Download New Guidelines for COPD - American Lung Association

New Guidelines for COPD
They keep changing. . . are you up to speed?
by
Scott Cerreta, BS, RRT
Director of Education
www.copdfoundation.org
Conflict of Interest
I have no real or perceived conflict of
interest that relates to this presentation. Any
use of brand names is not in any way meant
to be an endorsement of a specific product,
but to merely illustrate a point of emphasis.
Objectives
1. Discuss different definitions of COPD
2. Discuss current literature and research that
warrants the need to change COPD Guidelines
3. Describe new features of the GOLD Guidelines
4. Describe how these changes will impact
diagnosis and treatment recommendations
1. GOLD Definition
• COPD, a common preventable and
treatable disease, is characterized by
persistent airflow limitation that is usually
progressive and associated with an
enhanced chronic inflammatory response
in the airways and the lung to noxious
particles or gases.
• Exacerbations and comorbidities
contribute to the overall severity in
individual patients.
ATS / ERS Definition
• Chronic Obstructive Pulmonary Disease
(COPD) is a preventable and treatable
disease state characterised by airflow
limitation that is not fully reversible.
• The airflow limitation is usually
progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases,
primarily caused by cigarette smoking.
NHLBI Definition
• Chronic Obstructive Pulmonary Disease
• Serious lung disease that over time makes
it hard to breathe
– Emphysema
– Chronic Bronchitis
• Blocked (obstructed) airways make it hard
to get air in and out
COPD Foundation Definition
• Chronic Obstructive Pulmonary Disease
• Serious lung disease that over time makes
it hard to breathe
–
–
–
–
Emphysema
Chronic Bronchitis
Refractory Asthma and
Some forms of bronchiectasis
• Blocked (obstructed) airways make it hard
to get air in and out
COPD: Definitions of 21st Century1
Chronic bronchitis
• Preventable and treatable
• Airflow limitation that is not
fully reversible
• Progressive disease
• Abnormal inflammatory
response of the lungs
• Subsets of patients
Emphysema
COPD
Asthma
Box = FEV1/FVC < 70% or < LLN
Spirometry is REQUIRED for diagnosis
2. Literature Review
• COPD Gene Study – Dr. Crapo
– Why some smokers get COPD & others don’t
– Using HRCT and identified a large number of
people with emphysema despite normal
spirometry
• Spiromics – Dr. Rennard
– Identifying subsets of people with COPD
– collection and analysis of phenotypic,
biomarker, genetic, genomic, and clinical data
from subjects with COPD
Observations from Experts
• Not all forms of Emphysema or Chronic
Bronchitis are COPD.
• Not all severities of COPD are the same
– People with same FEV1 have different health
status, dyspnea scores, comorbidities,
exacerbation history, etc.
Dr. Vesbo, Chair of GOLD states:
• “Spirometry is essential for the diagnosis of
COPD, but it doesn’t fully capture the impact of
the disease on individual patients”
• Example: Some patients with Moderate COPD
may have severe breathlessness, while others
may have Mild COPD but more prone to acute
exacerbations
• Both groups require more aggressive therapy
than past guidelines would recommend
“COPD HETEROGENEITY”
Cote & Celli
PT # 1
58 y
FEV1: 28 %
MRC: 2/4
PaO2: 70 mmHg
6MWD: 540 m
BMI: 30
PT # 2
62 y
FEV1: 33%
MRC: 2/4
PaO2: 57 mmHg
6MWD: 400 m
BMI: 21
PT # 3
69 y
FEV1: 35%
MRC: 3/4
PaO2: 66 mmHg
6MWD: 230 m
BMI: 34
PT # 4
72 y
FEV1: 34%
MRC: 4/4
PaO2: 60 mmHg
6MWD: 154 m
BMI: 24
GOLD Treatment of COPD
FEV1 / FVC < 70%
I: Mild
II:Moderate
III: Severe
FEV1>80% pred
FEV1 50-80% pred
FEV1 30-50% pred
IV: Very Severe
FEV1 < 30% pred or FEV1 <50%
predicted plus respiratory failure
Active Reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator when needed
Add regular treatment with one or more long-acting
bronchodilators: ß2 agonists and anticholinergics
Add rehabilitation
Add ICS for repeated exacerbations
Add LTOT
Surgical interventions
http://www.goldcopd.org/
3. New Features Added in Dec 2011
• GOLD Spirometry Classification Stays
• NEW is Assessment Model – ABCD
– mMRC dyspnea scale or COPD Assessment
Test (CAT) health status
– Spirometry classification and
– Exacerbation History
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
 Assess symptoms
 Assess degree of airflow
limitation using spirometry
 Assess risk of exacerbations
 Assess comorbidities
Global Strategy for Diagnosis, Management and Prevention of COPD
(C)
(D)
>2
(B)
1
3
2
(A)
1
0
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item
measure of health status impairment in COPD
(http://catestonline.org).
