Interprofessional
Clinical Management:
COPD
Angela S. Garcia, PharmD, MPH, CPh
Assistant Professor of Public Health
Nova Southeastern University
College of Osteopathic Medicine
This activity is funded through the Medicaid section 1115(a) Demonstration “Texas Healthcare Transformation and Quality Improvement Program” (Project Number 11-W-00278/6).
Chronic Obstructive Pulmonary Disease
(COPD) Management: Self-Assessment
• What are three primary measures to assess for the
appropriate staging of COPD?
• What management tools are available to increase
communication and care among providers and patients?
• What steps are involved in determining appropriate
medication therapy?
• What education is necessary to communicate to patients
with COPD?
• What opportunities exist for collaborative practices that
integrate best practices in primary care?
Objectives
Upon completion of this module, interprofessional healthcare
providers will be able to:
• Discuss etiology and differences in pathophysiology from asthma
that contribute to growing public health concerns
• Apply strategies from COPD guidelines into best practices for the
care and management of patients
• Utilize validated tools and strategies to improve education and
self-management of COPD
• Identify ongoing opportunities to improve practice care models
and quality of life outcomes
Etiology, Pathophysiology &
Impact on Public Health
• More than 24 million
Americans are living with
COPD1…
• ~15 million patients report a
diagnosis & are being treated
• More than12 million are subclinical,
undiagnosed & at increasing risk
for decompensation
• The number of patients diagnosed
with COPD is growing
• Lack of awareness for screening &
effective treatment  increasing
burden to health care
Adapted from MMWR2002;51(SS06):1-16
http://fleetowner.com/site-files/fleetowner.com/files/uploads/2013/10/cigarettes.jpg
Cause for Concern1
• COPD is reported as the 3rd leading cause of death in the US
• Smoking remains the primary cause of pathogenesis;
however, not every smoker will develop COPD
• Causes of death in COPD are mainly due to
cardiovascular diseases and lung cancer
• Although COPD cannot be cured, it is a
preventable disease & if diagnosed early, may be
managed successfully
• Airflow limitation is not fully reversible and is usually
progressive and associated with abnormal inflammatory
responses further complicating outcomes
Public Health Gaps & Goals with COPD2
• Increase surveillance and reporting
• Improve understanding, awareness, prevention & treatment
• Increase effective collaborations
• Improve communication
• Addressing factors of morbidity and mortality is essential
•
•
•
•
Improve early diagnosis and treatment
Smoking Cessation
Reduce hospitalizations & health complications
Reduce deaths
Updating definitions of COPD3
• COPD has been defined as having either
chronic bronchitis or emphysema
• More accurate/updated definition addresses 3 mechanisms
related to pathogenesis and development of COPD
• Loss of support of small airways leading to collapse  Emphysema
• Chronic inflammation in the small airways  Bronchiolitis/Small
Airway Disease
• Presence of mucus in the small airways  Bronchiolitis/Airflow
Obstruction
Pathophysiologic Hallmarks & Symptoms4,5
• The pathophysiologic hallmark of COPD is expiratory flow
limitation; whereas the most common symptom is dyspnea
• Lung hyperinflation
• Abnormal  in volume of air remaining in the lungs at the end
of spontaneous expiration
• Resultant of the permanent destructive changes of
emphysema & expiratory flow limitation
Physiologic Consequences1,4,5
• Thoracic hyperinflation  flattening of diaphragm muscles;
chest wall reconfiguration  barrel chest
• Systemic Comorbidities
• Extrapulmonary effects: cachexia & skeletal muscle
dysfunction
• Comorbid risks: sleep disorders, diabetes,
fracture/osteoporosis, depression, MI, etc.
