Respiratory Index    Asthma in Adults: A Breathless Update (CME206 ‐ CME207)  Asthma in Adults: PBL (CME208 ‐ CME209)  Chronic Obstructive Pulmonary Disorder (COPD): A Breathless Update (CME211 ‐  CME210)   Chronic Obstructive Pulmonary Disorder (COPD): PBL (CME212 ‐ CME213)  Fungal Respiratory Infections: Fungal Lung Infections, Not So Rare (CME214 ‐ CME215)  Influenza Update: Influenza Management in Primary Care (CME216 ‐ CME217)  Influenza Update:PBL (CME218 ‐ CME219)  Obstructive Sleep Apnea: Therapeutic Choices in Sleep Apnea: Tailoring Treatment to  the Patient (CME220 ‐ CME221)  Pneumonia: Community and Hospital‐Acquired, the Forgotten Killer (CME222 ‐ CME223)  Pulmonary Function Testing: Office Spirometry Interpretation (CME224 ‐ CME225) 

ACTIVITY DISCLAIMER Asthma in Adults: A Breathless Update LTC Douglas Maurer, DO, MPH, FAAFP

DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Learning Objectives 1.

Reviewed current NHLBI asthma guideline.

2.

Discussed new EIB guideline.

3.

Evaluated latest evidence for asthma treatment.

4.

Discussed prevention of asthma.

5.

Reviewed some asthma in pregnancy pearls.

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

LTC Douglas Maurer, DO, MPH, FAAFP Program Director, Faculty Development Fellowship, Madigan Army Medical Center, Tacoma, Washington; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Associate Professor, University of Washington School of Medicine, Seattle. LTC Maurer is a graduate of the Ohio University Heritage College of Osteopathic Medicine, Athens, and completed his family medicine residency at Tripler Army Medical Center, Honolulu, Hawaii. He earned a Master of Public Health (MPH) degree at the University of Washington, Seattle, and completed faculty development fellowships in Waco, Texas, and at Madigan Army Medical Center, Tacoma. LTC Maurer served for five years as program director of the Carl R. Darnall Army Medical Center (CRDAMC) Family Medicine Residency in Fort Hood, Texas. He currently practices full-service family medicine with a diverse patient population at Madigan Army Medical Center. Having taught medicine for nearly 20 years, LTC Maurer has won multiple teaching awards, including the 2015 Teacher of the Year award at Madigan Army Medical Center. His research interests include medical simulation, medical apps, student interest in primary care, prevention of obesity, and evidence-based medicine.

Audience Engagement System Step 1

Step 2

Step 3

1

Disclosures How many asthma patients do you see? The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

How do you normally treat them? How comfortable are you treating them?

Practice Recommendations • No changes in current NHLBI asthma guideline • New EIB guideline favors SABA’s not LABA’s • Symptom-based ICS or SiT use may be “OK”

Current Guideline Review

• Careful using LABA’s (but don’t stop them!) • Don’t use LRA’s as monotherapy • Asthma exacerbations tx same in pregnancy!

AES Poll Question #1

Asthma Diagnosis

Which of the following is the correct spirometry criteria to diagnose asthma?

• Reversibility: 12% in baseline FEV1 or 10% of percent predicted FEV1 • Methacholine challenge most sensitive test • Positive: decrease in FEV1 > 20% at 8 mg/mL • Decreased FEV1/FVC suggestive of dz • Normal spirometry does not exclude asthma!

A. B. C. D.

Non-reversible obstruction of at least 10% FEV1 Reversibility of at least 12% in baseline FEV1 Reversibility of at least 5% in baseline FEV1 Non-reversible obstruction of at least 20% FEV1

2

Risk Factors for Asthma • Wheezing before age 3 years • Atopy, allergic rhinitis • Environmental: tobacco smoke, pets, gas cooking, mold, cockroach, dust-mites, cleaning, farming • Perinatal: preterm delivery, maternal smoking • Respiratory infections early in life • Meds: aspirin/NSAIDS (sensitivity only), acetaminophen? • Other: genetics, day care, overweight/obesity

Acute Asthma Treatment • SABA’s drug of choice for acute exacerbations • Systemic corticosteroids reduce relapse, hospitalization, and SABA use • Initial treatment: O2, SABA’s, ipratropium bromide, and systemic corticosteroids* • Severe exacerbations: IV magnesium or heliox

Chronic Asthma Treatment • 4 categories: – Mild intermittent – Mild persistent – Moderate persistent – Severe persistent

AES Poll Question #2 First line maintenance therapy for mild persistent asthma is which ONE of the following? A. B. C. D. E.

Short acting beta agonists (SABA) Long acting beta agonists (LABA) Oral Prednisone Inhaled corticosteroids (ICS) Leukotriene receptor antagonists (LRA)

Chronic Asthma Treatment • Stepwise treatment of categories – SABA only as needed for all categories – ICS preferred controller – LABA’s preferred add-on agent after ICS – LRA’s acceptable controller

3

Severe Asthma • Definition: – Requires high-dose ICS PLUS second agent OR – Oral steroids for ≥ 50% of previous year

• Eval and tx comorbidities: sinusitis, polyps, GERD, OSA, obesity, smoking, etc. • Consider steroid resistance and eosinophilia • Tx with ICS/LABA plus low dose theophylline or tiotropium or omalizumab

AES Poll Question #3 Treatments for exercise induced bronchoconstriction (EIB) include which of the following EXCEPT? A. B. C. D. E.

Short acting beta agonists (SABA) Long acting beta agonists (LABA) Cromolyn Ipratropium bromide Leukotriene receptor antagonists (LRA)

Exercise-Induced Bronchoconstriction • • • • • •

Formal postexercise spirometry for diagnosis SABA 15 min prior to exercise Alternant: mast cell stabilizer, anticholinergic NO LABA’s! If use SABA daily: ICS or LRA Nondrug: warm up first, use mask or scarf

Latest Evidence on Acute Asthma Management

4

ER Management • • • •

Nebulizers no better than MDI’s via spacer Inhaled mag sulfate: no benefit; stick with IV Ketamine showed NO benefit in it’s only RCT Weak data for IV beta agonists + inhaled – NO benefits for adults – Limited evidence in children

ER Management • ICS in the ER for acute exacerbations – Reduced admissions if not treated with oral or IV – May reduce admissions when added to systemic

• Increasing ICS as part of an action plan ineffective • Choice of oral steroid? – Prednisone vs. dexamethasone

Symptom-Based ICS?

