Early Identification and Diagnosis of Chronic Respiratory Diseases: The Primary Role in Improving Patient Outcomes in Asthma, COPD, and IPF

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1 Early Identification and Diagnosis of Chronic Respiraty Diseases: Learning Objectives Early Identification and Diagnosis of Chronic Respiraty Diseases The Primary Role in Improving Patient Outcomes in Asthma, COPD, and IPF Ellen H. Miller, MD Profess of Science Education & Medicine Hofstra Nthwell School of Medicine Seni Medical Direct Nth She - LIJ CareConnect East Hills, NY Detect the early warning signs of common respiraty diseases and apply appropriate diagnostic tests to make timely and accurate diagnoses of asthma, Chronic Obstructive Pulmonary Disease (COPD), and Idiopathic Pulmonary Fibrosis (IPF) in the primary care setting Provide guideline-driven care f patients with asthma, COPD, and IPF, including specialist referrals when necessary Describe strategies to facilitate patient self-management and a multidisciplinary care approach f chronic respiraty conditions by engaging patients and moniting f response and progression MISSED OPPORTUNITIES in primary care f earlier diagnoses and timely initiations of appropriate therapies f asthma, COPD, and IPF Me than 60% of asthma patients do not reach appropriate levels of control, resulting in 14 million physician office visits, 2 million emergency room visits, and 500,000 hospitalizations per year 85% of patients with COPD visited their primary care doct a clinic at least once with respiraty symptoms in the 5 years befe diagnosis Me than 50% of IPF patients are initially misdiagnosed with other fms of respiraty illness Burden of COPD and Asthma COPD is a leading cause of mbidity and mtality wldwide COPD is often not diagnosed until symptoms have increased in severity and significant (irreversible) lung damage has occurred 35.5 million Nth Americans have asthma resulting in a prevalence of 11.2%, among the highest in the wld Every day in America 40,000 people miss school wk due to asthma There are me than 4,000 deaths due to asthma each year, many of which are avoidable with proper treatment and care Five-year Survival of IPF (and severe COPD) is Wse than Most Cancers Bladder Breast Colon Kidney Leukemia Lymphoma Lung Prostate Pancreas Skin Thyroid Uterus What is the primary role in improving outcomes? Early diagnosis Guideline-driven management Multidisciplinary care that fosters patient selfmanagement IPF year survival rate f IPF and different cancers (%) Vancheri et al. Eur Respir J. 2010;35:

2 Early Identification and Diagnosis of Chronic Respiraty Diseases: Early Diagnosis = Better Outcomes Patients often attribute their shtness of breath and decreased ability to perfm usual activities to the nmal aging process and only seek treatment in urgent-care settings f acute exacerbations Primary Care Physicians Can Recognize Early Warning Signs of Chronic Respiraty Disease Monday mning I come into the office, and the first three patients present with cough and breathlessness: Betsy Carl Alice F an adult who presents with respiraty symptoms: Does the patient have chronic airways disease? If yes, is it asthma, COPD, something else? Betsy: 52-year-old Woman with Cough and Breathlessness Histy of Present Illness Cough x 5 days, yellow sputum Past Medical Histy Hypertension Similar bronchitis episode earlier this year Social Histy 2 ppd f 30 years ROS Progressive exertional dyspnea x 2 years Physical Examination Afebrile, RR 22, mild distress Mild fced expiraty wheezing Global Strategy f Diagnosis, Management, and Prevention of COPD Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance 2015 Global Initiative f Chronic Obstructive Lung Disease Parenchymal Destruction Loss of alveolar attachments Decrease of elastic recoil Global Strategy f Diagnosis, Management, and Prevention of COPD Risk Facts f COPD Global Strategy f Diagnosis, Management, and Prevention of COPD Diagnosis of COPD Genes Infections Socio-economic status SYMPTOMS shtness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indo/outdo pollution è Aging Populations 2015 Global Initiative f Chronic Obstructive Lung Disease SPIROMETRY: Required to establish diagnosis 2015 Global Initiative f Chronic Obstructive Lung Disease 2

