COPD: Guideline based care

Dr John Hurst

Consultant Respiratory Physician

john.hurst@nhs.net

COPD

Chronic BronchitisEmphysema

COPD

Chronic BronchitisEmphysema

PATHOLOGICAL

diagnosis

CLINICAL diagnosis

COPD

Chronic BronchitisEmphysema

PHYSIOLOGICAL

DIAGNOSIS:

Post-BD FEV1/FVC <0.7

Take Home Message

Not every smoker gets COPD

The diagnosis of COPD requires spirometry

Diagnostic Pathway

Diagnosis

Suspect the diagnosis

Case Find (Handheld spiro)

Diagnosis requires post-BD

Big change suggests asthma

Refer if unsure

What are we trying to achieve?

What are we trying to achieve?

Reduction is symptoms

Increase in exercise capacity

Reduction in exacerbations

Preservation of lung function

Take Home Message

The main reasons to optimise treatment are to reduce symptoms, improve exercise, and prevent exacerbations

Value in COPD Care

Value in COPD Care

London Respiratory “Value Pyramid”

Management Pathway

Management Pathway

Take Home Message

The cornerstone of COPD therapy is:

Smoking cessation

Pulmonary Rehabilitation

Influenza and Pneumococcal vaccination

Medicines Management

Responsible Respiratory Prescribing Group endorsed

Very comprehensive

(IMHO): too complex for daily use

GOLD Staging

mMRC ≥2

CAT≥10

mMRC 0-1

CAT<10SYMPTOMS

GOLD Staging

mMRC ≥2

CAT≥10

mMRC 0-1

CAT<10SYMPTOMS

RISK

Exacerbations

≥2*

1

0

GOLD Staging

mMRC ≥2

CAT≥10

mMRC 0-1

CAT<10SYMPTOMS

RISK

Exacerbations

≥2*

1

0

DC

A B A: Low Risk, Fewer Symptoms

B: Low Risk, More Symptoms

C: High Risk, Fewer Symptoms

D: High Risk, More Symptoms

2017 Assessment of COPD

C D

A B

4

3

2

1

RISK

GOLD

Stage

≥

2

1

0

RISK

Exacerbations

FEV1

<30%

30-50%

50-80%

>80%

GOLD A: smoking; vaccines; PR…

Group A

A bronchodilator

Continue, stop or

try alternative class

of bronchodilator

Evaluate

effect

GOLD 2017

GOLD B: smoking; vaccines; PR…

Group B

A long-acting bronchodilator

(LABA or LAMA)

LAMA + LABA

Persistent

symptoms

GOLD 2017

GOLD C: smoking; vaccines; PR…

Group C

LAMA

LAMA + LABA

Further

Exacerbation(s)

LABA + ICS

GOLD 2017

Preferred

GOLD D: smoking; vaccines; PR…Group D

LAMA + LABA

Further

Exacerbation(s)

Consider

macrolide

LAMA LABA + ICS

LAMA + LABA + ICS

Further

Exacerbation (s)

Persistent

symptoms/further

exacerbations

GOLD 2017

Consider roflumilast if

FEV1 <50% pred. and

patient has chronic

bronchitis

PharmacotherapyGroup D

LAMA + LABA

Consider

macrolide

LAMA LABA + ICS

LAMA + LABA + ICS

Further

Exacerbation (s)

Persistent

symptoms/further

exacerbations

GOLD 2017

Consider roflumilast if

FEV1 <50% pred. and

patient has chronic

bronchitis

PharmacotherapyGroup D

LAMA + LABA

Further

Exacerbation(s)

Consider

macrolide

LAMA LABA + ICS

LAMA + LABA + ICS

Further

Exacerbation (s)

Persistent

symptoms/further

exacerbations

GOLD 2017

Consider roflumilast if

FEV1 <50% pred. and

patient has chronic

bronchitis

Additional Considerations

Inhaler technique

New evidence in exacerbation prevention:

ICS-LABA=LAMA

LABA-LAMA>LAMA

LABA-LAMA>ICS-LABA

Steroid Withdrawal

Take Home Message

Pharmacotherapy in COPD is guided by symptoms and exacerbations rather than FEV1

We need to better target inhaled corticosteroids (unlike asthma where ICS go in early!)

