COPD: Enhancing Recognition and Improving Outcomes
MiCMRC Care ManagementEducational Webinar
MiCMRC Care Management Educational Webinar:Enhancing Recognition and Improving Outcomes
Expert Presenter:
Catherine A. Meldrum PhD RN MS CCRCUniversity of Michigan
Financial Disclosure
I do not any financial interests related to the content of this presentation.
Objectives Epidemiology: Burden Risk factors
Screening When and who to screen
Management: Is not just spirometry Advantages of the GOLD classification How to make it simple Pharmacologic therapies By GOLD group By phenotypes (CB. frequent exacerbation)
Non-pharmacologic therapies Comorbidities
Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.
Global Initiative for Chronic Obstructive Lung Disease (GOLD) ;a project initiated by the NHLBI and WHO define COPD 2016
Defining COPD
Objectives Epidemiology: Burden Risk factors
Screening When and who to screen
Management: Is not just spirometry Advantages of the GOLD classification How to make it simple Pharmacologic therapies By GOLD group By phenotypes (CB. frequent exacerbation)
Non-pharmacologic therapies
0
10
20
30
40
50
60
70
1980 1985 1990 1995 2000
Men Women
COPD Mortality in the US 1980-2000Maybe not what you would suspect?
Year
Dea
ths
x 10
00
Mannino et al. MMWR Surveill Summ. 2002;51:1-16.
Percent Change in Age-Adjusted US Death Rates
3.0
2.5
2.0
1.5
1.0
0.5
01965-1998 1965-1998 1965-1998 1965-1998 1965-1998
CoronaryHeart
Disease
Stroke Other CVD
All Other Causes
-64%-59% -35% -7%
COPD
+163%
Global Initiative for Chronic Obstructive Lung Disease. NHLBI/WHO workshop report.2001. http://www.goldcopd.com/workshop/toc.html. Accessed: 14 November 2003.
COPD: Risk Factors
Tager et al. Am Rev Respir Dis. 1988;138:837-849; Holt. Thorax. 1987;42:241-249.
Established Probable PossibleCigarette
smoking Occupational
exposure
α1-Antitrypsin deficiency (genetic abnormality)
Air pollution
Exposure to primary and secondary smoke
Hyperactive airways
Alcohol
Poverty
Low birth weight
Childhood respiratory infections
Family history
Atopy
IgA deficiency
Blood type A
COPD: The Vicious Circle
Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.
Chronic Pulmonary Disease
Physical Deconditioning
Physical Reconditioning
Decreased Exercise Capacity
Increased Exercise Capacity
Increased Breathlessness
Decreased Breathlessness
Immobility Pulmonary Rehabilitation
Increased VERequirement
Decreased VERequirement
Objectives Epidemiology: Burden Risk factors
Screening When and who to screen
Management: Is not just spirometry Advantages of the GOLD classification How to make it simple Pharmacologic therapies By GOLD group By phenotypes (CB. frequent exacerbation)
Non-pharmacologic therapies
COPD Diagnosis
Audience question
Which of the following screening tests is recommended by the USPHS Preventive Task Force:– Colonoscopy for detection of colon cancer– Mammogram for breast cancer detection– Chest CT for lung cancer detection– Neonatal tests for CF– Spirometry for COPD detection
Systematic Review of the Evidence: US Preventive Services Task Force
Conclusions:– No direct evidence indicates that screening
patients for COPD using spirometry improves long-term health outcomes.
– Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction who would not experience additional health benefits if labeled as having COPD.
Siu et al. JAMA 2016;315:1372-7.
Spirometry use
VA study, 2003-2004. 93K new COPD diagnosis.– Just 36.7% with new diagnosis of COPD had
spirometry 2y prior, to 6m after diagnosis.– Regional variation.
2002-2003 Ntl. Committee for Quality Assurance. 1.5M members, 5K new COPD.– Claims 2y prior to, to 6m after diagnosis.– Just 32% with new diagnosis of COPD had
spirometry. Lower in older patients.
Han MK. Chest 2007;132: 403Joo M. Chest 2008; 134: 38
Barriers to COPD diagnosisPessimistic view of the disease:
– Tobacco-related. Self-inflicted.– There is nothing than can be done for a COPD patient
who continues smoking.Barr et al. Am J Med 2005; 118: 1415e.
Perceived efficacy of spirometry and recommendations:– Conflicting recommendations about screening
spirometry.– Conflicting recommendations about treatment.
Salinas et. al. Int J COPD 2011; 6: 171.
Pathway to Diagnosing COPD
Global Initiative for Chronic Obstructive Lung Disease.. http://www.goldcopd.org. Accessed: 10 February 2017.
SYMPTOMSShortness of breath
Chronic coughSputum
RISK FACTORSHost factors
TobaccoOccupation
Indoor/outdoor pollution
SPIROMETRY: Required to establish diagnosis
Adapted from Fletcher et al. BMJ. 1977;1:1645-1648.
