updates in copd, focusing on the outpatient setting · updates in copd, focusing on the outpatient...

Updates in COPD,Focusing on the

Outpatient SettingDr. Amy Ford Turner, DO

Department of Pulmonary and Critical Care Medicine Cox Medical Group, Ferrell-Duncan Clinic

July 2018

Multiple Choice Questions:1. A 64yo Male presents to your office with a 6 month

progressive symptoms of shortness of breath and cough. He has had 2 urgent care visits for episodes of acute bronchitis within the last year and has had 1-2 per year for the last 5 years. He smokes 1PPD for the last 40 years. He has had to quit his job as a construction manager due to his breathing. You perform a spirogram which shows severe obstruction, FEV1 39%. How would you rate the severity of his disease? A. GOLD Grade A B. GOLD Grade B C. GOLD Grade C D. GOLD Grade D

Multiple Choice Questions:2. The same patient above was given an albuterol inhaler from

the urgent care center. He states that he was also given some antibiotics and a course of steroids, but as soon as he ran out of these, he is feeling worse again. What therapy do you choose to start depending on his GOLD Grade listed above? A. Leave him on the current inhaler and wait for the next episode of

bronchitis. B. Place him on oxygen since oxygen helps everyone. C. Place him on an inhaled corticosteroid alone. D. Place him on a long-acting muscarinic agent + a long acting beta-

agonist.

Multiple Choice Questions:3. The same patient listed above follows up with you 8 weeks

later so you can check on his progress. His wife was able to convince him to quit smoking. He has been taking his treatment and feels better. Upon arrival, his oxygen saturation is 79%, but returns to 88% after rest for 10 minutes. How do you address this? A. Not do anything. B. Test him to see he if responds to oxygen with ambulation. C. Prescribe another inhaler. D. Place him on chronic oral steroids.

Multiple Choice Questions:

4. True or False: All patients with COPD should be tested for Alpha-1-antitrypsin disease? A. True. B. False.

Lecture objectives• Brief COPD Overview • Updates and review of GOLD 2017 guidelines

• Brief synopsis of Diagnosis and Severity • Management strategy based on 2017 guidelines • New bronchodilator regimens • Rehabilitation and Quality of Life goals

• Interventional Pulmonary and Surgical options • Lung transplant

*** There are certain aspects of COPD that will be left out due to time constraints.

Disclosures• None

* Use of GOLD Guidelines, tables, pictures, graphs were utilized with permission. These slides are depicted with the GOLD insignia at the top of the slide. ** Use of other slides were also used by permission from NEJM or UTD.

The Impact of COPD• Affects more than 6.3% of the population in the U.S. (2013

data) • 3rd ranked cause of death in the U.S., killing 120,000 each year

(MMWR data, 2011). • Deaths have increased worldwide by 11.6% since 1990 (2015

data), 4th leading cause of death worldwide. • Prevalence of COPD increased by 44.2% since 1990. • Of those with COPD, 64.2% felt that dyspnea/SOB negatively

impacted their QOL.

COPD Definitions• Limitation of airflow that is

not fully reversible and is associated with an abnormal inflammatory response in the small airways and alveoli.

• Subtypes: • Emphysema • Chronic bronchitis • Chronic obstructive asthma • Bronchiectasis* • Small airway disease*

ASTHMA

CHRONIC BRONCHITIS EMPHYSEMA

IRREVERSIBLE AIRFLOW OBSTRUCTIONReversible Airflow Obstruction

http://goldcopd.org

Global Initiative for Chronic Obstructive Lung Disease (GOLD)• "COPD is a common, preventable, and treatable disease that is

characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

• The chronic airflow limitation that characterizes COPD is caused by a mixture of small airways disease (e.g. obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person.

• Chronic inflammation causes structural changes, small airways narrowing, and destruction of lung parenchyma. A loss of small airways may contribute to airflow limitation and muco-ciliary dysfunction, a characteristic feature of the disease.“

COPD At-a-Glance Decision Tree

• Diagnosis

• History and physical • Rule out other causes • CXR, Pulse oximetry

• Assess Severity

• Assess Degree of Airflow Limitation (Spirometry) • Assess Symptoms (Questionnaires) • Assess Exacerbation Risk and Comorbidities • Triage into Management Categories (GOLD ABCD Grading System)

• Management

• Choose drugs and therapy based upon Grading System • Prevention (Vaccines) and reduce risks (Smoking Cessation, Exacerbation

Prevention) • Improve QOL Measures (Pulmonary Rehab, Nutrition, etc.)

