copd 202 management

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COPD 202MANAGEMENT

Barbara P. Yawn, MD, MSc, FAAFPBig Sky March, 2021

Department of Family and Community HealthUniversity of Minnesota

Disclosures

Barbara P. Yawn, MD, MSc, FAAFP, discloses that she serves on the advisory board for AstraZeneca, Boehringer Ingelheim, GSK and Teva.

All relevant financial relationships have been mitigated.

NOTE: This CME activity includes discussion about medications not approved by the US Food and Drug Administration and uses of medications outside of their approved labeling.

Learning Objectives

Participants in this presentation will be better able to:• Move beyond diagnosis to longterm management• Expand COPD team to include patients and families• Individualize guideline-recommended therapy • Select COPD therapy in context of holistic approach

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4COPD, chronic obstructive pulmonary diseaseGlobal Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020

Breathlessness Wheezing Chronic cough Sputum production Chest tightness

COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors, including abnormal lung development

Most common symptoms of COPD

COPD: Definition and symptoms

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Confirmation of COPD

Spirometric indices1,2

FVC Total volume of air that a person can forcibly exhale after taking a deep breath

FEV1 Volume of air that a person can exhale in the first second of a forced expiration

FEV1/FVC ratio

Percentage of a person’s vital capacity that he/she is able to expire in the first second of a forced expiration

COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020; 2. Barreiro TJ and Perillo I. Am Fam Physician. 2004;69:1107-1114; 3. Spirometry for health care providers. Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2010. Available at: https://goldcopd.org/wp-content/uploads/2016/04/GOLD_Spirometry_2010.pdf. Accessed Aug 24, 2020; 4. Rush L. Prim Health Care. 2018;28:34-41; 5. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2020. Available at: https://ginasthma.org/. Accessed Aug 24, 2020

Pre-bronchodilator and post-bronchodilator fixed ratio of FEV1/FVC

Not fully reversibleFixed FEV1/FVC ratio < 0.705

In Their Own Words:The COPD Patient Experience Their Own WordsIt feels like I’m drowning or

smothering.

You get depressed over it because

you can’t go out. You can’t

move…stuck in the house

You know what my fear is?...One day not being able to breathe on my own. Struggling, having to be on a machine…Just the idea of maybe one

day I suffocate to death because I can’t get enough air.

Everything is an effort—to get up, to move, to breathe.

A lot of the functions that you would normally do are limited,

such as you can’t reach for things. It’s hard to bend over.

It also affects your personality—it’s hard to be happy when you’re

facing constant imminent changes.

“Sometimes I can’t even get up and go to the bathroom because I have to get on my

face oxygen to help me breathe.

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Impact of COPD on patient functionalityImpact of COPD on patient functionality

• Mortality: Marked• Exacerbations: Frequent• Hospitalizations: Recurrent• Symptoms: Daily• Activity: Limited• Quality of life: Poor• Costs: High

Vestbo J, et al. Am J Respir Crit Care Med. 2013;187(4):347-65.Benton M, et al. Respirology. 2018 Mar 4. doi: 10.1111/resp.13285.Surveill Summ. 2002;51(6):1-16

Self-reported COPD vs no COPD.*Age-adjusted.Mannino DM. MMWR

Patient Burden of COPD

“Getting OLD”What she tells you• Angela is 50• “Bad cold again”• Still off cigarettes• HTN—usually take pills—BP OK at

pharmacy• “Depressive menopause” • “Getting old” and “smoker cough

still”• Thinking it may be time to retire

• Stairs at school library• Denies chest pain or GI symptoms

Physical examination• 138/90, 20, 80, 99.6, 94% (Pulse Ox)• HEENT—OK, no JVD• Lungs---maybe basilar rales+/-

• Coughs with deep breaths• Abdomen—negative• Extremities—maybe trace edema

What you see in EHR or from intake• Antibiotics 3x for cold or bronchitis • To ED twice for respiratory issues• GYN put on estrogen for “depression”• mMRC grade 2 but 3 with “bad cold”

Impact on symptoms and lungfunction

Negativeimpact on

quality of life

Impact Of COPD Exacerbations

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

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Severe Exacerbations Per Year – All-Cause Mortality

Reproduced from Severe Acute Exacerbations and Mortality in Patients with Chronic Obstructive Pulmonary Disease. Soler-Cataluna JJ, Martinez-Garcia MA, Sanchez PR, Salcedo E, Navarro M, Ochando R. Thorax, volume 60, pages 925-931, © 2005 with permission from BMJ Publishing Group Ltd.

