1. Treating Mild COPD Dr Vincent Mak (v.mak@nhs.net)
Consultant in Respiratory Integrated Care
Imperial College Healthcare Trust, London
NHS England (London) Respiratory Network

2. Disclosures for Dr Vincent Mak
Research Support/P.I.
No relevant conflicts of interest to declare
Employee
Consultant
Major Stockholder
Speakers Bureau
Honoraria and support for conference attendance
AZ, GSK, Boehringer. Almirall, Novartis, TEVA
Chiesi
Scientific Advisory Board

3. What do we mean by “Mild COPD”?
Are we talking the same language?

4. Define Mild COPD - Use Spirometry?
GOLD 2014 and NICE (UK)
FEV1/FVC <0.70 and FEV1 > 80% predicted
With or without symptoms
Seems fairly simple

5. Problems with spirometry based diagnosis of Mild COPD
Why does FEV1/FVC<0.70 define airflow obstruction?
Why not 0.75 or 0.65? Makes COPD a dichotomous disease rather than a continuum.
If a heavy smoker with breathlessness has FEV1/FVC 0.70 and FEV1 80% predicted – “by definition” they do not have COPD (and do not fit into any guideline).
What if FEV1/FVC=0.69 but FEV1 is >100% predicted?
Fixed ratio tends to underdiagnose younger patients and overdiagnose elderly patients
When lower limit of normal (LLN) is used rather than fixed ratio, fewer elderly patients are classified as having airflow obstruction
So what do they have? Emphysema? Where is the guideline for that?

6. Fixed FEV1/FVC ratio vs LLN
Lamprecht B et al. Pulm Med. 2011;2011: doi: /2011/780215

7. Define Mild COPD using symptoms – is this Mild disease?
Any stage GOLD/NICE spirometry with:
No self reported symptoms
MRC ≤2 (mMRC 1)
<1 exacerbation/year

8. Is Mild COPD same as Early COPD?
COPD – “a story with no beginning, a middle that is a way of life and an uncertain and unlooked for end” * - a continuous process
Early COPD
Starts in utero?
In early childhood? In the workplace? At home?
With first cigarette?
Does an 80 year old ex-smoker with FEV1/FVC 0.65 and FEV1 80% predicted have early disease? (because it’s a bit late!)
*Pinnock H et al. BMJ. 2011;342:

9. Does Early/Mild COPD matter?
Symptoms/Quality of Life
Patients underestimate/under-report severity of their disease*
Physiological impairment
Despite lack of symptoms, patients exhibit significant physiological impairment**
Exacerbations
Some patients have frequent exacerbations***
Disease progression
Mild airflow obstruction may signify risk of disease progression
* Rennard S et al. Eur Respir J 2002; 20: 799–805.
** O’Donnell D et al. Respirology Feb;21(2): doi: /resp.12619
*** O’Reily J et al. Prim Care Respir J Dec;15(6):346-53

10. Screening for Early/Mild COPD
Logical arguments for screening for COPD:
Having abnormal lung function may encourage people to stop smoking
Treatment of early disease may prevent disease progression
May unmask those who actually have symptoms which they have attributed to aging
Should be cost effective in long run preventing people getting worse

11. Screening for Early/Mild COPD
Two recent evaluations of population screening for COPD (UK* and USA**)
Both came to same conclusion that population screening not cost effective (in developed countries) because:
No evidence that screening for COPD in asymptomatic persons improves health-related quality of life, morbidity, or mortality.
No consistent evidence that detecting early COPD improves smoking cessation rates – besides everyone should stop smoking regardless of disease
Both determined that early detection of COPD, before the development of symptoms, does not alter the course of the disease or improve patient outcomes
However, cost-effective evidence does exist for case-finding symptomatic individuals with more advanced COPD and this should continue
*Cartwright S
**USPTF. JAMA. 2016;315(13): doi: /jama

12. Effect of diagnosing COPD using spirometry on smoking quit rates
Mixed results on effect of abnormal spirometry on motivating patients to quit.
5 RCTs – 1 supportive of abnormal spirometry (using lung age) improving quit rates*. One large descriptive non-randomised study supportive**
Overall combined effect not thought to be significant
*Parks G et al. BMJ Mar 15;336(7644): doi: /bmj
**Bednarek M et al. Thorax Oct;61(10):869-73

13. Approach to Case Finding for Early/Mild COPD
Adapted from Price D et al. Prim Care Respir J Sep;18(3): doi: /pcrj

14. Problems with spirometry based diagnosis of COPD
What about GOLD “stage 0” (ATS/ERS – At Risk) – “normal” spirometry?
Heavy smokers without symptoms – but still evidence of oxidative stress*
Heavy smokers without obstruction may have significant impairment**
With symptoms and evidence of significant emphysema on CT/gas transfer(up to 26%)**/***
* Rytila P. et al. Respiratory Research 2006, 7:69 doi: /
** Regan EA et al. JAMA internal medicine. 2015;175(9): doi: /jamainternmed
*** Suranna N – Abstract PCRS meeting 2015

15. GOLD Stage 0 – A Lost Tribe

16. Approach to Case Finding for Early/Mild COPD
If normal – for full lung function/HRCT
Adapted from Price D et al. Prim Care Respir J Sep;18(3): doi: /pcrj

17. When we have found it – How should we manage Early/Mild COPD?

18. London Respiratory Team
COPD ‘Value’ Pyramid

19. How should we manage Mild COPD?
Apply Triple Therapy for mild COPD
Avoid/minimise risk factors: Cigarette smoking, cannabis, occupational exposure, impaired childhood and adolescent lung growth, indoor and outdoor air pollution, asthma)

20. Effect of smoking cessation on lung function
Anthonisen NR et al, JAMA :1497

21. How should we manage Mild COPD?
Apply Triple Therapy for mild COPD
Avoid/minimise risk factors: Cigarette smoking, cannabis, occupational exposure, impaired childhood and adolescent lung growth, indoor and outdoor air pollution, asthma)
Flu/pneumonia vaccination
Lifestyle change: increase activity/exercise. If you don’t get breathless when you exercise – it ain’t exercise! Good nutrition

22. New Triple Therapy for Mild COPD
Avoiding/minimising risk factors
Prevents disease progression
Flu vaccination
Helps reduce risk of exacerbation and deteriorating lung function
Exercise
Reconditioning and optimising cardio-respiratory function

23. Patient Centred Drug treatment for Mild Symptomatic COPD
Predominant Breathlessness
SABA ➔ LAMA ➔LAMA+LABA
?effective in GOLD stage 0 for hyperinflation
Predominant Exacerbator (trumps breathlessness)
LAMA ➔LAMA+LABA or LABA+ICS
?effective in GOLD stage 0
Predominant Asthma (-COPD overlap)
SABA + ICS ➔LABA+ICS

24. Some things to think about when you return home
Is obstruction necessary in COPD? (Or should we remove the “O”?)
If so, which cut-off do we use (Fixed ratio or LLN)?
How will I initiate a case finding programme for at risk individuals?
What will I do with symptomatic patients without obstruction – the Lost Tribe?
How will I apply the new triple therapy to all my early/mild COPD patients?
Is my prescribing individualised for my patient’s needs?