1. COPD: One Patient’s Journey
Ralph J. Panos, MD
Cincinnati VAMC
Pulmonary, Critical Care, and Sleep Division
University of Cincinnati College of Medicine

2. She smoked about half a pack for less than 10 years during her 20’s
Cathy’s COPD Journey: Chapter yoF for her initial evaluation. Worked in a retail store for 40 years. She has HTN treated w/ diuretic and has “pre-DM”. Her weight has been inc’ing since retirement, she is relatively inactive . She has noted mild breathlessness on climbing up a flight of steps. PE: BP 154/92; P 86; RR 14 weight 182 pounds; height 63 inches She has Grade 1 hypertensive retinopathy on funduscopic examination. Cardiac RRR, 2/6 systolic flow murmur. The chest is resonant with symmetric air movement and no wheezes. Abdomen NML. There is no clubbing, cyanosis, or edema. Neuro NML. Under what circumstances would you order spirometry for this patient?
FamHx lung disease
She smoked about half a pack for less than 10 years during her 20’s
She is unable to walk with her peers due to breathlessness
A cardiac evaluation reveals no evidence of CAD
Chest imaging shows radiographic evidence of emphysema
C - She is unable to walk with her peers due to breathlessness

3. 1. When to Perform Spirometry 2. COPD Respiratory Symptoms
Answer: C. She is unable to walk with her peers due to breathlessness
Objectives:
1. When to Perform Spirometry
2. COPD Respiratory Symptoms
3. Gender differences in COPD susceptibility and presentation

4. Indications for Spirometry
Role of screening spirometry is controversial and is not recommended for asymptomatic individuals
Indications for Spirometry
1. Significant risk factors
> 20 pack years of smoking
Exposure to chemicals, dusts, fumes
2. Respiratory Symptoms or Recurrent Chest Infections
Shortness of Breath
Cough
Phlegm Production
Wheezing and Chest Tightness

5. Patients under-report and providers under-detect respiratory symptoms
Screening Questionnaires for the recognition of respiratory symptoms
Veterans Airflow Obstruction Screening Questionnaire (VAFOSQ)
COPD Population Screener
11-Q COPD Screening Questionnaire
Lung Function Questionnaire
Personal Level Screener for COPD
Screening Questionnaire Variables:
Age
Dyspnea
Cough
Smoking
Activity limitation
Other:
Veterans Airflow Obstruction Screening Questionnaire
Personal Level
Screener
11-Q COPD Screening Questionnaire
COPD Population Screener
Lung Function Questionnaire
LLN
Specificity
44%
67% 9%
45%
13%
Sensitivity
72%
53%
97%
73%
95%
LR+
1.27
1.61
1.07
1.34
1.09
LR-
0.65
0.70
0.32
0.59
0.40
PPV
32%
37%
28%
33%
NPV
81%
80%
89%
82%
87% FR
43%
69%
46%
14%
66%
50%
94%
1.17
1.03
1.29
1.11
0.78
0.73
0.67
0.33
51%
42%
47%
68%
LLN n
ROC AUC
Confidence Limits
VAFOSQ
376
0.604
(0.542,0.666)
PLS
336
0.600
(0.540,0.660)
11-Q
255
0.629
(0.553,0.705)
COPD-PS
362
0.621
(0.556,0.686)
LFQ
0.661
(0.597,0.725) FR
0.575
(0.516,0.633)
0.594
(0.541,0.648)
0.612
(0.542,0.683)
0.623
(0.565,0.681)
0.655
(0.599,0.712)

6. Gender Differences in COPD Susceptibility and Presentation
In contrast to previous studies that reported M>F COPD prevalence and mortality, more recent data from developed countries show M=F
2000 more women than men died from COPD
2011 women twice as likely to be diagnosed with chronic bronchitis:
56.7 vs per 1000
2011 women more likely to be diagnosed with emphysema:
21.4 vs 19.0 per 1000
M=F in recent studies