3 Volume, liters Volume, liters Early Identification and Diagnosis of Chronic Respiraty Diseases: Perfm Spirometry Essential if chronic airways disease is suspected Confirms chronic airflow limitation Me limited value in distinguishing between asthma with fixed airflow limitation and COPD Measure at the initial visit subsequent visit If possible measure befe and after a trial of treatment Medications taken befe testing may influence results Peak expiraty flow (PEF) Not a substitute f spirometry Nmal PEF does not rule out asthma COPD Repeated measurement may confirm excessive variability, found in asthma GINA 2016, Box 5-3 Spirometry Nmal Trace Showing FEV1 and FVC Global Initiative f Chronic Obstructive Lung Disease FEV 1 = 4L FVC = 5L FEV 1 /FVC = Time, sec FVC Spirometry: Obstructive Disease Assessment of COPD- Determine COPD Categy 5 Nmal In patients with FEV 1 /FVC<0.70: 4 Classification Severity FEV FEV 1 = 1.8L FVC = 3.2L FEV 1/FVC = 0.56 Obstructive GOLD 1 Mild 80% predicted GOLD 2 Moderate 50% FEV 1< 80% GOLD 3 Severe 30% FEV 1<50% GOLD 4 Very Severe FEV 1<30% predicted Time, seconds All symptomatic patients with obstruction should be tested f AAT deficiency with an AAT serum level 2015 Global Initiative f Chronic Obstructive Lung Disease Diagnostic Confusion Between COPD and Asthma is Common Pathology of Asthma Asthma Asthma involves inflammation of the airways Nmal Asthma Source: What You and Your Family Can Do About Asthma by the Global Initiative F Asthma Created and funded by NIH/NHLBI,

4 Respiraty Function/Symptoms Early Identification and Diagnosis of Chronic Respiraty Diseases: Distinguishing between COPD and Asthma Spirometry Characteristics COPD Asthma Age Patient typically over 40 1,2 Typically begins at an early age 1,3,4 Smoking Smokers and ex-smokers at highest risk 1,4 No direct relationship between smoking and asthma 3 Dyspnea Cough Shtness of breath, especially with exertion, progressing to dyspnea at rest 1 Present intermittently every day (generally Variable 4 productive) 6 Episodic attacks after exposure to allergen, irritant, exercise 4,5 Disease course Steadily wsens, with exacerbations 2 Intermittent symptoms, nmal to near-nmal function between exacerbations in most patients 4,8,9 1. Celli et al and the ATS/ERS Task Fce. Eur Respir J. 2004;23: O Donnell. Can Respir J. 2003;10: GINA. Wkshop Rept Updated Available at: Accessed October 19, NLEHP. Chest. 1988;113(2 suppl):123s-163s. 5. American Lung Association. Asthma in Adults Fact Sheet. 6. Global Initiative f Chronic Obstructive Lung Disease. Wkshop Rept Updated Available at: 7. McFadden. Asthma. In: Harrison s Principles of Internal Medicine. 2005: Bateman ED et al. Lancet Respir Med. 2015;3: Nielsen M et al. Int J Chron Obstruct Pulmon Dis. 2015;10: Obstruction Reversibility GINA 2016, Box 5-3 A spirometric sce of: Asthma COPD Nmal FEV 1/FVC Compatible Not compatible Post-BD FEV 1/FVC <0.7 Indicates airflow limitation; may improve Required f GOLD criteria FEV 1 80% Compatible Compatible with A B COPD FEV 1 <80% Post-BD increase in FEV 1 >12%-15% and mL from baseline risk fact f exacerbation High probability of asthma risk fact f exacerbation and death Unusual in COPD; consider Asthma-COPD Overlap Syndrome (ACOS) Carl: 52-year-old Man with Cough and Breathlessness Histy of Present Illness Cough x 6 months, yellow sputum x 5 days Increasing breathlessness Past Medical Histy Hypertension Social Histy Non-smoker ROS Intermittent exertional wheeze Physical Examination Afebrile, RR 18, no distress Bibasilar rales Identification of Velcro" crackles is a key component of early diagnosis of IPF If you suspect IPF, refer to a pulmonologist Role of PCP Getting relevant histy (occupational/environmental/drug exposure, family histy, connective tissue disease) Initiate testing (PFTs, imaging) Treating combid conditions (GERD) Smoking cessation counseling Pulmonary rehab Oxygen therapy Specialist treatment options New therapies Lung transplant Patient suppt groups Codinated, specialized care Disease Progression in IPF Is Variable and Often Unpredictable Rapid Decline Slow Decline Acute Exacerbation Years HTN = hypertension Disease Progression Minimal Symptoms Hypoxemia Increased Disability Pulmonary HTN Death Interstitial Lung Disease While IPF is the most common ILD, there are many look alike diseases Histy, symptoms, physical exam, imaging and sometimes histology are required to make the IPF diagnosis IPF is a diagnosis of exclusion Honeycomb upper lobes lower lobes Irregular Lines Peripheral/ Subpleural Lower lobe predominant Adapted from Kim DS et al. Proc Am Thacic Soc. 2006;3: American Thacic Society. Am J RespirCrit Care Med. 2002;165: Courtesy of Dr. Fernando J. Martinez. 4

5 Early Identification and Diagnosis of Chronic Respiraty Diseases: Interstitial Lung Diseases There are over two hundred recognized types of diffuse parenchymal lung diseases They are a heterogeneous group of disders classified together because of similar clinical, radiographic, physiologic, pathologic manifestations The term "interstitial" refers to pathologic appearance that the abnmality begins in the interstitium When to Suspect ILD Common first symptoms: dyspnea on exertion, cough Symptoms may be present years befe diagnosis Age >50 Male predominance Risk facts associated with IPF: histy of smoking, environmental exposure, GERD Clubbing of fingertips Velcro-like crackles on auscultation Distinguishing between COPD and IPF Characteristics COPD IPF Age Patient typically over 40 1,2 Patient typically over 45 Smoking Dyspnea Cough Smokers and ex-smokers at highest risk 1,4 Shtness of breath, especially with exertion, progressing to dyspnea at rest 1 Present intermittently every day (generally productive) 6 No direct relationship with smoking Gradual onset of exertional dyspnea Nonproductive Disease course Steadily wsens, with exacerbations 2 Unpredictable with steadily wsening symptoms, frequent exacerbations Chest X-Ray Hyperinflation, bullous changes Predominantly basal Interstitial markings; hallmark on CT scan: honeycombing Physical exam Rhonchi, wheezing, clubbing, cyanosis Velcro rales, clubbing, cyanosis What is the primary role in improving outcomes? Early diagnosis Guideline-driven management Multidisciplinary care that fosters patient selfmanagement Guideline-driven Management Benefits of Guideline-based Treatment Guidelines New agents/combinations When to refer Improved lung function 1,2 Improved symptoms 1,2 Improved exercise tolerance 1,2 Improved QoL 1,2 Prolonged life and better QoL with smoking cessation 1,2 Delayed time to first exacerbation 1,2 Fewer exacerbations 1,2 Fewer hospitalizations 1,2 Cost savings 3 1. Restrepo RD et al. Int J COPD. 2008;3: Global Initiative f Chronic Obstructive Lung Disease (GOLD) Accessed 3/10/ Asche CV et al. Int J Chron Obstruct Pulmon Dis. 2012;7:

6 Increasing Risk GOLD spirometric classification me 1 hosp Exacerbation histy Increasing Risk Early Identification and Diagnosis of Chronic Respiraty Diseases: Goals of COPD and Asthma Management The long-term goals of asthma management are 1. Symptom control: to achieve good control of symptoms and maintain nmal activity levels 2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation, and medication side-effects Determine Initial Treatment Initial pharmacotherapy choices are based on both efficacy and safety If syndromic assessment suggests asthma as single diagnosis Start with low-dose ICS Add LABA and/ LAMA if needed f po control despite good adherence and crect technique Do not give LABA alone without ICS If syndromic assessment suggests COPD as single diagnosis Start with bronchodilats combination therapy ICS alone may not be efficacious in modifying