• Adverse effects (AE) from ↑ number of medications and
prolonged therapy
Phenotypes & Frequency & Disparity1,5
Clinical Phenotypes
• Pink Puffer: emphysema is the primary underlying pathology
• Blue Bloater: chronic bronchitis is the primary underlying pathology
Disease Frequency Measures
• Exacerbation Frequency
• Lung Function & Symptomology
Gender & Racial Disparities
• Women vs. Men
• Caucasian vs. Minority
Key Indicators for Diagnosis1,3
• Consider COPD as a diagnosis & perform spirometry if the
patient is >40 with the presence of:
• Progressive dyspnea (exercise induced or persistent)
• Intermittent and/or unproductive cough
• Any pattern of chronic sputum production
• History of risk factors
• Tobacco smoke, home cooking/heating fuels,
occupational exposures
http://www.bostonmagazine.com/health/blog/2013/04/12/lung-disease-treatment/
Spirometry2,3,5-7
• Gold standard measurement for confirmation of COPD
diagnosis
• Forced Vital Capacity (FVC) & Forced Expiratory Volume in
first second of expiration (FEV1) post-bronchodilator:
• Decreases in the FEV1/FVC ratio indicates airflow obstruction
or non-reversible airflow limitation FEV1/FVC <0.7
• Airflow obstruction associated with COPD (FEV1 <80%
predicted) with normal ranges depend on age, sex, & height
Guidelines & Best Practices
• Reduce symptoms
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Reduce risk
• Prevent disease progression
• Prevent & treat exacerbations
• Reduce mortality
• Increase utilization of GOLD guidelines for treatment &
Management of COPD
http://thenypost.files.wordpress.com/2013/11/lungs.jpg
Goals for Treatment of Stable COPD1,3,5
Classification of Severity & Clinical
3,5
Presentation of COPD
 Global Initiative for Chronic Obstructive Lung Disease
(GOLD) classification/staging
 2 measures for basis of disease severity
 Objective  spirometric measurement
 Subjective  self-report symptoms, complications, &
exacerbation history
 Staging assists with targeted education, research and
guidance management strategies
Global Initiative for Chronic Obstructive Lung
Disease (GOLD)5
Stage
Classification
III
Severe
Spirometry
FEV1/FVC < 0.7
30% ≤ FEV1 < 50%
predicted
IV
Very Severe
FEV1/FVC < 0.7
FEV1 < 30% predicted
OR
FEV1 < 50% predicted +
chronic respiratory
failure
Clinical Presentation
• Despite combo therapy & ↓ in risk factors: ↑
clinical symptoms, ↑sputum purulence & chest
tightness
• ↑ incidence of respiratory infections
• Consider adjuvant therapies
• Recommendation: pulmonary rehabilitation
• Despite combo therapy & ↓ in risk factors: ↑
clinical symptoms, ↑sputum purulence & chest
tightness
• ↑ hospitalizations, significant deterioration &
exacerbations
• Strong Recommendation: pulmonary
rehabilitation
• Consideration for oxygen therapy
Global Initiative for Chronic Obstructive Lung
Disease (GOLD)5
Stage
Classification
I
Mild
Spirometry
FEV1/FVC < 0.7
FEV1 ≥ 80% predicted
II
Moderate
FEV1/FVC < 0.7
50% ≤ FEV1 < 80%
predicted
Clinical Presentation
• Dyspnea, cough and wheeze
• Risk factor influence
• Airflow obstruction
• PRN monotherapy
• Progression of symptoms despite
combination pharmacotherapy &
decrease in risk factors
• Oxidative capacity: diminished
• Recommendation: pulmonary
rehabilitation
Combined COPD Assessment5
When assessing risk, choose the highest risk category
Adapted from Figure 2.3 GOLD Guidelines 2011
mMRC 0-1
mMRC > 2
CAT < 10
CAT > 10
Symptoms
(mMRC or CAT Score)
• Group A
• Low Risk/Less Symptoms = Stage 1 or Stage 2
• 0-1 exacerbations & mMRC grade 0-1 OR CAT <10
• Group B
• Low Risk/More Symptoms = Stage 1 or Stage 2
• 0-1 exacerbations & mMRC grade > 2 OR CAT > 10
• Group C
• High Risk/Less Symptoms = Stage 3 or Stage 4
• > 2 exacerbations & mMRC grade 0-1 OR CAT <10
• Group D
• High Risk/More Symptoms = Stage 3 or stage 4
