copd and asthma update - tucson osteopathic … · copd and asthma update april 29th, 2017 ... no...

COPD and Asthma Update

April 29th, 2017

Rachel M Taliercio, DO

Staff, Respiratory Institute

What we’ll be talking about

• COPD: diagnosis, management of stable

COPD, COPD exacerbations

• Asthma: diagnosis, comorbidities,

management

• Asthma/COPD Overlap: phenotype,

management

• Smoking cessation: pearls, electronic

cigarettes

55 year old male, current smoker (25 pack

year history), presents with several months

of worsening dyspnea on exertion. Has a

chronic cough which he attributes to

smoking. Two colds this past year, took him

weeks to recover from each episode.

Your diagnosis:

1. Asthma

2. COPD

3. Asthma/COPD Overlap

4. Unable to determine

COPD: Spirometry is Required to

Make the Diagnosis

• Assesses lung function by measuring

expiratory volumes and flow rates

• Obtain spirometry on all patients with chronic

cough, sputum production or dyspnea

COPD = Fixed Airflow Obstruction

• Airflow limitation that is irreversible or

partially reversible with bronchodilator

• FEV1/FVC ratio < 0.70 or < LLN

• FEV1: measure of severity of airflow

obstruction

• Spirometry is not recommended as

screening tool

COPD and Smoking

• Majority of risk for developing COPD is from smoking (~80%)

• 15 to 20% of smokers develop clinically significant COPD

– Symptoms typically develop after 20 or more pack years

• Smokers lose lung function at an accelerated rate

– Quitting is beneficial at any age, more pronounced in earlier quitters

• Passive smoke exposure has been implicated as a cause of COPD (affects women > men)

Kohansal et al. Am J Respir Crit Care Med 2009;180:3–10

81 year old female, never smoker, presents

with several month history of dyspnea on

exertion. No associated cough, wheeze or

chest tightness. No history of asthma. No

history of chronic respiratory illness as a

child or adult. Homemaker. No significant

second hand smoke exposure.

COPD in Never Smokers

• Up to 20% of patients with COPD

• More common in women

– Typically moderate to severe obstruction

– Additional risk factors: low BMI, low

education level, history of asthma,

severe respiratory infections in childhood

• Occupational exposures: organic dust,

biomass fuel

Chest 2011; 139(4): 752-763

COPD: Management

• Goal of treatment: to improve symptoms

and exercise capacity, reduce

exacerbations and hospitalizations

• Considerations for initial therapy:

– Symptoms

– FEV1

– History of exacerbations

• Past exacerbation history is the best predictor of

future flares

63 yo male, former smoker, new diagnosis of

COPD. FEV1 75% predicted (mild

obstruction). Reports occasional dyspnea.

No history of COPD flare.

Which of the following is indicated?

1. Short-acting bronchodilator

2. Short-acting bronchodilator and flu vaccine

3. Short-acting bronchodilator, flu vaccine, long-acting bronchodilator (LABA or LAMA)

4. Short-acting bronchodilator, flu vaccine, combination therapy (ICS/LABA)

Short-Acting Bronchodilators

(SABA)

Short-Acting Bronchodilators

(SAMA)

57 yo female with COPD here to establish

care. FEV1 60% predicted (moderate

obstruction). Has noticed breathlessness

during walking on a flat surface. No h/o flare.

What is the recommended first-line inhaled

therapy?

1. Short-acting bronchodilator

2. Inhaled steroids

3. Long-acting bronchodilator

4. Long-acting bronchodilator/inhaled steroid combination

COPD: Bronchodilators (BD) are Key

Long-Acting Bronchodilators

Same patient, here for six month follow up visit.

Went to urgent care two months ago, diagnosed

with bronchitis. Given prednisone and antibiotics.

Taking Tiotropium daily. Still breathless with

activity. What is the best next step?