Diagnosing COPD• Should be considered in any

patient with: • Dyspnea

• Progressive over time • Characteristically worse with

exertion • Persistent/Pervasive

• Chronic cough or sputum production

• Features vary: can be intermittent, may also be unproductive vs productive

• Recurrent wheeze may be present

• H/o exposures/risk factors • Host factors: genetics,

congenital • Family history of COPD/asthma • Recurrent respiratory infections as a

child • Tobacco smoke/inhalational

products • Cooking fires/fuels • Occupational influences:

• Dusts (Grain workers) • Vapors (Diesel exhaust) • Fumes (Welders) • Gases (Firefighters)

Diagnosing COPD• Good History

• Signs and symptoms of COPD • Family history of COPD

• Physical Exam: • Barrel-shaped chest, Hoover’s sign (insp. retraction of the lower ribs),

prolonged expiration on exam, accessory muscle use. • *** Not all that wheezes is COPD or asthma • Digital clubbing is not common in COPD

• Chest radiograph, especially if they have not had one within 5 years • CT not needed unless some other disease process suspected or if annual CT

lung cancer screening is warranted

• Pulsoximetry annually


• Diagnosis


• Assess Severity


• Management



DiagnosingCOPD• Spirometry is

required to diagnose within the clinical context

• FEV1/FVC ratio to determine if airflow limitation is present

• ***Bronchodilator response of little clinical value other than helping to determine overlap syndromes or an extremely reactive airway

Symptoms do not usually occur until a threshold is met, usually when FEV1 is below 50%.*

*This threshold, where symptoms occur, can vary from patient to patient.

Pathology of COPD• Airway

• Chronic inflammation • Infiltration by certain cell types • Increased goblet and mucous glands • Fibrosis • Narrowing • Reduction of small airways • Airway collapse due to alveolar cell

wall destruction

• Pulmonary vessels • Hyperplasia of smooth m. and

intima • Chronic hypoxic vasoconstriction

• Parenchyma • Affects the structures past the

Terminal Bronchiole • Proximal Acinar / Centrilobular

• Proximal structures • Tobacco, Pneumoconiosis

• Panacinar (all) • A1AT deficiency

• Distal acinar / Paraseptal

Niewoehner DE. N Engl J Med 2010;362:1407-1416.

Pathophysiological Features of Airflow Obstruction in Chronic Obstructive Pulmonary Disease (COPD).

Niewoehner DE. N Engl J Med 2010;362:1407-1416.

Classification of severity of airflow limitation

© 2017 Global Initiative for Chronic Obstructive Lung Disease

Assess Severity of Obstruction ➔ Spirometry

GOLD Guidelines• Assess Symptoms:

• The COPD Control Questionnaire (CCQ). http://ccq.nl/

• The COPD Assessment Test (CAT). http://www.catestonline.org/

• mMRC Dyspnea Scale • (Modified Medical Research Council) • Next slide

• St. George’s Respiratory Questionnaire (SGRQ)

GOLD Guidelines• Assess exacerbation risk:

• Mild • Outpatient, treated with short

acting rescue methods and OTC products

• Moderate • Outpatient, treated with SABA +

Abx, +/- oral corticosteroids • Severe

• Inpatient/ER • Could include acute respiratory

failure

• Assess Comorbidities: • CV and PV disease • CHF, Right heart failure • Skeletal muscle dysfunction • Metabolic syndrome • Osteoporosis • Depression/Anxiety • Lung cancer • Other cancers • OSAS • Bronchiectasis • GERD

GOLD Grading System: ABCD Format

***Does not include Airflow Limitation ➔ Why

➔ Because it correlates less well with functional limitation and QOL

Copyrights apply

Other Staging Tools• Bode or the Modified BODE

Index • Used as a way to individualize

prognosis and mortality • Some studies have shown that

it can predict hospitalizations

• Spirometry does not do that

ABCD Assessment Tool


Example

► Consider two patients: ➢ Both patients with FEV1 < 30% of predicted ➢ Both with CAT scores of 18 ➢ But, one (Patient A) with 0 exacerbations in the past year

and the other (Patient B) with 3 exacerbations in the past year.