1.0

0.8

0.6

0.4

0.2

0.00 10 20 30 40 50 60

Prob

abili

ty o

f Sur

vivi

ng

Time (months)

P <.0002

A

B

P =.069

C

P <.0001

No exacerbations1–2 exacerbations≥3 exacerbations

*Severe exacerbations = exacerbation required emergency department visit or hospital admission

A Paradigm Shift in Management Is Needed: Treat-to-Target

Achieve & Maintain Stable

Disease

Symptoms

QOL• ADL, functioning

Risk of Future Events

HCRU Risk of death

Acute Treatment of

Exacerbations

ADL, activities of daily living;HCRU, healthcare resource utilization; QOL, quality of life

Traditional Care Recommended Care

Global Initiative for Chronic Obstructive Lung Disease Inc. https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf. Accessed September 17, 2020.

• No exacerbations or only mild exacerbation yearly• Slow decline in lung function

• Slow or no increase in dyspnea

• Time horizon?• New idea and still being defined• This is a chronic progressive disease

• Can we slow or stop progression?

What is stable COPD?

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3

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Category 1 Category 2 Category 3 Category 4

Axi

s Titl

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Axis Title

Chart Title Series 1Series 2Series 3

Reduce symptoms Reduce risk

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Relieve symptoms

Increase exercise tolerance

Improve health status

Slow down disease progression

Reduce and treat exacerbations

Decrease mortality

Goals for treatment of stable COPD

COPD, chronic obstructive pulmonary diseaseGlobal Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020

Steps to Achieve & Maintain Stable Disease

Ach

ieve

& M

aint

ain

Stab

le D

iseas

e

Eliminate/Minimize risk factors

Initiate individualized therapy early; escalate

as needed

Nonpharmacologic

Pharmacologic

Identify & treat comorbidities

Diabetes, CHD, anxiety, depression,

musculoskeletal

Provide preventive therapy

Smoking cessationInfluenza &

pneumococcal vaccination

• Involve

multidisciplinary care team

• Optimize follow up,

transitions in care

• Promote self-

management

• Nurture hope

COPD Co-morbidities

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ATS Panel: Barriers to Optimal Care in COPD

Poor communication

Ineffective discharge guidance

Lack of effective follow-up

Limited efforts to engage patients &

family

Patient not placed at

center of careFragmented

care

Press BG, et al. Ann Am Thorac Soc. 2019;16(2):161-170.

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Initial pharmacological therapy1

In patients with a major discrepancy between the perceived level of symptomsand severity of airflow limitation, further evaluation is warranted

≥ 2 moderate exacerbations or ≥ 1 leading

to hospital admission

0 or 1 moderate

exacerbation(not leading to

hospital admission)

Exac

erba

tion

hist

ory

Symptoms

A bronchodilator LABA or LAMA

Group C

Group A Group B

Group D

mMRC 0-1CAT < 10

mMRC ≥ 2CAT ≥ 10

LAMALAMA or

LAMA+LABA* orICS+LABA**

*Consider if highly symptomatic (eg, CAT > 20)**Consider if eosinophil count is≥ 300 cells/µL

Bronchodilators remain the cornerstone

of COPD management2

For patients with severe breathlessness in GOLD groups B or D, initial therapy with a LAMA+LABA

may be considered1

CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; mMRC, modified Medical Research Council1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020; 2. Beeh KM. Tuberc Respir Dis (Seoul). 2016;4:241-247

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Axi

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Axis Title


Symptoms AssessedCough

Mucus production

Chest tightness

Dyspnea on exertion

Activity limitationsConfidence leaving

homeSleep disturbance

Energy level

CAT

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1CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; mMRC, modified Medical Research Council1. Fletcher CM. Br Med J. 1960;2:1662; 2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020; 3. Jones PW, et al. Eur Respir J. 2009;34:648-654

mMRC Dyspnea Scale1,2

Please tick in the box that applies to you (1 box only)

Grade 0 I only get breathless with strenuous exercise

Grade 1 I get short of breath when hurrying on the level or walking up a slight hill

Grade 2I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level

Grade 3 I stop for breath after walking about 100 meters or after a few minutes on the level

