A Pocket Guide for Primary Care Specialists

Transcription

1 A Pocket Guide for Primary Care Specialists Integrating Evidence into Practice: Including: Concise Guidelines-Based Information Patient Management Strategies Pulmonary Function Definitions and Analysis Appropriate ICD-9 Codes

2 Position Statement COPD (chronic obstructive pulmonary disease) is the 4th leading cause of death in America, affecting million people in the US. It is also estimated that another 12 million people have COPD, but do not know it. COPD develops slowly and leads to increased disability as the disease progresses. While there is no cure, there are methods to help slow the progression of COPD and to help patients feel better and remain active. Smoking is the major cause of COPD, and many patients with this disease have a long history of smoking or exposure to noxious chemicals or irritants. The purpose of this evidence-based pocket guide is to provide a quick and easy reference utilizing GOLD (Global Initiative for Chronic Obstructive Lung Disease) and ATS/ERS (American Thoracic Society/ European Respiratory Society) guidelines to assist with the diagnosis, management, and overall care of patients with COPD. As with any chronic illness, the main goal is to manage the disease while helping to improve or maintain quality of life for the patient. Expert Faculty Roy A Pleasants II, PharmD, BCPS Course Director Associate Professor Division of Pharmacy Practice Campbell University School of Pharmacy Buies Creek, NC Clinical Pharmacist Division of Pulmonary, Allergy, and Critical Care Medicine Duke University School of Medicine Durham, NC Stuart W Stoloff, MD, FAAAAI, FAAFP Clinical Professor of Family and Community Medicine University of Nevada School of Medicine Reno, NV Jill A Ohar, MD, FCCP Professor of Internal Medicine Director of Clinical Operations Section of Pulmonary, Critical Care, Allergy, and Immunological Disease Wake Forest University School of Medicine Winston-Salem, NC Joyce M Knestrick, PhD, CRNP, FAANP Coordinator of Graduate Education Frontier School of Midwifery & Family Nursing Certified Family Nurse Practitioner The Primary Care Center Mount Morris, PA George e B Cooper, BS, RRT-NPS, RPFT, RCP Senior Pulmonary Function Technologist Pulmonary Function Testing Lab Cardiopulmonary Services Novant Health Winston-Salem, NC Sponsored by through an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc. Definition of COPD and Associated Diseases Chronic Obstructive Pulmonary Disease (COPD) is a disease in which airflow is limited due to an abnormal inflammatory response to noxious stimuli and damage to the lungs. It is not fully reversible and many patients eventually require supplemental oxygen to maintain adequate blood oxygen levels. Chronic Bronchitis is defined clinically by a mucous-producing cough which persists for most days of the month over a period of 3 months in each of 2 consecutive years. Emphysema is defined by a reduction of air exchange into the blood caused by damage to the alveoli. Emphysema is an irreversible progressive disease that can develop after years of exposure to noxious stimuli. Asthma is defined as a reversible inflammation of the lungs and constriction of the bronchial muscles, typically caused by irritants. Asthma symptoms tend to be more episodic than those of COPD. NOTE: About 25% 30% of COPD patients have concurrent asthma, and differentiation between asthma and COPD may be difficult in some patients. Diagnosis of COPD COPD is a progressive disease; and, accordingly, the best clinical scenario involves early diagnosis and treatment in order to slow or halt the progression of the disease. If symptoms are present and the patient is exposed to certain risk factors, such as cigarette smoke, COPD should be considered as one of the possible diagnoses. Symptoms Cough Mucous Dyspnea Exposure to Noxious Stimuli Cigarette smoke Occupational dust/chemicals Smoke from home heat or cooking Spirometry

