Chronic Obstructive Pulmonary Disease

Transcription

1 Chronic Obstructive Pulmonary Disease Practical Approaches to Diagnosis and Management MARCH 20, :15 AM 10:30 AM Houston, Texas Sponsed by pmicme Educational Partner

2 Session 2: Chronic Obstructive Pulmonary Disease: Practical Approaches to Diagnosis and Management Learning Objectives 1. Evaluate the role of spirometry in chronic obstructive pulmonary disease (COPD) diagnosis and moniting. 2. Review recommended pharmacologic interventions to reduce COPD symptoms and decrease exacerbations. 3. Select appropriate patient counseling strategies. Faculty Barbara P. Yawn, MD, MSc, FAAPP Direct of Research Olmsted Medical Center Adjunct Profess Department of Family and Community Health University of Minnesota Rochester, Minnesota Dr Barbara Yawn is a family physician with many years of both practice and research experience. She has published me than 350 articles in peer reviewed journals, including many regarding obstructive lung disease such as asthma and COPD. She served on the National Heart, Lung, and Blood Institute national asthma guidelines Committee in 2007, and on the Wld Health Organization s COPD and asthma guidelines committees. Much of her respiraty-related research is designed to develop tools and methods to translate guidelines into everyday practice to improve patient outcomes. Her research is funded by the National Institutes of Health, the Agency f Healthcare Research and Quality, and the Centers f Disease Control and Prevention. She has been a frequent speaker at Pri-Med and has given many presentations on COPD in the United States and internationally. Her role as a primary care educat includes not only podium talks, but webinars, interactive virtual presentations, and group menting. Dr Yawn hopes to make COPD a comftable and productive part of every primary care physician s practice, while also facilitating other clinicians imptant roles in chronic disease management. Fernando J. Martinez, MD, MS Profess, Department of Internal Medicine Associate Chief f Clinical Research Division of Pulmonary and Critical Care Medicine Direct, Pulmonary Diagnostic Services University of Michigan Health System Ann Arb, Michigan Dr Fernando Martinez is profess of internal medicine and associate chief f clinical research in the division of pulmonary and critical care medicine at the University of Michigan Health System, medical direct of pulmonary diagnostic services, and co-medical direct of lung transplantation. After graduating from the University of Flida School of Medicine in Jacksonville, he completed his residency in internal medicine at Beth Israel Hospital, New Yk City, and his fellowship in pulmonary medicine at the Boston University Pulmonary Center, Massachusetts. Session 2

3 Dr Martinez s main research interests include COPD, interstitial lung disease, lung transplantation, and lung volume reduction. He is a member of numerous societies, including the American Thacic Society (ATS), the European Respiraty Society, American College of Chest Physicians, and the Fleischner Society. Previously, he was a member of the ATS committees that generated guidelines f the management of COPD, respiraty infections, and cardiopulmonary exercise testing; he is the fmer chair of the ATS assembly on clinical problems. He is currently a member of the GOLD (Global Initiative f Chronic Obstructive Lung Disease) science committee. Dr Martinez sits on a number of scientific journal editial boards, including f COPD: Journal of Chronic Obstructive Pulmonary Disease and American Journal of Respiraty and Critical Care Medicine. Faculty Financial Disclosure Statements The presenting faculty repted the following: Dr Yawn receives research funding from Boehringer Ingelheim; advis and speaker honaria from Amgen, Carden Jennings Publishing Co, Ltd, CSA Medical, Inc, Fest Labaties, Inc, GlaxoSmithKline, Ikaria, Inc, Merck & Co, Inc, Nycomed, and PeerVoice; and honaria f serving in expert capacity at US FDA meetings from Boehringer Ingelheim, GlaxoSmithKline, and Ikaria, Inc. Dr Martinez receives honaria/travel costs f European meeting attendance from Boehringer Ingelheim and Nycomed; and honaria f steering committee participation from GlaxoSmithKline and Janssen Pharmaceuticals, Inc. Education Partner Financial Disclosure Statement The content collabats at Miller Medical Communications, LLC, have no financial relationships to disclose. Suggested Reading List Centers f Disease Control and Prevention (CDC). Chronic obstructive pulmonary disease among adults--united States, MMWR Mb Mtal Wkly Rep. 2012;61(46); Gibson PG, Simpson JL. The overlap syndrome of asthma and COPD: what are its features and how imptant is it? Thax. 2009;64(8): Schnell K, Weiss CO, Lee T, et al. The prevalence of clinically-relevant combid conditions in patients with physiciandiagnosed COPD: a cross-sectional study using data from NHANES BMC Pulm Med. 2012;12:26. Mannino DM, Thn D, Swensen A, Holguin F. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J. 2008;32(4): Barnes PJ, Celli BR. Systemic manifestations and combidities of COPD. Eur Respir J. 2009;33(5): Mackay AJ, Hurst JR. COPD exacerbations: causes, prevention, and treatment. Med Clin Nth Am. 2012;96(4): Hurst JR, Vestbo J, Anzueto A, et al; f the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigats. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363(12): Vestbo J, Hurd SS, Agustí AG, et al. Global strategy f the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4): Maas AK, Mannino DM. Update on the management of chronic obstructive pulmonary disease. F1000 Med Rep. 2010;2. Tashkin DP, Ferguson GT. Combination bronchodilat therapy in the management of chronic obstructive pulmonary disease. Respir Res. 2013;14:49. Belletti D, Liu J, Zacker C, Wogen J. Results of the CAPPS: COPD--assessment of practice in primary care study. Curr Med Res Opin. 2013;29(8): Session 2