1. Continue long-acting bronchodilator, add combination therapy (ICS/LABA)

2. Switch from long-acting bronchodilator to combination therapy (ICS/LABA)

3. Switch from long-acting bronchodilator monotherapy to dual BD therapy (LABA/LAMA)

4. Continue long-acting BD and add ICS

• FLAME trial

• LABA/LAMA vs. ICS/LABA

• 17% reduction in moderate-to-severe

exacerbations with dual bronchodilator

therapy

Dual Bronchodilators (LABA/LAMA)

COPD: When to Think About

Inhaled Steroids

• Moderate to severe COPD

– Repeated exacerbations

– Low quality of life

• Asthma-COPD Overlap

• Always in combination with LABA

• Risks associated with use:

– Oral candidiasis, hoarseness

– Skin bruising

– Pneumonia

Which of the following has been

shown to impact survival in COPD?

1. Smoking cessation

2. Oxygen therapy (in patients with severe

chronic resting hypoxemia)

3. Maintenance medication

4. 1 and 2

5. All of the above

Pulmonary Rehab

• Improves dyspnea and exercise capacity

• Reduces hospitalization and improves

QOL in patients with a recent exacerbation

• What your patients should expect:

– Exercise training

– Education

– Inspiratory

muscle training

COPD Exacerbations:

Ambulatory Management

• GOLD 2017: “worsening of respiratory

symptoms that result in additional therapy”

• Give antibiotics

– Infection implied in up to 80% of episodes

– Shortened recovery time, reduces treatment

failure, increases time between flares

• Give oral steroids

– Improve lung function, trend toward fewer

hospitalizations

– Dosage? Duration? (no more than 10 to 14 days)

Sethi S. Chest 2000;117:380S-385S

Anthonisen NR et al. Ann Intern Med 1987;106:196

Wedzicha et al. ERJ 2017; 49: 1600791

COPD Exacerbations:

Antibiotic Selection

Anzueto A et al. Am J Med Sci 2010; 340(4): 309-318

Used with permission courtesy of Dr. Aboussouan

COPD: When to Refer

• Disease onset < 40 years old

• Frequent exacerbations (> 2 or more per

year) despite therapy

• Severe airflow obstruction (FEV1 < 50%)

• Patients on oxygen therapy

• Significant comorbidities

• Considering add-on therapy

Asthma

What percent of study participants with

physician-diagnosed asthma had no

evidence of current asthma (% of patients in

whom asthma was ruled out)?

1. 10%

2. 20%

3. 30%

4. 50%

5. 60%

Aaron et al. JAMA. 2017; 317(3): 269-279

Asthma: Diagnosis

• Chronic airway inflammation shortness

of breath, cough, wheezing, chest

tightness

– Variable symptoms (episodic)

– Variable airflow limitation

• Symptoms vary over time and in intensity

Airflow Obstruction with Positive

Bronchodilator Response

Asthma: Diagnosis

• Whenever possible, confirm diagnosis

before starting controller therapy

– Clinical urgency or other diagnosis unlikely

start empiric treatment

– Then diagnostic testing within 1 to 3 months

Asthma Triggers

Your patient has a clinical history suggestive

of asthma. You order lung function testing

and it is normal, no reversibility. What is the

best next step?

1. Consider alternative diagnosis

2. Treat empirically for asthma

3. Order methacholine challenge test

4. Check exhaled nitric oxide

Methacholine Challenge Test

Exhaled Nitric Oxide

(eNO, FENO)

• > 50 ppb: eosinophilic airway inflammation

• High eNO suggests steroid responsiveness

• Useful in monitoring inflammation

– 20% reduction = steroid responsiveness

– Assessment tool for adherence

• Not a good diagnostic test for asthma

– Also elevated in rhinosinusitis/atopy,

eosinophilic bronchitis, COPD, eczema

Asthma is Heterogenous

Asthma Phenotypes

• Allergic asthma

• Non-allergic asthma

• Late-onset asthma

• Asthma with fixed airflow obstruction

• Asthma with obesity

Your patient has allergic asthma and you tell

him the cat is a major trigger. He tells you

his girlfriend will break up with him before

she gets rid of the cat. Which of the

following are strategies to reduce exposure?

1. Remove carpets/HEPA filter on vacuum

2. Brush pet outside to remove dander

3. Remove the cat from the bedroom

4. Change your clothes after prolonged

exposure to the animal

5. All of the above

Which of the following is the most

common cause of uncontrolled

asthma:

1. Poor adherence

2. Incorrect inhaler technique

3. Incorrect diagnosis

4. Inadequate therapy

5. Persistent exposure to triggers

Asthma Management:

High Value, Low Cost

• Increase delivery of drug into the lung

– Increased potency of inhaled steroids

• Reduction in oropharyngeal candidiasis

Toogood et al. AJRCCM 1984; 129: 723-729.

