What is New in COPD: Times Are Changing! Meredith Chiasson, MD, FRCPC April 6, PDF Free Download

What is New in COPD: Times Are Changing! Meredith Chiasson, MD, FRCPC April 6, 2018

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objectives How to diagnose & Assess severity Treatment: Pharmacologic Non-Pharmacologic Maintenance Spirometry Inhalers Smoking Cessation Vaccines Rehabilitation Oxygen Treatment of Exacerbation Palliative Care INSPIRED

What is COPD??? Respiratory disorder largely caused by smoking, and is characterized by progressive, partially reversible airway obstruction and lung hyperinflation, systemic manifestations and increasing frequency and severity of exacerbations COPD is not asthma and should be managed differently. Can Respir J, 2008; 15(Suppl A): 1A-8A.

Diagnosis Clinical Suspicion Cough Shortness of Breath Sputum.. Screen all smokers?

Diagnosis POST bronchodilator spirometry NOT CXR Emphysema can be seen on CT Barriers??

Why is Diagnosis important?

How to assess severity? Spirometry Clinical degree of symptoms

MRC Class

COPD in Canada: Epidemiology and Costs

Percent Change in Age-Adjusted Death Rates, U.S., 1965 1998 (Proportion of 1965 Rate)

How to Decrease Mortality? Short Term: Non-invasive ventilation Long Term: 1. Smoking cessation 2. Home oxygen (?? Still the case) 3. Lung volume reduction surgery Can Respir J, 2008; 15(Suppl A): 1A-8A.

Basic framework Confirm the diagnosis spirometry Treatment Pharmacologic Non-Pharmacologic Maintenance Spirometry Inhalers Smoking Cessation Vaccines Rehabilitation Oxygen Treatment of Exacerbation Palliative Care INSPIRED

<30% 30-50 50-80 >80% http://goldcopd.org/

http://goldcopd.org/

Short Acting

Seebri 50mcg, 1 capsule 2 puffs daily Turdoza 400mcg1 puff B.I.D. LAMA (AKA LAAC) Spiriva Handihaler 18mcg, 1 capsule 2 puffs daily Spiriva Respimat 2.5mcg 2 puffs daily Incruse 62.5mcg, 1 puff daily

LAMA (AKA LAAC) LAMA vs placebo: Less dyspnea, exacerbations and fewer hospitalizations Better lung function, QoL LAMA vs SABA: Improved lung function Less frequent exacerbation and hospitalizations Fewer withdrawals from clinical trials. LAMA vs LABA Fewer exacerbations and hospitalizations Equal improvement in lung function, QoL Similar withdrawal from studies

LAMA (AKA LAAC) - MSI Moderate - severe COPD (ratio <70%, FEV1<60%) OR Inadequate response to short acting bronchodilators MRC Grade 3 after 2 months of: 8 puffs/day of short acting beta-2 agonist or 12 puffs/day of ipratropium or 6 puffs/day of ipratropium/salbutamol combo inhaler

LABA Equal class effects (as with LAMA) Foradil 12mcg 1 puff B.I.D. Oxese 6 or 12mcg 1 puff B.I.D. Onbrez 75mcg 1 puff daily Serevent 50mcg 1 puff B.I.D.

LABA - MSI Moderate - severe COPD (ratio <70%, FEV1<60%) OR Inadequate response to short acting bronchodilators MRC Grade 3 after 2 months of: 8 puffs/day of short acting beta-2 agonist or 12 puffs/day of ipratropium or 6 puffs/day of ipratropium/salbutamol combo inhaler

FLAME FLAME

LAMA/LABA Anoro 62.5mcg 1 puff daily Ultibro 50mcg (1 capsule) 2 puffs daily Inspiolto 2.5mcg 2 puffs daily Duaklir 400mcg 1 puff B.I.D.

