Chronic Obstructive Pulmonary Disease: Diagnosis and Treatment Options for the Family Physician

1
Chronic ObstructivePulmonary
DiseaseDiagnosis and Treatment Options for the
Family Physician

• An evidence-based CME program developed by the
• New Jersey Academy
• of Family Physicians

2
Learning Objectives

• Discuss current guidelines for managing chronic
  obstructive pulmonary disease (COPD)
• Differentiate the COPD patient from those with
  asthma or other pulmonary diseases
• Describe the usefulness of spirometry in
  diagnosing and managing COPD
• Outline a comprehensive stepwise treatment plan
  for COPD

3
Epidemiology of COPD

• The fourth leading cause of death in people over
  age 45
• 120,000 deaths attributed to COPD in the year
  2000

Calverley PM, Walker P. Lancet.
2003362(9389)1053-1061. Global Strategy for the
Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease. Global Initiative
for Chronic Obstructive Lung Disease. http//www.g
oldcopd.com. National Heart, Lung, and Blood
Institute. COPD Data Fact Sheet, 2003.
http//www.nhlbi.nih.gov/health/public/lung/other/
copd_fact.htm
4
Percent Change in Age-Adjusted Death Rates, U.S.,
1965-1998
Proportion of 1965 Rate
5
Epidemiology of COPD

• It is projected that by 2020, COPD will have
  become the third leading cause of death in the
  United States and worldwide
• In 2000, for the first time, more women than men
  died of the disease

National Heart, Lung, and Blood Institute. COPD
Data Fact Sheet, 2003. http//www.nhlbi.nih.gov/h
ealth/public/lung/other/copd_fact.htm Murray CJ,
Lopez AD. Lancet. 1997349(9064)1498-1504.
6
Epidemiology of COPD

• Direct medical costs were an estimated 20.9
  billion in 2004
• More than 85 of cases arise from prolonged
  exposure to tobacco smoke
• Morbidity and Mortality 2004 Chart Book on
  Cardiovascular, Lung, and Blood Diseases 2004.
• http//www.nhlbi.nih.gov/resources/docs/cht-book.h
  tm.
• Global Strategy for the Diagnosis, Management,
  and Prevention of Chronic Obstructive
• Pulmonary Disease. Global Initiative for Chronic
  Obstructive Lung Disease.
• http//www.goldcopd.com.

7
Epidemiology of COPDRisk Factors

• Prolonged exposure
• to tobacco smoke
• Exposure to occupational
• dusts and chemicals
• Exposure to air pollution
• Airway hyper-responsiveness
• Asthma
• Genetic factors

8
COPDDefinition and Symptoms
Airflow limitation that is not fully reversible,
associated with an abnormal inflammatory response
to noxious particles or gases.
Dyspnea with activity
Chronic cough
Sputum production
Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary
Disease. Global Initiative for Chronic
Obstructive Lung Disease. http//www.goldcopd.com.

9
COPDSymptoms and Findings

• Chronic cough
• Sputum production
• Dyspnea
• Hypoxemia
• Hypercapnia
• Pulmonary hypertension

• Cor pulmonale
• Weight loss
• Effort intolerance
• Waking at night
• Ankle swelling
• Fatigue

10
The Natural Historyof COPD

• A progressive disease, especially if exposure to
  the inciting agent (usually tobacco smoke)
  continues
• Stopping exposure will slow or even halt further
  progression

11
COPD Guidelines

• The Global Initiative for Chronic
• Obstructive Lung Disease (GOLD)
• Management Components
• Assess and monitor the disease
• Reduce risk factors
• Manage stable COPD
• Manage COPD exacerbations

12
COPD GuidelinesDifferential Diagnosis

• COPD is under-diagnosed and often misdiagnosed
• 16 million Americans have been diagnosed with
  COPD
• An estimated 30 million actually have the disease
• GOLD differentiates COPD from emphysema and
  chronic bronchitis
• Similarities in symptoms and clinical
  presentation between COPD and asthma and other
  pulmonary diseases
• Confronting COPD in America.
• http//www.lungusa.org/press/lung_dis/asn_copd2160
  1.html.
• Frontline Treatment of COPD A Monograph for
  Primary Care Physicians.
• Snowdrift Pulmonary Conference 2000.