Latest Evidence on Chronic Asthma Management

• Govt funded nonblinded RCT with 342 participants • Randomized into 3 groups: – Physician adjusted based on 2007 guideline – Biomarker adjusted based on exhaled nitric oxide – Symptom-based ICS matched puff to puff to SABA

• Symptom-based group with similar outcomes • Used half the dose of steroids as the other groups • 2015 Cochrane: less steroid, no loss of control – Mild asthma patients only, need more studies

Single Inhaler Therapy (SiT) • • • •

Combo formoterol/budesonide (SiT) 4 studies of over 9000 patients; no children < 12 All industry funded SiT reduced: – Asthma exacerbations requiring oral steroids – ER visits and hospitalizations – Adverse events unclear

• NNT 100 to prevent admission or ER visit

ICS plus LABA…Right Away? • • • • • •

Cochrane Review of 27 trials, 8050 participants RCT’s comparing ICS + LABA with ICS alone Combo ICS/LABA no better than ICS alone Higher dose ICS superior to add on LABA Children responded similarly to adults No difference in adverse events

5

ICS plus LABA…Then Again…! • • • •

2016 industry funded RCT, 11,751 pts, > 12 yrs All patients with moderate-severe asthma Fluticasone vs fluticasone-salmeterol BID Primary outcome: first severe asthma exacerbation • Combo reduced exacerbations more than ICS alone (8% vs 10%, NNT = 50 over 26 wks) • No difference in intubations or deaths

How to Stop a LABA? • Prescriber’s Letter recommends: – Step up tx, go to medium ICS before LABA – Step down tx, go to lower dose of combo first – Stop LABA, keep ICS same or double dose – Still symptomatic, restart combo ICS/LABA

When to Stop a LABA? • Black box: stop LABA once asthma controlled • Meta-analysis: 5 studies, 1292 pts says “No” – Patients did WORSE after stopping LABA – Lots of drop-outs due to poor control

• 2015 Cochrane: temporary loss of control

Risks of LABA’s • Cochrane Reviews of LABA safety – 6 deaths in combo formoterol vs. 1 in ICS alone – No difference in non-fatal events – Salmeterol deaths all occurred with drug alone – No diff in head to head comparisons

• Ongoing FDA surveillance studies…

Adult Height and ICS

LRA as Monotherapy?

• Risks appear mild; still concern about height • Govt funded RCT of 1000 children ages 5-13 • Treated with ICS, nedocromil or placebo for 4.3 yrs then enrolled in follow-up study • Height measured in adulthood (mean age 25) • ICS caused modest height reduction of 1.2 cm • Most pronounced in girls

• Industry study: LRA’s “equivalent” to ICS/LABA – Outcomes DOE’s not POEM’s – All “improvements” gone by 2 years

• Cochrane: 65 studies, 10K adults, 3K children – LRA’s more asthma exacerbations (NNH 28) – LRA’s more dropouts for poor control (NNH 31)

• LRA ONLY as add on to ICS and LABA

6

Tiotropium for Asthma? • 2012 industry funded RCT (N=900) – All with asthma not controlled on LABA or ICS – DOE improvements of pulmonary function – POEM decrease in exacerbations

New Asthma Treatments

• 1 less exacerbation after 8 yrs of treatment!

• Multiple Cochrane Reviews in 2014/2015 – LAMA add on therapy improves lung function – No difference in exacerbations of LAMA vs. LABA**

Omalizumab • 2013 Cochrane Review found omalizumab: – – – –

Reduces asthma exacerbations Reduces hospitalizations Well tolerated Reduce/withdraw steroids

• Adjunct to ICS and steroid tapering • FDA approved for ages 6 + with pos skin test • Expensive! One vial: $826!

Dupilumab • • • •

Monoclonal antibody targeting IL-4Ra 104 adults, 18 -65 years, persistent asthma Randomized to dupilumab or placebo x 16 wks Decreased exacerbations when ICS and LABA tapered off BUT no difference as add-on tx! • Not yet FDA approved

Bronchial Thermoplasty • Only FDA approved nondrug asthma therapy • Tube with four RF wires that destroy excess smooth muscle via bursts of heat • One study showed 78% decrease in ER visits! • Risk of exacerbation from procedure itself! • Reserved only for severe asthmatics not controlled on ICS and LABA

Prevention

7

Asthma Action Plans (AAP) • 2013 Cochrane: 13 RCTs (N=2,157), age > 17, ER visit received AAP – Decreased hospitalization, but not ER visits, quality of life or peak flow

• 2008 Cochrane: 36 RCTs, age > 16, evaluated PEF or symptoms plus AAP vs usual care – Decreased hospitalization, ER visits, missed work/school

AES Poll Question #4 Which of the following has been associated with the prevention of asthma and/or asthma exacerbations? A. B. C. D. E.

Probiotics Influenza vaccine Vitamin C Nuts All of the above

Asthma and Supplements • Probiotics during pregnancy or early infancy do not prevent asthma – – – –

Meta-analysis of 20 RCTs included 4866 children Various combinations/doses of probiotics Followed children from 2 to 6 years after birth No evidence of benefit

• Vitamin C not beneficial in asthma – 9 studies, 330 participants – One study with drop in FEV1 post-exercise

Influenza Vaccine • 2013 Cochrane Review of 18 trials – – – –

No reduction in influenza-related exacerbations No apparent risk from inactivated vaccine No risk from live intranasal influenza vaccination Vaccines do not worsen asthma

• Insufficient evidence to determine if asthma attacks prevented by influenza vaccination

Asthma and Supplements • Vitamin D does NOT prevent exacerbations in deficient patients – 250 pt RCT: vitamin D vs placebo; no difference in time to 1st exacerbation

• Caffeine improves airways function for up to four hours – 7 studies of 75 patients – Improved FEV1 by 12-18% – May need to avoid caffeine for at least four hours prior to spirometry

8

Nuts and Pregnancy • • • • • •

Avoiding nuts during pregnancy controversial Danish Birth Cohort of 101,045 pregnancies Self-report data from validated questionnaire Nut intake inversely associated with asthma Consumption may decrease risk of allergies Nut consumption not harmful

AES Poll Question #5 Which of the following is the preferred controller agent for persistent asthma in pregnancy? A. B. C. D. E.

Asthma and Pregnancy • Asthma may improve, worsen or stay the same – Mild: 12.6% exacerbation/2.3% hospitalization Smoking  – Moderate: 25.7%/6.8% – Severe: 51.9%/26.9% cessation!

• 15-20% increased risk of complications – Mortality, pre-e, preterm delivery, low birth weight

Budesonide Albuterol Salmeterol Fluticasone Tiotropium bromide

Asthma and Pregnancy • Medication safety – Albuterol (C), ICS (B/C), LABA (C), LRA (B), Ipratrop (B) – Carboprost (avoid!)

• • • •

“Best” data: albuterol, budesonide, salmeterol Less data: formoterol, LRA’s No diff in malformations b/t ICS vs. LABA/ICS Acute exacerbations in pregnancy tx’ed the same!

• Monitor peak flows bid +/- spirometry

Practice Recommendations • No changes in current NHLBI asthma guideline • New EIB guideline favors SABA’s not LABA’s • Symptom-based ICS or SiT use may be “OK” • Careful using LABA’s (but don’t stop them!) • Don’t use LRA’s as monotherapy • Asthma exacerbations tx same in pregnancy!

