COPD Management in 2017

Leonardo Seoane M.D., F.A.C.P.

Associate Professor

Head of School

UQ-Ochsner Clinical School

Objectives

• Review the new 2017 GOLD

guidelines

• Define COPD and classify by

severity

• Apply the treatment guidelines to

clinical case

• Develop COPD quality indicators

for your clinic

Risk Factors for COPD

Nutrition

Infections

Socio-economic

status

Aging Populations

Assessment of severity of airflow obstruction and prognosis

Follow-up therapeutic response

Consider alternative diagnosis

Discrepancy between spirometry and level of symptoms

Therapeutic decisions including procedural approaches

Identification of rapid decline

Spirometry: Normal and

Patients with COPD

Normal Inspiration

Expiration

alveolar attachments

Mild/moderate

COPD

loss of elasticity

Severe

COPD

loss of alveolar attachments

closure

small

airway

Dyspnea

↓ Exercise capacity

Air trapping

Hyperinflation ↓ Health

status

Air Trapping in COPD

Source: Peter J. Barnes, MD

Performance Metric

Spirometry

What % of patients seen in your clinic with risk factors

and symptoms of COPD had spirometry done and

documented?

The most available, reproducible, standardized and

objective way to measure exhalation air flow limitation.

Although spirometry is essential to diagnose COPD

it is not indicated in asymptomatic individuals

Case 1

• Danny is a 60 y/o male with a history of COPD and 50 pack year history of tobacco.

He quit smoking 5 years ago and has a good support system at home (His wife). He

is coming in for a routine visit, he states he is annoyed about getting SOB climbing up

a flight of stairs at home or walking up the hill to his garden. His spirometry in the

office demonstrates a FEV1/FVC ratio of 50% and FEV1 of 45% predicted. He has

had to visit the clinic twice in the past year for increasing SOB and cough due to his

COPD.

• What is his GOLD classification using refined ABCD assessment tool?

• A Grade 3

• B Grade 3

• C Grade 3

• D Grade 3

Global Strategy for Diagnosis, Management and Prevention of COPD

Assessment of COPD

Assess spirometry

Assess symptoms

History/future risk of exacerbations

Assess comorbidities

© 2014 Global Initiative for Chronic Obstructive Lung Disease

The Refined ABCD Assessment Tool

GOLD guidelines 2017

Modified Medical Research Council (mMRC)

Dyspnea Scale

Grade Description of Breathlessness

0 I only get breathless with strenuous exercise.

1 I get short of breath when hurrying on level ground our walking up a

slight hill.

2 On level ground, I walk slower than people of the same age because of

SOB, or have to stop for breath when walking at my own pace

3 I stop for breath after walking about 100 yards or after a few minutes on

level ground

4 I am too breathless to leave the house or I am breathless when

dressing.

COPD Assessment Test (CAT)

Score

I have cough I cough all the time

I have no phlegm My chest is full

My chest does My chest feels very

Not feel tight tight

When I walk up When I walk up a

Stairs I am not f light of stairs I am very

Breathless breathless

I am not limited I am very limited

doing home activities

I am confident I am not confident leaving

Leaving my home

I sleep soundly I don’t sleep soundly

I have lots of I have no energy at all

energy

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

0 1 2 3 4 5

0 1 2 3 4 5

0 1 2 3 4 5

Patient Characteristic Spirometric

Classification

Exacerbations

per year

CAT mMRC

A Low Risk

Less Symptoms GOLD 1-2 ≤ 1 < 10 0-1

B Low Risk

More Symptoms GOLD 1-2 ≤ 1 > 10 > 2

C High Risk

Less Symptoms GOLD 3-4 > 2 < 10 0-1

D High Risk

More Symptoms GOLD 3-4 > 2 > 10

> 2

Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD When assessing risk, choose the highest risk according to GOLD grade or

exacerbation history. One or more hospitalizations for COPD exacerbations should

be considered high risk.)

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Case 1 continues

• What treatment options would you recommend to Danny at this stage?

Goals for Treatment of Stable COPD

GOLD guidelines 2017

Principles of COPD Management

1. Individualized approach based on symptom severity and quality of life

2. Smoking status and risk factors addressed with intervention to improve

cessation

3. Appropriate inhaler technique

4. Screen for Depression and co-morbidities

5. Exercise and rehabilitation (strength & condition)

6. Vaccine, Influenza and Pneumococcal

Fletcher C and Peto R. BMJ. 1977;1:1645-1648.

severe

Smoking and smoking cessation in relation to

mortality in women JAMA 2008;299(17):2037-47

• Tobacco use remains the leading preventable cause of

death in the U.S.