disease; combination with LABA and/ LAMA is better If differential diagnosis is equally balanced between asthma and COPD, i.e. ACOS Refer to specialist GINA 2016 GINA 2016 Manage Stable COPD: Goals of Therapy Management of Stable COPD 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; reduce mtality Reduce symptoms Reduce risk Essential Smoking cessation Can include pharmacologic treatment Recommended: physical activity Depending on local guidelines Flu vaccination Pneumococcal vaccination Vestbo J et al. Am J Respir Crit Care Med. 2013;187: Vestbo J et al. Am J Respir CritCare Med. 2013;187: How to Determine Appropriate Therapy of Stable COPD C D How to Determine Appropriate Therapy of Stable COPD A B C D Minimal Symptoms Mild-Moderate & Exacerbations (0-1/yr) First choice: SABA SAMA (prn) Severe symptoms Mild-Moderate & Exacerbations (0-1/yr) Minimal Symptoms Severe-Very Severe &/ Exacerbations ( 2/yr) Sht-acting bronchodilat (prn) First choice: LABA LAMA First choice: ICS/LABA LAMA Severe Symptoms Severe-Very Severe &/ Exacerbations ( 2/yr) First choice: ICS/LABA and/ LAMA A mmrc 0-1 CAT <10 B mmrc 2 CAT 10 Increasing Symptoms Alternative choice: LABA LAMA SABA + SAMA (scheduled) Alternative choice: LABA + LAMA Alternative choice: LABA + LAMA LABA + PDE-4 inhibit LAMA + PDE-4 inhibit Alternative choice: ICS/LABA + LAMA ICS/LABA + PDE-4 inh LABA + LAMA LAMA + PDE-4 inh Consider Theophylline Consider Theophylline Consider Theophylline Consider Theophylline Adapted by Adams SG from the Global Strategy f Diagnosis, Management, and Prevention of COPD Global Initiative f Chronic Obstructive Lung Disease (GOLD). 6

7 Early Identification and Diagnosis of Chronic Respiraty Diseases: COPD: Pharmacologic Options Sht-acting Anticholinergic (SAMA): Ipratropium -agonists (SABA): Albuterol Levalbuterol Metaproterenol Pirbuterol SAMA + SABA: Ipratropium + albuterol Bronchodilats Long-acting Anticholinergic (LAMA): Tiotropium Aclidinium Umeclidinium -agonists (LABA): Salmeterol Fmoterol Arfmoterol Indacaterol (ultra) LAMA + LABA: Umeclidinium + vilanterol Tiotropium + olodaterol Theophylline Anti-inflammaty ICS + LABA Fluticasone + Salmeterol Budesonide + Fmoterol Fluticasone + Vilanterol PDE-4 inhibits Roflumilast Oral steroids Prednisone Methylprednisolone When to Refer to a Specialist Persistent symptoms and/ exacerbations despite treatment Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases, and other causes of respiraty symptoms) Suspected asthma COPD with atypical additional symptoms signs (e.g. haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis other structural lung disease) Few features of either asthma COPD Combidities present Reasons f referral f either diagnosis as outlined in the GINA and GOLD strategy repts Slide courtesy of Sanjay Sethi, MD. Alice: 25-year-old Woman with Cough and Breathlessness Histy of Present Illness Cough x 5 days, chest tightness, breathlessness Past Medical Histy Seasonal rhinitis Family Histy Maternal histy of asthma Social Histy Non-smoker Physical Examination Afebrile, RR 22, mild distress Mild fced expiraty wheezing Step 1 as-needed inhaled sht-acting beta 2 -agonist (SABA) PREFERRED CONTROLLER CHOICE Other controller options RELIEVER STEP 1 STEP 2 Consider low dose ICS Low dose ICS Leukotriene recept antagonists (LTRA) Low dose theophylline* As-needed sht-acting beta 2-agonist (SABA) *Not f children <12 years **F children 6-11 years, the preferred Step 3 treatment is medium dose ICS #F patients prescribed BDP/fmoterol BUD/ fmoterol maintenance and reliever therapy Tiotropium by mist inhaler is an add-on treatment f patients 12 years with a histy of exacerbations GINA 2016, Box 3-5, Step 1 (4/8) Low dose ICS/LABA** Med/high dose ICS Low dose ICS+LTRA Med/high ICS/LABA Add tiotropium* High dose ICS + LTRA As-needed SABA low dose ICS/fmoterol # Refer f add-on treatment e.g. tiotropium,* omalizumab, mepolizumab*, reslizumab* Add low dose OCS Step 2 low-dose controller + asneeded inhaled SABA Step 3 one