T5 - IE3 - Pulmonology - Munjy - COPD

COPD

chronic obstructive pulmonary disease

COPD is a ________, _________, and _______ disease with persistent respiratory symptoms, airflow limitation due to airway and/or alveolar abnormalities due to exposure to noxious stimuli

- common

- preventable

- treatable (disease)

COPD is a common, preventable, treatable disease with ____________ respiratory symptoms, airflow limitation due to airway and/or _________ _________ due to exposure to ___________ stimuli

- persistent (respiratory symptoms)

- airflow limitation

- (exposure to) noxious (stimuli)

COPD symptoms

dyspnea

cough

sputum production

COPD risk factors

smoking

biomass fuel exposure

air pollution

genetic abnormalities

abnormal lung development

accelerated aging

COPD vs. Asthma Onset

COPD: onset AFTER age 40

Asthma: onset BEFORE age 20

COPD vs. Asthma Onset - Asthma: onset _________ ____ _____

- BEFORE age 20

COPD vs. Asthma Onset - COPD: onset __________ _____ _____

- AFTER age 40

COPD vs. Asthma - symptoms

COPD: persistence of symptoms with treatment

Asthma: vary over time

COPD vs. Asthma - lung function

COPD: abnormal lung function between symptoms

Asthma: lung function may be normal between symptoms

COPD vs. Asthma response to bronchodilators

COPD: limited relief from bronchodilators (FEV1 does NOT return to normal after bronchodilator use)

Asthma: FEV1 can return to normal post-bronchodilator use

COPD vs. Asthma response to bronchodilators: COPD has ________ relief from bronchodilators (FEV1 does _______ __________ to normal after bronchodilator use)

- limited (relief)

- NOT return (to normal after bronchodilator use)

COPD vs. Asthma response to bronchodilators: asthma __________ to bronchodilators (FEV1 can return to _________ post-bronchodilator use)

- responds (to bronchodilators)

- (return to) normal

COPD vs. Asthma Chest X-Ray

COPD: severe hyperinflation or other changes on X-ray

Asthma: normal chest x-ray

Prevention of COPD

smoking cessation

influenza vaccination

pneumococcal vaccinations: PCV13, PPSV23

reduce exposure to risk factors

Prevention of COPD - smoking cessation: ____________ capacity to influence _________ history of COPD

- greatest (capacity)

- natural (history of COPD)

Prevention of COPD vaccines

influenza

pneumococcal vaccines

- PCV13

- PPSV23

Prevention of COPD vaccines - pneumococcal: PCV13, PPSV23

All patients ≥ 65 years old

Patients 19-64 years old with smoking history

Prevention of COPD: reduce exposure to risk factors

noxious stimuli

environmental toxins

Similar to asthma, COPD is assessed by looking at the patient's ____________ and history of ___________

- (patient's) symptoms

- (history of) exacerbations

COPD assessment: ________ __________ also assist in objective data for assessment

- GOLD categories (also assist in objective data)

AIRFLOW limitation: ___________ is used to assess airflow limitation

- Spirometry (is used to assess)

Spirometry is conducted after the administration of an adequate dose of at least one short-acting bronchodilator

COPD vs. Asthma Monotherapy Don'ts

COPD: DO NOT USE ICS monotherapy

Asthma: DO NOT USE LABA monotherapy

AIRFLOW limitation: Spirometry is conducted _______ the administration of an adequate dose of at least one ______-______ ______

- after (the administration)

- (at least one) short-acting bronchodilator

GOLD categories: in patients with FEV1/FVC <0.70 - GOLD I

MILD

FEV1 ≥ 80% predicted

GOLD categories: in patients with FEV1/FVC <0.70 - GOLD II

MODERATE

50 - 79% predicted FEV1

GOLD categories: in patients with FEV1/FVC <0.70 - GOLD III

SEVERE

30 - 49% predicted FEV1

GOLD categories: in patients with FEV1/FVC <0.70 - GOLD IV

VERY SEVERE

FEV1 < 30% predicted

COPD Symptoms Assessment

COPD Assessment Test (CAT)

Modified Medical Research Council dyspnea questionnaire (MMRC)