Asthma Management:

Anti-Inflammatory is the Standard

Combination Therapy: ICS/LABA

Asthma Management:

Additional Therapies

• Anti-leukotrienes: Montelukast (Singulair

®), Zafirlukast (Accolate®), Zileuton

(Zyflo®)

• Biologic agents/Monoclonal antibody:

Omalizumab (Xolair ®), Mepolizumab

(Nucala ®), Reslizumab (Cinqair ®)

• Long-acting muscarinic antagonist

(LAMA): Tiotropium (Spiriva®)

Stepwise Approach to Asthma

Therapy: Key Points

• Step 1: consider low dose ICS

– SABA alone for pts with asthma sxs less than twice/month, no nighttime sxs, no risks/hx flares

– ICS reduce risk of severe exacerbations

• Step 2: low dose ICS

– other options: LTRA, low dose theophylline

• Before considering step-up to 3 or 4:

– Check diagnosis, inhaler technique, exposures, adherence

Stepwise Approach to Asthma

Therapy: Key Points

• Step 3: low dose ICS/LABA

– other options: med/high dose ICS OR low

dose ICS + LTRA)

• Step 4: med/high dose ICS/LABA (add

tiotropium)

• Step 5: refer for add-on treatment

• Step 3 to 5 reliever therapy: SABA or low

dose ICS/LABA

Reddel et al. Eur Respir J 2015; 46: 579-582.

Asthma Control Test QualityMetric

incorporated, 2002. www.asthmacontrol.com

>= 20 : well controlled

16-19 : not well

controlled

≤15 : very poorly

controlled

http://www.asthmacontrol.com/

Asthma Management:

Assess for Comorbidities

• Upper airway disease: chronic rhinosinusitis, nasal polyposis

• Obstructive sleep apnea

• GERD (no role for treatment if patient asymptomatic)

• Paradoxical vocal fold motion (formally known as vocal cord dysfunction)

• Obesity

• Depression

Asthma-COPD Overlap

• Nearly 25% of patients with COPD report history of asthma

• Features of both: more symptoms, increased rate of exacerbations, more likely hospitalized, more rapid decline lung function

• Younger, women ˃ men, higher BMI, fewer pack years of smoking , greater % African-Americans

– Compared to COPD alone: similar lung function, less emphysema on imaging

Eur Respir J 2014; 44: 341–350

Asthma-COPD Overlap

• Suggested criteria– Age > 40

– FEV1/FVC < 0.70

– Exposure to cigarette smoke

– Previous/current history of asthma/atopy

– Marked bronchodilator response (>400 mL)

– IgE level > 100

– Blood eosinophils > 5%

• Treatment response is different – Early initiation of inhaled corticosteroids is

recommended

Chest. 2015; doi: 10.1378/chest.15-1055

Your patient is interested in quitting smoking.

Which of the following treatment methods

has the highest abstinence rate?

1. Nicotine patch

2. Nicotine patch + nicotine gum

3. Buproprion SR (Zyban)

4. Nicotine patch + Buproprion

5. Varencycline (Chantix)

Your patient is overweight and concerned

about weight gain after smoking cessation.

Which of the following would be a good option?

1. Nicotine patch

2. Nicotine patch + nicotine gum

3. Buproprion SR (Zyban)

4. Nicotine patch + Buproprion

5. Varencycline (Chantix)

Electronic Cigarettes

Most popular tobacco product

among high school and middle

school students

Highest prevalence (14%) in

young adults 18 to 24 years old

The Power of Advertising

Perceived as a tool to

quit or reduce smoking

Similar efficacy to

nicotine replacement

therapy

Electronic Cigarettes:

Lack of Evidence of Harm ≠ Safety

• Normalization of smoking behavior

• Gateway to other tobacco products – Students identify use of e-cigarettes as a

significant factor in being likely to try tobacco

products

• Known pulmonary toxicity – FDA now has authority to prohibit sale to

minors

Thank You!

copd and asthma update - tucson osteopathic … · copd and asthma update april 29th, 2017 ... no...

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