► Both would have been labelled GOLD D in the prior classification scheme.

► With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D.

► The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.

GOLD Grading System: ABCD Format

Patient A: 0 Exacerbations

Patient B: 3 Exacerbations

Management of Stable COPD: Goals• Prevent

Disease Progression

• Prevent and Treat Exacerbations

• Reduce Mortality

• Reduce Risk

• Relieve Symptoms

• Improve Exercise Tolerance

• Improve Health Status

• Reduce Symptoms


• Diagnosis


• Assess Severity


• Management



GOLD Guidelines: Prevention•Smoking cessation (Is included in ALL Guidelines)

• Is the #1 influence on the progression of COPD • The Lung Health Study (JAMA 1994) =

• Slowed decline of lung function • Reduced mortality rate

• Cochrane data base analysis (2016) of 16 studies (13,123 patients) found a combination of behavioral and pharmacotherapy is more effective in cessation.

GOLD Guidelines: Prevention• Immunizations: PCV13 and PPSV23 are recommended for all

over >65

COPD At-A-Glance Decision Tree

• Diagnosis


• Assess Severity


• Management



Treatment options: Bronchodilators•Recommended

• Long acting agents (LAMA, LABA) preferred over short acting (SABA)

• What agent to start is dependent on COPD subtype and category

• Inhaled preferred versus oral agents (i.e. PO albuterol, theophylline)

• May consider PDE4 inhibitor (Roflumilast) in recurrent exacerbations

• Macrolides daily may also be considered in recurrent exacerbations

• Low dose long acting opioids may be considered in severe disease

Treatment options: Bronchodilators•Not Recommended

• ICS not recommended as single agent

• Long term oral steroids not recommended

• Statin therapy not recommended for prevention (at this time)

• Mucolytics only recommended in subtypes populations

• Antitussives not typically recommendded unless disruptive to ADLs/sleep

• Drugs for primary pulmonary HTN are not recommended

Bronchodilators: Beta Agonists

• LABAs (Long acting beta agonists) • Salmeterol (BID)

• Most studied, TORCH trial (2007) • Formoterol (BID) and Arformoterol

(BID) • Only in nebulized form now

• Indacaterol • Daily, lower doses in US.

• Vilanterol • Daily, Always paired with an ICS

• Olodaterol • Daily

• SABA (Short acting beta agonists) • Albuterol/Levalbuterol

• Side effects of Beta-agonists

• Tremor • Hypokalemia • Tachyarrhythmia • Anxiety

➢ Work by acting on the beta-2 receptor of bronchial smooth muscle to achieve bronchodilation.

Bronchodilators: Muscarinic/Anticholinergic Agents

• LAMA (Long acting muscarinic agents)

• Tiotropium • Daily, Most studied • Improves function, decreases

hyperinflation, decreases dyspnea/exacerbations, slow rate of decline

• Aclidinium (daily) • Umeclidinium (daily) • Glycopyrrolate (daily)

• Short acting anticholinergics • Ipratropium

• Side effects/concerns of Anticholinergics

• Cardiovascular effects • UPLIFT Trial

• Acute urinary retention • UPLIFT Trial

• Glaucoma

➢ Acts on muscarinic receptors of the parasympathetic nervous system to gain bronchodilation.

ABCD Assessment Tool


Management of COPDGroup C Group D

Group A Group B

LAMA

LAMA + LABA LABA + ICS

A Bronchodilator

Continue, stop, or try alternative class of bronchodilator

Evaluate Effect

Further exacerbations

LAMA + LABA

A Long-Acting Bronchodilator (LABA or LAMA)

Persistent Symptoms

LAMALAMA +LABA

LABA + ICS

LAMA + LABA + ICS

Consider Roflumilast if FEV1 <50% and +Chronic Bronchitis

Consider Macrolide (in former smokers)

Further Flairs

Combination Agents (GOLD Grade B, C, D)

• Large Cochrane review (10,894 patients) found that LABA and LAMA combination:

• Better QOL, • Small increase in FEV1 (post-

BD)

• Tiotropium-Olodaterol • Umeclidinium-Vilanterol • Glycopyrrolate-Indacaterol • Glycopyrrolate-Formoterol

Combination Agents (GOLD Grade B, C, D)

• Triple therapy: LAMA, LABA, ICS

• Fluticasone, Umeclidinium, Vilanterol = Daily

• Multiple trials show benefit in Group D:

• IMPACT (NEJM, 2018) • TRINITY (Lancet, 2017) • TRILOGY (Lancet, 2016) • FULFIL (AmJRespCritCarMed,

2017)

GOLD Grade D Considerations• Assess for complicating disease processes

• Heart disease, Metabolic syndromes, Obesity, OSAS and/or sleep disturbances, Lung Cancer, Anxiety/Depression, Allergies/Sinus, GERD, Muscle Dysfunction

• Assess inhaler technique and compliance/adherence

• Re-assess severity and consider repeating testing etc.