13
COPD GuidelinesDifferential Diagnosis

• Symptoms
• Age of onset
• Tobacco use
• Airway hyper-responsiveness
• Progression of symptoms
• Airflow limitation

14
Differential DiagnosisCOPD and Other
Cardiopulmonary Diseases
15
Differential DiagnosisCOPD and Other
Cardiopulmonary Diseases
16
COPD GuidelinesSpirometry

• Should be used to help confirm a diagnosis of
  COPD
• Normalized for age, gender and height
• Measures the volumes of air a patient exhales as
  a function of time

17
Differential DiagnosisSpirometry

• FVC the forced vital capacity, the maximal
  volume exhaled after a maximal inhalation
• FEV1 the forced expiratory volume in 1 second
• FEV1/FVC the ratio of forced vital capacity to
  forced expiratory volume in 1 second

18
Differential DiagnosisSpirometry

19
Practice Recommendation
Spirometry, in addition to clinical examinations,
improves COPD diagnostic accuracy compared
to clinical examination alone and it is a useful
diagnostic tool in individuals with symptoms
suggestive of possible COPD.
The evidence supporting this recommendation is
based on a meta-analysis of seven randomized
controlled trials. EBM Source Wilt TJ,
Niewoehner D, Kim C-B, et al. Use of Spirometry
for Case Finding, Diagnosis, and Management of
Chronic Obstructive Pulmonary Disease (COPD).
Evidence Report/Technology Assessment No. 121.
Agency for Healthcare Research and Quality.
September 2005. http//www.ahrq.gov/downloads/pub/
evidence/pdf/spirocopd/spiro.pdf
20
COPD GuidelinesWays to Ensure Proper
Spirometry Technique

• Explain test to patient
• Prepare patient through instruction and
  demonstration
• Help patient maintain correct posture
• Make sure patient inhales completely
• Make sure patient exhales as forcefully and as
  long as possibleat least six seconds
• Make sure patient keeps lips sealed
• Confirm acceptability criteria are met
• Record at least three acceptable maneuvers

21
The GOLD Classification of COPD Severity
22
The GOLD Classification of COPD Severity
23
The Goals of an Effective COPD Management Plan

• Prevent disease progression, in most cases
  through smoking cessation
• Relieve symptoms
• Improve exercise intolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality

24
Prevention ofCOPD ProgressionSmoking Cessation

• Smoking cessation is paramount not only in
  reducing the risk of developing the disease but
  also in halting or slowing its progression.

25
Prevention ofCOPD ProgressionSmoking Cessation
Anthonisen NR et al. Am J Respir Crit Care Med.
2002166(5)675-679.
26
Smoking CessationThe Five As

• ASK about tobacco use at each office visit
  implement office-wide documentation
• ADVISE all patients who smoke to quit
• ASSESS the patients willingness to quit provide
  motivation
• ASSIST the patient through counseling and
  referral
• ARRANGE follow-up to evaluate and encourage

27
Smoking Cessation

• Promote telephone tobacco quit lines
• 1-800-QUITNOW

28
Practice Recommendation
Smoking cessation is the single most
effective--and cost-effective-- intervention to
reduce the risk of developing COPD and stop its
progression.
The evidence supporting this recommendation is
based on endpoints of well-designed, randomized
controlled trials that provide a consistent
pattern of finding in the population for which
the recommendation is made. EBM Source Global
Initiative for Chronic Obstructive Lung Disease
(GOLD), World Health Organization (WHO), National
Heart, Lung and Blood Institute (NHLBI). Global
strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary
disease. 2005. National Guideline Clearinghouse.
http//www.guideline.gov/summary/summary.aspx?doc_
id8128nbr004530stringCOPDAND smoking
29
Managing Stable COPDPharmacologic Treatment