Billing and Coding • Asthma: J45. – Allergic (predominantly) asthma – Allergic bronchitis NOS – Allergic rhinitis with asthma – Atopic asthma – Extrinsic allergic asthma – Hay fever with asthma – Idiosyncratic asthma – Intrinsic nonallergic asthma – Nonallergic asthma

9

Billing and Coding • Additional codes – Exposure to environmental tobacco smoke (Z77.22) – Exposure to tobacco smoke in the perinatal period (P96.81) – History of tobacco use (Z87.891) – Occupational exposure to environmental tobacco smoke (Z57.31) – Tobacco dependence (F17.-) – Tobacco use (Z72.0)

Billing and Coding When services performed in conjunction with: Office Visit 992xx 99406-99407 Smoking and tobacco use cessation counseling (3-10 minutes, >10 minutes) G0436-G0437 Smoking and tobacco use cessation counseling, asymptomatic patient (3-10 minutes, >10 minutes) Medicare use codes Additional 94010 94060 +94729 94664 94760 94761 94640

tests to confirm or monitor: Spirometry Pulmonary function testing, pre- and postDLCO Demonstration of aerosol generator, nebulizer, metered dose inhaler, or IPPB device Pulse oximetry;single determination ;multiple determinations (i.e., six-minute walk) Nebulizer treatment

Billing and Coding J45.2J45.3J45.4J45.5J45.9-J45.90-

Mild intermittent asthma Mild persistent asthma Moderate persistent asthma Severe persistent asthma Other and unspecified asthma Unspecified asthma

Fifth character: Fifth character: Fifth character: Fifth character:

J45.901 J45.902 J45.909 J45.99J45.990 J45.991 J45.998

Unspecified asthma with (acute) exacerbation Unspecified asthma with status asthmaticus Unspecified asthma, uncomplicated Asthma NOS Other asthma Exercise induced bronchospasm Cough variant asthma Other asthma

0, 1, 2 0, 1, 2 0, 1, 2 0, 1, 2

Asthmatic bronchitis NOS Childhood asthma NOS Late onset asthma

Learning Objectives • Reviewed current NHLBI asthma guideline • Discussed new EIB guideline • Evaluated latest evidence for asthma treatment • Discussed prevention of asthma • Reviewed some asthma in pregnancy pearls

Contact Information LTC Douglas Maurer, DO, MPH, FAAFP

Questions?

[email protected]

10

Associated Session • Asthma in Adults: PBL Interested in More CME on this topic? aafp.org/fmx-pulmonary

11

ACTIVITY DISCLAIMER Asthma in Adults: PBL LTC Douglas Maurer, DO, MPH, FAAFP

DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Learning Objectives

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

LTC Douglas Maurer, DO, MPH, FAAFP Program Director, Faculty Development Fellowship, Madigan Army Medical Center, Tacoma, Washington; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Associate Professor, University of Washington School of Medicine, Seattle. LTC Maurer is a graduate of the Ohio University Heritage College of Osteopathic Medicine, Athens, and completed his family medicine residency at Tripler Army Medical Center, Honolulu, Hawaii. He earned a Master of Public Health (MPH) degree at the University of Washington, Seattle, and completed faculty development fellowships in Waco, Texas, and at Madigan Army Medical Center, Tacoma. LTC Maurer served for five years as program director of the Carl R. Darnall Army Medical Center (CRDAMC) Family Medicine Residency in Fort Hood, Texas. He currently practices full-service family medicine with a diverse patient population at Madigan Army Medical Center. Having taught medicine for nearly 20 years, LTC Maurer has won multiple teaching awards, including the 2015 Teacher of the Year award at Madigan Army Medical Center. His research interests include medical simulation, medical apps, student interest in primary care, prevention of obesity, and evidence-based medicine.

Audience Engagement System Step 1

1. Reviewed diagnosis and assessment of asthma.

Step 2

Step 3

2. Discussed treatment of stable asthma. 3. Treated asthma exacerbations 4. Evaluated asthma in pregnancy

1

Practice Recommendations • No changes in current NHLBI asthma guideline • New EIB guideline favors SABA’s not LABA’s

Chief Complaint “Wheezing with exercise and allergies. Plus I cough a lot at night.”

• Symptom-based ICS or SiT use may be “OK” • Careful using LABA’s (but don’t stop them!) • Don’t use LRA’s as monotherapy • Asthma exacerbations tx same in pregnancy!

History of Present Illness “Jane”: 24 year old female • Presents today for her WWE/pap • Reports cough keeping her awake at night • Short of breath/wheezing with exercise • Allergies this summer were really bad

Medications, Allergies • • • • •

Fluticasone nasal spray QD Fexofenadine 180mg QD Etonogestrestrel subdermal implant NKDA Environmental allergies year round, but worst in the spring/summer • Bothered by smoke, animal dander

Past Medical History • History of childhood asthma: “grew out of it” • Allergic rhinitis

Immunizations • Declines flu vaccine this season • Completed HPV vaccine series

2

Family History • Father: HTN, diabetes • Mother: asthma, allergies • Brother: no issues

Social History • • • • •

Review of Systems • Denies: – Fever – Chills/sweats – Weight loss – Inhaler use – Hospitalization/intubation for breathing problems

What Is Your Differential Diagnosis?

Single, has female roommate, 1 cat, 1 dog Drinks 2-3 beers on the weekends Smokes “only when out with friends” Denies other drugs/substances In monogamous relationship with fiancée

Physical Examination • • • • • • •

VS: 98.9, 60, 115/70, 18, 99%, BMI 24 Gen: alert, oriented, no acute distress HEENT: pale swollen turbinates, post nasal drip CV: RRR, no M/R/G Lungs: CTA x 2, rare end exp wheeze bilaterally Abd: nl BS, NT, ND, no TTP, masses Pelvic/pap: wnl

What Labs/Rads/Work-up?

3

Laboratory/Radiology/Work-up • Pap smear: wnl • CXR: no acute disease • Spirometry:

Does This Patient Have Asthma?

– FVC: 90% predicted – FEV1: 70% predicted – Reversibility: 15%

Asthma Diagnosis • Reversibility: 12% in baseline FEV1 or 10% of percent predicted FEV1 • Methacholine challenge most sensitive test • Positive: decrease in FEV1 > 20% at 8 mg/mL • Decreased FEV1/FVC suggestive of dz • Normal spirometry does not exclude asthma!

How Would You Treat Jane?

Chronic Asthma Treatment • Stepwise treatment of categories – SABA only as needed for all categories – ICS preferred controller – LABA’s preferred add-on agent after ICS – LRA’s acceptable controller

4

Jane Returns 6 Months Later… • • • • •

Asthma interfering with her job SOB several times per week Several nights past month couldn’t sleep Using her SABA once per day x 2 months She can’t find her asthma action plan

Is Jane’s Asthma Under Control? What Is Her Asthma Control Test (ACT) Score?

Is Jane’s Asthma Under Control? What Is Her Asthma Control Test (ACT) Score?

What Medication(s) Would You Prescribe Now? Other Treatments/Recommendations?

5

Jane Goes to the ER Jane Returns 1 Month Later… Now Her ACT Score Is 18…What Now?

• • • • •

3 days of progressive SOB, wheezing Roommate has URI and so does fiancée Afebrile, 110, 22, 130/80, 90% RA Diffuse wheezing bilaterally CXR: no acute disease, hyperexpanded

ER Management How Would You Treat Jane’s Asthma Exacerbation?

• • • •

Nebulizers no better than MDI’s via spacer Inhaled mag sulfate: no benefit; stick with IV Ketamine showed NO benefit in it’s only RCT Weak data for IV beta agonists + inhaled – NO benefits for adults – Limited evidence in children

ER Management • ICS in the ER for acute exacerbations – Reduced admissions if not treated with oral or IV – May reduce admissions when added to systemic

• Increasing ICS as part of an action plan ineffective • Choice of oral steroid?