3 Use of Spirometry to Diagnose and Stage COPD The diagnosis of COPD is primarily based upon spirometry, clinical history, and physical examination. Spirometry is the gold standard for measuring airflow and is needed to make a firm diagnosis of COPD. Spirometry should be conducted both pre- and post-administration of a bronchodilator. Spirometry measures include: Forced Expiratory Volume in 1 second (FEV1) Forced Vital Capacity (FVC) FEV1/FVC ratio FEV1/FVC < 0.7 defines airflow obstruction FEV1 is used to determine the severity of disease stage Generally, if /FVC < 0.7 following use of a bronchodilator, the patient is defined as having obstructive lung disease. Spirometry should be performed: As part of the initial diagnosis As part of monitoring disease progression If symptoms increase drastically In all patients over the age of 40 with a smoking history (eg, > 20 pack years) After spirometry is conducted and obstruction is demonstrated, the severity of COPD is defined using the below figure. ICD-9 Diagnostic Codes The following codes for COPD-related symptoms may be useful for documentation purposes. Code Diagnosis 490 Bronchitis, not specified as acute or chronic 491 Chronic bronchitis Mucopurulent chronic bronchitis Chronic obstructive bronchitis without exacerbation Chronic obstructive bronchitis with exacerbation Unspecified chronic bronchitis 492 Emphysema Dyspnea Shortness of breath Wheezing Chronic cough NOTE: The presence of COPD symptoms should be carefully elicited and may be required for reimbursement of spirometry by insurers. A patient who has recurrent COPD symptoms is more likely to have progressive disease. Avoid risk factors; administer influenza vaccination Add short-acting bronchodilators PRN 1 Mild /FVC < % predicted 2 Moderate /FVC < % < 80% predicted 3 Severe /FVC < % < 50% predicted 4 very Severe /FVC < 0.70 < 0.30% predicted or < 50% predicted plus chronic respiratory failure Add regular treatment with 1 or more long-acting bronchodilators; add rehab Add inhaled glucocorticosteroids if repeated exacerbations Add long-term O 2 if chronic respiratory failure; consider surgical treatments Adapted from reference 2.

4 Modified Medical Research Council Dyspnea Scale The Medical Research Council (MRC) Dyspnea scale is an objective questionnaire used to measure perceived respiratory disability associated with COPD. It functions to measure the amount of breathlessness due to daily activities associated with COPD and may be beneficial as a supplement to spirometry in the diagnosis of COPD. Adapted from reference 3. Grade Degree of Activity-Related Breathlessness 0 I only get breathless with strenuous exercise. 1 I get short of breath when hurrying on the level or up a slight hill. 2 I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level. 3 I stop for breath after walking 100 yards or after a few minutes on the level. 4 I am too breathless to leave the house or I am breathless when dressing or undressing. Note: The modified MRC scale (0 4) can also be used for calculation of BODE index, a prognostic scoring system for COPD. Treatment of COPD Drug therapies (quick-relief and maintenance), smoking cessation/ prevention, pulmonary rehabilitation, and supplemental oxygen form the basis for the management of COPD. Quick-relief medications include short-acting b 2-agonists (eg, albuterol and levalbuterol) and shortacting anticholinergics (eg, ipratropium) which may be used as-needed, regularly, or intensified for treatment of worsening symptoms. Maintenance medications are used on a daily basis to control or prevent chronic symptoms. FDA-approved maintenance medications for COPD include long-acting b 2-agonists (eg, salmeterol, formoterol, and arformoterol), long-acting anticholinergics (eg, tiotropium), and inhaled steroid/long-acting b 2-agonist combinations (eg, budesonide/formoterol and fluticasone/ salmeterol). COPD Flares About 50% of health care dollars spent on COPD are for flares 15% of patients with a flare require at least an ED visit, if not hospitalization Interventions that can decrease the frequency and/or severity of flares include: Smoking cessation Pulmonary rehabilitation Optimizing maintenance bronchodilators Adding inhaled corticosteroids to LABA if FEV1 < 50% predicted Use of a COPD Action Plan for the patient, starting prednisone and antibiotics early in the appropriate patient may prevent acute care visits

