Spirometry Aids the Differential Diagnosis of Asthma and COPD Paul Enright, MD Barbara Yawn, MD, MSc A web-based learning module Target audience: Primary care physicians Disclosures Paul L. Enright, MD, has disclosed the following relevant financial relationships: Financial Relationship with a Commercial Interest: Consultant or Advisory Board: Pfizer Chantix Gilead IPF Expert Testimony: Setter Legal Asbestosis Relationship with Tobacco Entity: none Barbara P. Yawn, MSc, MD, has disclosed the following relevant financial relationships: Financial Relationship with a Commercial Interest: Novartis, BI-Pfizer: COPD screening study Merck: advisory board adult vaccines BiPfizer grant: Screening for COPD in family medicine practice Novartis grant: Rate of exacerbations before and after COPD diagnosis Merck: Incidence of Herpes Zoster eye complications Financial Support from a Non-Commercial Source: AHRQ grants: asthma tools for primary care and RCT, screening for post partem depression, use of LAMA in black adults with asthma CDC grant: Herpes Zoster surveillance Relationship with Tobacco Entity: none 1
Learning Objectives Appropriately screen patients for risk of asthma and COPD. Accurately interpret spirometry results. Identify characteristics that differentiate COPD and asthma. Classify spirometric abnormalities from mild to very severe. Monitor disease progression with spirometry. Cite evidence regarding new treatments in COPD that have been effective in slowing progression of the disease. Recognize patient symptoms/test results that should lead to referral to a pulmonary specialist. Evaluate and address comorbidities of COPD. All 10 of these adults are your patients. Naomi Frank Charlie All report 20 to 40 pack-yrs of smoking and a chronic cough. Some of them also report dyspnea. Ralph Doris Ned 1 has COPD. 1 has asthma. Lena John Cathy Lulu 2
In patients with respiratory symptoms, particularly dyspnea, spirometry should be performed to diagnose airflow obstruction. The Clinical Efficacy Assessment Subcommittee of the American College of Physicians Qaseem A, Ann Intern Med 2007 The Alphabet Soup The traditional Volume-Time graph FEV1 FEV6 FVC FEV1 = 2.9 liters FVC = 3.9 liters FEV1/FVC =.76 The exhalation starts here 3
The Flow-volume Curve peak flow This curve was invented to make the recognition of spirometry patterns easier. FVC You can t measure the FEV1 here. The blue Xs mark predicted values. Exhalation starts here Naomi 48 y/o bank teller Spirometry done by your PA Chronic, productive cough for 5 years. Smoked since age 22. Never tried to quit for fear of weight gain. Dyspnea playing tennis. BMI 28. Chronic rhinosinusitis. Clears throat frequently. Nasal congestion and halitosis on exam. Normal lung sounds. Normal CXR. What is her FEV1? a) 1.0 b) 2.2 c) 3.0 d) 6.5 4
Naomi Quit too soon Spirometry done by your PA QUIT Her FEV1 and FVC were grossly underestimated due to a very short expiratory maneuver. You coach her for a 6 second test and the results become entirely normal. Dx: Cough due to rhino-sinusitis with post-nasal drainage. Rx: generic loratidine qam and nasal lavage BID prn congestion Two weeks later she calls with the news that she no longer has a cough and her boyfriend enjoys kissing her. She will quit smoking with him. Empiric Treatment for Rhinosinusitis First gen. antihistamine Chlorpheniramine Brompheniramine Diphenhydramine Second-generation may be less sedating, but are less effective for cough due to PND Decongestant Long-acting pseudoephedrine Phenylephrine is less effective Consider a salt water sinus rinse 5
Respiratory Symptoms in Smokers are Often Not Due to COPD Chronic cough in smokers is just as likely due to post-nasal drip, GERD, or asthma. Dyspnea in smokers is often due to poor conditioning, CVD (CHF, PVD), the metabolic syndrome, or anemia. Hyperinflation is also caused by asthma. Don t prescribe a COPD inhaler until the O in COPD is confirmed. Spirometry done by a visiting respiratory therapist 30 minutes after nebulized albuterol and ipratropium (DuoNeb). Frank 75 y/o retired plumber Productive morning cough for many years. Drinks a 6-pack and smokes 30 cigs since teens. Tried to quit last New Year. Dyspnea during sex or golfing. BMI 34. Normal lung sounds. Normal CXR. FEV1/FVC = 0.60 FEV1 3.0 (94% pred) 6