CAT

COPD Assessment Test

MMRC

Modified Medical Research Council (MMRC) dyspnea scale

Exacerbation risk for COPD

acute worsening of respiratory symptoms that result in additional therapy

Mild exacerbation risk for COPD - treatment

short-acting bronchodilators (SABAs)

Moderate exacerbation risk for COPD treatment

treat with short-acting bronchodilators (SABAs)

Antibiotics (if infection)

and/or

oral corticosteroids

Severe exacerbation risk for COPD treatment

Hospitalization occurs AFTER visit to ED

Comorbidities associated with COPD

Cardiovascular disease

Skeletal muscle dysfunction

Metabolic syndrome

Osteoporosis

Depression

Anxiety

Lung Cancer

ABCD Assessment Tool Figure

ABCD Practice Case #1:

KL 65-year old female with COPD. She has had one exacerbation in the last year that she went to the ED for but did not result in hospital admission. Her CAT score is 9 and her mMRC score is 1.

How would you grade her COPD based the ABCD assessment tool?

a. A

b. B

c. C

d. D

A

Since KL's CAT score is 9 and her mMRC score is 1; she went to the ED but did NOT have hospital admission

ABCD Practice Case #2

DD is a 71-year old male with COPD. He has had 1 exacerbation in the last year that led to a hospital admission. His CAT score is 18 and his mMRC score is 2.

How would you grade his COPD based the ABCD assessment tool?

a. A

b. B

c. C

d. D

D

DD has a CAT score of 18 and mMRC of 2. He has had only 1 exacerbation but it LEAD to hospital admission

Drug therapy used in COPD - bronchodilators

LABAs and LAMAs are preferred over short-acting agents EXCEPT in patients with OCCASIONAL dyspnea

Inhaled bronchodilators are preferred over oral bronchodilators

Theophylline is NOT recommended unless other long-term treatment bronchodilators are UNAVAILABLE

Drug therapy used in COPD - bronchodilators: LABAs and LAMAs are preferred over short-acting agents EXCEPT in...

patients with OCCASIONAL dyspnea

Drug therapy used in COPD - bronchodilators: ________ and _________ are preferred over _____-acting agents EXCEPT in patients with OCCASIONAL dyspnea

- LABAs

- LAMAs

- (preferred over) short(-acting)

Drug therapy used in COPD - bronchodilators: _________ bronchodilators are preferred over ______ bronchodilators

- inhaled (bronchodilators)

- (preferred over) oral

Drug therapy used in COPD - bronchodilators: theophylline is _______ _________ unless other long-term treatment bronchodilators are unavailable

- NOT recommended (unless other-long term treatment)

Drug therapy used in COPD - anti-inflammatory agents

long-term monotherapy with ICS is not recommended

Consider ICS in conjunction with LABA for patients with history of exacerbations despite appropriate treatment with long acting bronchodilators

In patients with exacerbations despite LABA/ICS or LABA/LAMA/ICS, chronic bronchitis and severe to very severe airflow obstruction, a PDE4 inhibitor (roflumilast) can be considered

Consider macrolides in patients with smoking history who have exacerbations despite appropriate therapy

Drug therapy used in COPD - anti-inflammatory agents: long-term monotherapy with _______ is not recommended

- ICS (is not recommended)

Drug therapy used in COPD - anti-inflammatory agents: _____-_____ ___________ with ICS is not recommended

- long-term monotherapy (with ICS)

Drug therapy used in COPD - anti-inflammatory agents: long-term monotherapy with ICS is ______ ____________

- NOT recommended

Drug therapy used in COPD - anti-inflammatory agents: Consider ICS in _____________ with LABA for patients with history of __________ despite appropriate treatment with long acting bronchodilators

- conjunction (with LABA)

- (history of) exacerbations

Drug therapy used in COPD - anti-inflammatory agents: Consider ICS in conjunction with _______ for patients with history of exacerbations despite appropriate treatment with _______ ___________ ____________

- (conjunction with) LABA

- long acting bronchodilators

Drug therapy used in COPD - anti-inflammatory agents: In patients with exacerbations despite LABA/ICS or LABA/LAMA/ICS, chronic bronchitis and severe to very severe airflow obstruction, a _____ ___________ (___________) can be considered