4 Perez X, Wisnivesky JP, Lurslurchachai L, Kleinman LC, Kronish IM. Barriers to adherence to COPD guidelines among primary care providers. Respir Med. 2012;106(3): Joo MJ, Au DH, Fitzgibbon ML, McKell J, Lee TA. Determinants of spirometry use and accuracy of COPD diagnosis in primary care. J Gen Intern Med. 2011;26(11): Joo MJ, Sharp LK, Au DH, Lee TA, Fitzgibbon ML. Use of spirometry in the diagnosis of COPD: a qualitative study in primary care. COPD. 2013;10(4): Salinas GD, Williamson JC, Kalhan R, et al. Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians. Int J Chron Obstruct Plumon Dis. 2011;6: Session 2

5 SESSION 2 9:15 10:30am Chronic Obstructive Pulmonary Disease - Practical Approaches to Diagnosis and Management SPEAKERS Barbara P. Yawn, MD, MSc, FAAPP Fernando J. Martinez, MD, MS Presenter Disclosure Infmation The following relationships exist related to this presentation: Dr Yawn receives research funding from Boehringer Ingelheim. Dr Martinez receives advis and speaker honaria from Amgen; Carden Jennings Publishing Co, Ltd; CSA Medical, Inc; Fest Labaties, Inc; GlaxoSmithKline; Ikaria, Inc; Merck & Co, Inc; Nycomed; and PeerVoice; receives honaria f serving in expert capacity at US FDA meetings from Boehringer Ingelheim, GlaxoSmithKline, and Ikaria, Inc.; receives honaria/travel costs f European meeting attendance from Boehringer Ingelheim and Nycomed; and Dr Martinez receives honaria f steering committee participation from GlaxoSmithKline and Janssen Pharmaceuticals, Inc. Off-Label/Investigational Discussion In accdance with pmicme policy, faculty have been asked to disclose discussion of unlabeled unapproved use(s) of drugs devices during the course of their presentations. Faculty Chronic Obstructive Pulmonary Disease Practical Approaches to Diagnosis and Management Fernando J. Martinez, MD, MS Executive Vice Chair Department of Medicine Weill Cnell Medical Center New Yk, New Yk Barbara P. Yawn, MD, MSc, FAAFP Direct of Research Olmsted Medical Center Adjunct Profess Department of Family and Community Health University of Minnesota Rochester, Minnesota 3 4 Learning Objectives Friday Afternoon 4:45 PM Visit Upon completion of this activity, participants should be better able to: Evaluate the role of spirometry in COPD diagnosis and moniting Review recommended pharmacologic interventions to reduce COPD symptoms and decrease exacerbations Nancy 56 yo with cc of bronchitis Wants antibiotics befe the weekend Coughing me f 2 weeks, productive yellow?fever, some breathlessness up stairs Does not want to go to the ED again Does not want chest x ray The last kind she received wked