Grade 4 I am too breathless to leave the house or I am breathless when dressing or undressing

mMRC grade (range: 0-4)

2

Pharmacological therapy

COPD, chronic obstructive pulmonary disease; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist1. Beeh KM. Tuberc Respir Dis (Seoul). 2016;4:241-247; 2. Nici L, et al. Am J Respir Crit Care Med. 2020;201:e56–e69

Balance of benefits of dual therapy outweighs risks of

monotherapy2

LAMA+LABA combination therapy

LAMA or LABA monotherapy

Bronchodilators remain the cornerstone of COPD management1

2

Types of bronchodilators used to treat airway obstruction in COPD

LAMAsBind to muscarinic receptors and

block the bronchoconstrictive effects of acetylcholine binding1

Antagonists

Cholinergic pathwayCholinergic receptors are located on

smooth muscle cells; activation by acetylcholine increases peripheral airway

resistance1

Adrenergic pathwayβ2-adrenergic receptors are located on smooth muscle cells; activation by β2-

agonists results in relaxation of bronchial smooth muscle1,2

LABAsBind to β2-receptors to

induce bronchodilation and smooth muscle relaxation2

Agonists

Bronchodilators act by improving lung function and reducing dynamic hyperinflation at rest and during exercise3,4

LAMAs and LABAs have complementary mechanisms of action

COPD, chronic obstructive pulmonary disease; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist1. Barnes PJ, et al. Nat Rev Dis Primers. 2015;1:15076; 2. Ohar JA and Donohue JF. Semin Respir Crit Care Med. 2010;31:321-333; 3. O'Donnell DE, et al. Eur Respir J. 2004;23:832-840; 4. O'Donnell DE, et al. Eur Respir J. 2004;24:86-94

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Dual bronchodilator therapy (LAMA+LABA)

Increases FEV1 (Evidence A)

Reduces symptoms (Evidence A)

Reduces exacerbations (Evidence B)

LAMA+LABA1

Compared with monotherapy

Also improves QoL2,3

FEV1, forced expiratory volume in 1 second; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; QoL, quality of life; RCT, randomized controlled trial1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020; 2. Buhl R, et al. Eur Respir J. 2015;45:969-979; 3. Singh D, et al. Respir Med. 2015;109:1312-1319

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© 2020 Global Initiative for Chronic Obstructive Lung Disease

Pharmacological and non-pharmacological therapy should be adjusted as necessary and further reviews undertaken


*Not all medications and formulations are available in the United States


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Following implementation of therapy, patients should be reassessed for attainment of treatment goals and identification of any barriers for successful treatment. Following review of the patient response to treatment initiation, adjustments in pharmacological treatment may be needed.

• Why is COPD no longer stable?• What about adherence?

• Taking medications as prescribed?

• Using good inhaler technique?

• Experiencing other barriers/difficulties?

• Comorbidities under control?• Do you need to intensify treatment?• Preventive care plan?

• Smoking cessation, vaccinations

What do you do if the patient no longer has stable COPD?


Continuing adjustments in therapy are based on symptoms and exacerbations with strategies for each

Incorporate recent evidence from clinical trials and biomarkers--blood eosinophil counts to guide ICS therapy for exacerbation prevention.

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A Key Step at the Time of an Exacerbation

Post-discharge Visit5 to 7 days after discharge

Review all medications and devicesCo morbidities

Support at homePulmonary rehabilitation

Smoking cessationInhaler technique

2

Follow-up after being hospitalized for exacerbation– New patient: her primary care recently retired

*Fictional patient

CA

SE

STU

DY

ACE, angiotensin-converting enzyme; BMI, body mass index; CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; DPI, dry powder inhaler; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; JVP, jugular venous pressure; LABA, long-acting β2-agonist; mMRC, modified Medical Research Council; PFT, pulmonary function test; SABA, short-acting β2-agonist

Barbara* 56 years oldAdministrative assistant

Medical history

• Ex-smoker• LABA/LAMA and a SABA as needed• Steroids and antibiotics in hospital--Pneumovax® at

discharge• Comorbid

‒ Hypertension: ACE inhibitor ‒ Diabetes: metformin and sulfonylurea‒ Hypercholesterolemia: statin