Breathlessness Measurement using the
Modified British Medical Research Council
(mMRC) Questionnaire: relates well to other
measures of health status and predicts future
mortality risk.
Tools: COPD Assessment Test (CAT)
•
Measures health status
– Based on 8 questions
– Score from 0 to 5
– High scores = symptoms
•
May predict exacerbation
•
May reveal improvement after
attending Rehab
http://www.catestonline.org/english/index.htm
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Assess symptoms first
(C)
(D)
(A)
(B)
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
If mMRC 0-1 or CAT < 10:
Less Symptoms (A or C)
If mMRC > 2 or CAT > 10:
More Symptoms (B or D)
Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow
Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild
FEV1 > 80% predicted
GOLD 2: Moderate
50% < FEV1 < 80% predicted
GOLD 3: Severe
30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations use
history of exacerbations and
spirometry:
 Two or more exacerbations within
the last year or an FEV1 < 50 % of
predicted value are indicators of
high risk.
Tease Out All Exacerbations
• Must assess all exacerbations – increase
in symptoms that requires change in tx
– Hospitalizations
– ER / Urgent Care visits
– PCP / Pulmonologist visit
• Ask about infection or use of antibiotics,
the most common cause of exacerbation
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess risk of exacerbations next
3
(C)
(D)
>2
2
(A)
(B)
1
0
1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
If GOLD 1 or 2 and only
0 or 1 exacerbations per year:
Low Risk (A or B)
If GOLD 3 or 4 or two or
more exacerbations per year:
High Risk (C or D)
Global Strategy for Diagnosis, Management and Prevention of COPD
Use combined assessment
3
(C)
(D)
>2
2
(A)
(B)
1
0
1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation)
Risk
Combined Assessment of COPD
Patient is now in one of
four categories:
A: Less symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high
risk
Global Strategy for Diagnosis, Management and
Prevention of COPD
Combined Assessment
of COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation history
Patient
Characteristic
Spirometric
Classification
Exacerbations mMRC
per year
CAT
A
Low Risk
Less Symptoms
GOLD 1-2
≤1
0-1
< 10
B
Low Risk
More Symptoms
GOLD 1-2
≤1
>2
≥ 10
C
High Risk
Less Symptoms
GOLD 3-4
>2
0-1
< 10
D
High Risk
More Symptoms
GOLD 3-4
>2
>2
≥ 10
Maintenance Care vs. Acute Care
• Typical hospitalization requires aggressive
medication management
• Goal is to return patient to baseline
treatment recommendations
• Maintenance Therapy requires the least
amount of medication to control patient
symptoms and health status
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and
therefore not necessarily in order of preference.)
Patient
First choice
Second choice
Alternative Choices
A
SAMA prn
or
SABA prn
*LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
*LAMA
or
LABA
*LAMA and LABA
SABA and/or SAMA
Theophylline
*LAMA and LABA
*PDE4-inh.
SABA and/or SAMA
Theophylline
ICS and *LAMA or
*ICS + LABA and *LAMA or
*ICS+LABA and *PDE4-inh. or
*LAMA and LABA or
*LAMA and *PDE4-inh.