A $100 Pocket Spirometer Rules Out Clinically Important COPD* in 80% of Smokers It takes just 1 minute. If FEV1 >90% predicted, prompt smoking cessation. If FEV1 <90% predicted, refer for pre-post-bd diagnostic spirometry. * Low FEV1/FVC and FEV1 <65% pred. post-bd Treatment for stable COPD should be reserved for patients who have respiratory symptoms and FEV1 less than 60% predicted, as documented by spirometry. The Clinical Efficacy Assessment Subcommittee of the American College of Physicians Qaseem A, Ann Intern Med 2007 7
FEV1/FVC and FEV1 are normal. Normal spirometry rules out COPD. Charlie 68 y/o musician poor repeatability Non-productive cough for several years. Perfume and smoking cigs worsens it, but inhaling THC helps. Denies dyspnea during concerts, sex, and lawn bowling. Mannitol challenge in Sydney was normal. BMI 22. Normal ENT & lung exam. FEV1 = 5.0 liters (125%) FEV1/FVC 5/6 = 0.83 The allergist next door measures Charlie s eno = 80 ppb (high) Dx: Eosinophilic bronchitis Rx: Inhaled corticosteroid BID 2 wks later: no cough Ralph 52 y/o attorney from Chicago FEV1 = 5.0 liters (125%) FEV1/FVC 5/6 = 0.83 Chronic, non-productive morning cough for many years. Smoked since age 18. Multiple attempts at quitting, most recently using nicotine gum. No allergies. No dyspnea. Athletic since high school. BMI 24. Normal lung sounds. Normal CXR. 8
Post-BD (after albuterol) Doris 78 y/o nurse Spirometry done at a local PFT lab FEV1 Chronic cough as long as she can remember. Colds go to her chest for several weeks, especially in the winter. Smoked since age 40 (started during her first divorce). Hay fever since age 6, but no history of asthma. Sinus headaches several times a year. Scattered wheezing on forced expiration. Hyperinflation on CXR. FEV1 1.5 L pre-bd (42% pred) FEV1 2.4 L post-bd (67% pred) What is the most likely cause of her chronic cough? a) Asthma b) COPD c) Rhinosinusitis d) GERD 9
Asthma was confirmed by the airway obstruction & large response to albuterol. Hyperinflation on chest X-ray (or HRCT) occurs both with asthma and COPD. The PFT lab also performed a DLCO test, which was normal, ruling out emphysema. You prescribed a combo inhaler. 4 weeks later, she was overjoyed. Her FEV1 increased to 3.2 liters (89% pred). Doris Ned 60 y/o journalist Spirometry done at a local PFT lab FVC Wife complains of his chronic cough. Smoked since age 18 when he joined the Marines. Hay fever since age 6. Sinusitis several times a year. No dyspnea (but no exercise). Wheezing on forced expiration. Hyperinflation on CXR. FEV1 1.5 L pre-bd (44% pred) FEV1 1.7 L post-bd (48% pred) FVC 3.0 L pre-bd (63% pred) FVC 3.8 L post-bd (79% pred) 10
What is the most likely cause of his chronic cough? a) Asthma b) COPD c) Rhinosinusitis d) GERD COPD is highly likely considering the severe airway obstruction which persists post-bd. You ordered a lung HRCT (apical panlobular emphysema). The PFT lab also performed a DLCO test (40% pred), and 6-min walk (350 yards with oxygen desaturation to 86%). You order a coronary artery calcium scan which suggests substantial CAD. Due to his comorbidity, you obtain a pulmonary consult. Ned 11
Lena 75 y/o retired flight attendant She was diagnosed with COPD 3 years ago, but complains of multiple side-effects from her high-dose combination inhaler. She has a 30 pk-yr smoking history. She quit cold turkey 3 years ago. FEV1 = 2.8 L (105% pred) FEV1/FVC = 0.68 She does not have COPD. Her chronic cough was a side-effect of an ACE inhibitor. Terrible quality spirometry Only 1 good maneuver: FEV1 = 4.3 L (107% pred) FEV1/FVC = 0.90 John 55 y/o artist Intermittent but chronic cough. Intermittent smoking since age 25. Three bouts of walking pneumonia. Dyspnea for 3 years whilst snowboarding. BMI 27. Clear lungs. SpO2 = 93% Hyperinflation on CXR. Refer to a PFT lab for good quality spirometry and a methacholine challenge test for possible asthma. 12