Physical exam

• BMI: 40.2 kg/m2

• No respiratory distress• Decreased air movement

bilaterally• No pedal edema• JVP normal

Chest x-ray • Normal

Spirometry findings

• FEV1/FVC‒ Pre-bronchodilator: 0.67‒ Post-bronchodilator: 0.66

• FEV1: 49% predicted• FVC: 78% predicted

Symptoms scores

• mMRC dyspnea scale: 3• CAT: 25

3*Fictional patient

CA

SE

STU

DY

CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; RBC, red blood cell ; WBC, white blood cellGlobal Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020

Barbara* 56 years oldAdministrative assistant

Complete blood count report

Hemoglobin 12.5 g/dL

RBC count

AdequateTotal WBC count

Platelet count

Differential WBC count• Eosinophils 200 cells/µL

Points to consider before deciding treatment:

• Need for optimizing bronchodilator therapy

• Factors to consider for use of ICS (blood eosinophils)

• Risk/benefits associated with long-term use of ICS

Group D

LAMA orLAMA+LABA* or

ICS+LAMA+LABA**

*Consider if highly symptomatic (eg, CAT > 20)**Consider if eosinophil count is ≥ 300 cells/µL

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3

STRONG SUPPORT CONSIDER USE AGAINST USE

• History of hospitalization(s) for exacerbations of COPD*

• ≥ 2 moderate exacerbations of COPD per year*

• Blood eosinophils† > 300 cells/µL

• History of, or concomitant, asthma

• 1 moderate exacerbation of COPD per year*

• Blood eosinophils† 100-300 cells/µL

• Repeated pneumonia events

• Blood eosinophils† < 100 cells/µL

• History of mycobacterial infection

Adding ICS to LAMA + LABA--Factors to consider

Role of ICS in COPD

*Despite appropriate long-acting bronchodilator maintenance therapy†Note that blood eosinophils should be seen as a continuum; quoted values represent approximate cut points; eosinophil counts are likely to fluctuateCOPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020

Adjusted rate ratios of hospitalization for pneumonia associated with current use and dose of ICS*,1,2

30 1 2

High ICS dose

Medium ICS dose

Low ICS dose

Current use (past 60 days)

No use in past year (reference)

Adjusted rate ratio of hospitalization for pneumonia

70% increase in hospitalization risk due to

pneumonia

ICS and increased risk of pneumonia in patients with COPD

*Case-controlled trial in patients with COPD from Quebec, Canada, from 1988-2003 (N = 175,906)COPD, chronic obstructive pulmonary disease; ICS, inhaled corticosteroid1. Ernst P, et al. Am J Respir Crit Care Med. 2007;176:162-166; 2. Price D, et al. Prim Care Respir J. 2013;22:92-100 3

Non-pharmacological treatment1Non-pharmacological treatment is complementary to pharmacological treatment

and should be a part of the comprehensive management of COPD

Smoking cessation* and trigger identification and avoidance

Pulmonary rehabilitation

Appropriate nutritional advice

Exercise/activityVaccination(flu, pneumococcal)

Attention to comorbidities

Oxygen therapy and ventilatory support

Management of refractory dyspnea to includepalliative care and end-of-life planning

Self-management education• Risk factor management • Proper inhaler technique• Energy conservation

techniques• Written action plan

*Per GOLD 2020, the effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present.1 Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking2

GOLD, Global Initiative for Chronic Obstructive Lung Disease 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Available at: https://goldcopd.org/. Accessed Aug 24, 2020; 2. Bhatta DN and Glantz SA. Am J Prev Med. 2019; pii: S0749-3797(19)30391-5

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Lai CC, et al. Int J Chronic Obstr Pulm Dis. 2019;14:1539-1548.

Single Inhaler Triple Therapy (SIT) vs Single Inhaler Dual Therapy (SID) or Separate Triple Therapy

SGRQ, St. George’s Respiratory Questionnaire; SIT, single inhaler triple therapy*P<0.05

0.69*0.8*

0.97

0

0.25

0.5

0.75

1

1.25

1.5

Moderate/SevereExacerbations

Rate

Ra

tio: S

IT vs

Com

pa

rato

r

SIT vs LABA/LAMA SIT vs ICS/LABA

SIT vs Separate Inhalers

0.03*

-1.59*

0.1*

-1.53*

0.01

0.55

-1.75

-1.5

-1.25

-1

-0.75

-0.5

-0.25

0

0.25

0.5

0.75

Change in FEV1 Change in SGRQ

Mea

n D

iffer

ence

: SIT

vs C

omp

ara

tor

Favo

rs S

ITFa

vors

Com

para

tor

1.38*

1.24

0.88

0

0.25

0.5

0.75

1

1.25

1.5

Pneumonia

Risk

Ra

tio: S

IT vs

Com

pa

rato

r

Efficacy of SIT vs SID: ETHOS Trial

Rabe KF, et al. N Engl J Med. 2020;383(1):35-48.