5 Pulmonary Rehabilitation Goal Reduce systemic consequences, as well as behavioral and educational deficiencies in patients with COPD Who Should Participate Patients with FEV1 < 80% predicted Patients with persistent symptoms and/or limited activity levels Patients unable to adjust to illness in spite of appropriate medical care Who Should be Excluded Patients with significant physical disability Patients with uncontrolled comorbidities (eg, unstable cardiac disease, severe neurologic problems) Symptoms worsen in severity Frequent flares Onset of arrhythmias Elderly Severe COPD Criteria for Hospitalization Exacerbation unresponsive to intensified treatment 24 hrs High-risk comorbidities (eg, CHF, CAD) Respiratory acidosis Change in mental status Cyanosis Symptoms of a COPD Flare Increased breathlessness with: Wheezing Chest tightness Increased cough/mucus Change in mucus Fever Tachypnea Increased heart rate Use of accessory muscles for Decreased FEV respiration 1 Treatment of COPD Flares Treat with antibiotics if changes in sputum (especially if mucopurulent) occur with dyspnea or with other signs of infection Intensify quick-relief bronchodilators for acute flares Albuterol (2.5 mg via nebs or 2 puffs of MDI) or levalbuterol (1.25 mg or 2 puffs of MDI) + ipratropium (500 mcg via nebs or 2 puffs via MDI) every 4 to 6 hours as needed for symptom relief more often if needed for short time periods Start systemic steroids Minimum of prednisone mg daily, for 7 10 days. (Optimal dose not well-defined.) Courses > 14 days for flares are associated with increased risk of pneumonia Watch for hyperglycemia, sleeplessness, and worsening of heart failure Monitor arterial blood gas measurement or O2 saturation if possible NOTE: Following a significant exacerbation, spirometry results will remain below baseline of pre-exacerbation results for approximately 6 12 weeks. Benefits of Pulmonary Rehabilitation Improved Reduced Exercise performance Secondary morbidities Health-related QoL Severity of symptoms (eg, dyspnea) Self-management Health care costs Psychosocial status Exacerbations Participation in daily life Psychological dysfunction Components of Effective Pulmonary Rehabilitation Programs Exercise program Self-management education Dietary supplementation Psychological and social considerations Smoking Cessation Key Points Assess at each visit Spend at least 2 minutes reviewing smoking cessation in smokers, when possible In all patients, recommend counseling and drug therapies 5 A s to Help Patients Quit Smoking ASK ADVISE ASSESS ASSIST FEV1 (% of value at age 25 years) ARRANGE Determine/document all smokers and frequency at all visits Firmly recommend smokers to quit smoking in a personal, clear manner Establish patient s willingness to attempt to quit Help patient quit by providing cessation plan, counseling, and pharmacotherapy, if necessary Schedule follow-up appointment with patient The Natural History of Chronic Airflow Obstruction Smoked regularly & susceptible to its effects Onset of Symptoms Severe Disability 0 Death Adapted from reference 4. Age (years) Never smoked or not susceptible to smoke Stopped smoking at age 45 Stopped smoking at age 65

6 Clinical Pearls for Drug Use in COPD Emphasize smoking cessation in COPD patients Utilizing drug therapies doubles the rate of quitting Combining pharmacotherapy and behavioral modification increases rates further Review medication compliance and proper medication use Ensure that patients can use their inhalational devices properly The elderly tend to have difficulties Devices that require high inspiratory rates may not be desirable in COPD COPD guidelines recommend optimizing bronchodilators in COPD This is done by using drugs of different mechanisms and adding long-acting agents to short-acting agents Consider adding inhaled corticosteroids with long-acting bronchodilators in COPD when patients have one or more COPD flares each year If tiotropium is utilized, discontinue ipratropium (questionable benefit of ipratropium if receiving tiotropium, likely more anticholinergic side-effects if used in combination) COPD patients have a marked increase in risk of heart attacks (heart disease is the leading cause of death in COPD) Use of selective b-blockers are generally safe in COPD patients, but may increase risk of bronchospasm if concurrent asthma Non-selective agents (eg, propranolol and carvedilol) should generally be avoided in COPD Selective b-blockers (eg, metoprolol, nebivolol, and atenolol) are preferred in patients with obstructive lung disease Depression is common in COPD; consider anti-depressants in appropriate patients Use benzodiazepines and narcotics with caution, especially in combination and in COPD patients who have high carbon dioxide levels ( CO 2 retainers ) Use therapies to prevent COPD-associated osteoporosis in COPD patients who use prednisone bursts several times per year and/or have other risk factors for osteoporosis; patients receiving high doses of inhaled steroids may also benefit from osteoporosis preventive therapies Useful Resources for Patients National Lung Health Education Program National Heart, Lung, and Blood Institute Lung Information The American Lung Association COPD Foundation Useful Resources for Providers The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Institute for Clinical Systems Improvement COPD Guidelines American Thoracic Society Smoking Cessation Resources Smoke Free web site American Cancer Society quit smoking page Nicotine Anonymous (NicAnon) QUIT-NOW Better Breathers Club (American Lung Association affiliated COPD support group information) References 1. Barnes PJ. Immunology of asthma and chronic obstructive pulmonary disease. Nat Rev Immunol. 2008;8: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (updated 2008). Accessed 10/01/ Bestall JC, Paul EA, Garrod R, et al. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax. 1999;54: Fletcher C, Peto R. The natural history of chronic airway obstruction. Br Med J. 1977;1: Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. October Celli BR, MacNee W, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004;23: Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society (ATS/ERS) statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173: Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults. Chest. 2000;117: Copyright 2009 Prime Education, Inc. All rights reserved. 15PR091