Sometimes the Post-test Probability of a Disease is the Same as Pre-test High confidence Low confidence FEV1/FVC: 50% Abnormal Black 70% LLN Grey 90% Normal White Accept uncertainty when results are borderline abnormal or of poor quality. Cathy 55 y/o casino manager FEV1 = 2.6 L (81% pred) FVC = 3.0 L (73% pred) FEV1/FVC = 0.87 Increasing dyspnea on exertion for 3 years. Always coughs when lying down. Sour taste after spicy Mexican food. HCTZ for hypertension. Uncle with emphysema. BMI 36. Clear lungs. Osteopenia on CXR. Spirometer interpretation: Mild restriction Dx: GERD due to obesity Rx: Low carb diet, exercise, antacids 13
FEV1 = 3.0 L (93% pred) FVC = 3.2 L (75% pred) FEV1/FVC = 0.94 Quality grade = D Lulu 45 y/o professor Poor blast effort Hesitating start Quit too soon Coughing for 3 months. Mood swings, palpitations, chest tightness. Smoking since age 14. Dyspnea climbing stairs. BMI 27. No meds. BP 172/92. Clear lungs. Normal ECG and CXR. Spirometer interp: Mild restriction Dx: GERD due to obesity Rx: Low carb diet, exercise Bupropion & nicotine gum Summary (Key Points) 1. Spirometry is very helpful for patients with a chronic cough or new-onset dyspnea on exertion. 2. Asthma symptoms with normal spirometry do not rule out mild, intermittent asthma. 3. A normal FEV1 rules out clinically-important COPD. 4. Moderate to severe obstruction in an adult smoker: very high probability of COPD. 14
2007 Asthma Guidelines US Department of Health and Human Services, National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). NIH Item No 08-4051. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. NHLBI Asthma Guidelines National Asthma Education and Prevention Program: Expert Panel Report 1991 Asthma is an inflammatory disease 1997 Early recognition and treatment based on severity assessment 2002 Update on selected topics 2007 Control and more spirometry use 15
Classifying Asthma Severity: Impairment Components of Severity Impairment Normal FEV 1 /FVC: 8 19 y 85% 20 39 y80% 40 59 y75% 60 80 y70% Intermittent Classification of Asthma Severity Persistent Mild Moderate Severe Symptoms 2 d/wk >2 d/wk; not daily Daily Throughout day Nighttime awakening 0 2x/mo 2x/mo 1 2x/mo 3 4x/mo 3 4x/mo 3 4x/mo >1x/wk; not nightly >1x/wk; not nightly >1x/wk Often 7x/wk Often 7x/wk Short-acting β 2 - agonist use for symptoms not EIB prevention 2 d/wk >2 d/wk; not daily >2 d/wk; not daily >2 d/wk; not >1x/d Daily Several times per day Interferes with normal activity None Minor limitation Some limitation Extremely limited Lung function Normal FEV 1 between attacks FEV 1 >80% of predicted FEV 1 /FVC >85% Normal FEV 1 between attacks FEV 1 >80% of pred FEV 1 /FVC normal FEV 1 >80% of pred FEV 1 /FVC >80% FEV 1 >80% of pred FEV 1 /FVC normal FEV 1 =60 80% pred FEV 1 /FVC=75-80% FEV 1 60 to 80% pred FEV 1 /FVC reduced 5% FEV 1 <60% pred FEV 1 /FVC <75% FEV 1 <60% pred FEV 1 /FVC reduced >5% a EIB=exercise-induced bronchoconstriction. Adapted from NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007. Recommended for all age groups Children 4 y Children 5 11 y Persons 12 y Classifying Asthma Severity: Risk Classification of Asthma Severity Components of Severity Intermittent Persistent Mild Moderate Severe Risk Exacerbations requiring oral systemic corticosteroid 0 1/year 2 attacks in 6 mo requiring oral steroid or 4 wheezy episodes/1 yr lasting >1 day AND risk factors for persistent asthma Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category. 0 1/year 2/year Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. 0 1/year 2/year Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. Adapted from NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007. Recommended for all age groups Children 4 y Children 5 11 y Persons 12 y 16
Comorbid Conditions Evaluate for comorbid conditions during history and when asthma cannot be well controlled. Chronic comorbid conditions Allergic bronchopulmonary aspergillosis (ABPA) Gastroesophageal reflux disease (GERD) Obstructive sleep apnea (OSA) Obesity Rhinitis/sinusitis Stress/depression Treating comorbid conditions may adequately improve overall control of asthma and lessen requirements for asthma medications. NAEPP, NHLBI, NIH. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. August 2007. Intermittent Asthma Persistent Asthma: Daily Medication Age 12 yrs Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Step 1 Preferred: SABA PRN Step 2 Preferred: Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil, or Theophylline Step 3 Preferred: Low-dose ICS + LABA OR Medium-dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 5 Preferred: High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies Patient Education and Environmental Control at Each Step Quick-Relief Medication for All Patients Step 4 Preferred: Mediumdose ICS + LABA Alternative: Mediumdose ICS + either LTRA, Theophylline, or Zileuton Step 6 Preferred: High-dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. Use of beta 2 -agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment. Step up if needed (first, check adherence, environmental control, and comorbid conditions) Assess control Step down if possible (and asthma is well controlled at least 3 months) 17
Characteristics That Help Distinguish COPD From Asthma Feature COPD Asthma Onset Often in midlife Often in childhood Family history Variable Often Medical or social history Patients report symptoms as... Airflow obstruction Smoking (often 20 pack-years) Most notable during exercise Mostly bad days May be some reversibility with bronchodilation Atopy (ie, allergy and/or eczema) Most notable at night or early morning Mostly good days Largely reversible with bronchodilation Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. Doherty DE. Am J Med. 2004;117(12A):11S-23S. Beeh et al Questionnaire to Differentiate Asthma and COPD 40 % of Patients 30 20 10 0 <3 3-5 6-8 9-11 >12 Questionnaire Score COPD Asthma A short questionnaire asking about age at onset, smoking history, atopy status, and cough quality was developed for clinical use High scores on the questionnaire were associated with a diagnosis of COPD Beeh KM, et al. Respir Med. 2004;98(7):591-597. 18
Spirometric Diagnosis of COPD COPD is confirmed by post bronchodilator FEV1/FVC <0.7 Consider LLN Post-bronchodilator FEV1/FVC measured 10-15 minutes after 2 to 3 puffs of a short-acting bronchodilator Spirometry-based Diagnosis Dictates How to Implement Evidence-based Therapy GOLD Stage I Mild II Moderate III Severe Active reduction of risk factors: influenza vaccine. Add short-acting bronchodilators when needed IV Very Severe Add regular Rx with 1 long-acting bronchodilator. Add rehabilitation Add inhaled corticosteroids (ICS) if repeated exacerbations Long-acting bronchodilators and corticosteroids are also used for asthma but in the reverse order. Consider O 2 and surgery GOLD Executive Committee. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Gold Web site. http://www.goldcopd.org. Updated 2008. 19
2005 Severity Classification - Spirometry The number of categories and the exact cut-points are arbitrary. Enright: Caution re-shifting of disease severity, false positives, excess therapy, potential conflict of interest in clinical practice guidelines Enright PL. Flawed interpretative strategies for lung function tests harm patients Eur. Respir. J., 2006; 27(6): 1322-1323 Spirometry is Useful for Monitoring Disease Progression Changes Can Be Seen Earlier in Spirometry Than in Many Other Respiratory Parameters Spirometry Normal Borderline Mild Moderate Severe Symptoms Cough, sputum Exertional dyspnea Resting dyspnea Arterial blood gas Normal Hypoxemia Chest X-ray Normal Time Hyperinflation 20
Airflow Obstruction in COPD is Partially Reversible 15 * Degree of Reversibility Patients, % 10 5 *65.6% showed a 15% increase in FEV 1 0-30 -25-20 -15-10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Change in FEV 1 % Postbronchodilator FEV 1 measured after administration of 80 µg ipratropium and 400 µg albuterol. Adapted with permission from Tashkin DP et al. Eur Resp J. 2008;31:742-750. BODE Index* Variable Points on the BODE Index 0 1 2 3 FEV 1 (% predicted) Distance walked in 6 min (m) >65 50-64 36-49 <35 >350 250-349 150-249 <149 MMRC dyspnea 0-1 2 3 4 scale Body-mass index >21 <21 * Total possible values range from 0-10. BODE = body mass index, airflow obstruction, dyspnea, and exercise capacity. Reproduced with permission. Celli B et al. N Engl J Med. 2004;350:1005-1012. 2004 Massachusetts Medical Society. All rights reserved. 21
