1. Chronic Obstructive Pulmonary Disease Chronic Disease Management
KRISTEN Mounce, APRN, MSN, FNP-C
Center for Respiratory and Sleep Medicine/Indiana Internal Medicine Consultants

2. I have no relevant financial relationships to disclose.
Disclosure
I have no relevant financial relationships to disclose. .

3. Objectives
Define COPD based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) parameters.
List two major risk factors for COPD.
Understand and integrate evidence-based COPD practice recommendations and treatment guidelines.
Identify one of the benefits of referring for specialist involvement in COPD patient care.
In alignment with the National Institutes of Health 2017 COPD National Action Plan Goals, this presentation is geared toward improving the diagnosis, prevention, treatment, and management of COPD by improving the quality of care delivered across the health care continuum. Specific objectives, as noted, are…

4. COPD Burden
World Health Organization (WHO) estimates 65 million people globally with moderate to severe COPD, up to 210 million with COPD diagnosis1.
WHO projects COPD deaths will increase globally by 30% in the next 10 years, becoming the 3rd leading cause of death1.
Affects men and women about equally now, with men plateauing and women still increasing1.
Third leading cause of death in the US2.
Only leading cause of death still increasing3.
120,000 deaths annually in the United States (US) 4.
Accounts for estimated 15.5 million office visits, 1.5 million emergency visits, and 750,000 hospitalizations minimum annually in US3.
Majority of morbidity and mortality as well as healthcare costs occur from acute exacerbations3.

5. -16 million Americans diagnosed with COPD, with estimates of millions more undiagnosed4
-This map from the Centers for Disease Control (CDC) shows the states with the highest COPD prevalence, clustered primarily along the Ohio and Mississippi Rivers
-Approximately 8.3% of Indiana residents surveyed in 2011 reported being diagnosed with COPD2

6. https://foundation.chestnet.org/patient-education-resources/copd/
COPD Definition
GOLD definition: "a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.”5
Airway obstruction not fully reversible and progressive6
Abnormal inflammatory response to noxious stimuli
Emphasize COMMON, PREVENTABLE, and TREATABLE
-Emphysema: destruction of alveolar septa and formation of abnormally enlarged airspaces
-Chronic bronchitis: cough productive of sputum for > 3 months x 2 years

7. Risk Factors Tobacco smoking Outdoor air pollution
MAJOR RISK FACTORS5
ADDITIONAL RISK FACTORS5
Tobacco smoking
Outdoor air pollution
Occupational exposures
Indoor air pollution
Marijuana smoking
Genetic factors
Age and gender
Lung growth and development
Airway hyper-reactivity
Tobacco smoking includes cigarette, pipe, cigar, and water pipe
Secondhand smoke exposure part of air pollution factors
Indoor air pollution from biomass fuels commonly used for cooking and heating, especially in developing countries
Genetic factors such as alpha-1 antitrypsin deficiency
Aging and female gender increase risk for COPD
Any factor affecting lung growth during gestation and childhood (ex low birth weight, resp infections)
Airway hyper-reactivity, especially when suboptimally controlled, can progress to more asthma/COPD overlap due to airway remodeling.

8. https://myheart.net/articles/what-is-copd/
Signs/Symptoms
Shortness of breath, breathlessness
Cough
Sputum production
Wheezing
Chest tightness
Weight loss/anorexia in advanced disease
Cough syncope
Anxiety/depression

9. Clinical Suspicion Triggers
GOLD recommends considering COPD and performance of spirometry in any individual over age 40 with a history of risk factors and/or family history of COPD who has any of the following 5 :
progressively worsening dyspnea
persistent dyspnea
chronic cough, may be nonproductive
recurrent wheezing
chronic sputum production
recurrent lower respiratory tract infections

10. Physical Exam Findings
Wheezes, rhonchi, diminished breath sounds on auscultation
Cyanosis
Barrel chest
Use of accessory muscles
Inferiorly displaced heart sounds
Lower extremity edema

11. Co-morbidities Heart Failure Pulmonary Hypertension Lung Cancer
Obstructive Sleep Apnea
Anxiety and Depression
Coronary Artery Disease
Polycythemia
Osteoporosis
Metabolic syndrome
These are examples of common co-morbidities, not an exhaustive list.
Screenings for OSA and depression routinely done in our COPD clinic, as well as discussions and ordering of lung cancer screening CTs. Patients may be co-managed or transitioned to our pulmonary hypertension clinic when indicated.
Identification and management of co-morbid conditions is a key part of COPD management, as they can influence mortality and hospitalizations independently.

