Keeping Current with COPD Management in Family Practice

1. Keeping Current with COPD Management in Family Practice

2. Friday 4:45 pm visit • Nancy—56 yo with cc of bronchitis • Coughing >2 weeks, productive-yellow • ?Fever, some breathlessness climbing stairs • Does not want to go to the ED again • Does not want chest x-ray • Wants antibiotics before the weekend • The last kind she received worked

3. What Will You Do? • Give her the prescription and have her return in 2 weeks for evaluation • Take more history • Explain that she has no fever, no purulent sputum and does not need antibiotics • Begin smoking cessation discussion—she smells like tobacco smoke

4. What Should We Do? • Take more history • Smoker 35 pack years • Third episode of “bronchitis” in past 2 years • Colds last for weeks • Always worse than others • Decrease in activities due to trouble breathing with walking. Now SOB with 6 stairs. • Has “smoker’s cough” for past 3 years • Mother developed “asthma” at age 60 and died of CHF at age 68 • Think chronic lung disease!

5. 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 an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases • Exacerbations and comorbidities contribute to the overall burden of disease in individual patients Vestbo J et al. Am J RespirCrit Care Med 2013; 187: 347-65.

6. Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease • Airway inflammation • Airway fibrosis, luminal plugs • Increased airway resistance Parenchymal Destruction • Loss of alveolar attachments • Decrease of elastic recoil AIRFLOW LIMITATION

7. Burden of COPD • COPD is a leading cause of morbidity and mortality worldwide and third leading cause of death in the US • The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the world’s population • COPD is associated with significant economic burden

8. Why Is COPD Underdiagnosed?Clinicians Tell All Survey of 278 Clinicians MDs NPs/PAs 45 Patient has multiple chronic conditions 64 48 Patient fails to report/recognize dyspnea 50 22 Inadequate knowledge and training 33 20 Patient lacks specific symptoms 22 29 Lacks access to spirometry 21 7 Lack of effective treatment 5 0 10 20 30 40 50 60 70 Perceived Barrier (%) Yawn BP and Wollan PC. Int J COPD. 2008;3(2):311-317.

9. Key Barriers to COPD Diagnosis • COPD not in differential diagnosis • Failure of patients to notice and report symptoms • Early symptoms often do not interfere with activities of daily living • Symptom severity increases very slowly • Failure of health professionals to inquire about respiratory issues • Tools to help • Be specific • Misdiagnosis of COPD as asthma or bronchitis • Underuse of spirometry

10. More about Nancy • Need to treat acute episode but with what? Antibiotics, SABA, steroids? • Diagnosis what she has—asthma, COPD or something else? • Chest x-ray—little help? • Spirometry—can she do it now with cough? • Stress test—maybe breathlessness is CV in origin? • Smoking cessation—Never wrong, time to try! PMH Hypertension—diuretic Osteopenia—Ca and Vit D Hysterectomy—age 51 35 pack year history Multiple ED visits—bronchitis No asthma Family history—CVD, late asthma

11. COPD Population Screener (COPD-PS) 1. During the past 4 weeks, howmuchof the time did you feel short of breath? None of the time A little of the time Some of the time Most of the time All of the time 0 0 1 2 2 2. Do you ever cough up any “stuff,” such as mucus or phlegm? No, never Only with occasional colds or chest infections Yes, a few days a month Yes, most days a week Yes, every day 0 0 1 1 2 3. Please select the answer that best describes you in the past 12 months, I do less than I used to because of my breathing problems. Strongly disagree Disagree Unsure Agree Strongly agree 0 0 0 1 2 4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE? Don’t know No Yes 2 0 0 5. How old are you? Age 60 to 69 Age 70 + Age 35 to 49 Age 50 to 59 0 1 2 2 Martinez FJ, et al. COPD. 2008;5:85-95.

12. Characteristics That Help Distinguish COPD From Asthma Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. • Doherty DE. Am J Med. 2004;117(12A):11S-23S.

