Take My Breath Away: COPD Update. Jason Henderson D.O. Warren Clinic Pulmonary & Critical Care

Transcription

1 Take My Breath Away: Update Jason Henderson D.O. Warren Clinic Pulmonary & Critical Care

2 Objectives 1. Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema. 2. Describe the workup involved in diagnosing obstructive airway disease. 3. Utilize staging tools to determine disease classification and appropriate therapies. 4. Describe the treatment options for including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers. Take My Breath Away March 26, 2018 l 2

3 Recognize clinical signs and symptoms associated with chronic bronchitis and emphysema.

4 Chronic obstructive pulmonary disease () is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although affects the lungs, it also produces significant systemic consequences.

5 Complaints should be suspected in all patients who report any combination of the following: chronic cough, chronic sputum production, dyspnea at rest or with exertion, or a history of inhalational exposure to tobacco smoke, occupational dust, or occupational chemicals These are the 3 cardinal complaints, they prevent in varying degrees, also can have people compensate but becoming increasing sedentary to compensate and down play dyspnea

6 Cause of Most common cause depends on how your frame your patient population. In 1 st world countries, it is tobacco use In rest of world, 3 billion people use wood or other biomass fuels (i.e. cow poop/coal/crop residuals) to cook, under ventilated, indoors. American Thoracic Society states ~20% of is related to occupational exposures, coal dust, organic small particle dust, cotton textile workers, etc, Allegedly ~10% of patients have Alpha-1 antitrypsin deficiency, in my experience, ~10% are carriers and ~1% have homozygous disease.

7 Stats on 4 th leading cause of death in the United States, responsible for 6% of all global deaths each year (2012 apprx 3,000,000) Estimated to be 3 rd leading cause of death by some studies already ranking it 3 rd 16 million adults with diagnoses of Estimated 14 million who are undiagnosed Significant morbidity as well as mortality In US, 2 nd most common cause of decreased ADL tolerance Expensive to treat. Advair is apprx $300/month

8 The incidence of is on the Rise Introduction of the Atari Introduction of Nintendo Introduction of Sega Genesis From: Jemal A. et al. JAMA 2005

9 Pack-years of smoking effect on FEV 1 Smoking is by far the largest risk factor for development of, but not everyone who smokes heavily develops as demonstrated by Burrows et al Not everyone who smokes even heavily develops

10 Describe the workup involved in diagnosing obstructive airway disease.

11 STOP SMOKING First and foremost, smoking cessation is paramount regardless of diagnosis or workup. You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup. Stop smoking, stop smoking, stop smoking

12 Key points of the Treating Tobacco Use and Dependence guidelines Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment Five first-line pharmacotherapies for tobacco dependence have shown efficacy

13 Spirometry, Spirometry is the Gold standard Yet only 32% of patients with a new diagnosis of had undergone spirometry Spirometry Utilization for How Do We Measure Up? CHEST August 2007 vol. 132 no We are under utilizing Spirometry in the diagnosis of Spirometry can help us Confirm the diagnosis of as many as 20 percent of individuals with severe airway obstruction will have no symptoms Determine the severity of And help guide treatment options Gives us prognostic information about survival rates Lower FEV1 or FEV1/FVC means worse outcomes and worse survival

14 Differential diagnosis of obstructive lung diseases strong history of tobacco use, Asthma reversible obstruction, strong correlation with allergies (unless it s not allergy mediated) Bronchiectasis multiple different types, can be part of, Alpha-1 antitrypsin deficiency (hereditary ) Ciliary dyskinesia Rheumatoid arthritis ILD Cystic fibrosis has significant amounts of bronchiectasis, rarely diagnosed as adult ILD sarcoidosis, pulmonary Langerhans cell histiocytosis, LAM (lymphangioleiomyomatosis) bronchiolitis obliterans And many other esoteric obstructive lung diseases

15 What not to do How Severe is this patient s? A. Mild B. Moderate C. Severe D. Very Severe Take My Breath Away March 26, 2018 l 15

16 How Severe is this patient s? A. Mild Take My Breath Away March 26, 2018 l 16

17 How Severe is this patient s? A. Mild B. Moderate C. Severe D. Very Severe Take My Breath Away March 26, 2018 l 17

18 How Severe is this patient s? D. Very Severe Take My Breath Away March 26, 2018 l 18

19 What s the Diagnosis XR Chest PA and Lat PA and lateral chest x-ray FINDINGS: Upper lung emphysematous changes are identified. Linear upper lobe scarring is seen. A few calcified granulomas are present. IMPRESSION: Stable findings including parenchymal scarring, emphysematous changes. Take My Breath Away March 26, 2018 l 19