COPD versus ASTHMA (and ACO)DIAGNOSE CHRONIC AIRWAYS DISEASE

Do symptoms suggest chronic airways disease?STEP 1

Yes No Consider other diseases first

SYNDROMIC DIAGNOSIS IN ADULTS

(i) Assemble the features for asthma and for COPD that best describe the patient.

(ii) Compare number of features in favour of each diagnosis and select a diagnosis

STEP 2

Features: if present suggest ASTHMA COPD

Age of onset Before age 20 years After age 40 years

Pattern of symptoms Variation over minutes, hours or days

Worse during the night or early

morning. Triggered by exercise,

emotions including laughter, dust or

exposure to allergens

Persistent despite treatment

Good and bad days but always daily

symptoms and exertional dyspnea

Chronic cough & sputum preceded

onset of dyspnea, unrelated to triggers

Lung functionRecord of variable airflow limitation

(spirometry or peak flow)Record of persistent airflow limitation

(FEV1/FVC < 0.7 post-BD)

Lung function betweensymptoms Normal Abnormal

Previous doctor diagnosis of asthma

Family history of asthma, and other

allergic conditions (allergic rhinitis or

eczema)

Previous doctor diagnosis of COPD,

chronic bronchitis or emphysema

Heavy exposure to risk factor: tobacco

smoke, biomass fuels

Time course No worsening of symptoms over time. Variation in symptoms either seasonally, or from year to year

May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks

Symptoms slowly worsening over time (progressive course over years)

Rapid-acting bronchodilator treatment provides only limited relief

Chest X-ray Normal Severe hyperinflation

DIAGNOSIS

CONFIDENCE IN

DIAGNOSIS

Asthma

Asthma

Some features

of asthma

Asthma

Features of both

Could be ACOS

Some features

of COPD

Possibly COPD

COPD

COPD

NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or

COPD suggest that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS

Markedreversible airflow limitation(pre-post bronchodilator) or otherproof of variable airflow limitation

STEP 3PERFORM

SPIROMETRY

FEV1/FVC < 0.7

post-BD

Asthma drugs

No LABAmonotherapy

STEP 4

INITIAL

TREATMENT*

COPD drugs

Asthma drugsNo LABA

monotherapy

ICS, and usually LABA

+/or LAMA

COPD drugs

*Consult GINA and GOLD documents for recommended treatments.

STEP 5

SPECIALISED

INVESTIGATIONS

or REFER IF:

• Persistent symptoms and/or exacerbations despite treatment.• Diagnostic uncertainty (e.g. suspected pulmonary hypertension, cardiovascular diseases and other causes of respiratory symptoms).• Suspected asthma or COPD with atypical or additional symptoms or signs (e.g. haemoptysis, weight loss, night sweats, fever, signs of bronchiectasis or other structural lung disease).• Few features of either asthma or COPD.• Comorbidities present.• Reasons for referral for either diagnosis as outlined in the GINA and GOLD strategy reports.

Past history or family history

Multi-Morbidity

1/3 die from cardiovascular disease

1/4 die from cancer (principally lung cancer)

“What is the blood pressure?”

Summary

1: Not every smoker gets COPD

2: The diagnosis of COPD requires spirometry

3: The main reasons to optimise treatment are to reduce symptoms,

improve exercise, and prevent exacerbations.

4: The cornerstone of COPD therapy is:

Smoking cessation

Pulmonary Rehabilitation

Influenza and Pneumococcal vaccination

Summary

5: Pharmacotherapy in COPD is guided by symptoms and

exacerbations rather than FEV1

6: We need to better target inhaled corticosteroids (unlike asthma where

ICS go in early!)

7: Don’t forger co-morbidity

8: Discuss with the Community Team