GOLD Grade D Additional Meds• PDE4 Inhibitors (Roflumilast)

• Approved to reduce risk of COPD exacerbations

• Work by: • Decreasing inflammation • Promoting smooth muscle relaxation

• Can interact with CYP3A4 inhibitor drugs

• Limited benefit on lung function • Side Effects:

• Psychiatric • GI upset

• Chronic Daily Macrolides (NEJM, 2011, Cochrane Database, 2013)

• Preferred Azithromycin • Daily or MWF dosing • May work better in the 30% of

COPD patients who also have bronchiectasis

• Side Effects: • Cardiac (baseline EKG, sometimes

repeat one) • Assess hearing

GOLD Grade D Additional Meds• Theophylline

• Older drug • Not used as often • Side effect profile and narrow

therapeutic window make this difficult

• Blood levels 8-12 mcg/ml • May improve FEV1, FVC, DLCO

• Chronic Steroids • Only rarely used chronically • Have bad long term and short

term side effects • Titrate to the lowest effective

dose • Warn patients about side effect

profile

Step Down Therapy• Should always attempt to de-escalate safely

• OPTIMO Trial (2014) • Grade B patients could be safely taken off ICS inhaler without risk of

exacerbations • Real world study of 914 patients

• WISDOM Trial (2014) • Grade D patients, withdrawal of ICS not associated with increase risk of

exacerbations • However == drop in QOL and FEV1

• Some respond to ICS better • TORCH Trial (2007)

• Addition of ICS reduced moderate to severe exacerbations

New pharmocotherapy: future treatments• Anti-IL-5 therapy (Mepolizumab)

• COPD with asthma overlap • Recent trials, 2018 = 462 patients,

• Eosinophil count >150 cells/mL, recurrent exacerbations despite optimum treatment

• After 1 year = reduced exacerbation rates slightly • Authors admitted that additional studies needed

Alpha-1-Antitrypsin Deficiency• Autosomal dominant inheritance • Affects Lungs (COPD, Bronchiectasis) • Extra-pulmonary manifestations:

• Liver • Skin: panniculitis • Vasculitis (ANCA) • IBD • Intra-abdominal aneurysms • Glomerulonephritis

Alpha-1-Antitrypsin Deficiency• AAT is a protease inhibitor

that deals in the breakdown of elastase and other proteases.

• Because of this, the lung degrades due to the break down of Elastin.

• ***ALL COPD patients should be tested regardless of age or ethnicity***

• Treat as you would any COPD subclass

• Indications for treatment: • Homozygotes with lung

destruction, FEV < 65% • A1AT level <11mcmol/L or

<57mg/dl • Necrotizing panniculitis

• Types of treatment: • IV infusions • Weekly


• Diagnosis


• Assess Severity


• Management



Non-pharmacologic treatment• Education

• Written action plans beneficial, similar to asthma • Inhaler techniques

• Nutrition/Diet • Obesity and pulmonary cachexia are issues that can increase symptoms • Vitamin D deficiency (studies are underway)

• End of life discussions and Palliative Care • Deciding on when to refer can be tricky

• Life-threatening AECOPD = 10% die during admission, 50% may do not survive 4 years after. (Variability widely exists here)

• Decrease in 6MWT <50m, Bedridden/sedentary, pC02 or Pa02 worsening • Focusing on chronic dyspnea and a plan for the acute dyspnea crisis

Pulmonary rehab (GOLD Grade B, C, D)• Especially in those with recurrent exacerbations or high risk for

them • Reducing symptoms (dyspnea) • Improved exercise performance and activity level • Contraindications:

• Uncontrolled cardiac disease or severe pulmonary HTN • Other obstacles: dementia, neuromuscular weakness, arthritis issues,

language/cognitive barriers.