Please Write Jane a New Asthma Action Plan and Explain It to Her!

– Prednisone vs. dexamethasone

6

1 Year Later… • Jane has since gotten married! • She reports that she just found out she is pregnant (confirmed by clinic test) • Per LMP and US she is 12 weeks • She is taking PNVs and her subdermal implant was removed 6 months ago

Asthma and Pregnancy • Asthma may improve, worsen or stay the same

Would You Make Any Changes to Jane’s Medications?

– Mild: 12.6% exacerbation/2.3% hospitalization Smoking  – Moderate: 25.7%/6.8% – Severe: 51.9%/26.9% cessation!

• 15-20% increased risk of complications – Mortality, pre-e, preterm delivery, low birth weight

• Monitor peak flows bid +/- spirometry

Asthma and Pregnancy • Medication safety – Albuterol (C), ICS (B/C), LABA (C), LRA (B), Ipratrop (B) – Carboprost (avoid!)

• • • •

Asthma Apps • STAT Asthma

• Asthma Point of Care

“Best” data: albuterol, budesonide, salmeterol Less data: formoterol, LRA’s No diff in malformations b/t ICS vs. LABA/ICS Acute exacerbations in pregnancy tx’ed the same!

7

Practice Recommendations

Learning Objectives

• No changes in current NHLBI asthma guideline

• Reviewed diagnosis and assessment of asthma

• New EIB guideline favors SABA’s not LABA’s

• Discussed treatment of stable asthma

• Symptom-based ICS or SiT use may be “OK” • Careful using LABA’s (but don’t stop them!) • Don’t use LRA’s as monotherapy

• Treated asthma exacerbations • Evaluated asthma in pregnancy

• Asthma exacerbations tx same in pregnancy!

Contact Informaton LTC Douglas Maurer, DO, MPH, FAAFP

Questions?

[email protected]

Associated Session • Asthma in Adults: A Breathless Update Interested in More CME on this topic? aafp.org/fmx-pulmonary

8

ACTIVITY DISCLAIMER Chronic Obstructive Pulmonary Disorder (COPD): A Breathless Update LTC Douglas Maurer, DO, MPH, FAAFP

DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Learning Objectives 1. Examined COPD diagnosis and assessment.

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

LTC Douglas Maurer, DO, MPH, FAAFP Program Director, Faculty Development Fellowship, Madigan Army Medical Center, Tacoma, Washington; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Associate Professor, University of Washington School of Medicine, Seattle. LTC Maurer is a graduate of the Ohio University Heritage College of Osteopathic Medicine, Athens, and completed his family medicine residency at Tripler Army Medical Center, Honolulu, Hawaii. He earned a Master of Public Health (MPH) degree at the University of Washington, Seattle, and completed faculty development fellowships in Waco, Texas, and at Madigan Army Medical Center, Tacoma. LTC Maurer served for five years as program director of the Carl R. Darnall Army Medical Center (CRDAMC) Family Medicine Residency in Fort Hood, Texas. He currently practices full-service family medicine with a diverse patient population at Madigan Army Medical Center. Having taught medicine for nearly 20 years, LTC Maurer has won multiple teaching awards, including the 2015 Teacher of the Year award at Madigan Army Medical Center. His research interests include medical simulation, medical apps, student interest in primary care, prevention of obesity, and evidence-based medicine.

Audience Engagement System Step 1

Step 2

Step 3

2. Discussed treatment of stable COPD. 3. Evaluated treatment of acute exacerbations. 4. Reviewed the latest COPD evidence.

1

Disclosures

Practice Recommendations • Must have spirometry for COPD diagnosis

The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

• Long acting bronchodilators (LABAs/LAMAs) 1st • Add inhaled corticosteroids if LABAs/LAMAs fail • Prednisone 40mg x 5 days for exacerbations • Non-invasive ventilation for severe exacerbations

COPD Defined 2016 GOLD Guideline Updates

AES Poll Question #1 Spirometry is required to make a diagnosis of COPD? A. True B. False

• “Common preventable and treatable disease, characterized by 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 patients.” • Causes: tobacco smoke, air pollution, occupational dusts and chemicals, genetic

COPD Diagnosis • Consider if: dyspnea, chronic cough, sputum, and risk factors (smoking, family history, etc.) • Spirometry required for diagnosis • USPSTF does not rec screening for COPD in asymptomatic adults (D) • GOLD advocates “active case finding”

2

AES Poll Question #2 Which of the following spirometry results is consistent with a COPD diagnosis? A. B. C. D. E.

Postbronchodilator FEV1/FVC < 90% Postbronchodilator FEV1/FVC < 80% Postbronchodilator FEV1/FVC < 70% Non-reversible obstruction of at least 20% FEV1 Non-reversible obstruction of at least 10% FEV1

AES Poll Question #3 Assessment of the COPD patient per the 2016 GOLD guidelines includes all of the following EXCEPT? A. B. C. D. E.

Symptoms Spirometry Medications Exacerbation risk Comorbidities

Spirometry Categories • Positive: postbronchodilator FEV1/FVC < 70% • GOLD 1: mild, FEV1 ≥ 80% predicted • GOLD 2: moderate, 50% ≤ FEV1 10 minutes)

• • • • • • •

94010 94060 94729 94664 94760 94761 94640

•

J44.9 Chronic obstructive pulmonary disease, unspecified – Chronic obstructive airway disease NOS

Spirometry Pulmonary function testing, pre- and postDLCO Demonstration of aerosol generator… Pulse oximetry;single determination Multiple determinations (i.e., six-min walk) Nebulizer treatment

Billing and Coding • •

J44.-Other chronic obstructive pulmonary disease • Includes: – Asthma with chronic obstructive pulmonary disease – Chronic asthmatic (obstructive) bronchitis – Chronic bronchitis with airways obstruction – Chronic bronchitis with emphysema – Chronic emphysematous bronchitis – Chronic obstructive asthma – Chronic obstructive bronchitis – Chronic obstructive tracheobronchitis

Excludes: – Bronchiectasis (J47.-) – Chronic bronchitis NOS (J42) – Chronic simple and mucopurulent bronchitis (J41.-) – Chronic tracheitis (J42) – Chronic tracheobronchitis (J42) – Emphysema without chronic bronchitis (J43.-) – Lung diseases due to external agents (J60J70)

And Yes, There Are Apps!

iOS app: $5.99  (no Android version)

iOS app: Free     (no Android version)

9

Learning Objectives 1. Examined COPD diagnosis and assessment. 2. Discussed treatment of stable COPD. 3. Evaluated treatment of acute exacerbations. 4. Reviewed the latest COPD evidence.

Practice Recommendations • Must have spirometry for COPD diagnosis • Long acting bronchodilators (LABAs/LAMAs) 1st • Add inhaled corticosteroids if LABAs/LAMAs fail • Prednisone 40mg x 5 days for exacerbations • Non-invasive ventilation for severe exacerbations

Contact Informaton LTC Douglas Maurer, DO, MPH, FAAFP

Questions?

