Two or more exacerbations within the last year = High risk patient

One or more hospitalizations for COPD exacerbation = High risk patient

GOLD

Page 44: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Mortality and GOLD Stage

Stage FEV1 3 yr. mortalityGOLD 1 ≥80 ?GOLD 2 50‐80 11% (UPLIFT)GOLD 3 30‐50 15% (TORCH)GOLD 4 <30 24% (ECLIPSE)

GOLD

There are also other predictors of survival (ex. BODE).Bottom line:Higher GOLD Stage = worse mortality

Page 45: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Old NASCAR saying:“Cautions breed cautions.”Translation:  when you have problems, these lead to more problems.

New Pulmonary understanding:Exacerbations lead to exacerbations (and decline in lung function).

Page 46: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q7.

Our patient, Josephine Kamal, an active smoker, is diagnosed with COPD (GOLD 2) with an FEV1 of 71% post BD.  Initiation of a medication is an important first intervention.

A.  TrueB.  False

Page 47: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A7.

B. False

Smoking cessation is paramount to treating COPD.

Page 48: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPD

“Young doctor, without having your patient stop smoking, nothing can be accomplished.”

Clifford Zwillich, MD(on rounds at Penn State c. 1993)

Issues:Lung functionOptimization of efficacy of medsMy personal concern:  opening them up to 

inhale more smoke

Page 49: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPDLike falling down an elevator shaft

Page 50: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPDLung Function

Murray and Nadel, p. 761, 2015

Page 51: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPDReal Patient

Active smoker 5/21/2014 Quit Smoking (5/22/14) 4/20/2016FVC = 1.84L  FEV1 = 1.26L 53% FVC = 2.50L  FEV1 = 1.92L 83%

GOLD 2Moderate←

Normal→ 

WOW!

Page 52: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPD

NW rule:The first 3 things to think of in COPD are:

1.  STOP SMOKING2.  STOP SMOKING3.  STOP SMOKING

Page 53: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Smoking and COPD

FMH Smoking Cessation ClinicShanna Figgins, Resp Care240‐566‐[email protected]

FREE!

Page 54: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q8.

Which of the following have been shown to prevent AE COPD (acute exasperations of COPD)?

A.  PPSV23 (Pneumovax)B.  Influenza vaccineC.  BothD.  Neither

Page 55: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A.8.B. Influenza vaccine

ACCP/CTS guidelinesPPSV23

no improvement in AE COPD but is recommended, decreases CAP in COPD pts with FEV1 <40%

Influenza vaccinedecreases AE COPD and is recommended

NW bottom line:  Give pulmonary vaccines

Chest 147(4): 894‐942 Prev. of AE COPD. ACCP & ATS Guidelines, 2015

Page 56: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Q9.

Which agent should not be used alone in COPD?A.  ICS (inhaled corticosteroid)B.  LABA (long acting beta2 agonist)C.  LAMA (Long acting muscarinic agonist)

Page 57: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

A9.

A. ICS

Use ICS/LABA

For moderate, severe and very severe COPD use of ICS alone is not indicated. ICS/LABA does decrease exacerbations and thus is approved

NW caveat:  Use of a LAMA/LABA and ICS would be ok

Chest 147(4): 894‐942 Prev. of AE COPD. ACCP & ATS Guidelines, 2015

Page 58: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

The Main Event

What you have been waiting for:

HOW DO I CHOSE COPD MEDS FOR MY PATIENT?

Stratify by GOLD Stage (and/or exacerbation history) and symptoms.

Remember, you are not alone.    

Page 59: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

COPD Treatment

The medications:SABA:  albuterol, levalbuterolSAMA:  ipratropium

(M=muscarinic=anticholinergic)LABA:  formoterol, aformoterol, indacterol, 

olodaterol, salmeterol, vilanterolLAMA:  aclidinium, tiotropium, umeclindiniumICS:  beclomethasone, budesonide, fluticasoneOthers

Page 60: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk

(GOLD

 Classificatio

n of Airflow Lim

itatio

n))

Risk

(Exacerbation history)

≥ 2or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

0

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10 

BreathlessnessmMRC  0–1 mMRC > 2

COPD Treatment

GOLD Exacerbations

Page 61: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk

(GOLD

 Classificatio

n of Airflow Lim

itatio

n))

Risk

(Exacerbation history)

≥ 2or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

0

Symptoms

Low SXHigh Risk

High SXHigh Risk

Low SXLow Risk

CAT < 10

4

3

2

1

CAT > 10 

BreathlessnessmMRC  0–1 mMRC > 2

COPD Treatment

GOLD Exacerbations

High SXLow Risk

Page 62: COPD: A Common Four Letter Word - FIHN Aco...Apr 28, 2016  · New diagnosis of COPD Moderate/Severe/Very Severe COPD Poor response to meds or failure of treatment Exacerbations in

Risk

(GOLD

 Classificatio

n of Airflow Lim

itatio

n))

