Latest Guidelines for COPD Treatment Evaluation. by Scott Cerreta, BS, RRT Director of Education
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1 Latest Guidelines for COPD Treatment Evaluation by Scott Cerreta, BS, RRT Director of Education
2 CONFLICT OF INTEREST I have no financial conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis. I am an employee of the COPD Foundation. The COPD Pocket Consultant Guide lists all medications commonly used to treat COPD, including off-label use medications, which are clearly marked. I will not be describing meds.
3 OBJECTIVES 1. Discuss current literature and research that warrants the need to change COPD Guidelines 2. Describe new features of the COPD Foundation Treatment Guide 3. Introduce the 7 severity domains and implications for treatment. 4. Discuss how these changes will impact diagnosis and treatment recommendations
4 WHAT IS COPD? Chronic Obstructive Pulmonary Disease Serious lung disease that over time makes it hard to breathe Emphysema Chronic Bronchitis Refractory Asthma and Some forms of bronchiectasis Blocked (obstructed) airways make it hard to get air in and out
5 GOLD DEFINITION 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. Alpha-1 testing for young and/or low tobacco use or environmental exposures
6 ATS, ERS, ACP, ACCP DEFINITION Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Alpha-1 testing for all with diagnosed COPD
7 NHLBI DEFINITION Chronic Obstructive Pulmonary Disease Serious lung disease that over time makes it hard to breathe Emphysema Chronic Bronchitis Blocked (obstructed) airways make it hard to get air in and out
8 COPD FOUNDATION DEFINITION Chronic Obstructive Pulmonary Disease Serious lung disease that over time makes it hard to breathe Emphysema Chronic Bronchitis Refractory Asthma and Some forms of bronchiectasis Blocked (obstructed) airways make it hard to get air in and out
9 COPD: AIRWAY EFFECTS National Lung Health Education Program: Prevent COPD Now! Information for Patients Who May Be Developing COPD, download Save Your Breath, America!:
10 LITERATURE REVIEW COPD Gene Study Dr. Crapo Why some smokers get COPD & others don t Using HRCT and identified a large number of people with emphysema despite normal spirometry Spiromics Dr. Rennard Identifying subsets of people with COPD collection and analysis of phenotypic, biomarker, genetic, genomic, and clinical data from subjects with COPD
11 COPD: DEFINITIONS OF 21ST CENTURY Chronic bronchitis Emphysema Preventable and treatable Airflow limitation that is not fully reversible Progressive disease Abnormal inflammatory response of the lungs Subsets of patients COPD Asthma Box = FEV1/FVC < 70% or < LLN American Thoracic Society European Respiratory Society: Standards for the Diagnosis and Management of Patients with COPD, download manual:
12 Note: You can access the full MMWR at and online database at The Impact of COPD in the U.S. COPD is the nation s third leading cause of death and a leading cause of disability In 2012 the CDC published the first ever state by state COPD prevalence rates for COPD based on the Behavioral Risk Factor Surveillance System (BRFSS) Nationally, an average of 6.3% of adults reported a diagnosis of COPD, equating to over 15 million Americans and roughly 1 in every 15 adults BUT the NHLBI estimates that an additional 12 million Americans are likely living with COPD without an accurate diagnosis, leading to the possibility that COPD s impact is even greater than the data reveals