[email protected]

Billing & Coding When services performed in conjunction with: Office Visit    992xx  99406‐99407  Smoking and tobacco use cessation counseling (3‐10 minutes,  >10 minutes) G0436‐G0437  Smoking and tobacco use cessation counseling, asymptomatic  patient (3‐10 minutes, >10 minutes) Medicare use codes

10

Billing & Coding (Continued) Additional tests to confirm or monitor: 94010 Spirometry 94060 Pulmonary function testing, pre‐ and post‐ +94729 DLCO Demonstration of aerosol generator, nebulizer, metered dose inhaler,  94664 or IPPB device 94760 Pulse oximetry;single determination 94761 ;multiple determinations (i.e., six‐minute walk) 94640 Nebulizer treatment

Associated Session • Chronic Obstructive Pulmonary Disorder (COPD): PBL

Interested in More CME on this topic? aafp.org/fmx-pulmonary

11

ACTIVITY DISCLAIMER Chronic Obstructive Pulmonary Disorder (COPD): PBL LTC Douglas Maurer, DO, MPH, FAAFP

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. This activity is supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Learning Objectives 1. Evaluated COPD diagnosis with spirometry.

LTC Douglas Maurer, DO, MPH, FAAFP Program Director, Faculty Development Fellowship, Madigan Army Medical Center, Tacoma, Washington; Associate Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Associate Professor, University of Washington School of Medicine, Seattle. LTC Maurer is a graduate of the Ohio University Heritage College of Osteopathic Medicine, Athens, and completed his family medicine residency at Tripler Army Medical Center, Honolulu, Hawaii. He earned a Master of Public Health (MPH) degree at the University of Washington, Seattle, and completed faculty development fellowships in Waco, Texas, and at Madigan Army Medical Center, Tacoma. LTC Maurer served for five years as program director of the Carl R. Darnall Army Medical Center (CRDAMC) Family Medicine Residency in Fort Hood, Texas. He currently practices full-service family medicine with a diverse patient population at Madigan Army Medical Center. Having taught medicine for nearly 20 years, LTC Maurer has won multiple teaching awards, including the 2015 Teacher of the Year award at Madigan Army Medical Center. His research interests include medical simulation, medical apps, student interest in primary care, prevention of obesity, and evidence-based medicine.

Audience Engagement System Step 1

Step 2

Step 3

2. Practiced COPD assessment and grading. 3. Discussed treatment of stable COPD. 4. Practiced treatment of acute exacerbations

1

Practice Recommendations

Chief Complaint

• Must have spirometry for COPD diagnosis

“I have had a chronic cough for months and am short of breath when walking up stairs.”

• Long acting bronchodilators (LABAs/LAMAs) 1st • Add inhaled corticosteroids if LABAs/LAMAs fail • Prednisone 40mg x 5 days for exacerbations • Non-invasive ventilation for severe exacerbations

History of Present Illness “John”: 68 year old male • Cough productive of white/yellow sputum • Worse in morning after waking x 6 months • Short of breath with exercise or stair climbing

Medications, Allergies • • • • •

Metformin 1000mg BID Lisinopril 20mg QD Atorvastatin 20mg QHS Aspirin 81mg QD NKDA

Past Medical History • • • • •

Type II diabetes Hypertension Hyperlipidemia Tobacco use Obesity

Immunizations • Declines flu vaccine this season • PPSV23 at age 65 • PCV13 last year

2

Family History • Father: died of lung cancer at age 70, HTN, HLP, DMII • Mother: died of an MI at age 80, HTN, HLP, breast cancer • Brother: has CAD, HTN, HLP, DMII

Social History • • • •

Review of Systems • Denies: – Fever – Chills/sweats – Weight loss – Chest pain – Hospitalizations for breathing problems

What Is Your Differential Diagnosis?

Lives with his wife; two children out of home Drinks 2 beers/night Smokes 1ppd x 50 years Denies other drugs/substances

Physical Examination • • • • • • •

VS: 98.9, 80, 130/75, 18, 95%, BMI 32 Gen: alert, oriented, no acute distress Neck: no JVD CV: distant HS, RRR, no M/R/G Lungs: distant BS, CTA x 2 Abd: obese, nl BS, NT, ND, no TTP, masses Extrem: no edema, normal monofilament

What Labs/Rads/Work-up?

3

Laboratory/Radiology/Work-up • Normal CBC, normal chemistry, HbA1c: 7.2 • CXR: no acute disease, flattened diaphragms • Spirometry:

Does This Patient Have COPD?

– FVC: 80% predicted – FEV1: 60% predicted – FEV1/FVC: 0.65

Assessment of COPD What Grade of COPD?

Step 1: Symptoms: various questionnaires Step 2: Airflow limitation: spirometry (GOLD 1-4) Step 3: Risk of exacerbations: low or high Step 4: Comorbidities: various Combined assessment: Grade A-D

http://www.catestonline.org

4

Assess Exacerbation Risk • Low risk: 0-1 exacerbations per year

• High risk: 2 or more exacerbations per year OR FEV1 < 50%

Assess Comorbidities • • • • •

CV disease Metabolic syndrome Osteoporosis Depression Lung cancer Don’t forget to treat these too!!

Combined Assessment of COPD So Now What Stage COPD?

Combined Assessment of COPD How Would You Treat John?

5

Patient

Recommended First  Choice

Alternative Choice

Theophylline

SABA and/or SAMA Theophylline

• CAT score: 30

SABA and/or SAMA Theophylline

• COPD exacerbations: 2 in past year

A

B

LAMA  or LABA

LAMA and LABA

ICS + LABA or LAMA

LAMA and LABA or LAMA and PDE4‐inh. or LABA and PDE4‐inh.

ICS + LABA and/or LAMA

ICS + LABA and LAMA or ICS+LABA and PDE4‐inh. or LAMA and LABA or LAMA and PDE4‐inh.

D

How Would You Treat John, IF:

LAMA or LABA  or SABA and SAMA

SAMA  prn or SABA prn

C

Other Possible Treatments

• FEV1: 45% predicted

Carbocysteine SABA and/or SAMA Theophylline

Patient

Combined Assessment of COPD

Recommended First  Choice

Alternative Choice

Other Possible Treatments

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

ICS + LABA or LAMA

LAMA and LABA or LAMA and PDE4‐inh. or LABA and PDE4‐inh.

ICS + LABA and/or LAMA

ICS + LABA and LAMA or ICS+LABA and PDE4‐inh. or LAMA and LABA or LAMA and PDE4‐inh.

C

D

SABA and/or SAMA Theophylline

Carbocysteine SABA and/or SAMA Theophylline

John Gets Sick • Presents to clinic: – 3 days progressive SOB – Cough productive of green sputum

Should John Be Admitted?

• T 101.5, RR 22, BP 140/90, O2 Sat 85% RA

6

Management of Exacerbations How Would Your Treat Him?