• Background

– WHO projects 10 million tobacco related death annually by year 2030

– Determine the rate of mortality risk reduction after quitting smoking

• Methods

– Nursing health study

– Population based cohort study 104,519

Smoking Health Effects (>1 ½ packs/day)

• 114 (CI 42-306) times higher risk of COPD

• 40 (CI 30-52) times greater risk of developing lung cancer

• Risk of dying from COPD

– 14 X greater if a current smoker

– 155 X greater (CI 59 to 408) >1 ½ packs/day

• After cessation of smoking

• hazard ratios decline for COPD and lung cancer to rates of

non-smokers after 20 years

• 13% reduction in risk of all-cause mortality within 5 years of

quitting

Performance Metric

Smoking Cessation • Tobacco cessation counseling is recommended for all

who smoke.

• Incorporate tools to Identify smokers who received

smoking cessation counseling during an office visit

• Especially COPD patients who still smoke

Performance Metric

Assessment and Documentation of Pneumococcal

and Influenza Immunizations

CDC recommends that all patients with chronic diseases of the pulmonary system should

be vaccinated.

Influenza vaccination reduces: serious illness, death, and exacerbations

Vaccinations decrease the incidence of lower respiratory tract infections

Pneumococcal vaccinations PCV13 and PPSV23 are both effective

Case 1 continues

• What pharmacologic treatment options would you recommend to Danny at this

stage?

• A) Short acting β-agonist four times a day

• B) Inhaled corticosteroid (ICS) daily

• C) Long acting β-agonist (LABA) daily

• D) Long acting muscarinic Agent daily

Patient Characteristic Spirometric

Classification

Exacerbations

per year

CAT mMRC

A Low Risk

Less Symptoms GOLD 1-2 ≤ 1 < 10 0-1

B Low Risk

More Symptoms GOLD 1-2 ≤ 1 > 10 > 2

C High Risk

Less Symptoms GOLD 3-4 > 2 < 10 0-1

D High Risk

More Symptoms GOLD 3-4 > 2 > 10

> 2

Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD When assessing risk, choose the highest risk according to GOLD grade or

exacerbation history. One or more hospitalizations for COPD exacerbations should

be considered high risk.)

© 2014 Global Initiative for Chronic Obstructive Lung Disease

GOLD 2017 Guidelines

Bronchodilators in stable COPD

• Group A

– Regular and PRN use of SABA or SAMA improves FEV1 and symptoms

(Level A)

• Group B, C, and D

– LABA and LAMA significantly improve lung function, dyspnea, health

status, and reduce exacerbations rates (Level A)

– LAMA have a greater effect on exacerbation reduction compared to

LABA (Level A) and decrease hospitalizations (Level B)

– Combination treatment with LABA and LAMA increase FEV1 and

improve symptoms compared to monotherapy (Level A), reduces

exacerbations (level B)

Anti-inflammatory therapy

• Mainly reduce exacerbations

• ICS/LABA is more effective than either monotherapy in improving

lung function and reducing exacerbations (Level A)

• Regular treatment with ICS increases the risk of pneumonia

especially in those with severe disease (Level A)

– Current smokers

– Prior pneumonia

– Body index < 25

• ICS other side effects

– Oral candidiasis

– Horse voice

– Skin bruising

Anti-inflammatory therapy

• Group D

– ICS/LAMA/LABA in select patients improves lung function, symptoms,

and health status (level A)

• reduces exacerbations compared to ICS/LABA

• LAMA monotherapy

• Long term use of oral glucocorticoids has numerous side effects

(level A) with no evidence of benefits (Level C)

Performance Metric: Inhaler Technique

Performance Metric

Inhaler Technique • Key to routine management of any COPD patient

• Inhaler technique must be observed and checked

regularly

• Technique training a continuous process vs one-off

session at initiation of therapy

• Are patients on long-term inhaled therapy proficient

with their inhaler therapies?

Identify patients seen in pulmonary who had inhaler technique

education and documented.

PDE4 Inhibitors Roflumilast

• PDE4 inhibitors in patients with chronic bronchitis, severe to very severe COPD and a

history of exacerbations improves lung function and reduces moderate to severe

exacerbations (Level A)

• PDE4 inhibitors improve lung function and decrease exacerbations in patients on

LABA/ICS (Level B)

• Frequent Side effects:

– Nausea and Diarrhea

– Reduced appetite

– Weight loss (avoid in underweight patients)

– Sleep disturbance and headaches

• Use with caution in patients with depression

Other agents

• Long term Azithromycin (250mg/day or 500mg 3X week) or

erythromycin (500mg BID) reduce exacerbations in former smokers

(Level A)

– Associated with increase bacterial resistance and hearing test

impairment

• RELIANCE trial roflumilast vs Azithromycin

• Regular use of NAC and carbocysteine reduce the risk of

exacerbations in select populations (Level B)

