WINDY CITY WHEEZE: A PREVENTATIVE APPROACH TO COPD MANAGEMENT Thursday, October 25, 2018 Sarah Sungurlu DO Assistant Professor Division of Pulmonary and Critical Care Medicine
Disclosures I have no actual or potential conflict of interest in relation to this program/presentation. I will not be discussing off-label uses of any medications
Objectives Relate diagnostic criteria for COPD to improve patient and provider awareness of the disease Discuss available maintenance therapy for COPD that can be instituted in the ED setting Appraise the literature supporting and refuting vaccinations Prioritize the importance of proper medication use and smoking cessation in the overall management plan of the COPD patient.
Chronic Obstructive Pulmonary Disease Global strategy for chronic Obstructive Lung Disease (GOLD) definition: Preventable and Treatable disease with extrapulmonary effects and a pulmonary component characterized by airflow obstruction that is no longer fully reversible and is usually progressive and associated with abnormal inflammatory response of lung to noxious particles or gases 1. Pauwels et al. Am J Respir Crit Care Med. 2001, 163:1256-1276
Pathophysiology Chronic productive cough for at least 3 consecutive months in 2 consecutive years (driven by chronic inflammation) Abnormal enlargement of airways distal to terminal bronchioles due to destruction of their walls without obvious fibrosis
Remodeling: mucus hypersecretion, bronchiolar edema, smooth muscle hypertrophy and peribronchiolar fibrosis result in narrowing of small airways Barnes. NEJM. 2000, 343:269-280
Epidemiology COPD 3 rd leading cause of death in America 5 th most common worldwide 3 million deaths worldwide from COPD in 2005 1 NHANESIII data (US survey 2007-2010): Prevalence of 14% in US adults aged 40-79 when using the GOLD criteria of fixed ratio post-bronchodilator spirometry 2 More than 50% patients with low PFTs were unaware of COPD 1. CDC and WHO 2. Tilert et al. Respiratory Research. 2013, 14:103
Burden of disease In 2010 the United States spent 50 billion dollars on COPD 1 The costs associated with hospitalization accounts for more than 70% of this spending 2 1. Guarascio et al. Clinicoecom Outcomes Res. 2013; 5: 235-245 2. Sullivan et al. Chest. 2000. 117(2 Suppl): 5S-9S
Factors predicting readmission Lower socio-economic status Extremes of BMI Comorbidities It is important to remember that a major predictor for future exacerbations is previous exacerbations 1. Kumbhare et al. Chronic Obstr Pulm Dis. 2016; 3(2): 539-548
Many risk factors lead to COPD COPD 1. Eisner et al. Am J Respir Crit Care Med. 2010, 182:693-718
Diagnostic Criteria for COPD- Spirometry GOLD Criteria: Spirometry with post bronchodilator FEV1/FVC <0.70 ATS and ERS Criteria: Fixed ratio cutoff can lead to misdiagnosis of >20% of patients Use of LLN cutoff (equal to the 5 th percentile) based on NHANES III data for age, ethnicity, gender and height
Recognizing COPD in the Emergency Department Previous diagnosis of COPD Recognize that many patients have been clinically diagnosed without spirometry and therefore only have presumed COPD Should be encouraged to follow-up with primary care physician or pulmonologist to confirm diagnosis or rule out other causes with pulmonary function tests
Recognizing COPD in the Emergency Department, continued Emphysema on previous imaging Chronic bronchitis historical description Smoking history Age >55 Wheezing 1. Radeos et al. Am J Emerg Med. 2009; 27(2)191-6
Differential Diagnosis of COPD Diagnosis COPD Asthma Congestive Heart Failure Bronchiectasis Others Suggestive Features Mid life onset Slowly progressive symptoms History of exposure or risk factor Earlier onset (though can develop in adult) Widely variable symptoms day to day Diurnal symptoms (worse at night/early morning) Allergy, rhinitis, eczema Family history Chest X-ray shows dilated heart and pulmonary edema (cardiac asthma) Pulmonary function tests show restriction not obstruction Large volumes of purulent sputum Colonized with bacteria Chest X-ray and/or CT differentiate Tuberculosis, bronchiolitis obliterans, diffuse panbronchiolitis, lymphagioleiomyotasis, etc.
