COPD – Outpatient Management

Table of Contents

Table of Contents

Published September 2021

Kaitlyn McLeod, MD1, Kathryn Guinn, MD2, Meara Melton, MD3, Molly Brett, MD4, Trevor Steinbach, MD5

1 Assistant Professor, Department of Medicine, University of Colorado, 2 Cheif Resident, University of Colorado Internal Medicine Residency Program, 3 Fellow in Geriatric Medicine, University of Colorado, 4 Assistant Professor, Department of Medicine, University of Colorado, 5 Assistant Professor, Division of Pulmonary and Critical Care, University of Colorado

Objective(s)

  1. Define the diagnostic criteria for COPD.
  2. Categorize COPD therapies based on their mortality benefit, effect on disease progression, and ability to reduce symptoms and exacerbation.
  3. Assign GOLD group to guide initial and step-up inhaler therapy for patients with COPD.
  4. Identify three cardinal signs of a COPD exacerbation.
  5. Employ an evidence-based approach to treating COPD exacerbation in the outpatient setting.
  6. Identify indications for hospitalization of a patient with COPD exacerbation

Teaching Instructions

Plan to spend at least 20 minutes preparing for this talk by using the interactive board for learning/preparing, clicking through the graphic, and becoming familiar with the order of the content that appears on the graphic. The teaching script below details how to walk through the talk. Every interactive or “clickable” element is denoted with a rounded box and cursor icon.

Anticipated time to deliver the talk with and without cases or other features: without cases 15-20 minutes. The cases may take an additional 10-15 min.

The talk can be presented in two ways:
1. Project the “interactive Board for Presentation” OR
2. Reproduce your own drawing of the presentation on a whiteboard.
With either method, print out copies of the Learner’s Summary Handout so they may have this for reference after the discussion.

Introduction: State the title of the presentation and review the objectives to prime learners
Show Slide 1 during this introduction.

BONUS: Consider an activity to allow learners to recall info they already know about the topic: “Take 1 minute to write down anything you know about COPD.”

Objective 1: Define the diagnostic criteria for COPD.
Ask the group: “What are three criteria for diagnosing COPD?”
Click through slide 2 highlighting the common risk factors for COPD (age, tobacco use), the most common symptoms (chronic, progressive, productive cough and dyspnea), and the key diagnostic testing (spirometry).
Click on Spirometry
Click on “How do you order PFTs at your institution and how do you access the results?” Then, offer site specific information.
Progress to slide 2 and ask students to interpret the results of the PFT study.
Click the question to reveal the key characteristics making this PFT result consistent with COPD- scooped flow-volume cure indicating obstruction during expiration and a post-bronchodilator FEV1/FVC of <70.

BONUS: GOLD defines COPD in an international context and attempts to have diagnostic criteria that apply in both resource-rich and resource-poor settings. Debate about how best to using diagnostic imaging in the diagnosis of COPD is on the rise, partly because spirometry does not always correlate well to clinical symptoms. However, some studies suggest CT findings do correlate with symptoms and pulmonary function (1, 2). There is rising ideology that CT imaging should be used to help identify early COPD in patients that may have normal spirometry and not otherwise qualify for treatment.
(1) Relationship between quantitative CT metrics and health status and BODE in chronic obstructive pulmonary disease. Martinez CH, Chen YH, Westgate PM, Liu LX, Murray S, Curtis JL, Make BJ, Kazerooni EA, Lynch DA, Marchetti N, Washko GR, Martinez FJ, Han MK, COPDGene Investigators.Thorax. 2012 May; 67(5):399-406.
(2) Vestbo J, Edwards LD, Scanlon PD, Yates JC, Agusti A, Bakke P, Calverley PM, Celli B, Coxson HO, Crim C, et al. ECLIPSE Investigators. Changes in forced expiratory volume in 1 second over time in COPD. N Engl J Med. 2011;365:1184–1192.

Objective 2: Categorize COPD therapies based on their mortality benefit, effect on disease progression, and ability to reduce symptoms and exacerbation.
o Click through slide 4 to highlight the goals of each therapy
o Inhaler therapy therapies do not prevent progression of disease or mortality. They do address an important patient-centered outcome to improve symptoms and frequency of exacerbations.
o Pulmonary rehabilitation primarily benefits patients’ symptoms and exacerbation rate.
o Supplemental oxygen in patients with resting hypoxemia, defined as PaO2 of <88% or PaO2 <55mmhg, provides reduced symptom burden and can slow progression of disease. o Vaccinations PPSV23, influenza, likely COVID19 (data is preliminary) provide mortality benefit for patients with COPD. Note that this data was primarily collected prior to advancement in therapies for COPD. o Smoking cessation is key in COPD management. It offers benefit for all domains targeted with COPD therapy. 

