1. An Update on Chronic Obstructive Pulmonary Disease

2.  No Company Affiliations  Graduated from Medical University of South Carolina in Charleston, 2000  Experience-14+ Years in Cardiology and Pulmonary Practice in Coastal South Carolina  Now Back in Primary Care for past 9 months. What was I thinking!  80-100 patients per week (60% practice is Pulmonary medicine-40% Cardiology)

3.  Discuss the pathophysiology of COPD, manifestations of disease process and diagnosis of COPD  Name the financial and Social Impact of COPD on U.S. and South Carolina population  Interpret and review effective diagnostic testing for COPD  Discuss current Pharmacologic Treatments of COPD  Discuss Non-Pharmacologic Treatments options

4.  Defined as a common preventable and treatable disease, it is characterized by persistent airflow limitation that is also accompanied by chronic inflammation from exposure to noxious particles or gases  Causes include tobacco smoking, second hand smoke exposure, air pollution and occupational exposure

5.  Clinical Diagnosis of COPD should be considered with patients who have dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors. Spirometry is required to make diagnosis.  Assessment of COPD is based on the patients symptoms, risk of exacerbations, severity of COPD (bases on spirometry) and comorbid conditions.  COPD is the 3 rd leading cause of death in the United States  Many are not even aware they have it……

9.  COPD was the 3 rd leading cause of Death in the US in 2008  Approximately 13 million adults in US have COPD, however, estimated 24 million have evidence of impaired lung function=under diagnosis of disease  A retrospective analysis of HMO database showed that 81% of patients with COPD were not diagnosed until disease was moderate to severe

10.  The projected annual cost for COPD in the US for 2010 was $50 billion (not million, yes billion!!!!)  Estimated related to cost-between 50% and 75% of all COPD cost are related to exacerbations  Frequency of exacerbations: 2 or more exacerbations in the first year of observational study showed ◦ 22% of patients with stage 2 disease ◦ 33% of patients with stage 3 disease ◦ 47% of patients with stage 4 disease

12.  COPD  Asthma  CHF  Bronchectasis  TB  Obliterative Bronchiolitis  Diffuse Panbronchiolitis  Bronchitis

13.  Chronic Cough (smoker cough)  Chronic Phlegm Production  Shortness of Breath (limits activity)  Not able to take deep breath  Wheezing  Recurrent Respiratory Infections/Bronchitis  Hypoxemia

14.  Goals of assessment to determine severity of disease and it’s impact on patients health to guide treatment therapy ◦ Symptoms ◦ Degree of airflow limitation (using spirometry) ◦ Risk of exacerbations ◦ Co-morbidities May use tools such as CAT-COPD Assessment Tool

15.  In 2015-Updates to Gold Guidelines  Spirometry is required to make clinical diagnosis of COPD  Clinical Diagnosis should be considered in any patient over age 40 who has dyspnea, chronic cough or sputum production, history of exposure to risk factors for disease and/or family history of COPD

16. In Patients with FEV1/FEC <70 (Based on post- bronchodilator FEV1) GOLD 1MILDFEV1 >= 80% PREDICTED GOLD 2MODERATE50%<=FEV1<80% PREDICTED GOLD 3SEVERE30%<=FEV1<50% PREDICTED GOLD 4VERY SEVEREFEV1<30% PREDICTED

18.  Measure how well the lungs take in and release air  Measure how well the lungs move gases such as oxygen from the air into the body’s circulation  PFTs add additional information including Lung volume and diffusion capacity  Longer test and more expensive, however helpful in treatment  Use spirometry to make initial diagnosis and Full PFTs to guide therapy

20.  Well trained staff-Does not have to be RT but need to do test well for accurate results.  Patient cooperation-If patient is not following direction and you don’t have good loop, less accurate results (May need full PFT to help make diagnosis)  Patient should not have had any respiratory medications within 4 hours of test and preferable that am (if possible).

21.  Non-Pharmacologic  Pharmacologic  Management of Stable COPD  Management of COPD exacerbations

22.  Symptom relief  Increase exercise tolerance  Improve health  Decrease disease progression  Prevent exacerbations  Treat exacerbations  Decrease Mortality

23.  Smoking Cessation!!!!!! ◦ Counseling does help, counseling by physicians and other health care professionals significantly increases quit rates over self-initiated strategies ◦ Nicotine replacement Therapy-gum, patches ◦ Pharmacotherapy-varenicline, bupropion or nortriptyline are more effective than placebo ◦ Smoking prevention-once quit need to stay QUIT, keep smoke free homes ◦ Don’t Give Up! Keep on trying each and every time you see them.