Severity of Symptoms Grade 0 Description of breathlessness I only get breathless with strenuous exercise 1 I get short of breath when hurrying on level ground or walking up a slight hill 2 3 4 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace I stop for breath after walking about 100 yards or after a few minutes on level ground I am too breathless to leave the house or I am breathless when dressing
Severity of COPD GOLD 2017 ATS severity of obstruction: Mild >60% Moderate 30-60% Severe <30% GOLD 1 GOLD 3-4 C D 2 or 1 hospitalization GOLD 1-2 A B 1 or no hospitalization mmrc <2 or CAT <10 FEV1 (% predicted) 80 GOLD 2 50-79 GOLD 3 30-49 GOLD 4 <30 mmrc 2 or CAT 10 GOLD 2018 2 or 1 hospitalization 1 or no hospitalization C A mmrc <2 or CAT <10 D B mmrc 2 or CAT 10
Inhalers at a Glance
Acute exacerbation of COPD (AECOPD) An event in the natural course of the disease characterized by a change in baseline dyspnea, cough and sputum beyond normal day variations, with an acute onset, which may warrant a change in medication Initial therapies Oxygen, inhaled bronchodilators, systemic corticosteroids Early NIV has improved outcomes (over invasive ventilation with a success rate of 80-85%)
Treatment of AECOPD, steroids Steroids do shorten recovery, treatment failure, and reduce risk of early relapse Preferred dosing is prednisone 40mg for 5-7 days REDUCE trial: shorter course of systemic steroids yields equal length to next exacerbation Oral prednisone is equally effective to intravenous administration if oral access is available and intact.
Treatment of AECOPD, antibiotics Controversial, but some evidence of benefit with antibiotics in absence of pneumonia To reduce overexposure to antibiotics suggest use of antibiotics if have increase in dyspnea, sputum volume and sputum purulence Duration 5-7 days Choice should be based on local resistance pattern (macrolide, tetracycline)
Bronchodilators Increase FEV1, improve exercise performance, reduce dynamic hyperinflation Beta 2 agonists SABA (albuterol) LABA (formoterol, salmeterol ) Methylxanthines Theophylline Limited and contradictory evidence, risk of toxicity 1. Vogelmeier et al. Am J Respir Crit Care Med. 2017, 195:557-582
Bronchodilators Antimuscarinics SAMA (ipratropium) Slightly greater effect on lung function, health status, requirement for oral steroids over SABA 1 LAMA (tiotropium, aclidinium ) Greater effect on exacerbation rates than LABA 2 1. Appleton et al. Cochrane Database Syst Rev. 2006, (3):Cd006101 2. Vogelmeier et al. NEJM. 2011, 364:1093-1103
Combination Bronchodilators Combination of SABA/SAMA Improve FEV1 and symptoms compared to monotherapy (level A) Combination LABA/LAMA Improve FEV1 and reduce symptoms compared to monotherapy (level A) Reduce exacerbation compared with monotherapy or combination of ICS/LABA (level B) FLAME trial: 1 11% reduction in annual exacerbation rate in LAMA/LABA compared to ICS/LABA group Increased risk for pneumonia in ICS/LABA group- 4.8% vs 3.2% 1. Wedzicha et al. NEJM. 2016, 374:2222-2234
Anti-inflammatory Agents Reduce number of exacerbations Inhaled Corticosteroids ICS/LABA is more effective than either drug as monotherapy in improving lung function and reducing exacerbations in moderate to severe COPD (level A) TORCH trial 1 : In patients with FEV1<50% use of ICS/LABA decreases annual rate of exacerbation but not mortality Triple inhaled therapy ICS/LAMA/LABA improves lung function, symptoms and health status (level A) and reduces exacerbations (level B) compared to ICS/LABA or LAMA monotherapy Oral glucocorticoids No role in chronic daily treatment with numerous side effects (level A) and no evidence of benefits (level C) 1. Calverley et al. NEJM. 2007, 356:775-789 2. Vogelmeier et al. Am J Respir Crit Care Med. 2017, 195:557-582
DPI MDI SMI Inhalers at a Glance
Other considerations in choice of inhaler Arthritis of the hands/fingers Avoid metered dose inhalers (try dry powder breath actuated inhalers or nebulizers) Poor technique Spacers, breath actuated dry powder, or nebulizer Poor memory Simplify regimen, limit dose frequency Income Think about costs of drugs (Insurance formulary)
Education on proper use of medications Individualized and guided based on severity of symptoms risk of exacerbations side-effects comorbidities drug availability and cost and the patient's response, preference and ability to use various drug delivery devices Assess inhaler technique every visit with instruction and demonstration
Anti-inflammatory Agents, continued Phosphodiesterase 4 inhibitors (Roflumilast) Reduction in exacerbation if on LABA/ICS (level B) Chronic bronchitis, >1 exacerbation in last year, FEV1 <50% Side effects: diarrhea, nausea, reduced appetite, weight loss, abdominal pain, headache Antibiotics Azithromycin 250 or 500 three times per week reduces risk of exacerbations (level A) Azithromycin does increase incidence of bacterial resistance (level A) and hearing impairment (level B) QTc prolongation and sudden cardiac death 3 1. Martinez et al. Lancet. 2015, 385:857-866 2. Vogelmeier et al. Am J Respir Crit Care Med. 2017, 195:557-582 3. Albert et al. NEJM. 2011, 365:689-698
COPD discharge care bundles 1. Hopkinson et al. Thorax. 2012; 67:90-92
Natural history of lung function decline in smoker versus nonsmoker Nonsmoker healthy lungs lose 20-30mL/year of FEV1 after age 35 and rate of decline starts to accelerate with aging Smoking accelerates the rate of decline (on average 15ml/year larger) 1 As does COPD exacerbations 1. Kertsjens et al. Thorax. 1997;52:820-827.