Carbocysteine
SABA and/or SAMA
Theophylline
C
D
*ICS + LABA
or
*LAMA
*ICS + LABA
or
*LAMA
Consequences Of COPD Exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality
Scenario 1
Step 1:
assess mMRC or CAT. mMRC=1
– Left side, less symptoms
Step 2:
assess spirometry = FEV1 43%
assess exacerbation hx = 2
– Upper side, high risk
• Assessment Score = C
Scenario 1
• Old GOLD
– FEV1 = 43%
– Severe Stage 3
• Recommended Tx
– LABA or LAMA or
LABA + LAMA
– ICS
• New GOLD
– FEV1 = 43%, Group C
Less symp, Hi risk
• Recommended Tx
– ICS + LABA or LAMA
– PDE4 inh.
Scenario 2
Step 1:
assess mMRC or CAT. CAT=12
– Right side, more symptoms
Step 2:
assess spirometry = FEV1 81%
assess exacerbation hx = 0
– Lower side, Low risk
• Assessment Score = B
Scenario 2
• Old GOLD
– FEV1 = 81%
– Mild Stage 1
• Recommended Tx
– SABA prn
• New GOLD
– FEV1 = 81%, Group B
More symp, Low risk
• Recommended Tx
– LAMA or LABA
Scenario 3
Step 1:
assess mMRC or CAT. mMRC=4
– Right side, more symptoms
Step 2:
assess spirometry = FEV1 56%
assess exacerbation hx = 5
– Upper side, High risk
• Assessment Score = D
Scenario 3
• Old GOLD
– FEV1 = 56%
– Moderate Stage 2
• Recommended Tx
• New GOLD
– FEV1 = 56%, Group D
More symp, Hi risk
• Recommended Tx
– SABA prn
– ICS + LABA or LAMA
– LABA or LAMA or
LABA + LAMA
– PDE4 inh.
– Add everything else
Global Strategy for Diagnosis, Management
and Prevention of COPD, 2011: Summary
 Prevention of COPD is to a large extent possible
and should have high priority
 Spirometry is required to make the diagnosis of
COPD; the presence of a post-bronchodilator
FEV1/FVC < 0.70 confirms the presence of
persistent airflow limitation and thus of COPD
 The beneficial effects of pulmonary rehabilitation
and physical activity cannot be overstated
“COPD HETEROGENEITY”
Cote & Celli
PT # 1
58 y
FEV1: 28 %
MRC: 2/4
PaO2: 70 mmHg
6MWD: 540 m
BMI: 30
PT # 2
62 y
FEV1: 33%
MRC: 2/4
PaO2: 57 mmHg
6MWD: 400 m
BMI: 21
PT # 3
69 y
FEV1: 35%
MRC: 3/4
PaO2: 66 mmHg
6MWD: 230 m
BMI: 34
PT # 4
72 y
FEV1: 34%
MRC: 4/4
PaO2: 60 mmHg
6MWD: 154 m
BMI: 24
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Rehabilitation
 All COPD patients benefit from exercise training
programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
 Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective the results.
 If exercise training is maintained at home the
patient's health status remains above prerehabilitation levels.
COPD Pocket Consultant
Mobile App – Coming Soon
Summary
• Dx of COPD requires Spirometry but definitions
vary and change with new evidence
• Tx of COPD requires new assessment
– Spirometry, dyspnea score, exacerbation hx
and consider comorbidities
• New ABCD assessment model is more accurate
and will improve pt outcomes
• Learn how you can implement this model into
your system to decrease hospitalization rates
Thank You !
References
References
1.
GOLD Guidelines http://www.goldcopd.org/guidelines-pocket-guide-to-copd-diagnosis.html
2.
COPD Gene Study http://www.copdgene.org/
3.
Spiromics http://www.cscc.unc.edu/spir/
4.
COPD Foundation http://www.copdfoundation.org