Defusing Dyspnea from Chronic Lung Disease in the Post-Acute Setting

1. Defusing Dyspnea from Chronic Lung Disease in the Post-Acute Setting Amanda Renee Stephens, M.D. Medical Director of Palliative Care Services Assistant Professor of Pulmonary and Critical Care National Jewish Health April 26, 2019

2. A Frequent Occurrence in the Post-Acute Setting A patient discharged from hospital following a COPD Exacerbation is feeling short of breath.

3. Will they have to go to the hospital (again)? They look SO uncomfortable. Can I make them FEEL better? How much aggressive care do they want? Do we know? If this is a re-admission, will anyone get paid for this care? Is the patient going to DIE this time?

4. Objectives • Evaluate the evidence showing recurrent exacerbations an expected outcome of severe, end stage COPD and pharmacological interventions to help. • Learn how to align treatment plans with a patient’s individual goals using Advance Care Planning • Discuss specific treatment plans to achieve the patient’s goals: for symptom management within the nursing home or to continue recurrent admissions.

5. Objectives • Evaluate the evidence showing recurrent exacerbations an expected outcome of severe, end stage COPD and pharmacological interventions to help. • Learn how to align treatment plans with a patient’s individual goals using Advance Care Planning • Discuss specific treatment plans for symptom management within the nursing home

6. Disease Trajectories Clinic or Emergency Room Hospitalization ICU Admission Adapted from JAMA 2001 and Seamark, J R Soc Med, 2007

7. Re-admissions for COPD are common • Of admitted COPD patients in Spain, over 1 year: • 63% were re-admitted • 29% died • Risks for Re-admission: • >/= 3 admits for COPD in the prior year (HR 1.66) • Protective Factors Against Re-admission • Higher levels of physical activity (HR 0.54 CI 0.34-0.86) • The same cohort underwent multidisciplinary “integrated care” which improved risk factors, but not re-admissions. Garcia Aymerich et al. Thorax 2004 Garcia Aymerich et al. Respiratory Medicine 2007

8. Don’t Lose Hope: A Few Pharmacological Considerations from the GOLD 2019 Guidelines GOLD 2019 Guidelines

9. Inhaled Medications:Bronchodilators • Spiriva, Atrovent (Anti Muscarinic Agents) • Improves Dyspnea (St. George’s Respiratory Score)1 • Increase in time to first exacerbation (1216 months) (HR 0.86, p <0.0001)1 • With withdrawal, worsening of dyspnea index, Peak Flow and overall health status in three weeks.2 • Combination treatment with LABA/LAMA is better! Tashkin et al. NEJM 10/20082) 2) Adams S et al. Respiratory Medicine 10/2009 3) Bollu et al. Int J COPD 2013

10. Inhaled Medications: Bronchodilators • Albuterol (short acting B agonist) vs. formoterol (long acting beta agonists) • Significantly reduced re-admissions with long acting medications! • Combination with spirivabest to increase FEV1, reduce symptoms and exacerbations.

11. Inhaled Medications:Steroids • Inhaled corticosteroids work better IN COMBINATION than alone. • Advair (fluticasone/salmeterol) or symbicort (budesonide/formoterol) rather than flovent (fluticasone alone) or asmanex (budesonide alone). • Evidence from RCTs suggests higher prevalence of candidiasis, hoarse voice, skin bruising and pneumonia. • Studies are equivocal regarding withdrawal (no harm has been shown). GOLD 2017 Guidelines

12. Combinations are Best!Particularly LAMA/LABA Triple Threat (Trelegy): LABA/LAMA/ICS Stiolto: LABA/LAMA

13. Azithromycin 250mg daily vs. Placebo • Thought to be related to a immuno-modulatory effect of macrolides rather than specific antimicrobial effect. • 1.48 (Azithromycin) vs. 1.83 (Placebo) exacerbations per patient year. • Improved St. George’s Respiratory Questionnaire in azithromycin group as compared to placebo • Risks: Hearing decrements (25% azithromycin vs. 20% in placebo), NEJM 1/2011

14. Roflumilast (Daliresp) • Once a day PDE4 inhibitor. • RCT: Roflumilast 500mcg daily for a year vs. placebo. • Rate of moderate or severe exacerbations per year was 1.14 vs. 1.37 with placebo (reduction of 17%, p<0.003) • Adverse effects: Gastrointestinal side effects, weight loss. ?psychiatric effects. • Overall, reduce exacerbations but does not improve QOL scores or symptoms. Calverley PM Lancet 2009 Chong J Cochrane Review 2013

15. Non-Pharmacological Interventions

16. Hand Held Fan 50 patients randomized to either face to leg, then leg to face then crossed over. Galbraith JPSM 2010

17. Pursed Lip Breathing • Sit down in a chair • Relax shoulders and neck. • Take slow deep breaths in and out. • Pucker or Purse Your Lips while you do this. Works by “tenting airways open” (kind of like PEEP on a ventilator.

18. Pulmonary Rehabilitation • Helpful (and recommended) for patients with severe dyspnea or dyspnea out of proportion to disease. • Mostly hospital based: 3-4 h sessions several times per week for 6-12 weeks. • Benefits: • Improvement in exercise capacity • Reduction in dyspnea severeity • Increase health related QOL. • Aerobic exercise program (30 minutes per day) reduced dyspnea and coughing over four weeks. Casaburi et al NEJM 2009

19. To Sum Up • Exacerbations are a hallmark of severe or end stage COPD. Pharmacologically, there are several ways we can help patients: • Ensure patients have LAMA (spirivaor atrovent) if no contraindications and that this medication is NOT discontinued. • Combos that include LAMA are the best ways to use the other inhaled medications. • Consider azithromycin or roflumilast if necessary. • Pulmonary rehabilitation and smoking cessation.