Goals of Pulmonary

rehab

Psychological supportEducation

Breathing Exercises

Strength Training

Endurance Training

Treating Hypoxemia: Oxygen Therapy• GOLD Stage 3-4 may require this • Must be in chronic stable steady state

• Indications = Severe hypoxemia at rest or with exertion • Pa02 <55mmHg, or Sp02 <88 • Signs of pulmonary hypertension, peripheral edema, polycythemia

• Rx: at least 18 hours/day, maintain Sp02 >90%

• Improves survival in severe hypoxemia • May improve QOL?

• New trials are looking at this again in moderate hypoxemia (LOTT Trial, NEJM 2016)

• Did not help progression to death or to 1st hospitalization

Non-Pharmacologic Treatment


Treating Hypercapnia: Non-invasive Ventilation (NIV or NIPPV)• Largely due to V/Q mismatch or dead space ventilation

• Destruction of the airway • Respiratory muscle weakness, diaphragmatic fatigue • Malnutrition

• NIPPV • Daytime hypercapnia (pC02 >52mmHg) • Overnight hypoxemia (>5 minutes of Sp02 >88%) • Hospitalizations that may have required NIPPV

Lung Volume Reduction Surgery (LVRS)• Rationale

• Improves mechanical function of respiratory muscles (decreases FRC)

• Improved cardiac function (LVED filling pressures and CI)

• Improves DOE • Perhaps endothelial function and BP

• NETT (National Emphysema Treatment Trial, 2003, 2011)

• Improved exercise capacity • No survival advantage

• Short term mortality increased • Subgroup analysis

• Indications: • Age <75, non-smoker, DOE despite tx • No significant comorbid illnesses • FEV1 >20%, <45%. TLC >100%/RV

>150%, DLCO >20% • pC02 45-60 • 6MWT >140 meters • Upper lobe predominant bullous

disease • Long Term outcomes:

• Improved dyspnea, QOL, BODE • Not superior to lung transplant • Not a lot of long term data

Other lung volume reduction techniques• Endobronchial Valves

• VENT Trial (NEJM 2010) • Similar to the NETT (LVRS) trial, they compared

against medical therapy • Improved lung function and exercise performance • Slight increase in AECOPD and hemoptysis,

pneumonia. PTX. • STELVIO Trial (2015), IMPACT Trial (2016)

• Several devices now developed • Zephyr® = duckbilled shaped • Spiration® = umbrella shaped • Nitinol coils

• Chemicals • Thermal Airway Ablation


Lung transplantation• 2014, International Society for

Heart and Lung Transplantation (ISHLT)

• Guidelines for Selection:

• High risk of death in 2 years (>50%) if transplant not performed

• Survival past transplant >90 days,

• >5 years from general medical perspective

• Contraindications: • Malignancy in the last 2 years (except

localized skin cancer) • Advanced other organ failure • CAD not amenable to revascularization • Acute medical issues: sepsis, AMI, etc. • Uncorrectable bleeding disorder • Chronic infection, Active M.TB

infection • Chest wall or spinal deformity, severe • Obesity, BMI>35 • Medical noncompliance • Psychiatric conditions, Absence of

support system • Debility/Frailty with inability to rehab • Substance/Alcohol/Tobacco abuse or

dependency

Lung transplant (ISHLT guidelines)• Relative Contraindications: • Age >65 (** becoming less strict) • Obesity, BMI 30-34 • Malnutrition • Osteoporosis, severe/symptomatic • Previous extensive chest/lung surgery • Previous high risk infections • HIV • Ongoing Hepatitis B/C • Allograft Autoantibodies • Mechanical Ventilation/ECMO ***

Lung transplant for COPD (ISHLT guidelines)• Used to be most common Dx

for referral (ILD surpassed it) • When to refer:

• Disease progression despite optimum treatment

• Not a candidate for LVRS/endobronchial interventions

• BODE index >5 • pC02 >50mmHg, and/or Pa02

<60mmHg • FEV1 <25%

• When to list: • Bode index >7 • FEV1 <15-20% • AECOPD >3 or more per year • Or 1 severe exacerbation with

acute hypercapnia respiratory failure

• Moderate to severe pulmonary HTN

Lung Transplant for COPD• Choices:

• Single lung transplant • Bilateral lung transplant ***

• Offers survival advantage if <60yo • >60: SLT shorter/simpler operation

• COPD recipients seem to have better: • lung function, gas exchange, • exercise capacity, • QOL • Survival benefit

• 30.1% COPD vs 17.7% other lung transplant recipients at 5 years

• Lung is delicate, outcomes are not as good as for other solid organs

• Median wait time: <200 days (due to updates in LAS (lung allocation score), 2005)

• Post-transplant complications: • Peri-op complications • Primary graft dysfunction (25% of

mortalities) • Acute rejection • Chronic rejection (Bronchiolitis Obliterans

Syndrome) • Malignancies • Infections • Airway and vascular complications • Organ failure (Renal, DM)

Copyrights apply


• Diagnosis


• Assess Severity


• Management



Management of COPDGroup C Group D

Group A Group B

LAMA

LAMA + LABA LABA + ICS

A Bronchodilator

Continue, stop, or try alternative class of bronchodilator

Evaluate Effect

Further exacerbations

LAMA + LABA

A Long-Acting Bronchodilator (LABA or LAMA)

Persistent Symptoms

LAMALAMA +LABA

LABA + ICS

LAMA + LABA + ICS

Consider Roflumilast if FEV1 <50% and +Chronic Bronchitis

Consider Macrolide (in former smokers)

Further Flairs

Resources• https://goldcopd.org/ • http://www.thoracic.org/statements/copd.php • https://journal.copdfoundation.org/ • https://journal.chestnet.org/guidelines

• Patient resources: • http://www.thoracic.org/patients/patient-resources/fact-

sheets-az.php

Questions?

• Agusti A, Calverley PM, Decramer M, Stockley RA, Wedzicha JA. Prevention of exacerbations in chronic obstructive pulmonary disease: knowns and unknowns. Chronic Obstr Pulm Dis. 2014; 1(2): 166-184.

• Albert RK, Au DH, Blackford AL, Casaburi R, Cooper A, Criner GJ, et al. A randomized trial of long-term oxygen for COPD with moderate desaturation: The long-term oxygen treatment trial research group (LTOTT). N Engl J Med 2016;375:1617-27. DOI: 10.1056/NEJMoa1604344.

• Albert RK, Connett J, Bailey WC, Casaburi R, Cooper JA Jr, Criner GJ, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365(8):689. • Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease:

Towards a revolution in COPD health (TORCH) investigators. N Engl J Med 2007;356:775-89. • Celli B, Decramer M, Leimer I, Vogel U, Kesten S, Tashkin DP. Cardiovascular safety of tiotropium in patients with COPD. Chest 2010;137(1):20. • Chong J, Leung B, Poole P. Phosphodiesterase 4 inhibitors for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017;9:CD002309. Epub 2017 Sep

19. • Cosio MG, Saetta M, Agusti A. Immunologic aspects of chronic obstructive pulmonary disease. N Engl J Med 2009;360:2445-54. • Farne HA, Cates CJ. Long-acting beta2-agonist in addition to tiotropium versus either tiotropium or long-acting beta2-agonist alone for chronic obstructive

pulmonary disease. Cochrane Database Syst Rev. 2015. • Ferguson GT, Make B. Management of stable chronic obstructive pulmonary disease. In: UpToDate, May 2018. • Ferguson GT, Make B. Management of refractory chronic obstructive pulmonary disease. In: UpToDate, May 2018. • Fishman, A, Martinez F, Naunheim K, Piantadosi S, Wise R, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe

emphysema: National emphysema treatment trial research group (NETT). N Engl J Med 2003;348:2059-73. • Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH. COPD Surveillance—United States, 1999-2011. Chest 2013;144(1):284. • GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths, prevalence, disability-adjusted years, and years lived with disability for

chronic obstructive pulmonary diseas and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med 2017;5: 691-706.

• Global Initiative for Chronic Obstructive Lung Disease. 2018 Global Strategy for prevention, diagnosis, and management of COPD. https://goldcopd.org/gold-reports.