Risk

(Exacerbation history)

≥ 2or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

0

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10 

BreathlessnessmMRC  0–1 mMRC > 2

COPD Treatment

GOLD Exacerbations

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COPD Treatment

Assessing DyspneamMRC: Modified Medical Research Council QuestionnaireNW versionGrade Symptoms occur with:0 No/ only with strenuous exertion1 Rushing or Hill2  Level ‐ walk slow or stop3  Level – stop 100 yards 4  Dressing or don’t go out

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COPD Treatmentm MRC Questionnaire

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Risk

(GOLD

 Classificatio

n of Airflow Lim

itatio

n))

Risk

(Exacerbation history)

≥ 2or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

0

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10 

BreathlessnessmMRC  0–1 mMRC > 2

COPD Treatment

GOLD Exacerbations

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Exacerbatio

ns per year

0

CAT < 10mMRC 0‐1

GOLD 4

CAT > 10 mMRC > 2

GOLD 3

GOLD 2

GOLD 1

SAMA prnor

SABA prn

LABA or

LAMA

ICS + LABAor

LAMA

RECOMMENDED FIRST CHOICE

A B

DC

ICS + LABAand/orLAMA

2 or more or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

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Exacerbatio

ns per year

0

CAT < 10mMRC 0‐1

GOLD 4

CAT > 10 mMRC > 2

GOLD 3

GOLD 2

GOLD 1

ALTERNATIVE CHOICE

A B

DC

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

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Exacerbatio

ns per year

0

CAT < 10mMRC 0‐1

GOLD 4

CAT > 10 mMRC > 2

GOLD 3

GOLD 2

GOLD 1

OTHER POSSIBLE TREATMENTS

A B

DC

2 or more or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

SABA and/or SAMA

Theophylline

Carbocysteine

N-acetylcysteine

SABA and/or SAMA

Theophylline

TheophyllineSABA and/or SAMA

Theophylline

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Exacerbatio

ns per year

0

CAT < 10mMRC 0‐1

GOLD 4

CAT > 10 mMRC > 2

GOLD 3

GOLD 2

GOLD 1

SAMA prnor

SABA prn

LABA or

LAMA

ICS + LABAor

LAMA

NW recommends:RECOMMENDED FIRST CHOICE

A B

DC

ICS + LABAand/orLAMA

2 or more or

> 1  leadingto  hospitaladmission

1 (not leadingto hospitaladmission)

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COPD Treatment

Other Pharmacologic issues:NW summary ACCP/CTS guidelines LABAs and LAMAs preferred over SABAs and SAMAs Combined use of a short or long acting beta agonist and anticholinergic may be considered if sx not improved with single agents

In general theophylline not recommended Phosphodiesterase 4 Inhibitor, roflumilast, maybe used to decrease exacerbations in pts with severe or very severe COPD (FEV1 < 50%)

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Q10.

Long term therapy with oral steroids would be recommended in the treatment of COPD.

A.  TrueB.  False

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A10.

B.  False

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COPD Treatment

Other Pharmacologic issues:NW summary ACCP/CTS guidelines Long term use of oral corticosteroids is not recommended.

Oral steroid may be given to prevent hospitalization for subsequent  AE COPD in the first 30 days following the AE

Using steroids to treat outpatient AE COPD is acceptable

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COPD Treatment

Other NON‐PharmacologicNW summary GOLD and/or ACCP/CTS guidelines Smoking cessation

remember NW rule Pulmonary rehab

groups B, C, Dwithin 4 weeks of AE COPD

Daily physical exercise Pulmonary vaccines Palliative Care

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COPD Exacerbations

Exacerbations are……..A. not just a hospitalizationB. “an event that increases dyspnea, cough and/or 

sputum beyond day to day variance and may require a change in COPD medicines”

C. under reported by patientsD. a nuisance to you and the patientE. a cause of permanent loss of lung function

NW: think of AE COPD along the same line as an MI or a stroke but involving the lungs

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COPD Exacerbations

Treatment modalities:Antibiotics Steroids Oxygen Bronchodilators

SABAsHospitalization

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COPD Exacerbations

To reduce exacerbations be pre‐emptive Smoking cessation Pulmonary vaccines LABAs ICS/LABA LAMA PDE 4 I Macrolides NAC Pulmonary rehab

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When to refer to a Pulmonologist

Help needed in managing patientNew diagnosis of COPDModerate/Severe/Very Severe COPDPoor response to meds or failure of treatmentExacerbations in a year

2 or more – outpatientI or more inpatient

On oxygenCo‐morbidities

heart disease, arrhythmias, DM and steroidsOther

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Closing: one lap to go 

I know you are thinking, “thank God!”

Ask your patients (because they don’t tell) about: Smoking

If  they don’t get irritated, they started again Med use

All of them?Price is an issue

SOB Level of activity

“ok” is a non‐answer↑ SOB  =  ↓ Ac vity  → Muscle loss → Death

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Questions?

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