20 What s the Diagnosis? Take My Breath Away March 26, 2018 l 20

21 What s the Diagnosis? Take My Breath Away March 26, 2018 l 21

22 What s the Diagnosis? XR Chest PA and Lat TWO VIEWS OF THE CHEST: INDICATION: Chest pain FINDINGS: No consolidation, effusion, or pneumothorax. Increased lung volumes consistent with obstructive lung disease. Stable left upper lobe scarring. Cardiomediastinal silhouette is normal. Take My Breath Away March 26, 2018 l 22

23 What s the Diagnosis? FEV1/FVC 41% FEV1 39% Take My Breath Away March 26, 2018 l 23

24 What s the Diagnosis? PA and lateral chest x-ray Comparison: 10/1/2013 Findings: The cardiomediastinal silhouette and pulmonary vascular markings are normal. Mild basal scarring is seen. The costophrenic sulci and lungs are otherwise clear. Impression: No acute findings. Take My Breath Away March 26, 2018 l 24

25 What s the Diagnosis? PA and lateral chest x-ray Comparison: 10/1/2013 Findings: The cardiomediastinal silhouette and pulmonary vascular markings are normal. Mild basal scarring is seen. The costophrenic sulci and lungs are otherwise clear. Impression: No acute findings. Take My Breath Away March 26, 2018 l 25

26 What NOT to do.. Make diagnosis by radiology. Make diagnosis by history alone Make diagnosis without spirometry Order a spirometry then mark out machine interpretation of probable restriction and relabel obstruction to fit your bias

27 What Not to do.. CXR: poor sensitivity. Has sensitivity of less than 50% in detecting with moderate severity ABG The PaO2 usually remains near normal until the FEV1 is decreased to ~50% of predicted, PaCO2 elevation is not expected until the FEV1 is <25% of predicted CT Can give pathologic data, but nothing on the functional data, no data on sensitivity or specificity And since other conditions can present with symptoms similar to, don t misread the test data

28 80 % 70 % 80 % 80 % 80 %

29 yes FEV1/FVC ratio >70% no yes Normal FVC >80%? FVC >80%? no Possible restriction, get full PFT yes Obstruction Look at FEV1 to determine severity no Get full PFT

30

31 Step 1 FEV1/FVC ratio Step 2 FVC Step 3 FEV1

32 Utilize staging tools to determine disease classification and appropriate therapies.

33 Classification of per GOLD criteria GOLD I: Mild FEV 1 /FVC < 0.70 FEV 1 > 80% predicted GOLD II: Moderate FEV 1 /FVC < % < FEV 1 < 80% predicted GOLD III: Severe FEV 1 /FVC < % < FEV 1 < 50% predicted GOLD IV: FEV 1 /FVC < 0.70 Very Severe FEV 1 < 30% predicted

34 Choice of thresholds Assessment Test (CAT TM ) Chronic Respiratory Questionnaire (CCQ ) St George s Respiratory Questionnaire (SGRQ) Chronic Respiratory Questionnaire (CRQ) Modified Medical Research Council (mmrc) questionnaire 2017 Global Initiative for Chronic Obstructive Lung Disease

35 ABCD Assessment Tool Because FEV1 does not predict symptoms/progression 2017 Global Initiative for Chronic Obstructive Lung Disease

36 Treatment of Stable 2017 Global Initiative for Chronic Obstructive Lung Disease

37 You can not go just by FEV1 New guidelines treatment determined more by symptoms and exacerbations over FEV1, But few of us actually calculate the GOLD classification based off new guidelines, important information is Severity of obstruction, how symptomatic and how frequently they re exacerbating and have they quit smoking. Very cumbersome system, so the more they are exacerbating and more symptomatic they are, and the worse the FEV1 is, the more medications they get.