12. COPD Diagnosis
-Spirometry is required to diagnose COPD with persistent airflow limitation confirmed by  FEV1/FVC < post-bronchodilation5
-Staging/classification of airflow obstruction based on post-bronchodilator FEV15
Emphasize spirometry is the diagnostic tool for COPD.
We obtain full pulmonary function testing on all patients entering our COPD clinic and then continue to track numbers periodically. This helps provide patients with definitive measurement which can be beneficial to encourage self-management, and especially useful in ongoing smokers. Additionally helps to monitor for unexpected changes, which can help identify any additional developing pathologies.

13. Additional Testing Chest imaging: X-ray and CT ABG
Six-minute walk test
Alpha-1 antitrypsin level and genotype
Six-minute walk test used as an assessment of oxygen demand as well as exercise tolerance. Our COPD clinic patients get walks at routine intervals to assess both parameters.
Alpha-1 antitrypsin deficiency is a genetic disorder that can result in the development of emphysema as well as liver disease. It is a separate pathway from traditional emphysema and treated with augmentation therapy. Current recommendations are to test all COPD patients for alpha-1 level and genotype.

14. Treatment Goals
No cure for COPD, but a manageable chronic medical condition with treatment goals including:
Symptom management
Reduce exacerbation frequency and severity
Improve exercise tolerance and overall health status
Not curable, but PREVENTABLE and TREATABLE. Treatment goals as noted. Symptom management important for patient quality of life, reducing exacerbation frequency and severity is key to preserve lung function and reduce morbidity and mortality. Key to talk to patients who might be minimally symptomatic about the importance of trying to prevent exacerbations.

15. Assessment of Symptoms in Treatment
-GOLD redefined ABDC assessment tool emphasizes assessment of symptoms along with considering risk of exacerbations in guiding treatment decisions5
-mMRC is a dyspnea scale
-CAT and CCQ are more comprehensive symptom assessment tools
-GOLD emphasizes use treatment based on stage as well as assessment of symptoms and updated guidelines last year to reflect that with the tool shown here.
-Use of standardized tools for assessment such as mMRC (Modified British Medical Research Council Questionnaire), CAT (COPD Assessment Test), CCQ (COPD Control Questionnaire) – prefer CAT or CCQ as more comprehensive symptom assessment, our COPD clinic uses CAT tool as general standard, though mMRC and CCQ used as well.
-Discuss the redefined tool and the implications (consider two patients both with FEV1 < 30% and CAT scores of 18, but one had three exacerbations in the past year with two of those requiring inpatient management, and one had only one exacerbation easily managed in the outpatient setting - under previous recommendations both would be considered GOLD 4 and treatment would be the same, but under new recommendations one would be GOLD grade 4, group B and one GOLD grade 4, group D with treatment varying accordingly.

16. COPD Treatment Pharmacological therapy Exacerbation reduction
Tobacco cessation
Oxygen therapy
Exercise tolerance
Next we’ll talk more about the treatment of COPD, which commonly includes these elements, and I’ll focus more on what’s new in some of these areas.

17. Pharmacologic Therapy
Bronchodilators: beta2-agonists, antimuscarinics, short and long acting, as well as methylxanthines
Inhaled corticosteroids
PDE4 inhibitors
Mucolytics
Macrolide therapy
Oral glucocorticoids, primarily for acute symptom management5
Bronchodilators as single or combo agent therapies, now with a triple therapy incorportating bronchodilators and ICS in one device, which we will talk about a bit more later in the presentation. New in the 2017 GOLD guidelines is more of an emphasis on the use of long-acting beta2 agonist/anticholinergic combo inhalers, noted to be considered appropriate for GOLD Grade Groups B, C, and D. Exact inhaled therapy choice still recommended to be individualized based on severity of obstruction, risk, and symptoms.
Methylxanthines such as theophylline
PDE4 inhibitors – Daliresp – and Macrolide therapy, especially in exacerbating population, and we’ll go into more detail about those meds here in a bit.
Oral glucocorticoids still primarily recommending for acute symptom management only.
Keep in mind that with any medication, and especially inhaled medications, patient education on proper use is vital. Our COPD clinic patients get education on proper inhaler technique at several points of contact to ensure proper use, as several studies have shown that repeated education is necessary to ensure most effective compliance with correct technique.