Disease must be detectable in an early stage: Lung Function Over Time
FEV 1
(%) R
elat
ive
to A
ge 2
5
Never smoked or notsusceptible to smoke
Stopped Smoking at 45 (Mild COPD)
Stopped smoking at 65 (Severe COPD)Death
Disability
Smoked regularly and susceptible to its effects
Age (Years)50 75250
Symptoms
0
20
50
60
100
80
40
Mannino et al. MMWR Morb Mortal Wkly Rep. 2002;51:1-16.
050
100150200250300350400450
Diagnosed with chronic bronchitis or emphysema
Airflow limitation (GOLD 1 or higher)
Rate
per
100
0 of
Pop
ulat
ion
25-44 45-54 55-64 65-74 >/=75Age (years)
Underdiagnosis of COPD in the United States
7.2%
14%
20.7%
22.9%
Effects of Smoking Cessation on Lung Function
Smoking cessation even at early stages of disease slows the decline of lung function
Smoking Cessation Slows Lung Function Decline in Mild COPD:
Lung Health Study at 11 YearsReproduced with permission from:Anthonisen et al. Am J Respir Crit Care Med. 2002;166:675-679; Calverley et al. Lancet.2003;362:1053-1061. BMJ Publishing Group.
2.02.12.22.32.42.52.62.72.82.9
0 1 2 3 4 5 6 7 8 9 10 11
FEV 1
(L)
Year
Sustained Quitters
Intermittent Quitters
Continuous Smokers
Objectives Epidemiology: Burden Risk factors
Screening When and who to screen
Management: Is not just spirometry Advantages of the GOLD classification How to make it simple Pharmacologic therapies By GOLD group By phenotypes (CB. frequent exacerbation)
Non-pharmacologic therapies
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbidities
GOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
Airflow Limitation Severity in COPD
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbidities
GOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
COPD: Risk Factors
Tager et al. Am Rev Respir Dis. 1988;138:837-849; Holt. Thorax. 1987;42:241-249.
Established Probable PossibleCigarette
smoking Occupational
exposure
α1-Antitrypsin deficiency (genetic abnormality)
Air pollution
Exposure to primary and secondary smoke
Hyperactive airways
Alcohol
Poverty
Low birth weight
Childhood respiratory infections
Family history
Atopy
IgA deficiency
Blood type A
Smoking Cessation
First Line medication: buproprion, SR, varenicline, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine spray, nicotine patch
Second line agents: clonidine and nortriptyline
Counseling effective
Quit lines
What are the first-line medicationsRecommended in this Guideline update?
All seven of the FDA-approved medications for treatingtobacco use are recommended: bupropion SR, nicotine gum,
nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. The clinician should consider the first-line medications shown to be more effective than the nicotine patch alone: 2 mg/day varenicline or the combination
of long-term nicotine patch use + ad libitum NRT (nicotine replacement therapy). Unfortunately, there are no well-
accepted algorithms to guide optimal selection among thefirst-line medications.
Treating Tobacco Use and DependenceClinical Practice Guideline 2008
US Department of Health & Human Services
www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf accessed Feb 22, 2009
Bornemann, Paul, et al. "Smoking cessation: what should you recommend?" Journal of Family Practice, Jan. 2016, p. 22+. Academic OneFile, Accessed 15 Feb. 2017.
Spirometry is key:
Required for diagnosis
Determine “severity”
Useful to decide treatment
Quaseem. Ann Intern Med 2011;155: 179
Airflow Limitation Severity in COPD
ABCD Assessment Tool
GOLD Guidelines (in English)
Ask two questions– Symptoms (Dyspnea)– Risk of exacerbation (h/o AE)
Put the answers together– Low or high symptoms (mMRC 2)– Low risk (AE <2)
Create groups (2x2 table)
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbiditiesGOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
Achievable Outcomes of Therapy in COPD
Bronchodilators are effective in improving airflow and lung volume
Symptomatic patients with appropriate treatment can expect– Relief of dyspnea– Improvement of exercise tolerance– Improvement of quality of life– Decrease in exacerbations
Global Initiative for Chronic Obstructive Lung Disease. Executive Summary Updated 2017. Available at: http://www.goldcopd.com. Accessed February 11, 2017.