Strategies to encourage smoking cessation Ask: every patient at every visit smoking status Advise: strongly encourage quitting Assess: willingness and rationale to quit Assist: quit plan, counselling, social support, pharmacotherapy, supplemental materials Arrange: follow-up contact in person or via telephone Things to discuss: Tie tobacco to current health, social and economic costs and the impact of smoking on children and others in home Identify potential consequences (infertility, heart attacks, strokes, gum disease, lung cancer, children increased risk of SIDS and respiratory infections, etc.) Identify benefits they believe they derive from smoking and find alternative methods to fill these voids after cessation Identify their barriers (partner or coworkers who smoke etc.) 1. Vogelmeier et al. Am J Respir Crit Care Med. 2017;195(5):557-582
Pharmacotherapy Varenicline (Chantix) $450 Start with 0.5mg QD for 3 days then 0.5mg BID for four days, then 1mg BID for total 12 weeks Adjust dose for renal function Neuropsychiatric symptoms (unusual dreams, insomnia, agitation, depression, suicide) Bupropion SR (Zyban) $32-202 150mg SR QD for 3 days then 150mg SR BID Insomnia, dry mouth, SEIZURES, monitor for mood changes including suicidality Both increase long term quit rates but should be used as a component of supportive intervention program rather than sole intervention for smoking cessation. Nicotine Replacement Therapy Various forms increases longterm abstinence rate and is more effective than placebo Effectiveness and safety of e-cigarettes is uncertain at present
NRT Cost Dose Duration Directions Adverse Transdermal $58-80/24 patches 21, 14, 5mg/24 hr 8 week Can supplement with gum Skin reactions, sleep disturbances Lozenge $40/72 count 2 or 4mg 12 weeks Allow to dissolve, no drinking 15 min Gum $26-40/100 sticks 2 or 4mg 2-3 months Chew and then park between cheek and gum HA, diarrhea, nausea Jaw fatigue, belching, nausea Nasal $193/10mL bottle 1mg per nostril 2-3 months Spray technique Nasal irritation, rhinorrhea Inhaler $194/cartridge 80 puffs=1mg, requires 3-4 puffs/minute for 20-30min use Q1 PRN 2-3 months Puff more frequently then cigarrettes Cough, mouth/throat irritation. Avoid if RAD
Pulmonary rehabilitation A program of education and exercise designed to manage respiratory illness Sessions supervised by PT, RT, Pulmonologist, nutritionist Specifically designed for patient to the level they can handle Both strength and endurance training Most programs meet 2 times a week and last generally 8 weeks Medicare Part B covers pulmonary rehabilitation services for Moderate to Very Severe COPD as defined by GOLD Classification Improves symptoms, QOL, and physical and emotional participation in everyday activities
Outpatient follow-up Indicated within 1-4 weeks after acute exacerbation Review understanding of treatment regimen, inhaler technique Reassess oxygen needs PFTs are recommended at 8-12 weeks of discharge (baseline conditions) to establish diagnosis Can have significant improvement in FEV1 >8weeks after acute exacerbation Can consider acute spirometry in hospitalized patient or shortly after discharge to try to reduce overdiagnosis
Vaccinations Influenza Reduce serious illnesses such as LRTI and death, significant reduction in total number of exacerbations 1 Killed or live inactivated forms Pneumococcal PCV 13 and PCV 23 23 valent pneumococcal polysaccharide vaccine (PPSV23) reduce the incidence of community acquired pneumonia in COPD patients <65 with an FEV1 <40% predicted and in those with comorbidities including chronic heart or lung disease General population of adults >65 years the 13 valent conjugated pneumococcal vaccine (PCV13) has demonstrated significant efficacy in reducing bacteremia and serious invasive pneumococcal disease 1. Criner et al. Chest. 2015;147(4):894-942
Other cost effective interventions: Improving ventilation in areas where indoor cooking/heating takes place Hygiene Nutrition Prevention of infection.
Palliative care Relief of dyspnea, pain, anxiety, depression, fatigue, and poor nutrition along with advance care planning
Resources For patients: https://foundation.chestnet.org/patient-educationresources/copd/ https://www.copdfoundation.org/ For providers: ATS/ERS guidelines GOLD guidelines