Chronic Obstructive Approaches Pulmonary toPractical Diagnosis and Disease Management FEBRUARY 6, 2014 11:00 AM – 12:15 PM Fort Lauderdale, Florida

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Session 3: Chronic Obstructive Pulmonary Disease: Practical Approaches to Diagnosis and Management Learning Objectives 1. 2. 3.

Evaluate the role of spirometry in chronic obstructive pulmonary disease (COPD) diagnosis and monitoring. Review recommended pharmacologic interventions to reduce COPD symptoms and decrease exacerbations. Select appropriate patient counseling strategies.

Faculty Barbara P. Yawn, MD, MSc, FAAPP Director of Research Olmsted Medical Center Adjunct Professor Department of Family and Community Health University of Minnesota Rochester, Minnesota

Dr Barbara Yawn is a family physician with many years of both practice and research experience. She has published more than 350 articles in peer reviewed journals, including many regarding obstructive lung disease such as asthma and chronic obstructive pulmonary disease (COPD). She served on the National Heart, Lung, and Blood Institute National Asthma Guidelines committee in 2007 and on the World Health Organization’s COPD and Asthma Guidelines committees. Much of her respiratory related research is designed to develop tools and methods to translate guidelines into everyday practice to improve patient outcomes. Research is funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention. She has been a frequent speaker at Pri-Med and also has given many presentations on COPD in the United States and internationally. Her role as a primary care educator includes not only podium talks, but webinars, interactive virtual presentations, and group mentoring. Dr Yawn hopes to make COPD a comfortable and productive part of every primary care physician’s practice while also facilitating other clinicians’ important roles in chronic disease management. Fernando J. Martinez, MD, MS Professor, Department of Internal Medicine Associate Chief for Clinical Research Division of Pulmonary and Critical Care Medicine Director, Pulmonary Diagnostic Services University of Michigan Health System Ann Arbor, Michigan

Dr Fernando Martinez is professor of internal medicine and associate chief for clinical research in the division of pulmonary and critical care medicine at the University of Michigan Health System, medical director of pulmonary diagnostic services, and comedical director of lung transplantation. After graduating from the University of Florida School of Medicine, Jacksonville, he completed his residency in internal medicine at Beth Israel Hospital, New York City, and his fellowship in pulmonary medicine at the Boston University Pulmonary Center, Massachusetts. Dr Martinez’s main research interests include COPD, interstitial lung disease, lung transplantation, and lung volume reduction. At present, he is a member of numerous societies, including the American Thoracic Society (ATS), the European Respiratory Society, American College of Chest Physicians, and the Fleischner Society. Previously, he was a member of the ATS committees that generated guidelines for the management of COPD, respiratory infections, and cardiopulmonary exercise testing; he is the former chair of the ATS assembly on clinical problems. He is currently a member of the GOLD (Global Initiative for Chronic Obstructive Lung Disease) Science Committee. Dr Martinez sits on a number of scientific journal editorial boards, including for COPD: Journal of Chronic Obstructive Pulmonary Disease and American Journal of Respiratory and Critical Care Medicine.

Faculty Financial Disclosure Statements The presenting faculty reported the following: Dr Yawn receives research funding from Boehringer Ingelheim. Dr Martinez receives advisor and speaker honoraria from Amgen; Carden Jennings Publishing Co, Ltd; CSA Medical, Inc; Forest Laboratories, Inc; GlaxoSmithKline; Ikaria, Inc; Merck & Co, Inc; Nycomed; and PeerVoice; receives honoraria for serving in expert capacity at US FDA meetings from Boehringer Ingelheim, GlaxoSmithKline, and Ikaria, Inc.; receives honoraria/travel costs for European meeting attendance from Boehringer Ingelheim and Nycomed; and Dr Martinez receives honoraria for steering committee participation from GlaxoSmithKline and Janssen Pharmaceuticals, Inc.

Education Partner Financial Disclosure Statement The content collaborators at Miller Medical Communications, LLC, have no financial relationships to disclose.