13. Key Indicators of COPD • Chronic cough • Present intermittently or every day • Often present throughout the day;seldom only nocturnal • Chronic sputum production • Any pattern chronic sputum production may indicate COPD • Dyspnea that is • Progressive (worsens over month/years) • Persistent (present every day) • Worse with exercise • Worse during respiratory infections

14. Key Indicators of COPD • Presence of risk factors • Host factors • Genetics (alpha-antitrypsin) • Hyperresponsiveness • Lung growth • Exposure to • Tobacco smoke • Smoke from home cooking and heating fuels • Occupational dusts and chemicals

15. COPD Missed Diagnoses Hypothetical male patient with COPD symptoms Hypothetical female patient with COPD symptoms 42% diagnosed as COPD by physicians 32% diagnosed as COPD by physicians COPD symptoms in women were most commonly misdiagnosed as asthma 42% 32% Miravitlles et al. Arch Bronconeumol. 2006;42:3-8.

16. Nancy Needs Spirometry! • Often have to wait 4 to 6 weeks to return to baseline after acute event (exacerbation) • See her before you obtain test or at least evaluate over the phone • Needs pre and post bronchodilator to see about reversibility and if she meets obstruction definition • Need FEV1 and FVC to determine severity and how to begin maintenance therapy

17. Spirometry: Normal Trace Showing FEV1 and FVC FVC 5 4 FEV1 = 4L FVC = 5L FEV1/FVC = 0.8 Volume, liters 3 2 1 1 2 3 4 5 6 1 Time, seconds

18. Spirometry: Obstructive Disease Normal 5 4 3 Volume, liters FEV1 = 1.8L FVC = 3.2L FEV1/FVC = 0.56 Obstructive 2 1 1 2 3 4 5 6 Time, seconds

19. Prebronchodilator andPostbronchodilator Testing • Bronchodilator reversibility testing can help rule out asthma diagnosis and guide initial treatment decisions • Complete or very nearly complete reversibility (return to normal lung function metrics) suggests asthma, whereas partial reversibility (not returning to normal or near normal) suggests COPD1 • Some reversibility is possible in people with COPD2 • Basic Protocol • Give 1 puff, wait 1 minute, then administer the second dose • Wait 20 minutes for the inhaler to take effect • Repeat the pulmonary function study • Compare post results to pre results 1. Doherty DE. Am J Med. 2004;117(12A):11S-23S. 2. Celli BR et al.Resp Med.2011;105(8):1176-1188

20. Algorithm for Interpreting Spirometry Results Acceptable spirogram Yes Is FEV1/FVC ratio low? No Obstructive defect Is FVC low? Yes No Is FVC low? Restrictive defect Normal Yes No Pure obstruction Mixed obstructive/ restrictive defect or hyperinflation Further testing Near-total reversal with use of beta agonist? Yes No Further testing Asthma COPD Petty TL. Spirometry made simple. National Lung Health Education Program website. http://www.nlhep.org/resources/SpirometryMadeSimple.htm.Published January 1999.

21. Nancy’s Numbers • You do spirometry on Nancy and get the following results • Good quality tracing—rated B Pre-bronchodilatorPost-bronchodilator • FEV1 2.2 L 65% pred FEV1 2.7 L 68% pred • FVC 4.0 L FVC 4.1 L • FEV1/FVC 0.55 FEV1/FVC 0.66

22. What is Your Spirometry-Confirmed Diagnosis? • Normal spirometry • Poor quality can’t interpret • Asthma • Obstructive lung disease consistent with COPD • Restrictive lung disease

23. Avoid Interpretation Pitfalls Yawn BP et al. Chest. 2007;132(4):1162-1168.

24. Spirometry Reimbursement • Billing codes and reimbursement for simple spirometry vary by state a Append Modifier -25 code to CPT code in order to be reimbursed for these procedures. b 3 to 10 minutes. c >10 minutes. Final rule Medicare program’s fee schedule for physician’s services for calendar year 2007 and the Tax Relief and Health Care Act of 2006. Fed Reg. November 2006;70(216):68132-68215.

