COPD “Vital Inspiration” TAFP Texas Family Medicine Symposium 2020 Clare Hawkins, MD, MSc, FAAFP West Region Medical Officer Aspire Healthcare
Disclosure • Dr. Hawkins has disclosed that neither he nor members of his immediate family have any actual or potential conflict of interest.
Objectives By the end of this educational activity, the learner should be better able to: 1. Evaluate patients who are current or former smokers, and those who develop frequent viral infections, for symptoms that may indicate COPD or related conditions Interpret and validate results in symptomatic patients 2. Prepare treatment plans that include a combination approach to 3. therapy for patients who have COPD. Counsel patients who have COPD on the importance of quitting 4. smoking and receiving annual vaccinations for influenza and pneumonia.
Epidemiology of COPD • Third leading cause of death in the US 1 • 15.2% of adults had a diagnosis of COPD in 2010 2 • 14% of adults 14-70 had COPD in 2013 3 • $36 billion dollars annually in 2010, and costs are expected to rise to $49 billion for medical costs alone by 2020 4 • Worldwide, an estimated 74 million deaths were caused by COPD in 2015 5 1 CDC 2016, 2 Adeloye et al 2015, 3 Tilert et al 2013 4 Ford et al, 2015, 5 WHO Fact sheet 2016
COPD Phenotypes Overlapping Some COPD without classic features Chronic Bronchitis Emphysema Asthma No Phenotype 5
2. Testing for COPD • Physical Exam * • Office Spirometry • Other Pulmonary Function Testing • Chest X-ray & CT • ECG * Hilleman 1995
Diagnosis • Spirometry as the mainstay of diagnosis • Simple, inexpensive, but sometimes confusing • Spirometry classification of COPD patients by GOLD COPD has utility but does not easily explain illness trajectory • Health Status Measures assist (CAT and MRC dyspnea Scale)
Three Numbers • FVC : Forced Vital Capacity • FEV1 : Amount breathed out in 1 second • FEV1/FVC : How much of your lung’s air can be exhaled in the first second – Measure of caliber or function of airway – NOT A COMPARISON TO REFERENCE VALUES • More accurate than Peak Flow
Lung Volumes (ERV + RV = Functional Residual Capacity) Inspiratory Capacity Vital Capacity Tidal Volume Expiratory Reserve Volume Residual Volume
Dynamic Hyperinflation Inspiratory Capacity Vital Capacity Tidal Volume Expiratory Reserve Volume Residual Volume
Severity of obstruction (GOLD) FEV1 % of predicted Mild >80 Moderate 50 to 79 Severe 30 to 49 Very severe <30 * Severity of restriction FVC % of predicted Mild > 65 to 80 >50 to 64 Moderate <50 Severe
FEV 1 Thresholds (GOLD) • Grade 1: Mild FEV1 > 80% • Grade 2: Moderate 50% < FEV1 < 80% • Grade 3: Severe 30% < FEV1 < 50% • Grade 4: Very Severe FEV1 < 30% Compared with predicted values in patients with post-bronchodilator FEV1/FVC < 70
Caveat • FEV1/FVC 70 – Overestimates COPD diagnosis in Elderly – Underestimates COPD diagnosis in those under age 45
Normal Flow Volume Curve (Expiratory) 12 PEF 10 R 8 6 Fl ow FEV (L/sec) 4 1 2 0 0 1 2 3 4 5 6 Volume (L)
Normal, Obstructed, & Restrictive Curves 1 2 1 0 Normal Obstruction Restriction 8 Flow 6 (L/sec) 4 2 0 0 1 2 3 4 5 6 Volume (L)
Inspiratory Volume Loop Expiratory Flattened Inspiratory Loop Indicating possible Extrathoracic Obstruction
Is FEV 1 / FVC Ratio Low? (<70%) Yes Obstructive Defect Adapted with permission from Is FVC Low? (<80% pred) J S Lowry No Yes Pure Obstruction Combined Defect of Obstruction and Restriction /or Reversible Hyperinflation Obstruction with ß-agonist Reversible Obstruction and improved FVC with ß-agonist No Yes No Yes Suspect Further Testing with Suspect COPD Full PFT’s Asthma
Common Obstructive Disorders Diffuse Airway Disease Upper Airway Obstruction – Asthma – Foreign Body – COPD – Neoplasm – Bronchiectasis – Tracheal Stenosis – Cystic Fibrosis – Tracheomalaca – Vocal Cord Paralysis
Is FEV 1 / FVC Ratio Low? Diagnostic Flow (<70%) Diagram, Restriction No Is FVC Low?(<80% predicted) Yes No Restrictive Defect Normal Spirometry Further Testing with Full PFT’s and consider referral
Common Restrictive Disorders Parenchymal Pleural • Interstitial Lung Diseases – Effusion – Fibrosis – Fibrosis – Granulomatosis (TB) Chest Wall – Pneumoconiosis – Kyphoscoliosis – Pneumonitis (lupus) – Neuromuscular Disease • Loss of Functioning Tissue – Trauma – Atelectasis – Large Neoplasm Extrathoracic – Abdominal – Resection Distension – Obesity