• Oxygen: titrate to SpO2 88-92% • Bronchodilators: short acting beta-agonists with or without short acting anticholinergics • Steroids: 40mg prednisone daily x 5 days • Antibiotics: many options; give if: – 2/3 cardinal symptoms: inc dyspnea, inc sputum volume, inc sputum purulence – Inc sputum purulence and one other symptom – Patient requires mechanical ventilation

Indications for Admission • • • • • • • •

Marked increase in intensity of symptoms Severe underlying COPD Onset of new physical signs Failure to respond to initial management Presence of serious comorbidities Frequent exacerbations Older age Insufficient home support

COPD Apps •

COPD Pocket Consultant

•

GOLD COPD Guidelines

Indications for ICU Admission • Severe dyspnea not responding to initial therapy • Mental status changes • Severe hypoxemia (PaO2 < 40 mmHg) and/or acidosis (pH 20

• Crackles (rales)

Blood Cultures

• Early pneumonia

• Positive BC in 0% - 14%

• ↓ Breath sounds

Ebell MH. Predicting pneumonia in adults with respiratory illness. Am Fam Physician. 2007;76(4):562

• Pneumocystis

• 13 studies

• Temp > 100⁰F (37.8⁰C) • HR > 100

False Negative CXRs

Impact of Blood Cultures

Two Clinical Signs

• Yield halved by prior antibiotic treatment

Wikimedia Commons

Blood Cultures

• No longer required for non-ICU CAP patients as of January 1, 2014 by CMS or JACHO – NNT - 143 to effect management – False positives increase LOS

• Rarely effects management – Sepsis and endocarditis

• Clean well, don’t hurry, get at least 7 ml of blood – 3% increase in yield with each ml

Howie N, et al. Emerg Med J. 2007 Mar;24(3):213-4 Kelly AM. J Accid Emerg Med. 1998 Jul;15(4):254-6

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• Useful with

Sputum Cultures

– Lung cavities

– Poor response to outpatient therapy – Pleural effusion

– ICU admissions

Sputum Studies

• 40% - 60% unable to produce sputum • 45% - 50% inadequate because of contamination

• 80% yield with pneumococcal pneumonia • 40% pneumonias multiple organisms, can‘t narrow antibiotics based on culture Musher DM, et al. Clin Infect Dis 2004; 30:165-169

Who Needs Blood Cultures?

• Cavitation

• Alcoholics, end stage liver disease • Critically ill

• Neutropenia • Asplenia

• Pleural effusion

Pulse Oximetry

• All admitted patients - CMS guideline

• pO2 ≤ 90% good specificity for adverse outcomes

• Admit all hypoxic patients

– Oxygen saturation < 90%

– Arterial saturation < 60 mm Hg on room air

Wikimedia Commons

Primary Care Respiratory Journal (2010) 19(4): 378-382

Limits of Pulse Oximetry - CO

• Requires normal hemoglobin • Oxygen or carbon monoxide read the same – Same absorption peaks (920 nm)

• False normal readings with

– Carbon monoxide poisoning – Smoke inhalation – Cigarette smoking

• Can be hypoxic with normal pulse oximetry

Limits of Pulse Oximetry

• Anemia will have less oxygen

– Low oxygen, normal saturation

• Requires pulsating blood – low profusion – – – – –

Hypothermia Hypotension Vasoconstriction Peripheral vascular disease Low cardiac output

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Other Studies

Urine Antigen Testing

• Urine antigen for S. pneumoniae in moderate to high severity

• Higher yield in more severe illness • Pneumococcal disease

• Urine antigen for Legionella in high severity

– 15 minute results

• PCR for mycoplasma

– 50% - 80% sensitivity, > 90% specific

• Chlamydophila antigen and/or PCR detection tests when psittacosis suspected • Viral studies

– Works after ABX begun

• Legionella

– Detects subgroup 1; 80%-95% of Legionella CAP

Thorax 2009;64:iii1-iii55 doi:10.1136/thx.2009.121434

Indications for Extensive Tests

ICU

Indication

Outpatient failure

Blood Culture

X

Cavities

X

Alcoholism

X

Leukopenia

X

Liver Disease

X

Severe COPD Asplenia

X

Recent Travel

+Legionella UAT

+Pneumococcal UAT Pleural Effusion

X X

Sputum Culture

Legionella UAT

Pneumococcal UAT

X

X

X

X

X

X X

X

X X X X

X X

X X

X

X X

Pleural Effusions

• 20% - 60% of CAP

• Tap most mild to moderate effusions • Treat transudates with antibiotics

• Repeat taps or chest tube for exudates

X

Mandell LA, et al. Clin Infect Dis. 2007;44(suppl 2):S40

Reasons to Avoid Hospitalization

• 25 times greater cost

INPATIENT OR OUTPATIENT?

• 80% prefer outpatient

• Faster return to activity • Lower mortality

• Thromboembolic events

• Hospital resistant bacteria ATS pneumonia guidelines, 2007

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Port or PSI

Mortality of Hospitalized CAP • 14% mortality in hospitalized patients • 30% inpatient mortality in elderly • Comorbidities

• PNA Outcomes Research Team

• PSI – Pneumonia Severity Index

– COPD, diabetes, renal insufficiency, HF, CAD, cancer, chronic liver disease Niederman MS et al. Am J Respir Crit Care Med. 2001; 163:1730-1754

PORT: Step 1: Class I or Classes II-V

Presence of:

> 50 years of age

Altered mental status

Yes/No

Pulse ≥ 125/min

Respiratory rate > 30/minute SBP < 90

Temperature < 35⁰C or ≥ 40⁰C

History of:

Neoplastic disease Heart failure

Cerebrovascular disease Renal disease Liver disease

Any YES’s, proceed to Step 2

All NO’s, assign to Risk Class 1

PORT Severity Index

Demographic factors: Age (in years)

Points

• Female

Age – 10 yrs

• Male

• Nursing home

Age

Age + 10 yrs

Outpatient mortality 0.1%

PORT Severity Index

Coexisting Conditions Points – Neoplastic Disease – Liver Disease – CHF – Cerebrovascular – Renal Disease

+30 +20 +10 +10 +10

PORT Severity Index

Initial Exam Findings

– Altered mental Status – Respiratory rate >30 – Systolic 30 Na < 130 Glucose ≥ 250 Hct < 30 APO2 < 60 or O2 < 90% Pleural effusion

Points +30 +20 +20 +10 +10 +10 +10

CURB-65 Scoring

• One point for each

– Respiratory Rate > 30

– Blood pressure (SBP < 90, DBP < 60)

• • • • • •

30 Day Mortality

II

Outpatient

0.6%

IV

Inpatient

I

≤70

71-90

BUN ≥ 20 Confusion/disorientation Hypotension needing aggressive IV fluids Hypothermia < 96.8⁰F WBC < 4,000 Multilobar infiltrates PaO2/FiO2 ratio ≤ 250 RR ≥ 30 Platelets < 100,000

>130

Inpatient

V

Inpatient

0.1%

0.9-2.8%

8.2-9.3%

27.0-29.2%

CURB-65 Treatment Site Mortality % 0.6% 2.7%

2

6.8%

3

14.0%

4 or 5

27.8%

Risk

Suggested Site

Low

Outpatient

Moderate

Short stay/ Supervised outpatient

High

Inpatient/ICU

Moderate to high

Inpatient

British Thoracic Society

Major

• Invasive mechanical ventilation • Septic shock needing vasopressors

Mandell LA et al. Clin Infect Dis. 2007;44(suppl 2):S38

Outpatient

III

91-130

Score

Site of Therapy

British Thoracic Society

Criteria for Severe CAP

Minor (3)

None

1

– Uremia (BUN > 19)

