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PFT Refresher and Modern Inhaler Strategy for COPD. Todd C. Hoopman, MD North Idaho Lung, Asthma and Critical Care Coeur d’Alene, ID. Pulmonary Function Testing. Indications: Evaluate: Cough, wheeze, breathlessness, crackles Monitor: COPD, asthma, pulmonary vascular disease
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PFT Refresher and Modern Inhaler Strategy for COPD Todd C. Hoopman, MD North Idaho Lung, Asthma and Critical Care Coeur d’Alene, ID
Pulmonary Function Testing • Indications: • Evaluate: Cough, wheeze, breathlessness, crackles • Monitor: COPD, asthma, pulmonary vascular disease • Preoperative evaluation: lung resection, abdominal surgery, cardiovascular surgery • Surveillance for respiratory complications: CTD or neuromuscular disease • Post-lung transplantation • Contraindications: • AMI < 30 days • Unstable angina • Recent eye surgery • Current pneumothorax • Current tracheostomy • Recent thoraco-abdominal surgery
Pulmonary Function Testing • Components: • Spirometry (pre and post-bronchodilator) • Lung volumes evaluation • Diffusion capacity • Other tests: • Maximum Voluntary Ventilation • Mean Inspiratory Pressure • Mean Expiratory Pressure
Spirometry • Measure volume against time and flow against volume • Most frequently used measure of lung function • FEV1, FVC, FEV1/FVC ratio, FEF25-75%, Bronchodilator response
Spirometry - Obstruction • FEV1/FVC ratio < 70% (absolute not predicted)
Spirometry - Obstruction • Pathophysiology: • Alveoli and support structures are destroyed (reduced tethering/loss of recoil) • Bronchial passageways are blocked by secretions and inflammation • Airway compression by adjacent over distended lung units 1 www.NEJM.org
Spirometry - Restriction • FEV1/FVC ratio > 70% (absolute not predicted) • Reduced FVC (<80% predicted) • Lung volumes needed to confirm (TLC < 80% predicted) • Concurrent reduction of FVC in severe obstruction
“Other Obstructions” of the Flow-Volume Loop Tracheomalacia Polychrondritis Tumors of trachea Vocal Cord Paralysis Glottic strictures Tumors/Goiter
Bronchodilator Response • Measure basic spirometry and then administer a bronchodilator • 20% improvement AND200 mL improvement in either FEV1 OR FVC • Evaluate pre-bronchodilator effort carefully • 6 second exhalation
Lung Volumes • Measure total lung capacity at maximal inspiration • Measure amount of air left in the lungs after maximal expiration (Residual Volume) • *Body plethysmography • Nitrogen washout • Helium washout • Confirm the degree of restriction seen with spirometry • Determine if a reduced Vital Capacity is due to air trapping or intrinsic lung disease
Lung Volumes • Plethysmography can be difficult for some patients: • Morbid obesity • Claustrophobia • Hard of hearing • Mixed disorder • TLC < 80% with with FEV1/FVC < 70% • COPD + IPF • Asthma + Obesity
Diffusion Capacity of Lung for Carbon Monoxide • Measure of gas exchange • Effort dependent • Exhale to RV and then inhale to vital capacity using air mixed with CO & Helium • Hold breath for 10 seconds and then exhale QUICKLY • Measure concentrations of CO and Helium as a function of the exhaled volume • Dependent upon the surface area of the alveolar membrane • <80% is considered a reduced value
COPD Facts1 • Currently the 4th leading cause of death in the world1 • 2012: 3 million deaths • Projected to be the 3rd leading cause by 2020 • Continued exposure to COPD risk factors and aging of the population • Risk Factors • Exposure to noxious particles or gases • #1: Tobacco • Others: pipe, cigar, water pipe, marijuana • Outdoor, occupational and indoor air pollution (burning of biomass fuels) • Non-smokers: complex interplay of long-term exposures combined with host factors 1 GOLD 2018 Edition
COPD Facts1 • Currently the 4th leading cause of death in the world1 • 2012: 3 million deaths • Projected to be the 3rd leading cause by 2020 • Continued exposure to COPD risk factors and aging of the population • Risk Factors • Exposure to noxious particles or gases • #1: Tobacco • Others: pipe, cigar, water pipe, marijuana • Outdoor, occupational and indoor air pollution (burning of biomass fuels) • Non-smokers: complex interplay of long-term exposures combined with host factors 1 GOLD 2018 Edition