38 Treatment of Stable 2017 Global Initiative for Chronic Obstructive Lung Disease

39 Non-Pharmacologic Treatment Education and self-management Self-management education and coaching by healthcare professionals should be a major component of the Chronic Care Model within the context of the healthcare delivery system. The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease Global Initiative for Chronic Obstructive Lung Disease

40

41

42 Monitoring and Follow-up Monitoring disease progression and development of complications and/or comorbidities Measurements. Decline in FEV 1 can be tracked by spirometry performed at least once a year. Symptoms. At each visit, information on symptoms since the last visit should be collected, including cough and sputum, breathlessness, fatigue, activity limitation, and sleep disturbances. Exacerbations. The frequency, severity, type and likely causes of all exacerbations should be monitored. Imaging. If there is a clear worsening of symptoms, imaging may be indicated. Smoking status. At each visit, the current smoking status and smoke exposure should be determined followed by appropriate action Global Initiative for Chronic Obstructive Lung Disease

43 Useful Guidelines and resources The Global Initiative for Chronic Obstructive Lung Disease

44 Describe the treatment options for including short and long acting beta agonists, anticholinergics and combined pharmacologic inhalers.

45 STOP SMOKING First and foremost, smoking cessation is paramount regardless of diagnosis or workup. You have a patient you see who is smoking, full stop, spend time to educate them on stopping, then proceed on symptoms and workup. Stop smoking, stop smoking, stop smoking

46 Key points of the Treating Tobacco Use and Dependence guidelines Tobacco dependence is a chronic condition that warrants repeated treatment until long-term or permanent abstinence is achieved Effective treatments for tobacco dependence exist and all tobacco users should be offered these treatments Brief tobacco dependence intervention is effective and every tobacco user should be offered at least brief intervention There is a strong dose-response relationship between the intensity of tobacco dependence counselling and its effectiveness Three types of counselling were found to be especially effective: practical counselling, social support as part of treatment and social support arranged outside treatment Five first-line pharmacotherapies for tobacco dependence have shown efficacy

47 Treatment of Stable SABA - short acting beta agonist LABA long acting beta agonist SAMA short acting muscarinic antagonist LAMA long acting muscarinic antagonist ICS inhaled corticosteroid PDE4 - Phosphodiesterase 4 inhibitor 2017 Global Initiative for Chronic Obstructive Lung Disease

48 Current medications LABA Arcapta (indacaterol) Serevent (Salmeterol) Striverdi (olodaterol) ICS Aerospan (flunisolide) Alvesco (ciclesonide) Arnuity (fluticasone furoate) Asmanex (mometasone) FLovent (fluticasone propionate) Pulmicort (budesonide) Qvar (beclomethasone) ICS/LABA Advair (fluticasone/salmeterol) Breo (fluticasone/vilanterol) Dulera (mometasone/formoterol) Symbicort (Budesonide/formoterol) LABA/LAMA Anoro (umeclidinium/vilaterol) Stiolto (tiotroprium/olodaterol) Utibron (glycopyrrolate/indacaterol) LAMA Seebri (glycopyrrolate) Incruse (umeclidinium) Spiriva (tiotropium) Tudorza (aclidinium) Presentation Title l March 26, 2018 l 48

49 Treatment of Stable 2017 Global Initiative for Chronic Obstructive Lung Disease

50 ABCD Assessment Tool Because FEV1 does not predict symptoms/progression 2017 Global Initiative for Chronic Obstructive Lung Disease

51 Other treatment considerations Everyone w/ should have a rescue SABA on hand, Inhalers don t work if they aren t being used properly, Check technique Spacer chamber Other treatment considerations Possible Lung volume reduction surgery Lung transplant??? Endobronchial 1-way valves??? Anti-IL5 for eosinophilic asthmatic overlap syndromes

52 Updates and likely changes in recommendations - The use of combination therapy with LAMA/LABA is newly emphasized within last year as first line therapy, - Monotherapy with LABA or use w/o ICS previously discouraged due to SMART study in asthma, - Moderate hypoxemia treatment does not improve mortality, Old recommendations

53 Beware the combo products Very easy to over medication with many different ICS/LABA and LABA/LAMA combinations.

54 Non-Pharmacologic Treatment Education and self-management Self-management education and coaching by healthcare professionals should be a major component of the Chronic Care Model within the context of the healthcare delivery system. The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behaviour(s) and develop skills to better manage their disease Global Initiative for Chronic Obstructive Lung Disease

55 Non-Pharmacologic Treatment Oxygen therapy Long-term oxygen therapy is indicated for stable patients who have: PaO 2 at or below 55 mmhg or SaO 2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or PaO 2 between 55 mmhg and 60 mmhg, or SaO 2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%). Resting sats >89% but desats on ambulation no benefit in mortality,? Insurance changes in coverage for this in coming years Global Initiative for Chronic Obstructive Lung Disease

56 Questions?