- PDE4 inhibitor (roflumilast)

Drug therapy used in COPD - anti-inflammatory agents: In patients with exacerbations despite _______/_____ or ______/________/_______, chronic bronchitis and severe to very severe airflow obstruction, a PDE4 inhibitor (roflumilast) can be considered

- LABA/ICS

- LABA/LAMA/ICS

i.e., patients need to be on LABA / ICS or LABA / LAMA / ICS prior to PDE4 inhibitor usage

Drug therapy used in COPD - anti-inflammatory agents: Consider ___________ in patients with smoking history who have exacerbations despite appropriate therapy

- macrolides (in patients with smoking history)

i.e., azithromycin, clarithromycin etc.

Drug therapy used in COPD - anti-inflammatory agents: Consider macrolides in patients with __________ history who have ____________ despite appropriate therapy

- smoking (history)

- (who have) exacerbations (despite appropriate therapy)

ICS use in COPD: _______ __________ as monotherapy or _____ _______ for patients with grade A or B disease

- not indicated (as monotherapy)

- [not indicated for] first line

ICS use in COPD: blood eosinophil count of ___ ______ cells / uL seen in trials to be indicator for use of ICS therapy earlier on to prevent exacerbations

- > 300 (cells / uL)

ICS use in COPD: _______ _________ count of > 300 cells / uL seen in trials to be indicator for use of _____ therapy earlier on to prevent exacerbation

- blood eosinophil (count)

- ICS (therapy earlier on to prevent exacerbation)

Suggests inflammatory pathway is prominent in pathophysiology of disease

ICS use in COPD: >300 cell/uL blood eosinophils suggests _________ pathway is prominent in ____________ of disease

- inflammatory (pathway)

- pathophysiology (of disease)

ABCD Assessment tool and initial therapy: Group A

bronchodilator usage

(GROUP A)

ABCD Assessment tool and initial therapy: Group B

Long acting bronchodilator (LABA or LAMA)

(GROUP B)

ABCD Assessment tool and initial therapy: Group C

LAMA

ABCD Assessment tool and initial therapy: Group D

LAMA

LAMA + LABA (if highly symptomatic)

ICS + LABA when blood eosinophil ≥ 300

ABCD Assessment tool and initial therapy: Group D when blood eosinophil ≥ 300

use ICS + LABA

ABCD Assessment tool and initial therapy: Group D if highly symptomatic

LAMA + LABA

Goals for management of COPD

reduce symptoms

- relieve symptoms

- improve exercise tolerance

- improve health status

reduce risk

- prevent disease progression

- prevent and treat exacerbations

- reduce mortality

Patient Case:

KL is a 68-year old female who is currently on a LABA + LAMA combination therapy for COPD. She has been complaining of worsening dyspnea and

increased limitation of her daily activities. It is noted that in the last year she has had 2 exacerbations in which she received treatment in the ED before being discharged. She is a former smoker with a 15-pack year history. Her blood eosinophil count is 150 cells/uL.

Patient KL seems to be experiencing exacerbations in her condition and has had dyspnea.

Since she has both follow the exacerbations guideline.

Note she also has eosinophil count of 150 cells / uL and is on LABA + LAMA (GROUP D) and blood eosinophil count is 150 cells / uL follow LABA + LAMA + ICS

If patient is experiencing only dyspnea follow dyspnea flow chart or exacerbations follow exacerbations flow chart

However, if patients experience BOTH dyspnea and exacerbations follow the ___________ flow chart

- exacerbations (flow chart)

COPD Gold Guidelines 2019 Flow Chart

If a patient is already on LABA + LAMA + ICS and experience exacerbations they may try...