Coding and Reimbursement Diagnosis ICD‐10 Cough R05 Simple chronic bronchitis J41.0 Mucopurulent chronic bronchitis without J44.9 exacerbation Acute bronchitis J20.9 Chronic obstructive pulmonary disease w J44.1 exacerbation Shortness of breath/ dyspnea R06.00 Pulmonary Fibrosis J84.10 Asthma J45.909
Coding and Reimbursement Procedure CPT Code Reimbursement* 94010 $32.82 Single spirometry 94060 $57.71 Pre‐post spirometry 94620 $71.77 Pulmonary stress test simple Medication administration bronchodilator supply separate 94640 $13.34 Demonstration / instruction 94664 $14.79 99406 $12.98 Smoking Cessation <8x/ yr Equipment Cost Office spirometer $1,500 – 2,500 Reimbursements based on Medicare payments 2009 Trailblazer Spirometry cost estimated from several vendors
COPD Assessment Test (CAT): • CAT: An 8-item measure of health status impairment in COPD • CCQ: Clinical COPD Questionnaire (CCQ): – Self-administered questionnaire developed to measure clinical control in patients with COPD (http://www.ccq.nl) • mMRC dyspnea: Breathlessness Measurement using the Modified British Medical Research Council: – Relates well to other measures of health status and predicts future mortality risk http://catestonline.org
CAT (COPD Assessment Test) I never cough 1 2 3 4 5 I cough all the time I have no phlegm in my chest at all 1 2 3 4 5 My chest is full of phlegm My chest does not feel tight at all 1 2 3 4 5 My chest feels very tight When I walk up a hill or one flight of 1 2 3 4 5 When I walk up a hill or one flight of stairs I am stairs I am not breathless very breathless I am not limited doing any activities at 1 2 3 4 5 I am very limited doing activities at home home I am confident leaving my home 1 2 3 4 5 I am not at all confident leaving my home despite my lung condition because of my lung condition I sleep soundly 1 2 3 4 5 I don’t sleep soundly because of my lung condition I have lots of energy 1 2 3 4 5 I have no energy at all
CAT Impact level Possible Management Considerations score • Smoking Cessation • Annual influenza vaccination <10 Low • Reduce exposure to exacerbation risk factors • Therapy as warranted by further clinical assessment. • Reviewing maintenance therapy – is it optimal? • Referral for pulmonary rehabilitation 10–20 Medium • Ensuring best approaches to minimizing and managing exacerbations • Reviewing aggravating factors – still smoking? • Referral to specialist care (if you are in general practice) 21–30 High • Additional pharmacological treatments
mMRC Dyspnea Scale 0 I only get breathless with strenuous exercise 1 I get short of breath when hurrying on the level or walking up a slight hill 2 I walk slower than people of the same age on the level because of my breathlessness, or I have to stop for breath when walking on my own pace on the level 3 I stop for breath after walking about 100 meters or a few minutes on the level 4 I am too breathless to leave the house or I am breathless when dressing or undressing
Prognosis Model in COPD
Exac/ yr CAT mMRC Characteristics Spirometric Class A Low Risk, Less Symptoms Gold 1‐2 <1 <10 0‐1 B Low Risk, More Symptoms Gold 1‐2 <1 >10 >2 C High Risk, Less Symptoms Gold 3‐4 >2 <10 0‐1 D High Risk, More Symptoms Gold 3‐4 >2 >10 >2
3. Treatment Plans • Medications for Stable COPD • Medications for COPD Exacerbations • Pulmonary Rehabilitation • Oxygen Therapy • Comorbidities • End of Life Care
GOALS • Relieving symptoms • Slowing disease progression • Enhancing exercise tolerance and functional status • Preventing and treating complications • Improving overall health
3. Treatment Plans: Stable COPD Grade 1 or Stage A Grade 2 or Stage B Grade 3 or Stage C Grade 4 or Stage D Mild Moderate Severe Very Severe FEV1 > 80 FEV1 50‐80 FEV1 30‐50 FEV1 < 30 Or < 50 with Cor Pulmonale PCV 23,13 LABA and/or LAMA Influenza ICS for recurrent Pulmonary Rehab & SABA exacerbations Oxygen & LVRS?
Medication Categories • Short-Acting Beta Agonist (SABA) • Short-Acting Anticholinergic • Long-Acting Anticholinergic (LAMA) • Long-Acting Beta Agonist (LABA) • Inhaled Corticosteroid (ICS)
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Long-Acting Beta Agonists LABA • SERAVENT Diskus, (salmeterol) DPI device • FORADIL Aerolizer, (formoterol) DPI • BROVANA (arformoterol) nebulized • PERFORMIST (salmeterol) DPI • STRIVERDI Respimat, (olodaterol) DPI • ARCAPTA Neohaler, (indacaterol) DPI
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