7. Airway Cross Sectional Area (mm2)
Gender Differences in COPD Susceptibility and Presentation
Women may be more susceptible to the effects of tobacco smoke than men
Develop greater airflow limitation at younger ages and with less tobacco smoke exposure
Experience a faster rate of lung function decline than men
Higher risk for hospitalization for COPD exacerbations
Dysanapsis: airway size disproportionate to lung size
Elevated susceptibility to inflammation and mucus hypersecretion
Different effects of hormones
Differences in pulmonary particle deposition
Greater and longer tobacco smoke inhalation by women compared to men
Airway Cross Sectional Area (mm2)
Matched For Lung Size
Airway Men Women % Difference
Trachea %
RMB %
LMB %

8. Presence of persistent respiratory symptoms
Cathy’s COPD Journey: Chapter 2 Cathy says that she may have underestimated her smoking hx and thinks that she smoked 30 years intermittently up to 1.5 packs per day and quit 5 years ago but still smokes an occasional cigarette. She does have a minimal morning cough but does not produce any phlegm. She is breathless upon walking >4 blocks on the level and going up any incline. Spirometry is obtained and the results are:
FEV1/FVC <70% is obstructive
D – All three
You consider the diagnosis of COPD based upon these criteria:
Presence of persistent respiratory symptoms
Exposure to noxious particles or gases.
Airflow limitation quantified by spirometry
Presence of persistent respiratory symptoms, exposure to noxious particles or gases, and airflow limitation.

9. 1. GOLD Definition of COPD 2. Review Interpretation of Spirometry
Answer: D. Presence of persistent respiratory symptoms,
exposure to noxious particles or gases, and
airflow limitation
Objectives:
1. GOLD Definition of COPD
2. Review Interpretation of Spirometry
3. Definition and Classification of Airflow Obstruction

10. COPD: sx’s, exposure, spirometry

11. Definition of COPD FEV1/FVC Age 0.7 LLN Underdiagnosed Overdiagnosed
2017 GOLD COPD definition: COPD is a common, preventable and treatable dz characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abNMLties usually caused by significant exposure to noxious particles or gases.
Spirometry
Definition of airflow limitation
FEV1/FVC ratio
Different thresholds and their advantages and disadvantages
FEV1/FVC < 0.7 or LLN (lower limit of normal)
FEV1/FVC
Age
0.7
LLN
Underdiagnosed
Overdiagnosed

12. Albuterol metered dose inhaler PRN
Cathy’s COPD Journey: Chapter 3 She has never required healthcare for breathing problems. Her breathlessness and cough are unchanged and her PE reveals no new findings. You review the results of the spirometry with them. What pharmacologic treatment would you initiate at this time?
Albuterol metered dose inhaler PRN
Albuterol PRN and long acting antimuscarinic agent (LAMA)
Albuterol PRN and a LABA/ICS combo
Albuterol PRN and an ICS
B - Albuterol PRN and long acting antimuscarinic agent (LAMA)

13. 1. Present 2016 GOLD staging of COPD: Spirometry Symptoms and risk
Answer: B. Albuterol prn and long acting antimuscarinic agent
Objectives:
1. Present 2016 GOLD staging of COPD:
Spirometry
Symptoms and risk
2. Discuss 2016 GOLD COPD Management Guidelines
Pharmacologic Treatments

14. COPD: Management Objectives
Prevent dz progression
Relieve sx’s
Improve exercise tolerance
Improve health status
Prevent and treat exacerbations and complications
Reduce mortality
Minimize side effects from tx

15. COPD: Management Objectives
Reduce Risk Factors
Reduce total personal exposure to prevent progression
Tobacco smoke
Occupational dusts and chemicals
Indoor and outdoor air pollutants
Smoking cessation
Single most effective and cost-effective intervention to reduce the risk of developing COPD and slow its progression.