13 COPD IN THE U.S.
14 COPD IN THE U.S. Prevalence of COPD by Age in the U.S. 15.0% 10.0% 5.0% 0.0%
15 COPD IN THE U.S.
16
17 COPD GUIDELINES Full Document Summary GOLD 76 pages 19 pages ATS/ERS Standards 80 pages 15 pages NICE 673 pages 20 pages ACP/ACCP/ATS/ERS Consensus Statement 13 pages
18 Increasing Risk GOLD classification of airflow limitation or more Exacerbation history Increasing Risk COPD ASSESSMENT: A NEW MODEL C D A B mmrc < 2 CAT < 10 mmrc > 2 CAT > 10 Increasing Symptoms
19 ATS, ERS, ACP, ACCP DEFINITION COPD w/symptoms and FEV1 60%-80% BD use weak rec, low evidence COPD w/symptoms and FEV1 <60% BD use strong rec, mod evidence COPD w/symptoms and FEV1 <60% Mono LAMA or LABA strong, mod evi COPD w/symptoms and FEV1 <60% Combo LAMA or LABA or ICS weak, mod Alpha-1 testing in all people with COPD
20 2 PANEL POCKET CONSULTANT
21 2 PANEL POCKET CONSULTANT
22 GUIDE TO DIAGNOSIS COPD DEFINITION Defined by post bronchodilator FEV1/FVC ratio<0.7 on spirometry This helps differentiate from asthma A significant bronchodilator response (increase in FEV1>12% and >200 cc) can be seen in both COPD and asthma
23 GUIDE TO DIAGNOSIS: SPIROMETRY Indicated if symptoms present: dyspnea, chronic cough/sputum Should be considered if: Risk factors are present- smoking, other exposures, asthma history, childhood infections, prematurity, family history AND if one or more comorbidities present-heart disease, metabolic syndrome, osteoporosis, depression, lung cancer, premature skin wrinkling
24 OTHER CONSIDERATIONS Alpha-1 testing for all Supported by ATS, ERS, ACP, ACCP Smoking cessation for all Vaccinations for all Exercise for all
25 OTHER CONSIDERATIONS
26 SEVEN SEVERITY DOMAINS 1. Spirometry Grades 2. Regular Symptoms 3. Exacerbations 4. Oxygenation 5. Emphysema 6. Chronic bronchitis 7. Comorbidities
27 SEVERITY DOMAIN: 1. SPIROMETRY GRADES
28 1. SPIROMETRY GRADES
29 2. REGULAR SYMPTOMS
30 SEVERITY DOMAIN: 2. REGULAR SYMPTOMS Dyspnea at rest or exertion Chronic cough/ sputum Use COPD Assessment Test (CAT) or mmrc Breathless Scale to follow course of disease Presence of regular symptoms has therapeutic implications and should be evaluated in every patient at every visit.
31 COPD ASSESSMENT TEST (CAT) A CAT score over 10 suggests significant symptoms A change in CAT score of 2 or more suggests a possible change in health status A worsening of CAT score could be explained by an exacerbation, poor medication adherence, poor inhaler technique, or progression of COPD or comorbid condition. An adjustment in therapy may be needed.
32 MMRC BREATHLESSNESS SCALE Grade Description of Breathlessness 0 I only get breathless with strenuous exercise I get short of breath when hurrying on level ground or walking up a slight hill On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace I stop for breath after walking about 100 yards or after a few minutes on level ground I am too breathless to leave the house or I am breathless when dressing Chris Stenton. The MRC breathlessness scale. Occup Med (Lond)(2008)58(3): doi: /occmed/kqm162, Table 1. By permission of Oxford University Press on behalf of the Society of Occupational Medicine.
33 3. EXACERBATIONS
34 SEVERITY DOMAIN: 3. EXACERBATIONS High Risk: Two or more exacerbations in past year Especially if FEV1<50% predicted High risk for exacerbations has therapeutic implications and should be evaluated in every COPD patient at every visit.
35 4. OXYGENATION
36 SEVERITY DOMAIN: 4. OXYGENATION Severe hypoxemia: resting O2 sat <88% or arterial po2<55 mmhg Episodic hypoxemia: exercise or nocturnal desaturation Severe hypoxemia has therapeutic implications and should be evaluated in every COPD patient with FEV1<60%, SG 2/3. Episodic hypoxemia may have therapeutic implications
37 5. EMPHYSEMA
38 SEVERITY DOMAIN: 5. EMPHYSEMA Reduced density on CT scan Can be diffuse or localized Abnormal high lung volumes Abnormal low diffusion capacity Localized emphysema particularly localized to upper lung zones could have therapeutic implications and should be evaluated if FEV1<30%, SG 3.
39 6. CHRONIC BRONCHITIS
40 SEVERITY DOMAIN: 6. CHRONIC BRONCHITIS Cough, sputum most days for at least 3 months in at least 2 years Presence of chronic bronchitis has therapeutic implications and should be evaluated in every COPD patient at every visit.
41 7. COMORBIDITIES
42 SEVERITY DOMAIN: 7. COMORBIDITIES Comorbidities are extremely common in COPD and impact morbidity, hospitalization and re-hospitalization rates and mortality. Evidence suggests that COPD may be an independent risk factor for the development of cardiovascular disease, lung cancer, depression, osteoporosis. Defining and treating comorbid conditions, particularly cardiovascular, are critical components of COPD care and should be evaluated in every patient at every visit.
43 MOBILE APP COMING SOON
44 MOBILE APP COMING SOON
45 JOURNAL OF COPD MANUSCRIPT PUBLICATION The full manuscript is available as a Free download from Informa Healthcare by visiting /toc/cop/current June 2013, Vol. 10, No. 3, Pages (doi: / )
46 ONLINE ORDERS
47 6 PANEL POCKET CONSULTANT GUIDE
48 6 PANEL POCKET CONSULTANT GUIDE
49 SUMMARY Dx of COPD requires Spirometry but definitions vary and change when new evidence is discovered. Implications for treatment of COPD requires consideration for seven severity domains. COPD Foundation s Pocket Consultant Guide is a tool derived from existing guidelines that is simple, convenient and portable. COPD is a complex disease associated with co-morbid conditions and proper management is required for optimal health.
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