• Simvastatin does not prevent exacerbations (Level A)

• Leukotriene modifiers have not been tested adequately in COPD

• Vasodilators worsen gas exchange with no improvement in health

status and should be used with caution in patients with pulmonary

HTN and COPD

Pulmonary Rehabilitation Programs

• Patients with high symptom burden and risk of

exacerbations

– Group B, C, D

– Participate in rehab program that considers the individual’s

characteristics and comorbidities

– Combination of constant load or interval training with strength

training provides better outcomes than either method alone

• Reduce readmissions and mortality in patients following

a recent exacerbation (less than 4 weeks prior

hospitalization)

• Tiotropium improves the effectiveness of pulmonary

rehab in increasing exercise performance (Level B)

Treatment of Hypoxemia

• In patients with severe resting hypoxemia long-term oxygen therapy

(>15 hours/day) is indicated as it has been shown to reduce

mortality (Evidence A)

– PaO2 ≤ 55mmHg or SaO2 ≤ 88% confirmed twice over a 3 week period

– PaO2 between 55mmHg and 60mmHg, or SaO2 88% if there is evidence of:

• Pulmonary hypertension

• Peripheral edema suggesting congestive heart failure

• Polycythemia (hematocrit >55)

• ? Moderate hypoxemia or desaturations with activity

Oxygen Therapy for COPD Ann Intern Med. 2017;166:JC17

• Randomized unblinded trial

• Long term oxygen was of no benefit:

– Moderate resting hypoxemia SpO2 89%-93%

– Moderate desaturation with activity (SpO2 decreased to 80% to 89% during 6

MWT)

• Outcomes measured

– Death

– First hospitalization

– COPD exacerbations

– Quality of life

Body mass index Obstruction Dyspnea Exercise Index

Best predictor of survival

0 1 2 3

BMI >21 <21

FEV1 >65 50-64 36-49 <35

MMRC

dyspnea

0-1 2 3 4

6MWT

(m)

>350 250-349 150-249 <149

Adapted from Celli B et al. NEJM

2004;350:1005-12.

4-year predicted

survival

0-2 80%

3-4 67%

5-6 57%

7-10 18%

Palliative Care in COPD

• Breathlessness

– Opiates

– Oxygen and fans blowing air onto the face

• Malnutrition

– Nutritional supplementation improves overall health status

• Fatigue

– Self-management education

– Pulmonary Rehab

– Nutrition

– Mind-body interventions

COPD Checklist for Every Clinic Visit

Smoking cessation

Depression

Spirometry needed?

Inhaler Technique

Vaccinations

Pulmonary rehabilitation

Oxygen needed?

PCP, ER, or Hospital for AECOPD in last

year

Co-morbidities (CAD, osteoporosis, lung

cancer)

Surgical Options needed?

Palliative Care needed?

Management of COPD exacerbations: ERS/ATS Guideline

Eur Respir J March 2017;49:1600791

Recommendation Strength

Quality

of

Evidence

1

For ambulatory patients with an exacerbation of COPD, we suggest a short

course (≤14 days) of oral corticosteroids

Conditional

Very low

2 For ambulatory patients with an exacerbation of COPD, we suggest the

administration of antibiotics Conditional Moderate

3

For patients who are hospitalized with a COPD exacerbation, we suggest the

administration of oral corticosteroids rather than intravenous corticosteroids if

GI access and function are intact

Conditional Low

4

For patients who are hospitalized with a COPD exacerbation associated with

acute or acute-on-chronic respiratory failure, we recommend the use of

noninvasive mechanical ventilation

Strong Low

5

For patients with a COPD exacerbation who present to the emergency

department or hospital, we suggest a home-based management program

(hospital-at-home)

Conditional Moderate

6 For patients who are hospitalized with a COPD exacerbation, we suggest the

initiation of pulmonary rehabilitation within 3 weeks after hospital discharge Conditional Very low

7 For patients who are hospitalized with a COPD exacerbation, we suggest not

initiating pulmonary rehabilitation during hospital stay Conditional Very low

NIMV for COPD

• Reduce WOB

• Improve gas exchange

• Reduce hospital morbidity

• Reduce ICU and Hospital LOS

• Improve Survival

• GOLD Recommends Acute Exacerbations with:

– Respiratory acidosis

– Severe Dyspnea with signs of respiratory failure

• Data for home chronic use inconclusive

• COPD and OSA patients CPAP improves survival and avoids hospitalization

Brochard et al NEJM 1995;333:817-22

Antonelli et al NEJM 1998;339:429-35

Kramer et al AJRCCM 1995;151:1799-1806

Confalonieri et al EurRJ 1996;9:422-30

Bott et al Lancet 1993;341:1555-57