16. GOLD 2016 COPD Management Guidelines
Symptoms
Exacerbation Risk (Exacerbations in past year)
mMRC >2
< CAT >10
0-1 Outpatient
> 2 Outpatient
> 1 Hospitalization
Less Symptoms
High Risk C
Lower Risk A
More Symptoms B D
GOLD COPD Management Guidelines
High risk of exacerbation is class C&D
More symptoms is class B or D

17. GOLD 2016 COPD Management Guidelines
Symptoms
Exacerbation Risk (Exacerbations in past year)
mMRC >2
< CAT >10
0-1 Outpatient
> 2 Outpatient
> 1 Hospitalization
LAMA or
LAMA+ICS or
LAMA+LABA C
Bronchodilator A
Long Acting
LAMA or LABA or
LABA+LAMA B
LAMA+LABA+ICS
? Roflumilast
? Macrolide D
GOLD COPD Management Guidelines

18. COPD is treatable but no interventions prolong life.
Cathy’s COPD Journey: Chapter 4 You discuss COPD and its px & tx with the patient and her daughter. In addition to low dose screening chest CT, you suggest influenza and pneumococcal vaccinations and pulmonary rehabilitation. The patient and her daughter are very concerned about this new diagnosis and what her future will be. During your discussion with Cathy and her daughter, you explain:
COPD is treatable but no interventions prolong life.
She should seek lung transplantation evaluation.
Spirometry can be used to predict the course and duration of illness.
Now is a good time to begin advanced care planning discussions.
Start supplemental O2 because it is the only tx for COPD that prolongs life.
D - Now is a good time to begin advanced care planning discussions.

19. 1. COPD Disease Trajectory is Poorly Predictable
Answer: D. Now is a good time to begin advanced care planning discussions.
Objectives:
1. COPD Disease Trajectory is Poorly Predictable
2. Discuss COPD Management Goals
2. Advanced Care Planning should begin at COPD Diagnosis

20. COPD Disease Trajectory
Diagnosis
Intermittent Acute
Management
Death
Health
Symptomatic
Pre-Diagnosis
Chronic Disease Management
Advanced Care Planning
Palliative Care Hospice End of Life
Care
Bereavement
COPD Disease Trajectory

21. Evidence-Based Interventions that Reduce Mortality in COPD
Smoking Cessation
Oxygen for Patients with Resting Hypoxemia
Vaccination
Noninvasive Ventilation for Exacerbations
Lung Volume Reduction Surgery
Pulmonary Rehabilitation/Exercise
Tiotropium

22. Azithromycin and prednisone Clarithromycin and fluticasone
Cathy’s COPD Journey: Chapter 5 She completes pulmonary rehabilitation, completely stops smoking, and establishes a regular exercise program. In pulmonary rehabilitation, she learns how to use her inhalers correctly and she is religiously adherent with them. Her low dose chest CT revealed no abnormalities and she receives a yearly influenza vaccination. She develops a severe cough productive of yellow to greenish phlegm, fevers, increased breathlessness that is not relieved with her albuterol and she is having difficulty sleeping at night due to dyspnea. She presents to the ED. Her medications are HCTZ, albuterol MDI, and tiotroprium. PE: temperature is 102.4, BP 176/94, P 110, RR 28 SpO2 88% RA. Tachycardia; breath sounds are reduced and there are diffuse inspiratory and expiratory wheezes. After an albuterol nebulizer treatment and breathing 2 LPM supplemental oxygen by nasal cannula, her SpO2 is 92%; she remains tachypneic and exam reveals persistent diffuse wheezes. In addition to continuing her SABA and supplemental oxygen, you initiate treatment with:
Azithromycin and prednisone
Clarithromycin and fluticasone
Intravenous corticosteroids and cetriaxone
Doxycycline and salmeterol/fluticasone
Erythromycin and roflumilast
A - Azithromycin and prednisone
Inc’d exacerbation risk, now class C&D. But this is an exacerbation.