two controllers + asneeded inhaled reliever PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Low dose ICS/LABA** Refer f add-on treatment e.g. Med/high tiotropium,* omalizumab, ICS/LABA mepolizumab*, reslizumab* PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Low dose ICS/LABA** Refer f add-on treatment e.g. Med/high tiotropium,* omalizumab, ICS/LABA mepolizumab*, reslizumab* Other Consider low controller dose ICS options Leukotriene recept antagonists (LTRA) Low dose theophylline* Med/high dose ICS Add tiotropium* Add low Low dose ICS+LTRA High dose ICS dose OCS + LTRA Other Consider low controller dose ICS options Leukotriene recept antagonists (LTRA) Low dose theophylline* Med/high dose ICS Add tiotropium* Add low Low dose ICS+LTRA High dose ICS dose OCS + LTRA RELIEVER As-needed sht-acting beta 2-agonist (SABA) As-needed SABA low dose ICS/fmoterol # RELIEVER As-needed sht-acting beta 2-agonist (SABA) As-needed SABA low dose ICS/fmoterol # *Not f children <12 years **F children 6-11 years, the preferred Step 3 treatment is medium dose ICS #F patients prescribed BDP/fmoterol BUD/ fmoterol maintenance and reliever therapy Tiotropium by mist inhaler is an add-on treatment f patients 12 years with a histy of exacerbations GINA 2016, Box 3-5, Step 1 (4/8) *Not f children <12 years **F children 6-11 years, the preferred Step 3 treatment is medium dose ICS #F patients prescribed BDP/fmoterol BUD/ fmoterol maintenance and reliever therapy Tiotropium by mist inhaler is an add-on treatment f patients 12 years with a histy of exacerbations GINA 2016, Box 3-5, Step 1 (4/8) 7

8 Early Identification and Diagnosis of Chronic Respiraty Diseases: Step 4 two me controllers + asneeded inhaled reliever Step 5 higher level care and/ add-on treatment PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Low dose ICS/LABA** Refer f add-on treatment e.g. Med/high tiotropium,* omalizumab, ICS/LABA mepolizumab*, reslizumab* PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 Low dose ICS Low dose ICS/LABA** Refer f add-on treatment e.g. Med/high tiotropium,* omalizumab, ICS/LABA mepolizumab*, reslizumab* Other Consider low controller dose ICS options Leukotriene recept antagonists (LTRA) Low dose theophylline* Med/high dose ICS Add tiotropium* Add low Low dose ICS+LTRA High dose ICS dose OCS + LTRA Other Consider low controller dose ICS options Leukotriene recept antagonists (LTRA) Low dose theophylline* Med/high dose ICS Add tiotropium* Add low Low dose ICS+LTRA High dose ICS dose OCS + LTRA RELIEVER As-needed sht-acting beta 2-agonist (SABA) As-needed SABA low dose ICS/fmoterol # RELIEVER As-needed sht-acting beta 2-agonist (SABA) As-needed SABA low dose ICS/fmoterol # *Not f children <12 years **F children 6-11 years, the preferred Step 3 treatment is medium dose ICS #F patients prescribed BDP/fmoterol BUD/ fmoterol maintenance and reliever therapy Tiotropium by mist inhaler is an add-on treatment f patients 12 years with a histy of exacerbations GINA 2016, Box 3-5, Step 1 (4/8) *Not f children <12 years **F children 6-11 years, the preferred Step 3 treatment is medium dose ICS #F patients prescribed BDP/fmoterol BUD/ fmoterol maintenance and reliever therapy Tiotropium by mist inhaler is an add-on treatment f patients 12 years with a histy of exacerbations GINA 2016, Box 3-5, Step 1 (4/8) Step 5 Refer to specialist f higher level care and/ add-on treatment (1) Preferred option is referral f specialist investigation and consideration of add-on treatment GINA 2016 If symptoms uncontrolled exacerbations persist despite Step 4 treatment, check inhaler technique and adherence befe referring Add-on tiotropium f patients 12 years with histy of exacerbations Add-on omalizumab (anti-ige) f patients with severe allergic asthma Add-on mepolizumab (anti-il5) f severe eosinophilic asthma ( 12 yrs) Step 5 Refer to specialist f higher level care and/ add-on treatment (2) Refer f expert advice and extra investigations if patient has: GINA 2016 Persistent symptoms