COPD Facts1 • COPD should be considered in any patient who has dyspnea, chronic cough or sputum production and/or history of exposure to risk factors for the disease • Spirometry is required to make the diagnosis • Post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation • Key Indicators: • Progressive dyspnea.: Worse with exercise & Persistent • Chronic cough: May be intermittent and may be non-productive • Chronic sputum production • History of risk factors: tobacco, biomass fuel burning, occupational • Family Hx of COPD and/or childhood factors: low birthweight, childhood resp infxn 1 GOLD 2018 Edition
Pharmacotherapy for COPD • Bronchodilators: increase FEV1 and/or change in spirometry • Beta2 Agonists: Relax airway smooth muscle; antagonize bronchoconstriction • Antimuscarinics: Block the bronchoconstrictor effects of acetylcholine on airway smooth muscle • Methylxanthines: toxicity is dose-related; most benefit occurs at near-toxic doses • Anti-inflammatory agents • Inhaled and oral corticosteroids • Phosphodiesterase-4 inhibitors • Antibiotics • Azithromycin 3x per week (increased bacterial resistance and reduced hearing)
Technique is everything • Wide variety of devices available: • Nebulizers • Pressurized metered dose inhalers (pMDI) • Dry powder inhalers (DPI) • Soft mist inhalers (SMI) • Significant patient error with device usage • Meta-analysis: 100% of patients demonstrate at least one error1 • 92% of patients experience critical errors (i.e. impacts effectiveness of the drug) • Right Device for the Right Patient: • Age • Ethnicity • Dexterity • Inspiratory capacity 1 Prim Care Resp Med: 27; 22. 2017
Technique is everything 1 Prim Care Resp Med: 27; 22. 2017
ABCD Assessment Tool of 2011 • Incorporated patient-reported outcomes and highlighted the importance of exacerbation prevention: • No better than spirometry for mortality prediction • Confusion and concerns by this system • Significant patient error with device usage • Meta-analysis: 100% of patients demonstrate at least one error1 • 92% of patients experience critical errors (i.e. impacts effectiveness of the drug) • Right Device for the Right Patient: • Age • Ethnicity • Dexterity • Inspiratory capacity
ABCD Assessment Tool of 2011 • Incorporated patient-reported outcomes and highlighted the importance of exacerbation prevention: • No better than spirometry for mortality prediction • Confusion and concerns by this system • Significant patient error with device usage • Meta-analysis: 100% of patients demonstrate at least one error1 • 92% of patients experience critical errors (i.e. impacts effectiveness of the drug) • Right Device for the Right Patient: • Age • Ethnicity • Dexterity • Inspiratory capacity
Severity of COPD (based upon post-bronchodilator FEV1) • Patient with an FEV1/FVC < 0.70: 1 GOLD Guidelines 2018.
Long-Acting Muscarinic (LAMA) Therapy for COPD (MOA: Block Acetylcholine interaction with airway smooth muscle to prevent contractions) • Mid 2000s: UPLIFT Trial • 4 year trial with Tiotroprium (Spiriva) vs Placebo • Increased QOL • Reduced exacerbation rate by 14% and reduced time to first exacerbation • No demonstration of reduced rate of decline in FEV1 • Mostly GOLD 2 and 3 (90% of enrolled participants) • 2/3 on inhaled LABA or inhaled steroid or both • Led to GOLD recommendation for LAMA Therapy for GOLD 2 patients as first-line therapy • 3 additional LAMAs: • Aclidimium (Tudorza) • Umeclidinium (Incruse) • Glycopyrrolate (Lonhala)
LAMA and LABA combinations1 • 2016: • GOLD Report: LAMA + LABA for Group B (high sx/low risk) if not better with 1 agent • 2017: • GOLD Report: LAMA + LABA for Group B (high sx/low risk) w/ severe breathlessness • NEJM 2016: LAMA + LABA superior to ICS + LABA at preventing COPD exacerbations for patients with one or more COPD exacerbations • GOLD Recommendation for Group D (high symptoms/high risk) • LAMA + LABA > LABA + ICS • Bevespi (Glycopyrrolate/Formoterol) • Anoro (Umeclidinium/Vilanterol) • Stiolto (Olodaterol/Tiotropium) • Utibron (Indacaterol/Glycopyrrolate) 1 NEJM. 2016; 374 (23): 2222-2234.
Triple Therapy Combination for COPD • 2018:Trelegy (Fluticasone + Umeclidinium + Vilanterol) • Evidence: • IMPACT Study: NEJM May 20181 • Compared ICS/LAMA/LABA vs. ICS/LABA or LAMA/LABA) • Trelegy v. Breo v. Anoro • Primary endpoint: annual rate of moderate or severe COPD exacerbations • Results: • 34% reduction in COPD hospitalizations vs. Anoro • 13% reduction in COPD hospitalizations vs. Breo (non-significant) • ICS (Trelegy and Breo) had a lower on-treatment risk of mortality vs. Anoro • Higher rate of pneumonia in the ICS groups • GOLD Recommendation: Triple therapy for Group D patients who continue to experience exacerbations despite dual therapy. 1 NEJM. 2018; 378 : 1671-1680.