• Bronchodilators
• ß2-agonists
• Anticholinergics
• Methylxanthines
• Relax airway smooth muscle and improve lung
  emptying
• Relatively small changes to FEV1, but larger
  changes in lung volume and a reduced perception
  of breathlessness

30
Stable COPDBronchodilators

• Short-acting
• May be prescribed on a regular/
• as-needed basis
• Predictable and dose-dependent side effects
• Long-acting
• Convenient dosing and better compliance
• More effective as maintenance therapy

31
Practice Recommendation
Tiotropium reduces exacerbations and improves
quality of life in stable COPD and can be
recommended for clinical practice, although its
effects require more research, particularly to
see how it compares with other long-acting
bronchodilators.
The evidence supporting this recommendation is
based on 69 identified references and a
meta-analysis of nine randomized controlled
trials involving 6,584 patients. EBM Source
Barr RG, Bourbeau J, Camargo CA, et al.
Tiotropium for stable chronic obstructive
pulmonary disease. The Cochrane Database of
Systematic Reviews. 2006. http//www.cochrane.org
/reviews/en/ab002876.html
32
Management of COPDTreatment Algorithm
33
Stable COPDSecond-line Therapy

• Inhaled Corticosteroids
• Consider adding for symptomatic patients with
  severe COPD despite maximal bronchodilators
• Theophylline
• Can be used in severe COPD patients not fully
  responsive to inhaled bronchodilators
• Caution and monitoring advised because of low
  therapeutic index

34
COPD MedicationsTypically Used in the US
35
Stable COPDPharmacologic Delivery Systems

• Effectiveness of therapy directly related to
  ability to deliver medication to airways
• Bronchodilator therapy can usually be
  administered with a hand-held MDI or DPI
• Physician should instruct, demonstrate, assess
• Nebulizer may be used as an alternative

36
Stable COPDVaccines

• Viral infection may be the cause of one third of
  all COPD exacerbations, paving the way for
  bacterial infections
• Influenza vaccination is highly effective in
  preventing influenza-related acute respiratory
  illness
• Pneumococcal vaccination of COPD patients
• Reduces the number of hospitalizations
• for pneumonia
• Reduces mortality rates
• Lowers medical care costs

37
Stable COPDVaccines

• An annual influenza vaccine as well as a
  pneumococcal vaccine should be recommended to all
  patients with COPD.

38
Stable COPDNon-pharmacologic Treatment

• Oxygen Therapy
• Improves exercise, sleep and cognitive
  performance in hypoxemic patients
• Increases survival
• Initiated in patients with very severe COPD,
  resting oxygen saturation lt 88
• Goal is to maintain oxygen saturation gt 90
• Patients should use therapy for 15 20 hours per
  day

39
Stable COPDNon-pharmacologic Treatment

• Pulmonary Rehabilitation
• Should include exercise training, education,
  nutrition counseling
• Can improve quality of life for COPD patients
• Can be initiated in inpatient, outpatient and
  home settings
• Should be offered to any patient who is
  symptomatic despite medical therapy
• Baseline and outcome assessments
• of patients progress should be made

40
Practice Recommendation
Pulmonary rehabilitation relieves dyspnea and
fatigue and enhances patients sense of control
over their condition. These improvements are
moderately large and clinically significant. The
average improvement in exercise capacity is
modest. Rehabilitation forms an important
component of the management of COPD.
The evidence supporting this recommendation is
based on a meta-analysis of 23 randomized
controlled trials. EBM Source Y Lacasse, L
Brosseau, S Milne, et al. Pulmonary
rehabilitation for chronic obstructive pulmonary
disease. The Cochrane Database of Systematic
Reviews. 2006. http//www.cochrane.org/reviews/en
/ab003793.html
41
Stable COPDSurgical Treatments

• Bullectomy
• Lung volume reduction surgery (LVRS)
• Lung transplantation

42
COPD Exacerbations

• A sudden and sustained worsening of the COPD
  patients condition
• The primary cause of urgent medical visits,
  hospital admissions, mortality among COPD
  patients
• Results in 2.3 billion in direct medical costs
  annually

Niederman MS et al. Clin Ther. 199921(3)576-591.