24.  Occupational Exposure  Indoor and Outdoor Air Pollution  Vaccination Pneumococcal and FLU  Physical Activity ◦ Which leads to PULMONARY REHABILITATON ◦ The more you do the more you can do is so true for COPD

25.  Defined as evidence –based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities  Pulmonary rehab is designed to reduce symptoms, optimize functional status, increase participation and reduce health-care cost through stabilization

26.  Utilized various healthcare disciplines  Individualized plan of care with realistic goals for patient  Attention to physical and social function  Each patient plan includes ◦ Patient assessment ◦ Exercise training ◦ Education ◦ Psychosocial support

27.  Medicare has a maximum life-time visits  Private Insurance-Co pays  Maintenance programs  Patient Compliance  Exacerbations  Access to programs

28. Abbreviations:  SA-short acting  LA-long acting  AC-anticholinergic  BA-beta agonist  ICS-inhaled corticosteroid  PDE-4-phosphodiesterase-4

29.  Patient Types: ◦ Type A-Low risk, Low symptoms ◦ Type B-Low risk, Increased symptoms ◦ Type C-High risk, Low symptoms ◦ Type D-High risk, High symptoms

30. Patient Type1 st 2 nd Other Type A-LR,LSSA AC or SA BALA AC or LA BA Or SA AC or SA BA Theophylline Type B-LR, ISLA AC or LA BALA AC & LA BASA AC &/or SA BA Theophylline Type C-HR, LSICS & LA BA or LA AC LA AC & LA BA or LA AC & PDE4 Or LA BA & PDE4 SA BA &/or SA AC Theophylline Type D-HR, ISICS & LA BA &/or LA AC ICS & LA BA & LA AC Or ICS & LA BA & PDE4 Or LA BA & LA AC Or LA AC and PDE4 Carbocystiene N-acetylcysteine SA BA &/or SA AC Theophylline

31. Does anything Go?

32.  Proair HFA-Albuterol  Ventolin HFA-Albuterol  Proventil HFA-Albuterol  Xopenex HFA-Salbuterol  Xopenex nebulizer  Albuterol nebulizer

33.  Arcapta Neohaler (Indacterol)-1 cap inhalation daily  Foradil Aerolizer (Formoterol)-1 inhalation BID  Serevent Diskus (Salmeterol)-1 inhalation BID  Striverdi Respimat (Olodaterol)-2 inhalations daily  Performist Nebulizer (Formoterol)-1 neb BID  Brovana Nebulizer (Arformoterol)- 1 neb BID

34.  Aerospan (Flunisolide) 80mcg 2-4 puffs BID  Asmanex Twisthaler (Mometasone)110mcg and 220mcg 1-2 puffs daily-BID (max 440mcg/day)  Asmanex HFA (Mometasone) 100,200mcg 2 puffs BID (max 800mcg/day)  Alveso (Ciclesonide) 80mcg and 160mcg-1 puff BID (max 320mcg/day)  Pulmicort Flexhaler (Budesonide)90mcg and 180mcg-2 puffs BID  Flovent Diskus (Fluticasone propionate) 50mcg, 100mcg and 250mcg- 1-2 puffs BID (max 1000mcg/day)  Flovent HFA (Fluticasone propionate) 44mcg, 110mcg, 220mcg-2 puffs BID (max 880mcg/day)  Qvar HFA (Beclomethasone dipropionate)40mcg, 80mcg- 1-4 puffs BID (max 640mcg/day)  Arnuity Ellipta (Fluticasone furoate)-1 inhalation daily

35.  LA BA and Corticosteroid ◦ Advair Diskus, (Fluticasone Propionate/salmeterol) 100/50, 250/50, 500/50-1 inhalation BID ◦ Advair HFA (Fluticasone Propionate/salmeterol) 45/21, 115/21, 230/21-2 puffs BID ◦ Symbocort HFA (Budesonide/Formoterol) 80/4.5, 160/4.5-2 puffs BID ◦ Breo Elipa (Fluticasone furoate/vilanterol)100/25-1 inhalation Daily ◦ Dulera (Mometasone/formoterol) 100/5, 200/5-2 puffs BID

36.  Atrovent HFA (Ipratropium bromide)-2 puffs qid  Atrovent Nebulizer (Ipratropium)-1 neb qid  Spiriva Handihaler (Tiotropium)-1 inhalation Daily  Spiriva Respimat (Tiotropium)-2 puffs Daily  Tudorza Pressair (Aclidinium bromide)-1 puff BID  Incruse Ellipta (Umeclidinium)-1 puff Daily  Combivent Respimat (ipratropium bromide/albuterol)-1 inhalation QID  Anoro Elipta (Umeclidinium/vilanterol)-1 inhalation daily

37.  LA BA and AC  Combivent Respimat (ipratropium bromide/albuterol)-1 inhalation QID  Anoro Elipta (Umeclidinium/vilanterol)-1 inhalation daily  Duonebs (ipratropium/albuterol) Nebulizer-1 QID