• > 2 exacerbations & mMRC grade > 2 OR CAT > 10
http://www.risknewstand.com/wp-content/uploads/2013/01/risk_measurement_400_clr_5483-300x300.png
Comprehensive Risk
5
Measurement
Symptom Assessment: Validated Questionnaires5
• Modified British Medical Research Council (mMRC)
• Disability due to dyspnea
• Correlates to other measures of health status
• Predicts future mortality risk
• COPD Assessment Test (CAT)
• Broad application to ADL and QOL
• Global application
• Correlates to health status using St George Respiratory
Questionnaire (SGRQ)
• High reliability **
First Choice
Patient
Group
Second Choice
Alternative Choice
A
Short-acting anticholinergic (SAAC) PRN
Or Short-acting beta2 agonist (SABA) PRN
LAAC
Or LABA
Or SABA & LAAC
Theophylline
B
Long-acting anticholinergic (LAAC)
Or Long-acting beta2 agonist (LABA)
LAAC & LABA
SABA and/or SAAC
Inhaled corticosteroid + long-acting beta 2
agonist (ICS + LABA)
Or Long-acting anticholinergic (LAAC)
LAAC & LABA
C
Theophylline
Phosphodiesterase 4
Inhibitor
SABA and/or SAAC
Theophylline
D
Inhaled corticosteroid + long-acting beta2
agonist (ICS + LABA)
Or Long-acting anticholinergic (LAAC)
Adapted from GOLD 2012
ICS & LAAC or
ICS + LABA & LAAC or
ICS + LABA & Phos-4 or
LAAC & LABA or
LAAC & Phos 4
Carbocystine
SABA and/or SAAC
Theophylline
• Based on the number of cardinal symptoms
• Worsening of dyspnea
• ↑ in sputum volume
• ↑ in sputum purulence
http://www.cortjohnson.org/wp-content/uploads/2013/05/ChainWhiteW-150x150.jpg
Staging COPD Exacerbation1,3-5
Treatment of COPD1,3,5,7
• Medications do not alter natural course of disease
• May slow progression by controlling symptoms
• Individualized treatment based on
• Symptoms, disease progression, QOL issues
• Progression of disease  unavoidable increase in number of
medications
• Evaluation of therapy & determination of benefit
• Presence or absence of clinical symptoms, response to treatment,
objective evaluation with spirometry
COPD Education &
Management Tools
Clinical Pearls & Benefits to Patients1,3,5
• Recommend smoking cessation
• Inhaler technique (continue to reassess at every encounter
• Be able to explain the difference between different COPD
medications
• Ask your patient, How many doses are left in your inhaler?
Tobacco Cessation
• Smokefree.gov
• Freedom From Smoking® Online/Group Clinics
• Lung HelpLine (American Lung Association)
• Centers for Disease Control and Prevention
• Area Health Education Centers (AHEC)
• Ask and Act Tobacco Cessation Program (AAFP)
• Merck Manual for Smoking Cessation
COPD Risk & Smoking Cessation1,5,7
FEV1 (% of value at age 25)
Never smoked or not
susceptible to smoke
Stopped smoking
at 45 (mild COPD)
Smoked regularly
and susceptible to
effects of smoke
Stopped smoking
at 65 (severe COPD)
Disability
Death
Age (years)
Fletcher C et al. Br Med J. 1977;1:1645–1648.
Patient Education Programs8,9
• Efficacy of programs in the literature has mixed results, but
successful program include key measures
• Medical information about disease
• Self-efficacy & self-management
• Behavioral modification
Pulmonary Education Program (PEP)10
• COPD Foundation developed this education and self-management
curriculum, built around pulmonary rehabilitation services
• Provides clinical support and training necessary for comprehensive
and effective disease management
• Reviews concepts with patients including
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•
•
•
•
Breathing techniques
Nutrition
Relaxation
Oxygen
Travel
Coping with changes (disease progression)
Peer support network
Importance of Immunizations1,5,11,12
• CDC Recommendations based on age, comorbidities, risk
factors
• Inactivated Influenza
• Pneumococcal
• Pertussis
• Infection Prevention
• Preventing communicable diseases (hand washing hygiene,
coughing, etc.)
