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5 Pearls on COPD

Core IM

This episode is based on practice gaps in longitudinal COPD management. 1. Imprecise understanding of the diagnostic testing necessary to establish the diagnosis of COPD and the indication for empiric therapy. 2. Lack of clarity on the lab evaluation all COPD patients should have on diagnosis, and the criteria to guide selection of a first therapeutic agent. 3. Confusion about types of inhalers and the differences between them. 4. Insufficient understanding about indications to stop inhaled steroids in COPD patients. 5. Insufficient awareness of end-of-life issues that should be raised for all COPD patients.  The Core IM team invites you to learn with them as they explore 5 Pearls on COPD.

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Core IM

Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

Pearl 1: Diagnosis and Empiric Therapy

  • COPD label without spirometry is very common
    • About 33% of patients are diagnosed empirically and do NOT receive spirometry
    • You cannot diagnose COPD without spirometry
  • “History and physical examination are poor predictors of airway obstruction and its severity” - Joint statement from 2011 from  ACP, ACCP, ATS, and ERS 
  • A note on defining airflow obstruction (AFO):
    • Historically (and currently, by GOLD), defined as post-bronchodilator FEV1/FVC < 0.7 or by FEV1 < 80% of predicted. 
    • However, there are concerns that this can ignore normal, age-associated decreases in FEV1/FVC and lead to overdiagnosis. 
    • The ERS/ATS are now recommending using the lower limit of normal (defined as the 5th percentile) to define AFO.
  • Empiric initiation of maintenance inhalers for COPD generally shouldn’t be done
    • However, in patients with radiographic evidence of emphysema/COPD and with symptoms consistent with the diagnosis, it’s probably ok to start maintenance inhalers so long as outpatient PFTs are ordered for confirmation

Pearl 2: The Initial Visit–Blood Work and Initial Treatment Choices

  • Blood work in COPD:
    • 1) Every new diagnosis of COPD should be checked for alpha-1-antitrypsin deficiency
    • 2) Every COPD patient should have a CBC with diff checked at least once to look at their eosinophils. Specifically, do not interpret eosinophils when they’re taking systemic steroids or have an acute infection.
      • The idea behind this is that COPD patients with higher eosinophils may have an allergic or inflammatory phenotype that an ICS will directly treat and therefore reduce exacerbations.
        •  Exact values differ between studies and individual’s practice patterns, but there’s evidence that peripheral eosinophils >100 cell/microL predicts 
      • On the other hand, patients without high eosinophils don’t have an inflammatory phenotype and so are only getting the risk for immunosuppression and pneumonia with ICS use
        • ICS use is associated with an increased risk of PNA
        • Data supports that if eos are < 100, patients may have a higher rate of PNA and so at higher risk of harm from ICS use.
  • Simplify inhalers by remembering that there are only 3 classes of medications:
    • 1) Beta agonists 
      • Generally end with “-ol”
      • E.g. formoterol, salmeterol
    • 2) Muscarinic antagonists
      • Generally end with “-ium”
      • E.g. tiotropium, aclidinium, the umeclidinium
    • 3) Inhaled corticosteroids 
      • Generally end with “-one”
      • E.g., fluticasone, beclomethasone
  • The most widely used staging/grouping schema (see infographic) is described by GOLD, which uses a combination of spirometry, symptom burden, and history of exacerbations over the last year to determine grade and group. 
    • COPD grade informs prognosis 
    • COPD group informs initial therapy. 
      • Memorization of specific cutoffs isn’t necessary, and can be looked up.
  • The way you assess symptom burden matters. 
  • For Group A and B, you can start with either a LAMA or a LABA.
  • For Group C, LAMAs are recommended over LABAs because they are more effective in reducing exacerbation rates
  • For Group D, start with a combination of LAMA/LABA or LAMA/ICS, if the patient has the inflammatory phenotype and has higher eosinophil count.

Pearl 3: Inhaler Devices

Pearl 4: Inhaled Steroids and Inhaler Escalation

  • Every visit should have a review of symptoms, exacerbations, and inhaler technique. 
  • Gold recommends annual spirometry to monitor for rapid disease progression 
  • It can also be useful to monitor other measurements of lung function/gas exchange such as functional capacity via a 6MWT, as this helps prognosticate
  • Try and de-escalate inhaled steroids if you can–there is evidence of a dose dependent risk of systemic side effects with inhaled steroids!
  • Other inhaled medications are not adjusted via GOLD group. They are adjusted based on the specific issue being targeted: dyspnea or exacerbations. Gold has algorithms for both. 
    • To simplify, add either a LAMA or LABA (whatever the patient isn’t already taking) so they are on combination therapy. And think about inhaled steroids if they have high eosinophils and frequent exacerbations.
    • If they are already on a combination of inhalers and are still short of breath, check their technique. If this isn’t the issue, try adjusting the inhaler device or specific drug within that class they’re inhaling (EG, a different LABA).
    • Finally, as part of management of refractory COPD with frequent exacerbation there are roflumilast and other PDE4 inhibitors. These are for patients with an FEV1 < 50%, and are generally only prescribed for severe COPD and most patients will not be on them.
  • Pulmonary rehab is incredibly important–it raises quality of life, reduces readmissions, and lowers mortality.
    • It is so effective that the Cochrane review recommended against further studies of its effectiveness.
    • Accessibility can be an issue, but there is essentially no reason not to refer a patient. It’s just like ordering outpatient physical therapy.

Pearl 5: Communication, Palliative Care, and End of Life Care in COPD

 

Contributors

Luke Hedrick, MD – Author/Host

Shreya Trivedi, MD, ACP Member – Author/Host

Kai Saukkonen, MD – Expert Discussant

Richard Schwartzstein, MD, FACP – Expert Discussant

Rebecca Omlor, MD – Expert Discussant

Ali Trainor, MD – Author/Host

Aaron Troy, MD – Producer/Author

Reviewers

Nick Mark, MD

Lakshman Swamy, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  June 22, 2022

Expiration Date: June 22, 2025

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates this enduring material (podcast) for 0.75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.