18. Exacerbations
Acute change in shortness of breath, cough, and/or sputum
Beyond normal day-to-day variations
Generally warrants a change in baseline pharmacological therapy
MILD: Symptoms present but no change in treatment is indicated
MODERATE: Managed with antibiotic and/or systemic corticosteroid
SEVERE: Requiring inpatient management
Exacerbations are to COPD what MIs are to CAD – acute, trajectory changing and sometimes deadly manifestations of a chronic disease. Remember that the majority of morbidity and mortality as well as healthcare costs occur from acute exacerbations.
MILD EXACERBATION: No change in treatment aside from increased short acting bronchodilator use

19. Mild/Moderate Exacerbation Management
This flow chart from UpToDate is a nice guideline for outpatient management of mild to moderate COPD exacerbations. Again, severe exacerbation by definition requires inpatient management. Mild exacerbation flow chart of treatment on the left, moderate exacerbation on the right.

20. Exacerbation Reduction
Tobacco cessation
Pulmonary rehab
Triple combination inhaled therapy
PDE4 inhibitors
Macrolide therapy
Reduction of exacerbation frequency and severity, again, is a key component of COPD management. Strategies for reducing them include these elements, which we’ll talk a bit more about in the next several slides.

21. Tobacco Cessation 20.6% of US population still smoking3
Quitting at any age dramatically reduces mortality risk - if quit by age 40 able to nearly avoid all excess smoking-related death3
Pharmacotherapy and nicotine replacement therapy reliably increase long-term abstinence5
Safety and efficacy of e-cigarettes as a cessation aid is uncertain presently
Tobacco is still the main risk factor associated with COPD and cessation is a key component of COPD management as far as treatment, exacerbation reduction and exercise tolerance. Repeated emphasis on cessation by every healthcare provider at every encounter is vital.

22. Cessation Interventions
Pharmacologic
Non-pharmacologic
Varenicline
Bupropion sustained release
Nicotine replacement therapy
Cessation counseling
Cessation programs
Support groups
Varenicline (Chantix) no longer carries black box warning based on a double-blind, randomized, placebo-controlled clinical trial published in 2016 which found incidence of adverse neuropsych events about the same for active drug treatment versus placebo.
Nicotine replacement therapy includes gum, inhaler, nasal spray, and patch.
GOLD guidelines recommend Rx of varenicline, bupropion or nicotine replacement therapy unless contraindicated.
CHEST guideline recommends combining pharmacologic and non-pharmacologic therapies to attain highest cessation rates of up to 34.5%.
Cessation counseling includes even brief discussions with healthcare providers which, again, should occur at every contact, as well as other counseling avenues such as telephone like QUIT-NOW.

23. Pulmonary Rehab
Structured program focused on education, support, and supervised exercise4
Outcomes include:
Improvement in quality of life, exercise tolerance, and overall health status
Exacerbation reduction, both frequency and severity
Recommended for all patients in GOLD Groups B, C, and D5
Recommended for exacerbation reduction in all patients with moderate to very severe COPD who have had an exacerbation within previous 4 weeks6
Angela will be speaking next in much more detail about pulmonary rehab, so I’ll leave that to her but I do want to emphasize the role of rehab as far as recommendation for reduction exacerbation recurrence, noting that a previous exacerbation is the single biggest predictor of future exacerbation. Also note that it is generally recommended by GOLD for a majority of all diagnosed COPD patients.