• Avoid crowds during influenza season
• Good oral hygiene
• Grandchild care & transmission
Grade
Grade 0
Grade 1
Grade 2
Grade 3
Grade 4
Modified Medical Research Council (mMRC) Scale
Description of Breathlessness
I only get breathless with strenuous exercise
I get short of breath when hurrying on level
ground or walking up a slight hill
On level ground, I walk slower than people of the
same age because of breathlessness, or I have to stop
for breath when walking at my own pace on the level
I stop for breath after walking about 100 yards or
after a few minutes on level ground
I am too breathless to leave the house or
I am breathless when dressing
Adapted from GOLD 2012
COPD Assessment Test (CAT)5,13
5-point scale assessing 8 items
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Severity of cough
Quantity of sputum
Dyspnea
Chest tightness
Capacity for exercise & activities
Confidence
Sleep quality
Energy levels
COPD Action Plan and Management Plan
(ALA & Astra Zeneca)
Exacerbation Management3,5,7
• Exacerbation is an acute event with worsening symptoms
beyond normal day-to-day variations leading to
pharmacotherapy modification
• Most common cause is viral/bacterial URI and infections of the
tracheobronchial tree
• Goal: minimizing impact of current exacerbation
• Systemic corticosteroids and antibiotics decrease time to
recovery, improve lung function and arterial hypoxemia,
reduce early relapse/treatment failure/length of hospital stay
Emerging Care Models &
Improving Patient Outcomes
Transitional Care Models9
• Administration on Aging (AOA) has Evidenced-based Care Transitions Grantees in
16 states (including Texas)
• Common Themes:
• Interdisciplinary communication & collaboration
• Transitional care staff
• Patient-centered
• Medication Management
Intervention
• Hospitalization due
• Follow up with
• Enhanced follow-up
to poorly managed
providers
•
•
•
•
•
•
Care Transitions InterventionSM
Bridge Program
BOOST
GRACE
Guided Care®
Transitional Care Model
disease
• Exacerbations
• Comorbidities
Incident
• Discharge Planning
• Evaluation of needs
& gaps
• Planning for
successful selfmanagement
• Community-based
care coordinated
• Reduce burden of
disease and increase
QOL
Prevention
Patient-Reported Outcome Diary8,9
• Quantifies symptoms and exacerbations
• Able to be scored and correlates to disease activity/progression
• Allows physicians develop patient-specific objective measures
• Cost of care secondary to exacerbations is approximated to be
half the overall cost of treating COPD (from hospitalizations)
• Result in lesser quality of life
• Progression of disease
• Severe advanced disease  cause for mortality
Developing a Primary Care Spirometry
Clinic2,7,9
• Target patients ≥ 45 years who are current smokers or those
who recently quit to detect COPD (even if asymptomatic)
• Early screening & early detection
• Provides objective measures to assess treatment
• Stability of lung capacity/lung function
• Changes to lung function that warrant medication modifications or
adjustments
• NLHEP promotes the use of simple spirometry for diagnosis
and monitoring of disease
• “Test Your Lungs, Know Your Numbers,”
• Includes an educational component for patient/caregivers
• Stratification by breathlessness intensity Improvement in
exercise tolerance & alleviate dyspnea
• May prove to be cost-effective measures
with multidisciplinary interventions in the
primary care & ambulatory care levels
• 2 to 3 sessions/week for 6-12 weeks
http://www.bostonmagazine.com/health/blog/2013/04/12/lung-disease-treatment/
Pulmonary Rehabilitation5,7,9,10
The importance of Nutrition in COPD14,15
• A patient with COPD may burn 10 times more calories breathing than a
healthy person leading to nutritional challenges
• Increase their resting energy expenditure (REE) by up to 10 – 15%
• Nutritional care is critical to minimize unwanted weight loss, avoid
losses of fat-free mass (FFM) and improve pulmonary status
• Loss of weight and FFM reducing strength and function of respiratory and skeletal