and/ exacerbations despite treatment Diagnostic uncertainty, especially if alternative diagnosis (e.g. TB, cardiovascular disease) needs to be excluded Suspected airways disease with atypical additional symptoms signs (e.g. hemoptysis, weight loss, night sweats, fever, chronic purulent sputum). Do not wait f a treatment trial befe referring Suspected chronic airways disease but few features of asthma, COPD, ACOS Combidities that may interfere with their management Issues arising during on-going management of asthma, COPD, ACOS Goals of COPD and Asthma Management The long-term goals of asthma management are 1. Symptom control: to achieve good control of symptoms and maintain nmal activity levels 2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation, and medication side-effects Achieving these goals requires a partnership between patient and his/her health care providers Ask the patient about his/her own goals regarding their disease Good communication strategies are essential Consider the health care system, medication availability, cultural and personal preferences, and health literacy What is the primary role in improving outcomes? Early diagnosis Guideline-driven management Multidisciplinary care that fosters patient selfmanagement GINA

9 Early Identification and Diagnosis of Chronic Respiraty Diseases: Multidisciplinary Care Nurses, allergists, specialists, pharmacists Provide disease education Inhaler technique Adherence Patient self-management Moniting f response and progression Guided self-management education Highly effective in improving outcomes Reduced hospitalizations, ED visits, symptoms, night waking, time off wk, improved lung function, and quality of life Three essential components Self-moniting of symptoms and/ PEF Written action plan Describe how to recognize and respond to wsening symptoms Individualize the plan f the patient s health literacy and autonomy Provide advice about a change in treatment plan Regular medical review GINA 2016 Treating Modifiable Risk Facts Identify and Address Po Adherence Provide skills and suppt f guided self-management This comprises self-moniting of symptoms and/ PEF, a written action plan and regular medical review Prescribe medications regimen that minimize exacerbations Encourage avoidance of tobacco smoke (active ETS) Provide smoking cessation advice and resources at every visit F patients with severe disease Refer to a specialist center, if available, f consideration of add-on medications f patients with confirmed allergies Appropriate food avoidance Ensure availability of injectable epinephrine f anaphylaxis GINA 2016, Box 3-8 Barriers to adherence Inadequate education about disease and therapy 1 Perceived burden of medication regimen 1,2 Device is difficult to use 3 Depressed mood 3 Medication-related cost 3 Adverse effects 3 1. LaFest L et al. Prim Care Resp J. 2010;19: Gege J et al. Chest. 2005;128: Restrepo RD et al. Int J COPD. 2008;3: Red Flags f non-adherence Failure to refill prescriptions Excessive use of rescue medication Frequent exacerbations Rapid decline in FEV 1 Strategies f Individualizing Inhaler Choice Good hand-breath codination is required f meterdose inhalers (MDIs) May not be suitable f elderly, confused, those with hand conditions (e.g. arthritis) Dry-powder inhalers (DPIs) do not require codination of actuation and inhalation and are easier to use than MDIs Breath actuation may be difficult in patients with po inspiraty efft Avoid changing inhaler types f individual patients Vincken W et al. Prim Care Respir J. 2010;19: De Coster DA et al. Cur Respir Care Rep. 2014;;3: Small-Volume Nebulizers Nebulizers May be Beneficial f Some Patients 1. Dhand R et al. COPD. 2012;9: Sharafkhaneh A et al. COPD. 2013;10: Effective drug delivery requires less intensive patient training vs pmdis and DPIs 1 Newer ptable and efficient models available 1 Efficacy of long-term nebulizer therapy is similar superi to pmdi/dpis in moderate-to-severe COPD, including during exacerbations 1 Consider maintenance nebulizers in 1 Elderly patients Severe disease Frequent exacerbations Physical and/ cognitive limitations Patient/caregiver satisfaction is high 2 9