23. 1. Recognition of COPD Exacerbation
Answer: A. Azithromycin and prednisone
Objectives:
1. Recognition of COPD Exacerbation
2. Assessment and Treatment of COPD Exacerbations

24. COPD Exacerbations: acute worsening of respiratory symptoms that necessitates additional therapy
COPD Exacerbation Classification:
Mild: short acting bronchodilators: SABA and or SAMA
Moderate: short acting bronchodilators and antibiotics and/or oral corticosteroids
Severe: emergency department visit or hospitalization
Worsens Lung Fx +
Sx’s
Reduces
Quality of
Life
Inc’s Cost
COPD
Exacerbation
Augments Mortality
Quickens
Lung Fx
Decline

25. Supplemental oxygen 2 LPM continuously.
Cathy’s COPD Journey: Chapter 6 Three months after her hospitalization for her COPD exacerbation, presents for f/u. She has returned to regular exercise and only has her usual early morning cough and no phlegm production. She is short of breath walking up a slight incline or when hurrying. She continues to use tiotroprium daily and albuterol 2-4 puffs daily. PE: temperature 98.6, BP 154/82, P 82, RR 12 SpO2 91% while breathing room air. Heart and lung examinations RRR, 2/6 flow murmur, hyperresonance, prolonged expiration with diminished breath sounds and no wheezing. Your nursing assistant walks the patient in the hallway for 5 minutes and her SpO2 drops from 91% to a nadir of 86% and returns to 92% upon resting. Based upon recent events, these findings, and to improve her quality of life and reduce respiratory complications, you order:
Supplemental oxygen 2 LPM continuously.
Supplemental oxygen 2 LPM with exertion.
Supplemental oxygen 2 LPM with exertion and at night.
A long-acting beta agonist.
Theophylline SR 300 mg BID.
D - A long-acting beta agonist.

26. 1. Review the use of supplemental oxygen in COPD MRC/NOTT LOTT
Answer: D. A long acting beta agonist
Objectives:
1. Review the use of supplemental oxygen in COPD
MRC/NOTT
LOTT

27. Oxygen Therapy in Patients with COPD and Resting Severe Hypoxemia
NOTT 1980
203 of 1,043 screened patients in 6 centers; PaO2 < 59
Not blinded, treated with NOT or COT at 1-4 lpm
12 months: mortality tx:control 0.53 [ ]
24 months: mortality tx: control 0.45 [ ]
MRC 1981
87 patients randomized to O2 or no O2; not blinded; PaO
Treated with oxygen at a minimum flow rate of 2 lpm
First 500 days: men no difference in mortality; women improved mortality
5 years: [ ]
MRC Study:
Control risk of death: 0.67
O2 TX RR:
Absolute risk reduction: 0.22
NNT: 5 patients with severe hypoxemic COPD with supplemental oxygen saved one life over the 5 year study period.

28. 738 patients with:
moderate resting hypoxemia (SpO %) or
exercise desaturation (SpO2 >80% for 5 min and <90% for > 10 sec)
during 6MW
Treated with supplement oxygen or no oxygen
No change in
Mortality
First hospitalization
Quality of life
Lung function
6MW Distance

29. Supplemental Oxygen
Reduces mortality in individuals with COPD and resting hypoxemia:
PaO2 < 55 torr or 88%
PaO torr with edema
No effect on mortality, exacerbations, or quality of life for those with mild resting hypoxemia or exertional desaturation

30. Cathy’s COPD Journey: Epilogue
Cathy’s respiratory symptoms inc’d to breathlessness with daily activities and her respiratory medications were increased to LAMA+LABA+ICS with PRN SABA. Despite maximal pharmacologic tx, her resting SpO2 declined to 86-87% at age 74 and she started continuous supplemental oxygen. She continues with maintenance pulmonary rehabilitation. At age 77, she attended her grandson’s college graduation.
COPD is a preventable, incurable chronic disorder that is eminently treatable-
Best practice management can and does improve quality of life, reduce complications and exacerbations, and prolongs life