SID, single inhaler dual therapy (glycopyrronium 18 mcg/formoterol 9.6 mcg or budesonide 320 mcg/formoterol 9.6 mcg); SIT, single inhaler triple therapy (budesonide/glycopyrronium 18 mcg/formoterol fumarate 9.6 mcg)

1.08 1.07

1.421.24

0

0.5

1

1.5

2

Annual rate of moderate-severe COPD exacerbations/patient-

year

1.3%

1.8%

2.3%

1.6%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

% Patients Died

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COPD Maintenance Drug-delivery Devices• pMDIs with and without spacing devices

• DPIs

• Soft mist

• Nebulizers

• Small-volume nebulizers

pMDI = Pressurized metered dose inhaler; DPI = Dry powder inhaler.

https://www.nationaljewish.org/NJH/media/pdf/Inhaled-Medicines-Asthma-Inhaler-COPD-Inhaler-3-22-18.pdf

This is only the front as an exampleCan be download, printed and used in daily practice

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Factors influencing inhalation therapy

Inhaler technique3,

4

Education & training5,6

Adherence7

Behavioral factors1,2 Design and engineering

Particle size8

Aerosol velocity8

Aerosol duration8,9

Internal device resistance10,11

As with all inhaled drugs, the actual amount of drug delivered to the lung may depend on patient factors such as coordination between actuation of the inhaler and inspiration through the delivery system

A relationship between peak inspiratory flow and the efficacy of COPD medications has not been established.

Patient’s inspiratory flow

Patient-related factors Inhaler-related factors

1. World Health Organization. Adherence to Long-term Therapies: Evidence for Action. 2003. Available at: http://www.who.int/chp/knowledge/publications/adherence_full_report.pdf?ua=14. Accessed Aug 24, 2020; 2. von Leupoldt A, et al. Ann Behav Med. 2012;44:52-65; 3. Plaza V, et al. J Allergy Clin Immunol Pract. 2018;6:987-995; 4. Bosnic-Anticevich S, et al. Int J Chron Obstruct Pulmon Dis. 2016;12:59-71; 5. Pothirat C, et al. Int J Chron Obstruct Pulmon Dis. 2015;10:1291-1298; 6. Price D, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:695-702; 7. Darbà J, et al. Int J Chron Obstruct Pulmon Dis. 2015;10:2335-2345; 8. Capstick TG and Clifton IJ. Expert Rev Respir Med. 2012;6:91-101; 9. Dalby RN, et al. Med Devices (Auckl). 2011;4:145-155; 10. Dhand R, et al. Cleve Clin J Med. 2018;85:S19-S27; 11. Gardenhire DS, et al. A Guide to Aerosol Delivery Devices for Respiratory Therapists. 4th edition. American Association for Respiratory Care, 2017. Available at: https://www.aarc.org/wp-content/uploads/2018/03/aersol-guides-for-rts.pdf. Accessed Aug 24, 2020

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Adherence with Inhaled Medications• Do patients with COPD use their

medication?• Many abandon treatment

early1,2

• In 2 months, 50% had refills of <30%3

• Over 12 months, PDC for ICS/LABA was 49%4

• >50% did not fill meds within 90 days of hospitalization5

1. Bender BG. Curr Opin Pulm Med. 2014;20(2):132-137.2. Wurst KE, et al. Int J COPD. 2014;9:1021-1031.3. Davis JR, et al. Am Health Drug Benefits. 2017;10(2):92-102.4. Bogart M, et al. Int J COPD. 2019;14:343-352.5. Baker CL, et al. Int J COPD. 2014;9:431-439.