• King Han ML, Dransfield MT, Martinez F. Chronic obstructive pulmonary disease: definition, clinical manifestations, diagnosis, and staging. In: UpToDate, May 2018. • Kohnlein T, Windisch W, Kohler D, Drabik A, Geiseler J, et al. Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive

pulmonary disease: a prospective, multicenter, randomized, controlled clinical trial. Lancet Respir Med 2014;2(9):698. • Kosacz NM, Croxton TL, Ndenecho MN, Kiley JP, Weinmann GG, et al. Morbidity and mortality weekly report (MMWR): Chronic obstructive pulmonary disease among

adults-United states, 2001. Reported Nov 2012;61(46):938-943. • Lahzami S, Bridevaux PO, Soccal PM, Wellinger J, Robert JH, Ris HB, Aubert JD. Survival impact of lung transplantation for COPD. Eur REspir J. 2010;36(1):74. Epub

2009 Dec 8. • Lipson DA, Barnhart F, Brealey N, Brooks J, Criner G et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med

2018;378:1671-80. • Magnussen H, Disse B, Rodriguez-Roisin R, Kirsten A, Watz, WISDOM Investigators, et al. Withdrawal of inhaled glucocorticoid and exacerbations of COPD. N Engl J

Bibliography/References• Niewoehner DE. Outpatient management of severe COPD. N Engl J Med 2010;362:1407-16. • Ram FS, Jones PW, Castro AA, De Brito JA, Atallah AN, et al. Oral theophylline for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002. • Ravord ID, Chanez P, Criner GJ, Kerstjens HA, Korn, S, et al. Mepolizumab for eosinophilic chronic obstructive pulmonary disease. N Engl J Med 2017; 377:1613-29. • Rossi A, Guerriero M, Corrado A, (OPTIMO/AIPO Study group). Withdrawal of inhaled corticosteroids can be safe in COPD patients at low risk of exacerbation: a real-

life study on the appropriateness of treatment in moderate COPD patients (OPTIMO). Respir Res 2014; 15:77. • Sciurba FC, Ernst A, Herth FJ, Strange C, Criner G, Marquette et al. N Engl J Med 2010; 363:1233-1244. DOI: 10.1056/NEJMoa0900928. • Suissa S, Drazen J. Making sense of triple inhaled therapy for COPD. N Engl J Med. 2018;378(18):1723. • Sutherland ER, Cherniack, R. Management of chronic obstructive pulmonary disease. N Engl J Med 2004;350:2689-97. • Todd JL, Palmer SM. Lung transplantation in advanced COPD: Is it worth it? Semin Respir Crit Care Med. 2010 June; 31(3):365-372. • Valiour A, Slebos, DJ, Herth F, Darwiche K, Wagner M, et al. Endobronchial valve therapy in patients with homogenous emphysema: Results from the IMPACT Study. Am

J Respir Crit Care Med 2016;194(9):1073-82. • van Eerd EAM, van der Meer RM, van Schayck OCP, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database of Systematic

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Bibliography/References

Multiple Choice Questions:1. A 64yo Male presents to your office with a 6 month

progressive symptoms of shortness of breath and cough. He has had 2 urgent care visits for episodes of acute bronchitis within the last year and has had 1-2 per year for the last 5 years. He smokes 1PPD for the last 40 years. He has had to quit his job as a construction manager due to his breathing. You perform a spirogram which shows severe obstruction, FEV1 39%. How would you rate the severity of his disease? A. GOLD Grade A B. GOLD Grade B C. GOLD Grade C D. GOLD Grade D

Multiple Choice Questions:2. The same patient above was given an albuterol inhaler from

the urgent care center. He states that he was also given some antibiotics and a course of steroids, but as soon as he ran out of these, he is feeling worse again. What therapy do you choose to start depending on his GOLD Grade listed above? A. Leave him on the current inhaler and wait for the next episode of

bronchitis. B. Place him on oxygen since oxygen helps everyone. C. Place him on an inhaled corticosteroid alone. D. Place him on a long-acting muscarinic agent + a long acting beta-

agonist.

Multiple Choice Questions:3. The same patient listed above follows up with you 8 weeks

later so you can check on his progress. His wife was able to convince him to quit smoking. He has been taking his treatment and feels better. Upon arrival, his oxygen saturation is 79%, but returns to 88% after rest for 10 minutes. How do you address this? A. Not do anything. B. Test him to see he if responds to oxygen with ambulation. C. Prescribe another inhaler. D. Place him on chronic oral steroids.

Multiple Choice Questions:

4. True or False: All patients with COPD should be tested for Alpha-1-antitrypsin disease? A. True. B. False.

updates in copd, focusing on the outpatient setting · updates in copd, focusing on the outpatient...

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