LAMA/LABA - MSI Moderate - severe COPD (ratio <70%, FEV1<60%) Inadequate response to 2 months of LAMA or LABA

TORCH TORCH

ICS/LABA Advair Diskus (250mcg or 500mcg) 1 puff B.I.D. MDI (125mcg or 250mcg) 1 or 2 puffs B.I.D. Breo 100mcg (200mcg for asthma) 1 puff daily Symbicort 100mcg or 200mcg 1 or 2 puffs B.I.D. Zenhale is not approved for COPD in Canada

ICS/LABA TORCH trial rigorous study Decreased exacerbations by 25% Just missed mortality benefit (p=0.52) if had run longer most feel would have hit significance for mortality. Increased risk of pneumonia (NNH = 17)

LABA/ICS - MSI Frequent exacerbators

LABA/ICS + LAMA Moderate - severe COPD (ratio <70%, FEV1<60%) COPD exacerbation(s) ( in symptoms needing antibiotics &/or oral or IV steroids). Inadequate response to LABA/ICS or LAMA after 2 months.

Inhaled Corticosteroids (ICS)

Vaccinations Annual influenza vaccines Reduces hospitalization Reduces the number of COPD exacerbations (Cochrane 2010) Pneumococcal vaccination Pneumovax (polysaccharide) with a boost 5-10 years later in high risk COPD patients (Conj vaccine if immunosuppressed)

Oxygen MRC & NOTT trials Only therapy with mortality benefit Coverage: government & private Criteria: Non-smoker, at stable baseline On maximal medical therapy po2<55mmhg (<60 if right heart failure) Desaturation <80% with ambulation Overnight

NOTT AIM 1980. MRC Lancet 1981 Home Oxygen

Do you always want to prescribe? Compressor, 120 feet tubing 10 oxygen tanks Fall hazard Social stigma Discomfort ears and nose

COPD Exacerbation Acute increase in sx s beyond normal day-to-day variation: More severe and frequent cough More sputum, or change in character More SOB Exacerbations cause morbidity & mortality CXR usually unchanged, may have pneumonia Spirometry usually worsens

Acute Event Mortality AECOPD 22-43% of patients hospitalized with a AECOPD die within 1 year (1,2,3,4) In-hospital mortality rate for AECOPD is 8-11% (1,2) Acute MI 25% of men & 38% of women die within 1 year of 1 st recognized MI (5,6) In-hospital acute MI mortality rate is 8-9.4% (5,6) 1. Eriksen N. Ugeskr Laeger 2003;165:3499 3502. 4. Connors AF. Am J Respir Crit Care Med 1996;154:959 967. 2. Groenewegen KH. Chest 2003;124:459 467. 5. Thom T et al. Circulation 2006. 3. 3. Almagro P. Chest 2002;121:1441 1448. 6. Heart and Stroke Foundation of Canada

# of Patients AECOPD - #1 Cause for Hospital Admissions Among Chronic Illness in Canada 18,000 16,000 14,000 COPD Angina Asthma 12,000 10,000 8,000 6,000 Heart Failure Diabetes 2 or more repeat hospitalizations 1 repeat hospitalization Single hospitalization 4,000 2,000 0 Health Indicators 2008. Canadian Institute of Health Information. Page 21.

Corticosteroids in COPD Aaron, SD. NEJM, 2003; 348: 2618-25.

Exacerbation - Antibiotics When (Anthonisen criteria) beneficial to treat more severe purulent AECOPD What Increased SOB Increased sputum volume Increased purulence Simple vs complex exacerbation Have they had antibiotics in the last 3 months

Recommendations for ABX - What Simple Exacerbation Amoxicillin Cefuroxime Doxycycline TMP/SMX Azithromycin Complicated Exacerbation* Resp. fluoroquinolone Amox/Clav * FEV1 <50% or IHD >4 AECOPD per yr home O 2 chronic oral steroids

COPD Action Plan

Smoking Cessation

Smoking Cessation Cold turkey is best Cutting Smoking down to Cessation quit does Counselling not work Switching to e-cigarettes to quit does Refer to Tracey Cushing (R.T.) not work (jury is still out as to whether or not e-cigarettes Cobequid are safer) Counselling with pharmacologic therapy has best evidence.