43
COPD Exacerbations

• Primary symptomincreased dyspneamay be
  accompanied by wheezing and tightening of chest,
  increased cough and volume of sputum, a change in
  the color of sputum
• Possible malaise, insomnia, sleepiness, fatigue,
  fever, depression, confusion
• Most commonly caused by infection of the airways
  and air pollution
• Assessed through a targeted history and
  physical, spirometry, arterial blood gases or
  pulse oximetry, chest x-ray

44
COPD ExacerbationsIndications for Hospital
Assessment or Admission

• Impaired level of consciousness
• Acute confusion
• Sudden onset of resting dyspnea
• Severe COPD history
• Failure to respond to initial medical management
  of exacerbation

• Cyanosis or peripheral edema
• Significant co-morbidities
• Newly occurring arrhythmias
• Uncertain diagnosis
• Older age
• Bed confinement
• Insufficient home support

45
Managing COPD Exacerbations

• Bronchodilators
• Short-acting, inhaled ß2-agonists are the
  preferred treatment
• If no response, an anticholinergic is recommended
• The role of long-acting inhaled bronchodilators
  in conjunction with short-acting agents has not
  been assessed
• Use of intravenous aminophylline is controversial
• In the case of a severe exacerbation or
  inadequate response, a methylxanthine may be
  considered, but requires careful monitoring

46
Managing COPD Exacerbations

• Corticosteroids
• Used in addition to bronchodilator therapy, for
  the COPD patient with an exacerbation who is
  admitted to the hospital or who is an outpatient
  with significant increase in breathlessness
• Safe and efficacious dose 30 to 40 mg oral
  prednisone daily for 10 to 14 days
• Long-term use not advised

47
Practice Recommendation
Corticosteroids assist the recovery of people
with COPD who experience an acute exacerbation
but there are some side effects of treatment.
The evidence supporting this recommendation is
based on a meta-analysis of 10 randomized
controlled trials. EBM Source Wood-Baker RR,
Gibson PG, Hannay M, et al. Systemic
corticosteroids for acute exacerbations of
chronic obstructive pulmonary disease. The
Cochrane Database of Systematic Reviews.
2006. http//www.cochrane.org/reviews/en/ab001288.
html
48
Managing COPD Exacerbations

• Antibiotics
• Have proven beneficial in treating acute
  infective exacerbations of COPD
• Should be used in patient whose sputum has become
  more purulent, who shows evidence of infiltrate
  on chest x-ray, or who shows clinical signs of
  pneumonia
• Treatment may include ampicillin, a macrolide, a
  quinilone, or tetracycline

49
Managing COPD Exacerbations

• Ventilatory support
• In COPD patients with acute ventilatory failure,
  NIPPV reduces acidosis and PaCO2, and decreases
  dyspnea
• NIPPV reduces in-hospital mortality, intubation
  rates, length of stay
• In some patients, conventional endotracheal
  intubation and mechanical ventilation may be
  necessary
• Physician should have awareness of patients
  wishes and advance directives

50
Managing COPD Exacerbations

• End-of-life Care
• Patient Education
• Self-management

51
Websites for Additional Information on COPD

• Global Initiative for Chronic Obstructive
• Lung Disease (COPD) www.goldcopd.com
• Canadian Thoracic Society www.lung.ca/cts
• American Thoracic Society www.thoracic.org
• National Institute for Health
• and Clinical Excellence
• www.nice.org.uk
• American Academy of Family Physicians
• Tar Wars Program
• www.tarwars.org

52
Conclusions

• COPD is an enormous public health problem that
  can be addressed only with increased public
  awareness, improved delivery of care, and
  effective therapies
• The family physician is uniquely positioned as
  the point of first contact for COPD patients
• New guidelines provide an excellent framework for
  diagnosing and managing
  COPD