6 What should we do? Take me histy Smoker 35 pack years Third episode of bronchitis in past 2 years Colds last f weeks Always wse than others Decrease in activities due to trouble breathing with walking. Now SOB with 6 stairs Has smoker s cough f past 3 years Mother developed asthma at age 60 and died of CHF at age 68 Think chronic lung disease! 13 Definition of COPD Chronic Obstructive Pulmonary Disease Common, preventable and treatable disease Characterized by: persistent airflow limitation progressive and associated with an enhanced chronic inflammaty response in the airways and the lung to noxious particles gases Exacerbations and combidities contribute to the overall burden of disease in individual patients Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): 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 Why Is COPD Underdiagnosed? Clinicians Tell All Patient has multiple chronic conditions Patient fails to rept/recognize dyspnea Inadequate knowledge and training Patient lacks specific symptoms Lacks access to spirometry Lack of effective treatment Survey of 278 Clinicians Perceived Barrier (%) MDs NPs/PAs 15 Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2): Key Barriers to COPD Diagnosis Failure of patients to notice and rept symptoms Early symptoms often do not interfere with completing activities of daily living Symptom severity increases very slowly Failure of health professionals to inquire about respiraty issues Tools to help the COPD Population Screener Be specific Misdiagnosis of COPD as asthma bronchitis The COPD Population Screener (COPD PS) 1. During the past 4 weeks, how much of the time did you feel sht of breath? None of A little of Some of Most of All of the time the time the time the time the time Do you ever cough up any stuff, such as mucus phlegm? Only with No, never occasional Yes, a few Yes, most Yes, colds chest days days infections every day a month a week 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 Unsure Agree Strongly disagree agree Have you smoked at least 100 cigarettes in your ENTIRE LIFE? No Yes Don t know Underuse of spirometry How old are you? Age 35 to to Age 50 to Age Age 70 + Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2): Martinez FJ et al; COPD-PS Clinician Wking Group. COPD. 2008;5(2):

7 Asthma vs COPD Key Indicats of COPD Feature COPD Asthma Onset Often in midlife Often in childhood Family Histy Variable Often Medical Social Histy Patients rept symptoms as Airflow Obstruction Smoking (often 20 pack years) Most notable during exercise Mostly bad days May be some reversibility with bronchodilation Atopy (ie, allergy and/ eczema) Most notable at night early mning Mostly good days Largely reversible with bronchodilation Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. Doherty DE. Am J Med. 2004;117(suppl 12A):11S-23S. 20 Symptoms Chronic cough Chronic sputum production Dyspnea: Progressive, persistent Wse with exercise and respiraty infections Risk Facts Host facts Genetics (eg, alpha 1 antitrypsin deficiency), hyperresponsiveness, lung growth Exposures Tobacco, smoke from cooking fires, occupational dust, flour, chemicals 21 COPD Mis Diagnosis Nancy needs spirometry! Hypothetical Male Patient With COPD Symptoms 42% diagnosed as COPD by physicians Hypothetical Female Patient With COPD Symptoms 32% diagnosed as COPD by physicians Needs pre and post bronchodilat to see about reversibility and if she meets obstruction definition COPD symptoms in women were most commonly misdiagnosed as asthma Needs FEV1 and FVC to determine severity and how to begin maintenance therapy FVC=fced vital capacity FEV1=fced expiraty volume in 1 second Miravitlles M et al. Arch Bronconeumol. 2006;42(1): Spirometry: Obstructive Disease Volume, liters Nmal FEV 1 = 4 L FVC = 5 L FEV 1 /FVC = FEV 1 = 1.8 L FVC = 3.2 L FEV 1 /FVC = 0.56 Obstructive Time, seconds Algithm f Interpreting Spirometry Results Yes Obstructive defect Yes Is FVC low? Mixed obstructive/ restrictive defect hyperinflation Further testing No Acceptable Spirogram Near total reversal with use of beta agonist? Yes No Asthma Is FEV 1 /FVC ratio low? Pure obstruction COPD Yes Restrictive defect Further testing No Is FVC low? No Nmal 25 Petty TL. Spirometry made simple. National Lung Health Education Program. 1999;8:37,38,41. Published January Accessed January 5,

8 Nancy s Numbers Avoid Interpretation Pitfalls You do spirometry on Nancy and get the following results: Good quality tracing rated B Pre bronchodilat Post bronchodilat FEV L 65% pred FEV1 2.7 L 68% pred FVC 4.0 L FVC 4.1 L FEV 1 /FVC 0.55 FEV1/FVC 0.66 Common Interpretation Errs Among Family Physicians (N=12 practices) new to spirometry use Interpreting a nmal result as an obstructive pattern Interpreting a po efft as a restrictive pattern Diagnosing COPD in the absence of an FEV 1 /FVC ratio <70% 27 Yawn BP et al. Chest. 2007;132(4): COPD Management COPD Accding to GOLD 2014 Suspect COPD Determine: Spirometry Current level of patient s symptoms Modifications Select Rx based on: Symptoms FEV1 Exacerbations Inadequate response Adequate response Severity of the spirometric abnmality Frequency of exacerbations Presence of combidities Why inadequate? Adherence Triggers Combidities Psycho social Inhaler technique Exacerbations Disease progression 30 Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Assessment of COPD Modified MRC (mmrc) Questionnaire Assess symptoms Dyspnea: Progressive, persistent, and characteristically wse with exercise Chronic cough: May be intermittent and may be unproductive Chronic sputum production: COPD patients commonly cough up sputum Use mmrc, CAT, CCQ to assess the patient s level of symptom burden. mmrc=modified Medical Research Council. Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4):