Rehabilitation Cobequid and Mumford road Two days per week for three months 1 st hour is weight lifting and aerobic exercise (treadmill, bike, arm bike) 2 nd hour is counselling (smoking cessation, how to eat, how to breath etc)

Benefits of Pulmonary Rehabilitation

Key Message

Palliative Care Referral is challenging in Halifax (imminent death) Best to refer early and have at least one session in regards to advanced care planning/advanced directives, where they would like to die etc.

End of Life Care Who is at increased risk of death: Very severe airflow obstruction (FEV1 <30%), with hyperinflation ( TLC & FRC) MRC 4-5 BMI < 19 Older age Recurrent exacerbations (hospitalization and intubation) Pulmonary hypertension Can Respir J, 2008; 15(Suppl A): 1A-8A.

Case

Case - Presentation 65yo man in your office Current smoker 30 pack years SOB walks slower than most people own age (MRC 3). Daily smoker s cough productive of yellow sputum. No hemoptysis., Ventolin & Atrovent x 5 years. Unwell 2-3x/year for which you treat him with an antibiotic.

Case - Presentation PMHx: hypercholesterolemia, HTN,? TIA, stable angina MEDS: rosuvastatin, HCTZ, ASA, Ventolin, atrovent Vaccines: none recently ALLERGIES: None P/E: HR 110, RR 24, Spo2 87% on R/A, BP 162/98, afebrile Decreased breath sounds throughout, scattered wheezes, 1+ peripheral edema.

Case - Investigations Post bronchodilator PFTs, baseline FVC 2.94 (61%) FEV1 0.61 (16%) Ratio 21% Reduced Obstruction

Basic framework Pharmacologic Non-Pharmacologic Maintenance Inhalers Vaccines Oxygen Treatment of Exacerbation Spirometry Smoking Cessation Rehabilitation Palliative Care INSPIRED

Inhalers With his lung function and exacerbation history you can put him on triple therapy but not dual. Can start with LAMA, or tripple If you choose LAMA, then you can upgrade to LAMA/LABA (dual) in two months.

Seebri 50mcg, 1 capsule 2 puffs daily Turdoza 400mcg1 puff B.I.D. LAMA Spiriva Handihaler 18mcg, 1 capsule 2 puffs daily Spiriva Respimat 2.5mcg 2 puffs daily Incruse 62.5mcg, 1 puff daily

ICS/LABA Advair Diskus (250mcg or 500mcg) 1 puff B.I.D. MDI (125mcg or 250mcg) 1 or 2 puffs B.I.D. Breo 100mcg (200mcg for asthma) 1 puff daily Symbicort 100mcg or 200mcg 1 or 2 puffs B.I.D.

0.61 (16%) 21%

6 Amox/Clav 875mg BID X 3repeats Doxycyclin 100mg 4 Ventolin BID X 3repeats 50mg 5 OD 5 X 6repeats COPD Action Plan

Vaccination Yearly influenza vaccine Pneumovax every ten years (regardless of age!)

Oxygen Does not qualify as continues to smoke! If he quits need to refer to a specialist with oxygen prescribing capabilities PaO2<55mmHg or <60mmHg if right heart failure <80% on 6 minute walk test.

Non-Pharmacologic Smoking cessation even brief intervention can be worthwhile Rehabilitation Great idea! INSPIRED even continues to exacerbate Palliative care too early

Basic framework Pharmacologic Non-Pharmacologic Maintenance Inhalers Vaccines Oxygen Treatment of Exacerbation Spirometry Smoking Cessation Rehabilitation Palliative Care INSPIRED

Basic framework Pharmacologic Non-Pharmacologic Inhalers Spirometry Action Plan Smoking Cessation Vaccines Rehabilitation Oxygen Palliative Care

Livingwellwithcopd.com

Fee Code - COPD http://www.doctorsns.com/site/media/ DoctorsNS/ContinuingCareFees.pdf

References Gold 2017 and 2011

INSPIRED Program Outreach program Working with patients in the HRM who have advanced COPD Those who require frequent visits to health care facilities, or who cannot make it to outpatient respirology clinic Team is composed of a physician, respiratory therapist and spiritual care