20. Objectives • Evaluate the evidence showing recurrent exacerbations an expected outcome of severe, end stage COPD and pharmacological interventions to help. • Learn how to align treatment plans with a patient’s individual goals using Advance Care Planning • Discuss specific treatment plans for symptom management within the nursing home

21. COPD Disease Trajectory Clinic or Emergency Room Hospitalization ICU Admission Adapted from JAMA 2001 and Seamark, J R Soc Med, 2007

22. How Can We Use This Time To Help Our Patients? Opportunities for Discussion and Planning? Adapted from JAMA 2001 and Seamark, J R Soc Med, 2007

23. Advance Care Planning is Infrequent in COPD • 11%-15% of outpatients with COPD who are interviewed in clinic1-2 • 43% of outpatients who have required ICU admission for COPD exacerbations3 1. Au CHEST 2012 2. Heffner AJRCCM 1996 3. Stephens et al. JPM 2017

24. Barriers to Advance Care Planning In COPD • WhoIs Involved: • “unclear prognosis” • “responsibility to initiate ACP discussions and where” • “which patients are end of life?” • HowTo Speak About It: • Fear of • “Comparing COPD with cancer” • Causing “lack of motivation” which impedes chronic disease management All Nursing Home Patients Admitted Following a COPD Exacerbation should have an Advance Care Planning Discussion Gott et al Palliative Medicine 2009

25. How To Start The Discussion • How does COPD affect your life? • Eg: “I spend too much time in the hospital,” “I couldn’t see my daughter get married.” “Food shopping isn’t easy.” • What keeps your strong when your symptoms are really bothering you? • “Thinking about being around for my kids;” “my faith in my religion;” “I’ve never thought of anything else to do” • What do you like doing on your best days? • What are your hopes for the future? • What are your worries?

26. Develop the goals of care(not goals of treatment) Example: Patient states: COPD takes me away from spending time with my family. I used to be able to help them out around the house, but now I can’t even go visit my grandkids. Response: It sounds like being close and available to your family is very important to you. Should we look for ways we can focus on ways your medical care can achieve that goal?

27. Advanced Directives: Putting it Down on Paper

28. THE most important part of advance care planning. “If you ever get so sick or fuzzy that you cannot make medical decisions for yourself, who would you choose to make them for you on your behalf?”

29. To go a little deeper:Code Status “If you got so sick that your heart and lungs stopped (you died), have you thought about what would happen?” “If you are in the hospital, the default is to give compressions, shocks and place you on life support. There is important paperwork to put in place if you would prefer a natural death.”

30. Hospitalizations? Hospice?

31. Palliative Care Consultation For End Stage Lung Disease Patients • Provide ExtraSupport to Patients and Families Dealing with Severe Illness • Help With Decision Making Regarding the Aggressive of Medical Care Going Forward (including limitations on specific treatments) • Create an Individualized Symptom Management Plan • Determine whether patients will qualify and/or benefit from Hospice Services within the nursing home (or at home if possible).

32. Objectives • Evaluate the evidence showing recurrent exacerbations are not a feared complication, but rather an expected outcome of severe, end stage COPD • Learn how to align treatment plans with a patient’s individual goals using Advance Care Planning • Discuss specific treatment plans for symptom management within the nursing home

33. For Everyone: On Admission

34. For Everyone: Chronic Management

35. Acute Exacerbations: Full/Selective Treatments • Non-pharmacological: Fan, pursed lip breathing techniques. • Stacked nebulizers: albuterol or duonebs (albuterol/ipratropium) three times in a row. • Consider oral prednisone 40mg (IV dose if possible, as it works faster). • Oxygen for O2sat<88% or if it improves dyspnea. Can consider non-invasive ventilation (if available). • Chest X-Ray if concern for pneumonia (sputum, fevers, chills or other concerning symptoms). • Antibiotics (levaquin) if needed for pneumonia. • Indications for hospitalization: Dyspnea does not improve with medications with accessory muscle usage or altered mental status. Hypoxia along with these symptoms.

36. Acute Exacerbations: Comfort Care • Non-pharmacological: Fan, pursed lip breathing. • Stacked nebulizers: albuterol or duonebs (albuterol/ipratropium) three times in a row, stop if worsened anxiety or palpitations. • Consider burst prednisone- 40mg oral dose, potentially with slow taper if asthmatic component. • Empiric antibiotics for cough/sputum. • Morphine oral liquid 1-4mg q1-2h prn for dyspnea. • Oxygen for comfort (can stop if it is uncomfortable). Consider non-invasive ventilation for comfort. • Call hospice or palliative care if involved (hospice will often leave a comfort kit with medications including oral morphine and ativan)

37. Take Home Points • Exacerbations and re-hospitalizations are common and expected in end stage COPD, yet all of the pharmacological interventions are specifically targeted at relieving symptoms and reducing hospitalizations. • We have many tools to help our patients receive the medical care they desire at the end of life(whether curative or palliative) which start at the time of admission. • Well-timed, clear and compassionate advance care planning SHOULD occur in a post-acute care settingfollowing admission for COPD exacerbation. • While chronic treatment of COPD is often similar, the plan for acute exacerbation can be tailored to achieve a patient’s values and goals.

38. Questions?