Suggested Reading List Centers for Disease Control and Prevention (CDC). Chronic obstructive pulmonary disease among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(46);938-943. Gibson PG, Simpson JL. The overlap syndrome of asthma and COPD: what are its features and how important is it? Thorax. 2009;64(8):728-735. Schnell K, Weiss CO, Lee T, et al. The prevalence of clinically-relevant comorbid conditions in patients with physiciandiagnosed COPD: a cross-sectional study using data from NHANES 1999-2008. BMC Pulm Med. 2012;12:26. Mannino DM, Thorn D, Swensen A, Holguin F. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J. 2008;32(4):962-969. Barnes PJ, Celli BR. Systemic manifestations and comorbidities of COPD. Eur Respir J. 2009;33(5):1165-1185. Mackay AJ, Hurst JR. COPD exacerbations: causes, prevention, and treatment. Med Clin North Am. 2012;96(4):789-809. Hurst JR, Vestbo J, Anzueto A, et al; Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) Investigators. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010;363(12):1128-1138. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-365. Maas AK, Mannino DM. Update on the management of chronic obstructive pulmonary disease. F1000 Med Rep. 2010;2. Tashkin DP, Ferguson GT. Combination bronchodilator therapy in the management of chronic obstructive pulmonary disease. Respir Res. 2013;14:49. Belletti D, Liu J, Zacker C, Wogen J. Results of the CAPPS: COPD—assessment of practice in primary care study. Curr Med Res Opin. 2013;29(8):957-966. Perez X, Wisnivesky JP, Lurslurchachai L, Kleinman LC, Kronish IM. Barriers to adherence to COPD guidelines among primary care providers. Respir Med. 2012;106(3):374-381. Joo MJ, Au DH, Fitzgibbon ML, McKell J, Lee TA. Determinants of spirometry use and accuracy of COPD diagnosis in primary care. J Gen Intern Med. 2011;26(11):1272-1277. Joo MJ, Sharp LK, Au DH, Lee TA, Fitzgibbon ML. Use of spirometry in the diagnosis of COPD: a qualitative study in primary care. COPD. 2013;10(4):444-449. Salinas GD, Williamson JC, Kalhan R, et al. Barriers to adherence to chronic obstructive pulmonary disease guidelines by primary care physicians. Int J Chron Obstruct Plumon Dis. 2011;6:171-179.

Presenter Disclosure Information The following relationships exist related to this presentation:

SESSION 3

► Dr Yawn receives research funding from Boehringer Ingelheim.

11am–12:15pm

► Dr Martinez receives advisor and speaker honoraria from Amgen; Carden Jennings Publishing Co, Ltd; CSA Medical, Inc; Forest Laboratories, Inc; GlaxoSmithKline; Ikaria, Inc; Merck & Co, Inc; Nycomed; and PeerVoice; receives honoraria for serving in expert capacity at US FDA meetings from Boehringer Ingelheim, GlaxoSmithKline, and Ikaria, Inc.; receives honoraria/travel costs for European meeting attendance from Boehringer Ingelheim and Nycomed; and Dr Martinez receives honoraria for steering committee participation from GlaxoSmithKline and Janssen Pharmaceuticals, Inc.

Chronic Obstructive Pulmonary Disease - Practical Approaches to Diagnosis and Management SPEAKERS Barbara P. Yawn, MD, MSc, FAAPP Fernando J. Martinez, MD, MS

Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Faculty Chronic Obstructive Pulmonary Disease

Fernando Martinez, MD, MS Professor, Department of Internal Medicine Associate Chief for Clinical Research Division of Pulmonary and Critical Care Medicine  Director, Pulmonary Diagnostic Services University of Michigan Health System Ann Arbor, Michigan

Practical Approaches  to  Diagnosis and Management

Barbara P. Yawn, MD, MSc, FAAFP Director of Research Olmsted Medical Center Adjunct Professor Department of Family and Community Health University of Minnesota Rochester, Minnesota 3

4

Learning Objectives

Friday Afternoon 4:45 PM Visit    

Upon completion of this activity, participants  should be better able to: 



 

Evaluate the role of spirometry in COPD  diagnosis and monitoring Review recommended pharmacologic  interventions to reduce COPD symptoms  and decrease exacerbations

 

  

6

Nancy—56 yo with cc of bronchitis Wants antibiotics before the weekend Coughing more for 2 weeks, productive‐yellow ?Fever, some breathlessness up stairs Does not want to go to the ED again Does not want chest x‐ray The last kind she received worked 11

1

Definition of COPD

What should we do? 

Take more history



– Smoker 35 pack‐years – Third episode of “bronchitis” in past 2 years

Chronic Obstructive Pulmonary Disease  – Common, preventable and treatable disease – Characterized by: 

• Colds last for weeks • Always worse than others

• persistent airflow limitation 

– Decrease in activities due to trouble breathing  with walking.  Now SOB with 6 stairs – Has “smoker’s cough” for past 3 years – Mother developed “asthma” at age 60 and died  of CHF at age 68

Think chronic lung disease!

• 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 burden of disease in individual patients

Vestbo J et al. Am J Respir Crit Care Med. 2013;187(4):347-365.

13

Mechanisms Underlying Airflow  Limitation in COPD

14

Why Is COPD Underdiagnosed? Clinicians Tell All Survey of 278 Clinicians

Small Airways Disease

Parenchymal Destruction

Patient has multiple chronic conditions

• Airway inflammation • Airway fibrosis, luminal plugs • Increased airway resistance

• Loss of alveolar attachments • Decrease of elastic recoil

Patient fails to report/recognize dyspnea

64 48 50 22

Inadequate knowledge and training

33 20 22

Patient lacks specific symptoms

29

Lacks access to spirometry

21 7 5

Lack of effective treatment 0

10

AIRFLOW LIMITATION www.goldcopd.org.