Even when they do get it---errors

Error type Mean/patientLow peak inspiratory flow 10.0

Multiple inhalations 4.8

Multiple errors 2.3

Blister present, no inhale detected

1.5

Exhaling into the mouthpiece

1.1

Others 1.0

Total 20.7

4

With inadequate inhaler technique errors

Inhaler errors result in 1,2

Courses of oral steroids and antimicrobials2

Symptom control2

Risk of hospitalization and ED visits2

Exacerbations1

ED, emergency department1. Molimard M, et al. Eur Respir J. 2017;49:1601794; 2. Melani AS, et al. Respir Med. 2011;105:930-938

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Strategies for improving inhaler technique in patients

Training is facilitated by

Demonstration and Teach back1,3,4

Videos 1,5 Apps Online support1,5

1. Sanchis J, et al. Chest. 2016;150:394-406; 2. De Blaquiere P, et al. Am Rev Respir Dis. 1989;140:910-916; 3. Nimmo CJ, et al. Ann Pharmacother. 1993;27:922-927; 4. Press VG, et al. J Gen Intern Med. 2011;26:635-642; 5. Savage I and Goodyer L. Fam Pract. 2003;20:552-557

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Pulmonary Rehabilitation• Benefits

• Addresses systemic effects of disease and secondary morbidities

• Improves dyspnea, fatigue, exercise tolerance, emotional function, and health status

• Strongest evidence in moderate/severe disease

• Recommended for GOLD Groups B, C, D

• Optimal benefits achieved from 6-8-week programs

• Barriers• Accessibility, availability, uptake

Pulmonary rehab is associated with ~50% reduction in readmissions following AECOPD.

The RATE OF PULMONARY REHAB use within 12 months of COPD

hospitalization is only 2.7% among MEDICARE beneficiaries

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COPD Patient/Clinician Resources

For links to patient education videos and other clinical resources, please visit our Clinical Resource Center at www.ExchangeCME.com

Quick tips about inhaler devices.• MDI

• Eye/hand coordination• Strength• Most “rescue meds”

• DPI• Don’t shake• Keep in dry place• Don’t take all doses out of sheet• Peak inspiratory flow important

• Soft mist• May be difficult to assemble• On prescription write “AAP” (pharmacist--assemble, active, prime)

• Nebulizers• May only work for one medication• Cleaning

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• Repeat the CAT• Have patient complete in waiting room or examination room*

• Ask about:• Respiratory problems or events• Changes in comorbidities• Changes in activity level (be specific)• Difficulties with prescription refills• Difficulties following the treatment plan• Satisfaction with treatment

Checklist for the COPD Follow-up Office Visit

CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease

*Can be facilitated by using the COPD Foundation application (https://www.copdfoundation.org/Learn-More/The-COPD-Pocket-Consultant-Guide/Healthcare-Provider-Track.aspx?gclid=CjwKCAjwnIr1BRAWEiwA6GpwNZxd9C7jZuLRF55ItEdWb-gVSLyVEc_YaNAi8puwJ_8nymlXeBVrIhoC31wQAvD_BwE)

• Check inhaler technique by observation• Can be done by trained staff

• Review medications patient is taking to be sure they are the ones prescribed

• Requires patient to bring in actual medications instead of a list

• Brand may have been changed by pharmacist due to insurance

• Review patient’s goals and action plan*

Checklist for the COPD Follow-up Office Visit

CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease*Can be facilitated by using the COPD Foundation application (https://www.copdfoundation.org/Learn-More/The-COPD-Pocket-Consultant-Guide/Healthcare-Provider-Track.aspx?gclid=CjwKCAjwnIr1BRAWEiwA6GpwNZxd9C7jZuLRF55ItEdWb-gVSLyVEc_YaNAi8puwJ_8nymlXeBVrIhoC31wQAvD_BwE)

My COPD Action PlanWarning Signs!

Budde J, et al. Chronic Obstr Pulm Dis. 2019;6(2):129-131; Ramsey S, et al. Proc Am Thorac Soc. 2006;3:635–640; Mantero M, et al. Int J Chron Obstruct Pulmon Dis. 2017;12: 2687-2693; Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD), 2020 report. https://goldcopd.org/wp-content/uploads/2019/11/GOLD-2020-REPORT-ver1.0wms.pdf Accessed February 28, 2020.

Red - Emergency SignsRed - Emergency SignsRed - Emergency Signs

Yellow - Warning SignsYellow - Warning SignsYellow - Warning Signs

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Additional Resources

•The COPD Foundation http://www.copdfoundation.org

•The Global Initiative for Chronic Obstructive Lung Disease http://www.goldcopd.org

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