• • •

Risk Class

Score

0

– Confusion

– Age ≥ 65

PORT Severity Index

ICU Admission for CAP

• S. pneumoniae • Legionella

• H. Influenza

• Staph aureus Image source: U.S. Navy

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HOSPITAL-ACQUIRED PNEUMONIA

• • • • •

Health Care-Associated Pneumonia

Inpatient for ≥ 2 days in previous 90 days Nursing home or ECF Home infusion therapy Hemodialysis in previous 30 days Family member with multidrug-resistant pathogen • Immunosuppressive disease or therapy ATS and IDSA

Inpatient Pathogens

Non-ICU

ICU

• S. pneumoniae

• S. pneumoniae

• C. pneumoniae

• Legionella species

• M. pneumoniae • H. influenza

• Legionella species • Aspiration • Viruses

• Staphylococcus aureus • Gram-negative Bacilli • H. influenza

Prevention of HAP

• Hand washing

• Noninvasive ventilation • Breaks in sedation

• Assess for extubation

• Keep head of bed at 30⁰ to 45⁰ • Control glucose

Mandell et al. Clin Infect Dis 2007;44:S27-72

Antibiotic Timing

• Antibiotics within 4 hours of arrival to hospital

TREATMENT OF PNEUMONIA

– Mortality 6.8% v. 7.4% – 0.4 day shorter LOS

Houck PM et al. Arch Intern Med. 2004;164(6):637

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IDSA Empiric Antibiotics for CAP (Outpatient) Macrolide (strong I) Doxycycline (weak III)

Previously Healthy No ABX in past 3 months Comorbidities (heart, lung, liver, renal, DM, alcoholism, cancer, asplenia, immunosuppression) ABX in past 3 months

Regions with >25% high-level macrolideresistance

IDSA Empiric Antibiotics for CAP (Inpatient)

Inpatients Non-ICU ICU

Respiratory quinolone (strong I) β lactam (high dose) + Macrolide (strong I)

Pseudomonas

Respiratory quinolone (strong I) β lactam (high dose) + Macrolide (strong I)

MRSA

Respiratory Quinolone(strong I) or Anti-pneumococcal β lactam + macrolide (strong I) β lactam + Macrolide or resp quinolone (strong I) PCN allergy – resp quinolone + aztreonam Antipseudomonal β lactam + antipseudomonal quinolone or Antipseudomonal β lactam + aminoglycide + azithromycin or Antipseudomonal β lactam (PCN allergy – aztreonam) + aminoglycoside + antipseudomonal quinolone (mod III) Add Vancomycin or Linezolid (mod III) Mandell et al. Clin Infect Dis 2007;44:S27-72

Mandell et al. Clin Infect Dis 2007;44:S27-72

Initial ABX Selection and Outcome in Elderly, 30-Day Mortality 2nd

Initial Antibiotic

Generation Cephalosporin + Macrolide

Hazard Ratio (95% CI) 0.71 (0.52-0.96)

Non-pseudomonal 3rd Generation Cephalosporin + Macrolide

0.74 (0.60-0.92)

Fluoroquinolone alone

0.64 (0.43-0.94)

β-lactam/β- lactamase inhibitor + Macrolide

1.77 (1.28-2.46)

Aminoglycoside + Other Agent

1.21 (1.02-1.43)

Gleason PP et al. Arch Intern Med. 1999 Nov 22;159(21):2562-72.

Percentage of Macrolide Exposure From 2002-2011 61.% of population has had macrolide use in 9 years

Atypical Coverage for Bacteremic Pneumonia • 2,209 Medicare admissions for Bacteremic pneumonia from home or nursing facility • Any atypical coverage

– ↓ 30 day mortality, OR 0.76 – ↓ 30 day readmission, OR 0.67

• Benefits confined to macrolides, not fluoroquinolones nor tetracycline's – ↓ In-hospital mortality, OR 0.59 – ↓ 30 day mortality, OR 0.61 – ↓ 30 day readmission, OR 0.59

Mark L et al. Chest. 2007;131(2):466-473

Risk Factors Resistant Pneumococcus • > 65 years • Β-lactam, macrolide, or fluoroquinolone therapy within the past 3 to 6 months • Alcoholism • Comorbidities • Immunosuppressive illness or therapy • Exposure to child in daycare center

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Steroids For Inpatient CAP

• Meta analysis 12 trials

Switch to Oral Therapy

• Hemodynamically stable • Clinically improving

– All-cause mortality RR 0.67

• Able to ingest meds

– Mechanical ventilation RR 0.45 – ARDS 0.24

– Time to clinical stability - 1.22 days – Time for hospitalization - 1 days Ann Intern Med. Published online 11 August 2015

• Normally functioning GI tract

• Inpatient observation is no longer needed

– No difference in mortality nor readmission rate ATS Pneumonia guidelines 2007

Duration of Antibiotic Therapy • Minimum of 5 days

Response to Therapy

• Expect improvement in 3 days • 6% - 15% may not respond

• 7 days if fever persists after 4 days

• Pneumococcal pneumonia

• Expect improvement at day 3

– Cough resolves in 8 days

– Crackles clear in 3 weeks

Risk Factors for Response Failure

• Multilobar

• Cavitation

• Chest CT

• Liver disease

• Bronchoscopy

• Leukopenia

Menéndez R et al. Thorax. 2004;59(11):960

• Repeat history – travel, pet exposure

• Repeat CXR, sputum and blood cultures

• Pleural effusion • High PSI Index

Treatment Failures, Further Evaluation

• Lung biopsy Wikimedia Commons

Clin Infect Dis. 2007;44 Suppl 2:S27

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• • • • • • •

Clinical Stability at Discharge

Temp > 37.8⁰C RR > 24 HR > 100 SBP ≤ 90 O2 sat < 90% on room air Can‘t eat No mental status improvement

• If one parameter of instability present at discharge then

– Death rate 14.6% v. 2.1%

– Readmission 14.6% v. 6.5%

Simple Recommendations Mild CAP, no resistance

Doxycycline

Moderate CAP with comorbidity

Azithromycin + cefuroxime

Moderate CAP, recent ABX use Inpatient moderate CAP Severe inpatient CAP

Azithromycin + high dose amoxicillin IV azithromycin + ceftriaxone Cefepime + Fluoroquinolone

Dagan E et al. Scand J Infect Dis. 2006;38(10):860

Follow-up Chest X-ray?

• CXR responses lags behind clinical response • CXR response varies (age, #lobes)

– Under 50, no pulmonary disease; clears in 4 weeks – Older with underlying lung disease; clears in 12 weeks

• Get follow-up CXR with

PREVENTION OF PNEUMONIA

– Pleural effusion – Endotracheal tube

Mitl RL et al. Am J Respir Crit Care Med. 1994;149(3 Pt 1):630.

Pneumococcal Vaccination CAP Hospitalization

Hazard Ratio

Outpatient pneumonia

Pneumococcal bacteremia Death from any cause

Jackson LA et al. N Engl J Med 2003;348:1747-1755

1.21

1.14 0.58 0.88

Problems with Polysaccharide Vaccine

• Ineffective under age 2 • Not lifelong

• No mucosal immunity

– No protection from upper or lower tract infection – Little herd immunity

– No help with carrier rates

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Conjugated Vaccine (PCV 13)

• Mucosal immunity and longer lasting • Adults 19 and older with

– asplenia, sickle cell disease, cerebrospinal fluid leaks, cochlear implants, or other immunosuppressing conditions

• Should get PCV13 first followed in 8 weeks by PPSV23 • If PPSV23 already given, give PCV13 one year later

Pneumococcal Vaccines Prevents bacteremia

PVC13

PPSV23

+

?