25. COPD Management Suspect COPD Spirometery Select Rx based on: Symptoms FEV1 Exacerbations Modifications Inadequate response Adequate response Adherence Triggers Co-morbidities Psycho-social Inhaler technique Exacerbations Disease progression Why inadequate?

26. Using the Global Initiative for Chronic Obstructive Lung Disease™ (GOLD) GuidelinesA DiscussionSee full 2014 GOLD guidelines at www.goldcopd.org

27. Assessment of COPD: Goals See full 2014 GOLD guidelines atwww.goldcopd.org

28. Assessment of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

29. Symptoms of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

30. Modified MRC (mMRC) Questionnaire

31. Assessment of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

32. Classification of Severity of Airflow Limitation in COPD*: 2013 See full 2014 GOLD guidelines atwww.goldcopd.org

33. Assessment of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

34. Assess Risk of Exacerbations See full 2014 GOLD guidelines atwww.goldcopd.org

35. Nancy Again • MMRC is 2 • Exacerbations? Probably 2 per year • FEV1—68% of predicted • On no therapy until you treated “bronchitis” and began SABA.

36. Combined Assessment of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

37. Combined Assessment of COPD See full 2014 GOLD guidelines atwww.goldcopd.org

38. Additional Investigations See full 2014 GOLD guidelines atwww.goldcopd.org

39. Manage Stable COPD:Goals of Therapy See full 2014 GOLD guidelines atwww.goldcopd.org

40. Therapeutic Options: Key Points See full 2014 GOLD guidelines atwww.goldcopd.org

41. Cigarette Smoking in the US: The Epidemic Continues (2002 Data)* DC GU PR USVI 9.5%-22.0% 22.1%-23.0% 24.0%-32.6% *The percentage of all adults in each state/area who reported having smoked 100 cigarettes during their lifetime and who currently smoke every day or some days. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2004;52:1277-1280.

42. Addressing Smoking Cessation • Best thing parents can do for themselves and their children • Clinician intervention is effective and cost effective • Nicotine is addictive, relapse is prevalent

43. Smoking Cessation Interventions Marlow SP et al. Resp Care 2003;48:1238-1256

44. Therapeutic Options for COPD: Formulations and Duration of Action Global Strategies for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2011.

45. Therapeutic Options: COPD Medications

46. Pharmacotherapy Overview A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/or Exacerbations( ≥2/yr) Severe Symptoms Severe-Very Severe &/or Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Scheduled: Long-acting bronchodilator Scheduled: *Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist Consider adding other agents** *Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator) ** Other possible agents: PDE-4 inhibitor = phosphodiesterase-4 inhibitor and/or theophylline Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

47. Patients often do NOT progress through the Grades of COPD Sequentially A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/or Exacerbations( ≥2/yr) Severe Symptoms Severe-Very Severe &/or Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Scheduled: Long-acting bronchodilator Scheduled: Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist Consider adding other agents Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

48. Patients often do NOT progress through the Grades of COPD Sequentially A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/or Exacerbations( ≥2/yr) Severe Symptoms Severe-Very Severe &/or Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Scheduled: Long-acting bronchodilator Scheduled: Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist Consider adding other agents Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

49. Patients often do NOT progress through the Grades of COPD Sequentially A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/or Exacerbations( ≥2/yr) Severe Symptoms Severe-Very Severe &/or Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Scheduled: Long-acting bronchodilator Scheduled: Inhaled corticosteroid + long-acting beta2 agonist or Long-acting muscarinic antagonist Consider adding other agents Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

50. Recommended Pharmacotherapy A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) SABA (prn) Albuterol: ProAir® Proventil® Ventolin® Levalbuterol: Xopenex® Pirbuterol: Maxair® OR SAMA (prn) Ipratropium: Atrovent® Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/or Exacerbations( ≥2/yr) Severe Symptoms Severe-Very Severe &/or Exacerbations (≥2/yr) Short-acting bronchodilator (prn) SABA = short-acting beta2-agonist SAMA = short-acting muscarinic antagonist (anticholinergic) Adapted by Adams SG: from the Global Strategy for Diagnosis, Management, and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.