Objective 3: Assign GOLD group to guide initial and step-up inhaler therapy for patients with COPD. o Click through slide 5 o Acknowledge that inhalers primarily treat symptoms and exacerbations and that it is important to choose inhalers covered by insurance to avoid prohibitive cost. o Introduce the common acronyms for inhalers o Click through the flowchart to clarify how to choose initial therapy or how to escalate therapy. o To simplify the algorithm, it is appropriate to use the following step-up therapy  SABA for all  SABA + LAMA for group B or C  SABA + LAMA + LABA for group D  SABA + LAMA/LABA/ICS for group D + eosinophils >100

Objective 4: Identify three cardinal signs of a COPD exacerbation.
o Click forward to Slide 6 to discuss COPD exacerbations
o Ask students to identify the 3 symptoms of COPD exacerbation

Objective 5: Identify indications for hospitalization of a patient with COPD exacerbation
o Ask students to consider what should prompt emergency evaluation and hospitalization in a patient with the symptoms of an exacerbation.

Objective 6: Employ an evidence-based approach to treating COPD exacerbation in the outpatient setting.

  • For patients that are safe to treat in the outpatient setting, review an evidence-based approach by clicking through the flow chart.
  • CXR: only necessary if an alternative diagnosis is likely or if a patient is hospitalized.
  • Inhalers: everyone should get increased short acting inhaler therapy. Be aware that LAMAs should not be used in combination with SAMAs. MDI and Nebs are equivalent if able to perform appropriately with spacer and proper technique (3). Remember to evaluate inhaler technique.

BONUS: CDC has videos on correct usage of inhaler: https://www.cdc.gov/asthma/inhaler_video/default.htm

  • Steroids: In patient’s noticing a decrease in ability to do usual activity, steroids are indicated. They have been shown to reduces rate of relapse (RR~0.6) & symptoms (4). The preferred regimen is prednisone 40mg for 5-10 days. Longer courses do not offer additional benefit (5).
  • Antibiotics: The key to treating a COPD exacerbation with antibiotics is sputum change (in quality or quantity). Most often, patients are prescribed azithromycin or doxycycline in a COPD exacerbation.
  • Consider a sputum culture and pseudomonas coverage if a patient is known to be colonized with pseudomonas or is high risk for poor outcomes: FEV1 <30%, history of bronchiectasis, broad spectrum antibiotics in last 3 months, chronic systemic steroids. If PsA coverage is needed, a respiratory fluroquinolone is preferred. Many have studied the exact relationship btween PsA and COPD exacerbation. There is some data to suggest that aquiring new strains of PsA can lead to exacerbation. (7)

Practice Cases: Recommend giving students an opportunity to discuss the cases in pairs for 10-15 minutes. Then, ask for audience participation as you reveal the answers.

Handouts

Learner handout (coming soon) – Recommend printing out ahead of time and distribute to learners when you are ready to do pair-shares for the cases.

Tutorial on delivering the talk

Presentation Board

Take Home Point

  1. In patients with risk factors, spirometry with a scooped flow-volume curve and FEV1/FVC <70 is diagnostic of COPD.
  2. Smoking cessation is the only COPD intervention that reduces mortality.
  3. For COPD use a stepwise addition of SABA > LAMA or LABA > LAMA+LABA. Consider ICS with LABA if eosinophils are elevated, exacerbations persist, or evidence of reactive airway disease.
  4. Exacerbations should be treated with a combination of short-acting inhalers, steroids, and antibiotics.

References

Martinez, C. H., Chen, Y. H., Westgate, P. M., Liu, L. X., Murray, S., Curtis, J. L., … & COPDGene Investigators. (2012). Relationship between quantitative CT metrics and health status and BODE in chronic obstructive pulmonary disease. Thorax, 67(5), 399-406.

Vestbo J, Edwards LD, Scanlon PD, Yates JC, Agusti A, Bakke P, Calverley PM, Celli B, Coxson HO, Crim C, et al. ECLIPSE Investigators. Changes in forced expiratory volume in 1 second overtime in COPD. N Engl J Med. 2011;365:1184–1192.

Bach, P. B., Brown, C., Gelfand, S. E., & McCrory, D. C. (2001). Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Annals of internal medicine, 134(7), 600-620.

Leuppi, J. D., Schuetz, P., Bingisser, R., Bodmer, M., Briel, M., Drescher, T., … & Rutishauser, J. (2013). Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. Jama, 309(21), 2223-2231.

Murphy TF, Brauer AL, Eschberger K, Lobbins P, Grove L, Cai X, Sethi S. Pseudomonas aeruginosa in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008 Apr 15;177(8):853-60. doi: 10.1164/rccm.200709-1413OC. Epub 2008 Jan 17. PMID: 18202344.

Roman-Rodriguez, M., & Kaplan, A. (2021). GOLD 2021 Strategy Report: Implications for Asthma–COPD Overlap. International Journal of Chronic Obstructive Pulmonary Disease, 16, 1709.

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