9 Assessment of COPD Assess symptoms Assess airflow limitation using spirometry GOLD 1: Mild FEV 1 80% predicted GOLD 2: Moderate FEV 1 50% to 79% predicted GOLD 3: Severe FEV 1 30% to 49% predicted GOLD 4: Very severe FEV 1 <30% predicted Assessment of COPD Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations Use Assess histy combidities of exacerbations and spirometry. 2 exacerbations me within the last year FEV 1 <50 % of predicted value indicats of high risk Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): mmrc is 2 Nancy, cont d Exacerbations???? Probably 2 per year FEV1 68% of predicted On no therapy until you treated bronchitis and began SABA Combined Assessment of COPD (C) (A) Assess symptoms first (D) (B) If mmrc 0 1 CAT <10: Less Symptoms (A C) If mmrc 2 CAT 10: Me Symptoms (B D) SABA=sht acting beta 2 agonist 36 mmrc 0 1 CAT <10 mmrc 2 CAT 10 Symptoms (mmrc CAT sce) Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Risk (GOLD Classification of Airflow Limitation) Combined Assessment of COPD Assess risk of exacerbations next (C) (A) mmrc 0 1 CAT <10 (D) (B) mmrc 2 CAT 10 Symptoms (mmrc CAT sce) 2 1 leading to hospital admission 1 0 Risk (Exacerbation histy) If GOLD 1 2 and only 0 1 exacerbations per year: Low Risk (A B) If GOLD 3 4 two me exacerbations per year 1leading to hospital admission: High Risk (C D) 38 Increasing Risk Pharmacological Therapy of Stable COPD: GOLD 2011 GOLD spirometric classification When assessing risk, choose the highest risk accding to GOLD grade exacerbation histy C A mmrc 0-1 CAT <10 D B mmrc 2 CAT 10 Increasing Symptoms 0 1 >2 1 hosp Exacerbation histy Increasing Risk Patient is now in 1 of 4 categies: A: Less symptoms, lower risk B: Me symtoms, lower risk C: Less symptoms, higher risk D: Me Symtoms, higher risk

10 Additional Investigations Manage Stable COPD: Goals of Therapy Chest X ray: Seldom diagnostic, but valuable to exclude alternative diagnoses (CHF, lung cancer) and establish presence of significant combidities Alpha 1 Antitrypsin Deficiency Screening: In COPD patients of Caucasian descent <45 yrs old, with strong family histy of COPD Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a patient s oxygen saturation and need f supplemental oxygen therapy Assess and relieve symptoms Individual tools f assessment Improve exercise tolerance Pulmonary rehab Improve health status Prevent disease progression Exposure to smoking, occupational Prevent and treat exacerbations Pharmacotherapy, exposures Reduce mtality Reduce Symptoms Reduce Risk Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Therapeutic Options: Key Points Smoking cessation has the greatest capacity to influence the natural histy of COPD Pharmacotherapy and immunizations improve the lives of people with COPD Regular physical activity and should repeatedly be encouraged to remain active Nonpharmacologic Management: GOLD Overview A B C D Active reduction of risk facts Administer vaccinations Increase physical activity Add pulmonary rehabilitation Consider evaluation f need f supplemental oxygen Consider surgical eval Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Adapted by Adams SG; from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD), 44 Recommended Pharmacotherapy A B C D Severe symptoms Exacerbations( 2/yr) Recommended Pharmacotherapy A B C D Severe symptoms Exacerbations( 2/yr) Sht-acting bronchodilat (prn) SABA (prn) Albuterol Levalbuterol Pirbuterol OR SAMA (prn) Ipratropium SABA = sht-acting beta 2 -agonist SAMA = sht-acting muscarinic antagonist (anticholinergic) Sht-acting bronchodilat (prn) LABA (scheduled) SABA SAMA (prn) Arfmoterol Indacaterol Salmeterol OR LAMA (scheduled) Tiotropium Aclidinium LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) Adapted by Adams SG: from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD), 45 Adapted by Adams SG: from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD),