Roflumilast (FEV1 < 50% & chronic bronchitis)

Azithromycin (in former smokers)

Education and self-management of COPD

Educate patient regarding how to reduce risk of exacerbations , create an action plan, use other health-care professionals (social workers)

Rehabilitation is recommended in

ALL patients with relevant symptoms and/or high risk for exacerbations

Physical activity is a strong predictor of mortality and therefore patients should be encouraged to increase level based on individual ability

Education and self-management of COPD: educate patient regarding how to reduce risk of ____________ , create an ______ _____, use other _____-_____ professionals (social workers)

- (reduce risk of) exacerbations

- action plan

- health-care (professionals)

Education and self-management of COPD: ______________ is recommended in ALL patients with _________ symptoms and/or _____ risk for exacerbations

- Rehabilitation (s recommended in ALL patients)

- relevant (symptoms)

- high (risk)

Education and self-management of COPD: __________ activity is a strong predictor of mortality and therefore patients should be encouraged to increase level based on individual ability

- Physical (activity)

End-of-life & Palliative care: all clinicians managing COPD patients should determine if palliative care is ___________ for their patient

- appropriate (for their patient)

End-of-life & Palliative care: end-of-life disccusions should be considered with patients and family members

advance directives

place of death preference

Treatment of hypoxemia & hypercapnia: patients with __________ are indicated for long-term oxygen therapy considerations

- hypoxemia (are indicated for long-term oxygen)

Treatment of hypoxemia & hypercapnia: patients with hypoxemia are indicated for ______-_________ ________ therapy considerations

- long-term oxygen (therapy considerations)

Treatment of hypoxemia & hypercapnia: Patients with _______ COPD and _________ or ______-_______ moderate desaturation are NOT routinely indicated for long-term oxygen therapy

- stable (COPD)

- resting

- exercise-induced (moderate desaturation)

Treatment of hypoxemia & hypercapnia: patients with __________ _______ ______ and history of ________ for acute respiratory failure should be considered for long-term non-invasive ventilation

- severe chronic hypercapnia

- (history of) hospitalization (for acute respiratory failure)

Treatment of hypoxemia & hypercapnia: Patients with severe chronic hypercapnia and history of hospitalization for _____ _________ failure should be considered for long-term ____-______ ____________

- acute respiratory (failure)

- (long-term) non-invasive ventilation

Intervention bronchoscopy and surgery: _____ _______ ________ surgery is considered in patients with upper-lobe emphysema

- lung volume reduction (surgery)

Intervention bronchoscopy and surgery: lung volume reduction surgery is considered in patients with ______-_______ ________

- (patines with) upper-lobe emphysema

Intervention bronchoscopy and surgery: bronchoscopic lung volume reduction should be consider in selected patients with __________ ___________

- advanced emphysema

Intervention bronchoscopy and surgery: patients with very severe COPD may be considered for ________ ______________ if 1 of the following exists

- history of hospitalization exacerbation with acute hypercapnia ensures

- pulmonary hypertension despite oxygen therapy

- FEV1 < 20% and either DICO <20% of homogenous distribution of emphysema

- lung transplantation

Lung transplant patients for COPD

history of hospitalization exacerbation with acute hypercapnia ensues

pulmonary hypertension despite oxygen therapy

FEV1 < 20% and either DICO <20% of homogenous distribution of emphysema

Lung transplant patients for COPD: history of hospitalization exacerbation with ______ ____________ ensues

- acute hypercapnia (ensues)

Lung transplant patients for COPD: ___________ ___________ despite oxygen therapy

- pulmonary hypertension (despite oxygen therapy)

Lung transplant patients for COPD: FEV1 __ _____% and either DICO __ ____% of homogenous distribution of emphysema

- (FEV1) < 20(%)

- (DICO) < 20(% of homogenous distribution)

ACOS

asthma-COPD overlap syndrome

ACOS: syndrome of __________ diseases of the ________

- multiple (diseases)

- airways

ACOS: not clearly defined - ___________ airflow limitation with several features usually associated with ______ and several features associated with _______

- persistent (airflow limitation)

- asthma

- COPD

Never use _______ monotherapy in asthma OR ______ monotherapy in COPD

- (never use) LABA (monotherapy in asthma)

- [never use] ICS (monotherapy in COPD)

Treatment of ACOS: combination of ______ and ______ is acceptable EVEN if less than grade C or D on ABCD assessment tool

- ICS

- (and) LABA (is acceptable)

Treatment of ACOS: combination of ICS and LABA is acceptable EVEN if ______ than grade __ or __ on ABCD assessment tool

- less (than grade)

- C

- D

Treatment of ACOS: remember warning regarding increased risk of death for ________ monotherapy in asthma patients

- LABA (monotherapy in asthma patients)