38.  PDE-4 Phosphidiesterase-4 (roflumilast- Daliresp)  Mexthylxanthines- Theophylline/aminophylline  Mucolytic-Carbocystiene (not available in US)  Mucolytic-N-acetylcysteine (Mucomist) 10% /ml solution, 6-10 ml nebulized and 20%ml solution, 3-5ml nebulized. Q 2 hours, max dose 10% 20ml and 20% 10ml  ***must give with albuterol !!!!!**** Due to bronchospasms

39.  Therapy is used to reduce symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance ◦ Bronchodilators  Inhaled therapy is preferred  prescribed on as-needed or on a regular basis to prevent or reduce symptoms  Long-acting inhaled bronchodilators are convenient, and maintaining symptoms relief compared to short acting bd  Combining bronchodilators (short and long) may improve efficacy and decrease risk of side effects

40.  Inhaled Corticosteroids ◦ In patients with FEV1 < 60% predicted, regular tx with inhaled corticosteroids  improves symptoms  lung function  quality of life  reduces frequency of exacerbations There is associated increased risk of pnemonia, withdrawal may lead to exacerbation. Long-term monotherapy not recommended

41.  Combined Inhaled Corticosteriod/ Bronchodilator Therapy ◦ The IC/LBD is more effective than either individual therapy in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD

42.  Oral Corticosteroids-Long term not recommended  Phosphodiesterase-4 inhibitors- In Gold 3 and 4 patients with history of exacerbations and chronic bronchitis.  PD4 inhibitor is roflumilast or Daliresp  Your experience?  Our practice…

43.  Mexthylxanthines ◦ Less effective ◦ Less well tolerated than LBD ◦ Available and affordable ◦ Evidence of modest BD effect ◦ Aminophylline or Theophylline ◦ Theophylline with salmeterol produces a greater increase in FEV1 and relief of breathlessness than salmeterol alone. ◦ Low dose theophylline reduce exacerbations but does not improve post-bronchodilator lung function. ◦ Therapeutic values 10-20 (patient may get benefit and tolerate better at subtherapeutic levels of approx 8-12)

44.  Vaccines including: Influenza and Pneumococcal vaccines can reduce serious illness and death  Alpha 1 Antitrypsin Therapy-For COPD related to Alpha 1 Defiency  Mucolytic Agents-for patient with excessive sputum, overall benefits small  Antitussive-use not recommended (however*)  Vasodilators-stable COPD with Pulmonary HTN

45.  Pulmonary Rehabilitation  Oxygen Therapy  Ventilatory Support  Surgical Treatments ◦ Lung Volume Reduction Surgery (LVRS)-need to qualify, emphysema upper lobe ◦ Lung Transplant, costly, need to live near transplant facility for at least 1 year and age requirements

46.  Look at you patient type  Look at spirometry and/or PFTs  Mild/Moderate-start simple and work up  Severe/Very Severe-be aggressive and get symptoms under control then remember to back down (if able)  Symptom control/Quality of Life/Reduce Exacerbations & Mortality are key GOALS  Cost of meds does influence treatment

47. Patient Type1 st 2 nd Other Type A-LR,LSSA AC or SA BALA AC or LA BA Or SA AC or SA BA Theophylline Type B-LR, ISLA AC or LA BALA AC & LA BASA AC &/or SA BA Theophylline Type C-HR, LSICS & LA BA or LA AC LA AC & LA BA or LA AC & PDE4 Or LA BA & PDE4 SA BA &/or SA AC Theophylline Type D-HR, ISICS & LA BA &/or LA AC ICS & LA BA & LA AC Or ICS & LA BA & PDE4 Or LA BA & LA AC Or LA AC and PDE4 Carbocystiene N-acetylcysteine SA BA &/or SA AC Theophylline

49.  Defined as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication  Assess the severity ◦ ABGs ◦ CXR ◦ CBC ◦ Presence of purulent sputum ◦ Sputum C&S ◦ Spirometry NOT RECOMMENDED

50.  Oxygen for hypoxemia with target saturation of 88-92%  SBD  Systemic Corticosteroids ◦ 30-40mg for 10-14 days ◦ Optional tx tapering dose ◦ Patients with DM may have problems with elevated glucose ◦ Side effects of steroids

51.  Antibiotics given to patients with ◦ 3 symptoms of increased dyspnea, increased sputum volume, increased sputum purulence ◦ Increased sputum purulence and one other cardinal symptoms ◦ Who require mechanical ventilation

52.  CDC – www.cdc.gov/copd/data.htm  Global Initiative for Chronic Obstructive Lung Disease Pocket Guide (GOLD) 2015  Respiratory Care Connection-GSK Education connection  U.S. Department of health and human services, Agency for Healthcare Research and Quality- www.ahrq.gov and www.guideline.gov and type in pulmonary rehabilitationwww.guideline.gov  Aanma.org  Mayoclinic.org

53. Thank You