11 Recommended Pharmacotherapy A B C D Sht-acting bronchodilat (prn) Severe symptoms Exacerbations( 2/yr) Recommended Pharmacotherapy A B C D Sht-acting bronchodilat (prn) Severe symptoms Exacerbations( 2/yr) SABA SAMA (prn) LABA LAMA (scheduled) ICS/LABA Budesonide/Fmoterol Fluticasone/Salmeterol Fluticasone/Vilanterol SABA SAMA (prn) LABA LAMA (scheduled) ICS/LABA LAMA (scheduled) ICS/LABA Budesonide/Fmoterol Fluticasone/Salmeterol Fluticasone/Vilanterol OR &/OR ICS = inhaled cticosteroid LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) LAMA Tiotropium Aclidinium ICS = inhaled cticosteroid LABA = long-acting beta 2 -agonist LAMA = long-acting muscarinic antagonist (anticholinergic) LAMA Tiotropium Aclidinium Adapted by Adams SG: from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD), 47 Adapted by Adams SG: from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD), 48 First choice: SABA SAMA (prn) Alternative choice: LABA LAMA SABA + SAMA (scheduled) Consider Theophylline Pharmacotherapy (Summary) A B C D Sht-acting bronchodilat (prn) Severe symptoms First choice: LABA LAMA Alternative choice: LABA & LAMA Consider Theophylline Exacerbations( 2/yr) First choice: ICS/LABA LAMA Alternative choice: LABA + LAMA LABA + PDE-4 inhibit LAMA + PDE-4 inhibit Consider Theophylline First Choice: ICS/LABA &/ LAMA Alternative choice: ICS/LABA + LAMA ICS/LABA + PDE-4 inh LABA + LAMA LAMA + PDE-4 inh Consider Theophylline ß 2 Agonists Tachycardia Palpitations PVC* Trems Hypokalemia Adverse Effects of Therapy Anticholinergics Dry mouth Urinary retention Glaucoma *PVC=premature ventricular contraction Inhaled Glucocticoids Dysphonia Thrush Systemic effects: bruising, bone density, cataract Pneumonia Local irritation PDE-4 inhibit (Roflumilast) Diarrhea Weight decrease Headache Insomnia Depression/Suicidal ideations Adapted by Adams SG: from the Global Strategy f Diagnosis, Management, and Prevention of COPD 2013, Global Initiative f Chronic Obstructive Lung Disease (GOLD), 53 Tashkin DP et al. Respir Res. 2010;11:149 Rennard SI. Lancet ;364(9436): Saag et al. UpToDate Daliresp [package insert] Therapeutic Options: Other Pharmacologic Treatments Manage Stable COPD: Nonpharmacologic Treatments Influenza vaccines can reduce serious illness. Pneumococcal polysaccharide vaccine is recommended f COPD patients 65 years and older and f COPD patients younger than age 65 with an FEV 1 <40% predicted. The use of antibiotics, other than f treating infectious exacerbations of COPD and other bacterial infections, is currently not indicated. Patient Essential Recommended A B, C, D Smoking cessation (can include pharmacologic treatment) Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilitation Physical activity Physical activity Depending on Local Guidelines Flu vaccination Pneumococcal vaccination Flu vaccination Pneumococcal vaccination Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Wongsurakiat P et al. Chest. 2004;125(6): Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4):

12 Activity in People With COPD Therapeutic Options: Rehabilitation minutes Healthy GOLD I & II GOLD III GOLD IV FEV 1 65% FEV 1 38% FEV 1 25% Walking COPD patients are very inactive This inactivity is present in all GOLD stages 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 me effective the results If exercise training is maintained at home, the patient's health status remains above pre rehabilitation levels Nutrition counseling and education Pitta F et al. Am J Respir Crit Care Med. 2005;171(9): Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4): Address Combidities of COPD Must Haves f COPD Lung Cancer Pulmonary Hypertension Anemia Diabetes Metabolic Syndrome Cachexia Anxiety, Depression Cardiovascular Disease Peripheral Muscle Wasting & Dysfunction Osteoposis Peptic Ulcers GI Complications Spirometry Smoking cessation Pulmonary rehabilitation Pharmacotherapy Assessment and therapy of combidities Good across group communications Team approach Kao C, Hanania, NA. Atlas of COPD COPD Management Suspect COPD Spirometry Select Rx based on: Symptoms FEV1 Exacerbations Question & Answer Modifications Why inadequate? Inadequate response Adherence Triggers Combidities Psycho social Inhaler technique Exacerbations Disease progression Adequate response 71 8