MDs NPs/PAs

45

20

30

40

50

60

70

Perceived Barrier (%)

Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2):311-317.

15

16

The COPD Population Screener (COPD‐PS)

Key Barriers to COPD Diagnosis

1. During the past 4 weeks, how much of the time did you feel short of breath?



None of the time

Failure of patients to notice and report symptoms – Early symptoms often do not interfere with  completing activities of daily living – Symptom severity increases very slowly

Failure of health professionals to inquire about  respiratory issues

Only with occasional colds or chest infections



Underuse of spirometry

2

Yes, a few days a month

Yes, most days a week

1

Strongly disagree

Disagree

2

Yes, every day 2

1

Unsure

Agree

Strongly agree

0

1

2

0

4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE? No

Don’t know

Yes 2

0

0

5. How old are you? Age 35 to 49 Age 50 to 59

Yawn BP, Wollan PC. Int J Chron Obstruct Pulmon Dis. 2008;3(2):311-317.

All of the time

3. Please select the answer that best describes you in the past 12 months: I do less than I used to because of my breathing problems.

0

Misdiagnosis of COPD as asthma  or bronchitis 

Most of the time

1

0

0

– Tools to help—the COPD Population Screener – Be specific 

Some of the time

0

2. Do you ever cough up any “stuff”, such as mucus or phlegm? No, never



A little of the time

0

0

17

1

Age 60 to 69 2

Martinez FJ et al; COPD-PS Clinician Working Group. COPD. 2008;5(2):85-95.

2

Age 70 + 2

19

Key Indicators of COPD

Asthma vs COPD  Feature Onset

COPD

Asthma

Often in midlife

Often in childhood

Family History

Variable

Often

Medical or  Social History

Smoking  (often 20 pack‐years)

Atopy (ie, allergy and/or eczema)

Most notable  during exercise

Most notable at night  or early morning

“Mostly bad days”

“Mostly good days”

May be some reversibility with bronchodilation

Largely reversible  with bronchodilation

Patients report  symptoms as…

Airflow Obstruction

Symptoms  Chronic cough  Chronic sputum production  Dyspnea:  – Progressive, persistent   – Worse with exercise and respiratory infections

Risk Factors  Host factors – Genetics (eg, alpha‐1 antitrypsin deficiency), hyper‐ responsiveness, lung growth 

Briggs DD Jr, et al. J Respir Dis. 2000;21(9A):S1-S21. Doherty DE. Am J Med. 2004;117(suppl 12A):11S-23S.

Exposures – Tobacco,  smoke from cooking fires, occupational dust, flour,  chemicals

20

21

Nancy needs spirometry!

COPD Mis‐Diagnosis Hypothetical Male Patient  With COPD Symptoms

Hypothetical Female Patient With COPD Symptoms

42% diagnosed as COPD  by physicians

32% diagnosed as COPD by physicians

COPD symptoms in women were  most commonly misdiagnosed  as asthma



Needs pre‐ and post‐bronchodilator  to see about reversibility and if she  meets obstruction definition



Needs FEV1 and FVC to determine severity  and how to begin maintenance therapy FVC=forced vital capacity FEV1=forced expiratory volume in 1 second

22

Miravitlles M et al. Arch Bronconeumol. 2006;42(1):3-8.

24

Algorithm for Interpreting  Spirometry Results

Spirometry:  Obstructive Disease Normal

5

FVC  = 5 L

Yes

FEV1/FVC = 0.8

4 Volume, liters

Acceptable Spirogram

FEV1 = 4 L

3

Yes

FVC = 3.2 L FEV1/FVC = 0.56

1

1

2

3

4

5

Is FVC low?

Yes

Is FVC low?

FEV1 = 1.8 L

2

Obstructive

Mixed  obstructive/   restrictive defect  or hyperinflation

6

Further testing

No

Is FEV1/FVC ratio low?

Obstructive defect

No Pure obstruction Near‐total reversal with  use of beta agonist?

Yes

No

Asthma

COPD

Restrictive defect

No Normal

Further testing

Time, seconds Petty TL. Spirometry made simple. National Lung Health Education Program. 1999;8:37,38,41. http://www.nlhep.org/Documents/Spirometry%20Made%20Simple.htm. Published January 1999. Accessed January 5, 2014.

25

3

26

Nancy’s Numbers 

Avoid Interpretation Pitfalls Common Interpretation Errors  Among Family Physicians  (N=12 practices)  new to spirometry use

You do spirometry on Nancy and get the  following results:  Good quality tracing—rated B Pre‐bronchodilator 2.2 L 65% pred FEV1 FVC 4.0 L FEV1/FVC 0.55

• Interpreting a normal result as  an obstructive pattern

Post‐bronchodilator FEV1             2.7 L         68% pred FVC               4.1 L FEV1/FVC     0.66

• Interpreting a poor effort as a  restrictive pattern • Diagnosing COPD in the  absence of an FEV1/FVC ratio