10 STEP 1 STEP 2 DIAGNOSE CHRONIC AIRWAYS DISEASE Do symptoms suggest chronic airways disease? Yes No Consider other diseases first SYNDROMIC DIAGNOSIS IN ADULTS (i) Assemble the features f asthma and f COPD that best describe the patient. (ii) Compare number of features in favour of each diagnosis and select a diagnosis Features: if present suggest ASTHMA COPD Age of onset Befe age 20 years After age 40 years Pattern of symptoms Variation over minutes, hours days Persistent despite treatment Lung function Wse during the night early mning. Triggered by exercise, emotions including laughter, dust exposure to allergens Recd of variable airflow limitation (spirometry peak flow) Lung function between symptoms Nmal Abnmal Past histy family histy Time course Previous doct diagnosis of asthma Family histy of asthma, and other allergic conditions (allergic rhinitis eczema) No wsening of symptoms over time. Variation in symptoms either seasonally, from year to year May improve spontaneously have an immediate response to bronchodilats to ICS over weeks Good and bad days but always daily symptoms and exertional dyspnea Chronic cough & sputum preceded onset of dyspnea, unrelated to triggers Recd of persistent airflow limitation (FEV1/FVC < 0.7 post-bd) Previous doct diagnosis of COPD, chronic bronchitis emphysema Heavy exposure to risk fact: tobacco smoke, biomass fuels Chest X-ray Nmal Severe hyperinflation NOTE: These features best distinguish between asthma and COPD. Several positive features (3 me) f either asthma COPD suggest that diagnosis. If there are a similar number f both asthma and COPD, consider diagnosis of ACOS DIAGNOSIS CONFIDENCE IN DIAGNOSIS PERFORM SPIROMETRY INITIAL TREATMENT* SPECIALISED INVESTIGATIONS REFER IF: Asthma Asthma Marked reversible airflow limitation (pre-post bronchodilat) other proof of variable airflow limitation Asthma drugs No LABA monotherapy Some features of asthma Asthma Asthma drugs No LABA monotherapy Features of both Could be ACOS ICS, and usually LABA +/ LAMA *Consult GINA and GOLD documents f recommended treatments. Persistent symptoms and/ exacerbations despite treatment. Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases Symptoms slowly wsening over time (progressive course over years) Rapid-acting bronchodilat treatment provides only limited relief Some features of COPD Possibly COPD COPD drugs COPD COPD FEV1/FVC < 0.7 post-bd COPD drugs and other causes of respiraty symptoms). Suspected asthma COPD with atypical additional symptoms signs (e.g. haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis other structural lung disease). Few features of either asthma COPD. Combidities present. Reasons f referral f either diagnosis as outlined in the GINA and GOLD strategy repts. Early Identification and Diagnosis of Chronic Respiraty Diseases: Nurses Specialists How to Utilize Multidisciplinary Care Team Pharmacists Summary: What is the primary role in improving outcomes? Early diagnosis Guideline-driven management Multidisciplinary care that fosters patient selfmanagement Summary: Stepwise Approach to Diagnosis and Initial Treatment F an adult who presents with respiraty symptoms: 1. Does the patient have chronic airways disease? 2. Syndromic diagnosis of asthma, COPD and ACOS 3. Spirometry 4. Commence initial therapy 5. Referral f specialized investigations (if necessary) Velcro crackles Diagnostic uncertainty Frequent exacerbations Summary: Guideline-driven Management GINA guidelines f asthma Minimize daily symptoms and exacerbation risk with stepwise therapy options Consider add-on therapy to reduce exacerbations GOLD guidelines f COPD Select therapy based on severity of symptoms and frequency of exacerbation Refer patients with stage 3 and 4 COPD to specialist Refer suspected IPF cases to specialist GINA 2016, Box 5-4 Thank you! 10