24. Triple Combination Inhaled Therapy
New single-inhaler device available with triple therapy
IMPACT trial compared single-device triple to dual therapy
15% exacerbation reduction versus long-acting beta2 agonist/inhaled corticosteroid9
25% exacerbation reduction versus long-acting beta2 agonist/anticholinergic9
34% hospitalization reduction versus long-acting beta2 agonist/anticholingeric9

25. PDE4 Inhibitors and Macrolide Therapy
PDE4 Inhibitor therapy in patients with severe or very severe COPD with chronic bronchitis and history of exacerbation
17% exacerbation reduction when added to current bronchodilator therapy10
Improves lung function5
Recent studies have shown long-term macrolide therapy reduces exacerbations rate5
Going back to PDE4 inhibitors and macrolide therapy, mentioned previously in pharmacological treatment of COPD, both have been shown to help reduce exacerbations.
Roflumilast (Daliresp) is newly available in a 250mg dose tablet in the last few months to allow titration up to therapeutic dosing (500mg qd) with a four week run in on low dose with reduced GI side effects, increasing odds of patients continuing on therapy. It has been shown to reduce exacerbation rate by 17% and also shown to actually improve lung function. Indicated for patients with severe to very severe COPD.
Recent studies have also shown effectiveness of long-term macrolide therapy to reduce exacerbations

26. Additional Interventions in COPD Management
Vaccinations
Lung cancer screening CT
Patient education
Nutrition
Case management
Palliative care
GOLD, CHEST, and ATS all recommend to keep immunizations/vaccinations up to date to help reduce incidence of serious illness and death in patients with COPD – including influenza, pneumococcal 23, and pneumococcal 13.
Patient education a key component of COPD management, and studies show across the board that the more knowledgeable patients are about chronic diseases, the more they are engaged and able to self-manage.
Don’t forget nutrition is a key component of COPD, obesity can worsen symptoms and increase risk of other co-morbities, whereas malnutrition can be a battle with more severe or end-stage COPD patients given the amount of calories burned simply on breathing. Consider consultations for both as appropriate.
Palliative care also is an underutilized intervention available as part of COPD management, given that it is a chronic disease palliative can be consulted at any stage and can help with conversations to set goals of care, end of life wishes, etc.

27. Patient Education Inhaler technique Breathing exercises, techniques
Exercise tolerance
COPD action plan8
Pulmonary rehab
Group classes
Support groups
Patient education in our COPD clinic focuses on a variety of topics and strategies to try to get patients and caregivers information needed to help manage this chronic condition. We offer group and individual education sessions. There are a variety of support groups in our community which are great resources, as well. Pulmonary rehab is a tremendous program, again, which Angela will go further into next. I’ve already discussed the importance of inhaler technique education. And our COPD clinic utilizes the American Lung Association’s COPD action plan to help education and empower patients to manage their disease.

28. Benefits of Pulmonary Referral
Confirm diagnosis
Assess for presence of other pathology such as asthma, interstitial lung disease, bronchiectasis
Optimize treatment, especially in patients with persistent symptoms despite escalating therapy or those with recurrent exacerbations
Manage supplemental oxygen therapy
Assess the need for more complex and expensive therapies7
Application of comprehensive care model
Encouraged to refer early, not necessary to wait until more progressed disease. A key component is to ensure correct diagnosis and assess for other pathologies contributing to symptom complex which may need addressed via alternative pathways.
More complex and expensive therapies such as interventional bronchoscopic, lung volume reduction, and transplant procedures.
Discuss our COPD clinic in conjunction with comprehensive care model, offering full spectrum of services for the most part all on site, integration with primary care providers as well as other ancillary services as previously discussed and/or indicated.

29. References
World Health Organization (2018). Burden of COPD. Retrieved from
Centers for Disease Control. COPD Among Adults in Indiana. Retrieved from
May, S.M. & Li, J. T. C. (2015). Burden of chronic obstructive pulmonary disease: Healthcare costs and beyond. Allergy and Asthma Proceedings 36(1). doi /aap Retrieved from
American Thoracic Society (2017). COPD Today. Patient Information Series. Retrieved from
Global Initiative for Chronic Obstructive Lung Disease (2017). Pocket Guide to COPD Diagnosis, Management, and Prevention: A Guide for Health Care Professionals.
Criner, G. J. et al. (2015). Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. CHEST. 147(4): Retrieved from
National Clinical Guideline Centre (2010). Chronic Obstructive Pulmonary Disease: Management of COPD in Adults in Primary and Secondary Care. NICE Clinical Guidelines, No Retrieved from
American Lung Association (2016). My COPD Action Plan. Retrieved from
Lipson, D. A. et al. (2018). Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. The New England Journal of Medicine. Retrieved from
Calverley, P. M. et al. (2009). Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet. 374:

30. Chronic Obstructive Pulmonary Disease Chronic Disease Management
Questions?