muscles
• Low BMI (<20kg/sq meter)is associated with poor prognosis  patients with
COPD must maintain energy balance in light of increased caloric needs
• Smaller, frequent, balanced meals (4 to 6) produce less GI distress and
discomfort in breathing and supplemental shakes may be added
• RDN who specializes in COPD is a champion for self-management and
lifestyle changes
Discharge Criteria5 that is Effective for
Ongoing Community-based Management
• Demonstrates correct inhaler technique & timing of rescue
or short-acting medications
• No interruptions in eating and sleeping due to dyspnea
• Adherence to medication & frequent reassessment of
technique
• Education about disease management & medication
regimen
• Assessment for long-term oxygen therapy
• Comorbidity management
Reimbursement Opportunities for Primary
Care & Community-based Interventions
• Expanding the role of the pharmacist through Medication Therapy
Management (MTM)
• COPD Educator Course (American Association for Respiratory Care)
• COPD Educator Institute (American Lung Association)
• Provision & Planning of COPD Palliative Care (End-Stage)
• Tobacco Treatment Specialist-Certification (TTS-C)
• Advanced Certification in Chronic Obstructive Pulmonary Disease (The
Joint Commission) for Ambulatory Care Settings
•
COPD Management: Self-Assessment
• What are three primary measures to assess for the
appropriate staging of COPD?
• What management tools are available to increase
communication and care among providers and patients?
• What steps are involved in determining appropriate
medication therapy?
• What education is necessary to communicate to patients
with COPD?
• What opportunities exist for collaborative practices that
integrate best practices in primary care?
References
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15.
Centers for Disease Control and Prevention. What is COPD. Accessed April 2014 at http://www.cdc.gov/copd/
Centers for Disease Control and Prevention. Public Health Strategic Framework for COPD Prevention. Atlanta, GA: 2011. Accessed
April 2014 at http://www.cdc.gov/copd/pdfs/Framework_for_COPD_Prevention.pdf
Noujein C, BoKhalil P. COPD updates: what’s new in pathophysiology and management. Expert Rev Resp Med 2013;7(4):429-437.
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Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease
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O’Donnell DE. Hyperinflation, dyspnea, and exercise intolerance in chronic obstructive pulmonary disease. Proc Am Thorac Soc
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Ferguson GT, Enright PL, Buist AS, Higgins MW. Office spirometry for lung health assessment in adults: a consensus statement
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Harris M, Smith BJ, Veale A. Patient education programs – can they improve outcomes in COPD? Int J Chron Obstruct Pulmon Dis.
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National Transitions of Care Coalition. Improving on transitions of care: How to implement and evaluate a plan. Accessed April
2014 at http://www.ntocc.org/Portals/0/ImplementationPlan.pdf
COPD Foundation. Pulmonary Education Program. Accessed April 2014 at http://www.copdfoundation.org/What-is-COPD/Livingwith-COPD/Pulmonary-Rehabilitation.aspx#sthash.ELEjzbdD.dpuf
Centers for Disease Control and Prevention. H1N1 Flu. What adults with chronic obstructive pulmonary disease (COPD) should
know about 2009 H1N1 Flu. Access April 2014 at http://www.cdc.gov/h1n1flu/guidance/copd.htm#b
Centers for Disease Control and Prevention. Immunization Schedules. Accessed April 2014 at
http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html
COPD Assessment Test. Accessed April 2014 at http://www.catestonline.org/english/indexEN.htm
COPD Nutrition. Accessed June 24, 2014 at http://www.lung.org/lung-disease/copd/living-with-copd/nutrition.html
St. Florian I. Nutrition and COPD – dietary considerations for better breathing. Today’s Dietitian. 2009. February;11(2):54-56