Increased Mortality: BODE Score and ATS Staging A. 1.0 B. 1.0 Probability of Survival 0.8 0.6 0.4 0.2 0.0 P<0.001 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Months Quartile 1 Quartile 2 Quartile 3 Quartile 4 Probability of Survival 0.8 0.6 0.4 0.2 0.0 P<0.001 Stage I 0 4 8 12 16 20 24 28 32 36 40 44 48 52 Months Stage II Stage III No. at Risk 625 611 574 521 454 322 273 159 80 No. at Risk 625 611 574 521 454 322 273 159 80 Reproduced with permission. Celli B et al. N Engl J Med. 2004;350:1005-1012. 2004 Massachusetts Medical Society. All rights reserved. Spirometry Ameliorates Gender Bias Hypothetical male patient with COPD symptoms Hypothetical female patient with COPD symptoms COPD suspected on the basis of symptoms 74% COPD accurately diagnosed on the basis of spirometry 42% 31% Miravitlles M, et al. Arch Bronconeumol. 2006;42(1):3-8. 22
Peak Flow Meters are Cheaper but Less Efficient and Less Accurate If PEF >70% predicted, prompt smoking cessation. If PEF <70% predicted, refer for pre- & post-bd diagnostic spirometry. Use for asthma exacerbation assessment. Jithoo A, Nelson S, ERS 2010 abstracts John is 69 y/o Never Smoker Ht: 166.4 Wt: 73.6 FVC 2.32 63% FEV 1 0.69 24% FEV 1 /FVC 29.9 Reversibility of FEV1 to 70% 10 8 6 4 Control 2 Severe obstruction with normal peak flow. Has marked reversibility. May be severe asthma but will have to follow. 0 0 1 2 3 4 5 23
Mary is 37 y/o With 10 Pack Year Smoking History, Family History of Early COPD in Several People Ht: 177.2 Wt: 62.3 BMI: 19.9 FVC 4.65 90% 4.93 +6% FEV 1 1.93 46% 2.07 +7% FEV 1 /FVC 41.6 Moderate obstruction with hyperinflation and air trapping Little bronchodilator response Alpha 1-antitrypsin screening 10 9 8 7 6 5 4 3 2 1 0 Control Bronchodilator 0 1 2 3 4 5 Randall is 63 y/o Smoker With History of Asthma as a Young Adult and Repeated Chest Colds. Mild Dyspnea, Persistent Cough & Wheeze; Compensated Congestive Heart Failure Ht: 182.2 Wt: 83.3 FVC 3.74 74% 4.79 +28% FEV 1 1.93 50% 2.81 +46% FEV 1 /FVC 51.6 58.7 10 8 6 Control Bronchodilator 4 Moderate obstruction with large bronchodilator response, hyperinflation and air trapping on CXR?Asthma and Chronic Bronchitis 2 0 0 1 2 3 4 5 24
Nancy is 66 y/o With Severe Dyspnea 80 Pack Years, Quit 10 Years Ht: 173.5 Wt: 68.9 FVC 3.76 88% 4.70 +25% FEV 1 0.80 24% 0.98 +23% FEV 1 /FVC 21.2 Less than 200 cc increase in FEV or FVC 8 6 Control Bronchodilator 4 2 Very severe airways obstruction with marked hyperinflation, small bronchodilator response, oxygen desaturation COPD requiring desaturation evaluation 0 0 1 2 3 4 5 Pedro is 42 y/o With Mild Dyspnea on Exertion, 30 Pack Years, Ex-smoker Ht: 177.8 Wt: 215.5 BMI: 68.2 FVC 2.25 44% 2.33 +4% FEV 1 1.77 43% 1.92 +8% FEV 1 /FVC 78.7 10 8 6 Control Bronchodilator 4 Restriction in obesity Affect may be minimal Increased diffusing capacity is common Obstruction unrelated to obesity Severe COPD 2 0 0 1 2 3 4 5 25
Using Spirometry to Monitor Lung Function 61 Y/O Transplant Patient Ht: 162.6 Wt: 87.5 Trend showing dip with rejection episode Address Co-morbidities of COPD Lung Cancer Anxiety, Depression Pulmonary Hypertension Anemia Cardiovascular Disease Peripheral Muscle Wasting & Dysfunction Osteoporosis Diabetes Metabolic Syndrome Peptic Ulcers GI complications Cachexia Kao C, Hanania, NA. Atlas of COPD, 2008 26
Asthma or COPD Management Suspect Severity Symptoms FEV1 Select RX Spirometry Modifications Why inadequate? Inadequate Adherence Triggers Co-morbidities Psycho-social Inhaler technique Adequate In Addition to Improved Care, be Paid for Your Work Claim Reimbursement Procedure CPT Code MC $ (approx.) Spirometry 94010 $36 Bronchospastic Spirometry 94060 $64 Albuterol MDI J7613 Carrier Priced Flow Volume Loop 94375 $40 MDI Teaching 94664 $17 Simple Pulmonary Exercise Test 94620 $80 27
Smoking Cessation Counseling 99406 3-10 minutes $13 (approximate) 99407 >10 minutes $25 (approximate) May bill with an E&M code using a 25 modifier and different diagnoses like cough, asthma or COPD Limit 8 visits in 12 month period Summary Asthma and COPD can be difficult to separate Spirometry is the most important tool to help confirm But you have to suspect respiratory problems As in any chronic disease one test is not diagnostic You can do and interpret spirometry successfully 28