Limits non-Bacteremic pneumonia Prevents colonization

Response in young children Faster immune response More strains

+

+

+ + +

+

Influenza Vaccination

• 17,393 admissions for CAP in 4 year study – November thru April

PPSV23 BLUNTS RESPONSE TO PCV13

• 1590 vaccinated patients significantly less likely to die (odds ratio = 0.30)

• Influenza may increase pneumococcal susceptibility by 100 fold Spaude KA, et al.. Arch Intern Med. January 8, 2007;167:53–9

Antibiotics for Acute Respiratory

• 814,000 patients, 1.5 million visits

• 65% were diagnosed with bronchitis

• Significant minor adverse side effects in treated group • Less hospitalizations for pneumonia in antibiotic group – NNT is 12,225

Meropol SB et al. Ann Fam Med March/April 2013 vol. 11 no. 2 165-172

Centers for Disease Control and Prevention's Public Health Image Library (PHIL)

Time for a Vitamin D Slide • Finnish study of 1,421 subjects from 1998-2001 • Lowest 1/3 had 2.5 risk of pneumonia than those with high levels University of Eastern Finland. "Low vitamin D levels a risk factor for pneumonia." ScienceDaily. ScienceDaily, 30 April 2013

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Other Risk Reducers

Statins and Pneumonia

• High socioeconomic status

• 18 studies

• Recent dental examination • Statins

– RR 0.84 for CAP

Image source: U.S. Food and Drug Administration

– RR 0.68 short-term mortality Wikimedia Commons

Practice Recommendations

• Learn guidelines, they have potential to improve mortality

Khan AR, Riaz M, Bin Abdulhak AA, et al. The role of statins in prevention and treatment of community acquired pneumonia: a systematic review and meta-analysis. PLoS One. 2013;8(1):e52929

Questions?

• Discharge when switched to orals • Immunize against pneumococcal disease with both vaccines and influenza • Be rich with nice teeth

Billing & Coding

When services performed in conjunction with: Office Visit 992xx *

WILLIAM R. SONNENBERG, MD [email protected]

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Interested in More CME on this topic? aafp.org/fmx-pulmonary

18

Clare Hawkins, MD, MSC, FAAFP

Pulmonary Function Testing: Office Spirometry Interpretation

Family Medicine Residency Program Faculty, Houston Methodist Hospital; Lead Physician for Aspire Healthcare in Texas, Board Chair, Texas Academy of Family Physicians

Clare Hawkins, MD, MSC, FAAFP

Dr. Hawkins practices family medicine at a federally qualified health center in Houston, Texas and works in outpatient Palliative Care. He has been teaching for 29 years. He serves on the AAFP Commission on the Health of the Public and Science and the subcommittee on Clinical Practice Guidelines His topics of specialty include patient-physician relationships and patient-centered communication; physician work-life balance; pulmonary conditions; palliative care; health care reform; and sexually transmitted infections. Dr. Hawkins believes the greatest challenge facing family physicians is communicating the value of family medicine to the public, legislators, and colleagues in other specialties.

ACTIVITY DISCLAIMER

Learning Objectives

The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

DISCLOSURE

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

1.

Establish protocols for notification of when guidelines recommend the use of pulmonary function testing to detect, confirm, and monitor obstructive airway diseases (e.g. asthma, COPD, dyspnea).

2.

Instruct patients regarding proper pulmonary function testing technique.

3.

Recognize the interpretation of spirometry-normal values, obstructive and restrictive physiology.

4.

Evaluate training needs to administer spirometry tests and interpret and validate results in symptomatic patients.

Audience Engagement System

Step 1

Step 2

Step 3

All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

1

Who & When to Test for COPD

1.Establish protocols for notification of when guidelines recommend the use of pulmonary function testing to detect, confirm, and monitor obstructive airway diseases (e.g. asthma, COPD, dyspnea).

Guidelines-Protocols

• Asthma:

– NHLBI EPR-3 National Asthma Education & Prevention Program (2007)

• COPD:

– WHO-GOLD 2016 – (ACP 2013) – NICE, Australian, VA, ACP Exacerbation

• Other

Recommend testing for….

• Patients who are current or former smokers, and those who develop frequent viral infections, for symptoms that may indicate COPD or related conditions.

Symptoms Triggering COPD Assessment with Spirometry

• Chronic cough, which may be daily and productive, but can also be intermittent and unproductive • Breathlessness on exertion, initially intermittent and becoming persistent • Sputum production: any pattern of sputum production may indicate COPD • Frequent exacerbations of bronchitis • A history of exposure to risk factors, especially tobacco smoke, occupational dusts, home cooking and biomass fuels.

Screening Spirometry?

• Only Screen Symptomatic Patients • Pack-Year thresholds for Case-Finding? • “Lung Age” as a motivation to Stop Smoking • Inadvertent Reassurance

Polling Slide

• You have a patient who has a 20 pack year smoking history and has a cough. What is the likelihood that they have COPD? A. 20% B. 30% C. 40% D. 50% E. 60%

2

Natural History of Smoking & FEV1

Coding and Reimbursement Procedure

CPT Code

Single Spirometry Pre-post spirometry Pulmonary stress test simple

Medication administration bronchodilator supply separate Demonstration / instruction Smoking Cessation 80

Moderate

50 to 79

Severe

30 to 49

Very severe

Severity of restriction FVC

Mild

– Measure of caliber or function of airway – NOT A COMPARISON TO REFERENCE VALUES

• More accurate than Peak Flow

• • • •

Vital Capacity

Inspiratory Capacity

Tidal Volume Expiratory Reserve Volume

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

Lung Volumes

Functional ERV + RV = Residual Capacity

% of predicted >50 to 64

Severe

• 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

65 to 80

Moderate

Three Numbers

% of predicted

• FEV1/FVC 70

Caveat

– Overestimates COPD diagnosis in Elderly – Underestimates COPD diagnosis in those under age 45

Residual Volume

4

Normal Flow Volume Curve (Expiratory)

12

8

Flow (L/sec)

Coaching “Blow, Blow, Blow!”

PEF R

10

6

FEV

4

1

2 0

0

1

2

3

4

Volume (L)

5

6

Public Health Image Library, (PHIL), # 19298, Daniel A. Singer, MD, MPH, Medical Officer 2014 http://phil.cdc.gov/phil/details.asp accessed 8/11/16, public domain

Normal, Obstructed, & Restrictive Curves

Inspiratory Volume Loop

1 2 1 0

Normal Obstruction Restriction

8

Flow (L/sec)

Expiratory

6 4

Flattened Inspiratory Loop Indicating possible Extrathoracic Obstruction

2 0

0

1

2

3

Volume (L)

4

5

6

Is FEV1 / FVC Ratio Low? (10 >10

4. Obstruction Severity

mMRC

High Risk, Less Symptoms