COPD – Outpatient Management

Table of Contents

Table of Contents

Published September 2021

Kaitlyn McLeod, MD1, Kathryn Guinn, MD2, Molly Brett, MD4, Brandon Fainstad, MD4
Section Editor: 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 learning objectives.

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 the “Diagnosis of COPD” Slide 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).

Progress through the spirometry slide asking learners to interpret the results of the PFT study and identify the key values:

  • Diagnosis – Post-bronchodilator measurement of FEV1/FVC <70
  • Supporting features:
    • Increased TLC, Decreased RV, and Decreased DLCO
    • Scooped flow-volume curve

BONUS: GOLD defines COPD in an international context and attempts to have diagnostic criteria that apply in both resource-rich and resource-poor settings. There is increasing debate over how best to use PFTs and imaging to characterize COPD, 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). Some argue that CT imaging should be used to help identify early COPD in patients that may have normal spirometry and not otherwise qualify for treatment.

Objective 2: Categorize COPD therapies based on their mortality benefit, effect on disease progression, and ability to reduce symptoms and exacerbation.

Using the interactive table on the “Management” slide, ask the learners what they know to be the benefits of each of the listed interventions.  

  • Inhaler therapy therapies do not prevent the progression of disease or mortality. However, they do address an important patient-centered outcome to improve symptoms and frequency of exacerbations.
  • Pulmonary rehabilitation primarily benefits patients’ symptoms and exacerbation rate.
  • Supplemental oxygen in patients with resting hypoxemia, defined as PaO2 of <88% or PaO2 <55mmhg, provides reduced symptom burden and can slow the progression of the disease.
  • Vaccinations PPSV23, influenza, likely COVID19 (data is preliminary) provide mortality benefits 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 benefits for all domains targeted with COPD therapy.

 

Objective 3: Assign GOLD group to guide initial and step-up inhaler therapy for patients with COPD.

GOLD groups A-D are defined by the severity of symptoms (mMRC or CAT) and frequency of exacerbations.  Each inhaler type addresses these issues to a different degree and should be selected based on dominant features of a patient's disease (GOLD group).  The first part of the “Inhaler Selection” slide reminds learners of the three considerations when selecting an inhaler then reviews the benefits of each.

  • LAMA – reduces SYMPTOMS and EXACERBATIONS
  • LABA – primarily reduces SYMPTOMS and has mixed evidence for reducing exacerbations.
  • ICS – reduces EXACERBATIONS  (especially with elevated Eosinophils)

The second half of this slide is an adaptation of the GOLD group 2×2 diagram that guides inhaler selection.  This is an opportunity to ask learners to Group B and C and discuss the symptom severity scores (mMRC and CAT), then ask learners what initial agent they would select for either symptom predominant (Group B) or exacerbation predominant (Group C) disease.  If the disease is severe or persists despite the addition of the recommended inhaler then they become Group D with consideration of a second or third inhaler.

A significant takeaway with ICS is that they come with risks (primarily pneumonia) and do not offer benefits to every patient.  So, be selective for the patients most likely to respond and have a low threshold to discontinue if they do not demonstrate a favorable response.

Objective 4: Identify three cardinal signs of a COPD exacerbation.
Objective 5: Identify indications for hospitalization of a patient with COPD exacerbation
Objective 6: Employ an evidence-based approach to treating COPD exacerbation in the outpatient setting.

Using the “Exacerbations” slide, ask the learners about each of the sequential questions along the flow diagram. 

  • 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 the inhaler technique.

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

  • Steroids: In patients noticing a decrease in the ability to do usual activity, steroids are indicated. They have been shown to reduce the rate of relapse (RR~0.6) & symptoms (4). The preferred regimen is prednisone 40mg for 5-10 days. Longer courses do not offer additional benefits (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 at 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 fluoroquinolone is preferred. Many have studied the exact relationship between PsA and COPD exacerbation. There is some data to suggest that acquiring new strains of PsA can lead to an 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.

Halpin, D. M., Criner, G. J., Papi, A., Singh, D., Anzueto, A., Martinez, F. J., … & Vogelmeier, C. F. (2021). Global initiative for the diagnosis, management, and prevention of chronic obstructive lung disease. The 2020 GOLD science committee report on COVID-19 and chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine203(1), 24-36.

Share on facebook
Facebook
Share on twitter
Twitter
Share on linkedin
LinkedIn

Comment on this article