GOLD Guidelines OverviewGOLD Defined by: English
TranslationTreatment
A MMRC <2 Low symptomsLow risk
SABA or SAMA
B MMRC >= 2AE < 2
High symptomsHigh risk
LAMA or LABA
C MMRC <2AE > = 2
Low symptomsLow risk
ICS/LABA or LAMA
D MMRC >=2AE > = 2
High symptomsHigh risk
ICS/LABA and/or LAMA
Practical Implication of GOLD Groups
If patient has been admitted to a hospital– They are already high risk, regardless of
symptoms (C/D)– Needs ICS + LABA and/or LAMA– In addition to SABA
Pharmacologic therapy recommendations based on groups
Therapy
Pharmacologic therapy: BLABA vs. LAMA
AE COPD and related hospitalization: LAMA
Mortality and all-cause hospitalization: No difference
Symptoms and lung function: No difference
Group 1st line 2nd line
A SABA or SAMA
LABA or LAMASABA and SAMA
B LAMA or LABA
LAMA and LABA
ICS/LABA vs. LABA Mortality: No difference AE, QOL, symptoms:
ICS/LABAICS vs. LABA AE COPD and mortality:
Similar. Lung function: LABA QOL: ICS Pneumonia: ICS
Group 1st line 2nd lineA SABA or
SAMALABA or LAMASABA and SAMA
B LAMA or LABA
LAMA and LABA
C ICS/LABA or LABA
LAMA and LABA
Pharmacologic therapy: C
Pharmacologic therapy: D
Group 1st line 2nd line
C ICS/LABA or LABA
LAMA and LABA
D Same Same orICS/LABA and PD4I
LAMA vs. LABA in AE COPDLower AE frequency
LAMA plus ICS/LABA in COPDBetter lung function
Vogelmeier C. NEJM 2011; 364: 1093AaronSD. Ann intern Med 2007; 146: 545
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbiditiesGOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
Nonpharmacologic Treatments
Pulmonary Rehabilitation
Education & Self Management
Integrated Care Programs
Pulmonary Rehabilitation
Improves shortness of breath, health status and exercise tolerance
Reduces hospitalization among patients who have had a recent exacerbation (≤ 4 weeks from prior hospitalization)
Education & Self Management
Patient knowledge is important for behavior change though not sufficient to promote self-management interventions
Self management: – Improve outcomes in COPD– Improve health status– Reduces hospitalization– No impact on overall mortality
Integrated Care Programs
Evidence on this is divided
Meta-analysis of small trials demonstrated it may improve clinical outcomes but not mortality
One large multi-center study in primary care did not confirm this
Delivering integrated interventions by phone did not demonstrate a significant effect
Further research is needed in this area
Non-pharmacologic therapy recommendations based on groups
Groups Therapy A-D
– Smoking cessation– Physical activity– Flu and pneumococcal
vaccination
B-D– Add Pulmonary
Rehabilitation
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbiditiesGOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
AECOPD Consensus Definition
“A sustained worsening of the patient’s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”
Rodriguez-Roisin. Chest. 2000;117:398S-401S.
AECOPD Outpatient Management Patient education
–Check inhalation technique–Consider use of spacer devicesBronchodilators
–SABA and/or ipratropium MDI with spacer or hand-held nebulizer as needed
–Consider adding long-acting bronchodilator if patient is not using one
Corticosteroids –Prednisone 30-40 mg orally/day for at least 5 days–Consider using an inhaled corticosteroid
Celli BR, et al. Eur Respir J. 2004;23:932-946.
Preventing Frequent Exacerbation
Albert RK. NEJM 2011;365: 689
Practical Implication of Frequent Exacerbation Phenotype
If patient is discharged with AE COPD– Should already be on antibiotics– Is at high risk of readmission, new AE– No need to initiate chronic macrolide at time of
discharge– Include in your diagnosis “this is a patient with
frequent exacerbation phenotype (2 or more/y)”– Consider or discuss exacerbation prevention
interventions
Roflumilast in frequent exacerbation*
0
0.5
1
1.5
2
2.5
All patients Infrequent exacerbators Frequent exacerbators
Mea
n ra
te o
f mod
erat
e or
sev
ere
exac
erba
tions
per
yea
r
Placebo Roflumilast
Δ = –16.9%Rate ratio 0.831
(95% CI 0.75, 0.92)p=0.0003
n=1537
*FREQUENT EXACERBATORS (≥2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)INFREQUENT EXACERBATORS (<2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)
n=1554 n=1137 n=1124 n=417 n=413
Δ = –16.5%Rate ratio 0.835
(95% CI 0.73, 0.95)p=0.0062
Δ = –22.3%Rate ratio 0.777
(95% CI 0.66, 0.91)p=0.0017
a POST-HOC ANALYSESBateman ED et al Eur Respir J 2011; 38:553-560
Roflumilast in CB phenotype
Rennard SI et al; Respir Res 2011; 12: 1
Practical Implication of Chronic Bronchitis Phenotype
Roflumilast: specific therapy for a COPD phenotype– CB with frequent exacerbation– Can be initiated in- or out-patient– Consider roflumilast for exacerbation prevention
Goals for Treatment of Stable COPD
1. Assess airflow severity and monitor disease
2. Reduce symptoms and risk factors
3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment
4. Manage exacerbations
5. Presence of comorbidities
GOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.
Comorbidities
Cardiovascular disease
Skeletal muscle dysfunction
Metabolic syndrome
Osteoporosis
Depression
Anxiety
Lung cancer
OSA
Resources for COPD Informationwww.copdfoundation.org