💡 TLDR Primary Care #019 | Deep Dive (#019)

In This Issue:

🫁 The Latest COPD Guideline Review

⭐ Clinical pearls in managing COPD

✅ Useful calculators and scoring systems to classify COPD

📈 And more!

💡 Deep Dive: Chronic Obstructive Pulmonary Disease

In-depth review of key recent guidelines

This week, we’ll be reviewing the latest clinical guidelines on Chronic obstructive pulmonary disease (COPD). COPD is now among the top 3 leading causes of death worldwide, despite being largely preventable and treatable. COPD is most often caused by environmental exposure, such as tobacco smoking, and is diagnosed using pulmonary function testing with findings of ↓ FEV1, ↓ FVC, and ↓ DLCO. Poorly controlled COPD can lead to exacerbations with increased sputum production, dyspnea, pursed-lip breathing, and wheezing.

Chest X-Ray Source

The COPD guidelines are published by the Global Initiative for Chronic Obstructive Lung Disease (2022), the American Thoracic Society (2020), and the British Thoracic Society (2020) among others.

For a full review of the comprehensive COPD guidelines, head over to Pathway. We’ll cover some key takeaways below (with the recommendation strength in parentheses). 

A quick editor’s note: The GOLD guidelines are the gold (no pun intended) standard for COPD but many recommendations do not have grades with them and are marked with (/).

1. Diagnosis and Screening:

• Avoid screening for COPD in asymptomatic adults (D)
• Elicit a detailed history in patients with known or suspected COPD including exposure history, past history of asthma, allergy, or nasal polyps, family history of lung disease, history of exacerbations, presence of comorbidities, etc. (/)
• Spirometry is required to make the diagnosis of COPD; a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation (/)

2. Classification:

• Assign clinical stages based on exacerbation history and assessment of dyspnea over the past year, as follows: (/)
  • Group A: 0 or 1 exacerbations treated on an outpatient basis, with an mMRC 0-1 and CAT < 10
  • Group B: 0 or 1 exacerbations treated on an outpatient basis, with an mMRC > 2 or CAT > 10
  • Group C: > 2 exacerbations or 1 exacerbation requiring hospitalization, with an mMRC 0-1 and CAT < 10
  • Group D: > 2 exacerbations or 1 exacerbation requiring hospitalization, with an mMRC > 2 or CAT > 10
• Assign spirometric grades based on FEV1, as follows: (/)
  • GOLD 1 (mild): FEV1 ≥ 80% of predicted
  • GOLD 2 (moderate): FEV1 50-79% of predicted
  • GOLD 3 (severe): FEV1 30-49% of predicted
  • GOLD 4 (very severe): FEV1 ≤ 30% of predicted

3. Respiratory Support:

• Initiate long-term oxygen therapy to increase survival in patients with resting hypoxemia (O2 sat < 88%) (A)
• Do not initiate long-term oxygen therapy routinely in patients with stable COPD and resting or exercise-induced moderate desaturation, because it does not lengthen the time to death or first hospitalization or provide sustained benefits in health status, lung function, or 6-minute walk distance (D)
• Consider offering long-term noninvasive positive-pressure ventilation to improve hospitalization-free survival in patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure (C)

⭐ Check out these landmark trials on oxygen support in COPD:

NIV in COPD with Chronic Hypercapnia - JAMA 2017

NOTT Trial - Annals of Internal Med 1980

4. Medical Management:

Bronchodilators:

• Initiate regular inhaled bronchodilators to prevent or reduce symptoms in patients with stable COPD (A)
• Initiate long-acting β-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) to improve lung function, dyspnea, and health status and reduce exacerbation rates in COPD (A)
• Prefer LABAs and LAMAs over short-acting agents except for patients with only occasional dyspnea (A)
• Initiate combinations of LABAs and LAMAs for better improvement in FEV1 and reduction of symptoms (A) and exacerbations compared to monotherapy (B)
• Recognize that LAMAs have a greater effect on exacerbation reduction compared with LABAs (A) and lead to decreased hospitalizations (B)

Inhaled Glucocorticoids:

• Offer inhaled corticosteroids (ICSs) combined with LABAs to improve function and health status and reduce exacerbations in patients with moderate to very severe COPD (A)
• Offer combined inhaled LABA/LAMA/ICS for greater improvement in lung function, symptoms, and a larger reduction of exacerbations (A)
• Do not use long-term ICS monotherapy (D)

Oral Bronchodilators:

• Use inhaled bronchodilators over oral bronchodilators (A)
• Consider adding a PDE4 inhibitor to long-acting bronchodilators, with or without ICS, to improve lung function and reduce moderate to severe exacerbations in patients with severe-to-very severe airflow limitation, chronic bronchitis, and exacerbations (C)
• Do not use theophylline unless other long-term bronchodilators are unavailable or unaffordable (D)
• Oral corticosteroids:
• Do not use long-term oral corticosteroids in patients with COPD because of the numerous side effects and lack of benefit (D)

Mucolytics:

• Consider regular treatment with mucolytics, such as erdosteine, carbocysteine, or N-acetylcysteine, to reduce the risk of exacerbations in select patients (B)

Long-term Antibiotics:

• Consider offering long-term macrolides, particularly azithromycin, to reduce exacerbations in former smokers with exacerbations despite appropriate therapy (C)
• Recognize that azithromycin is associated with an increased incidence of bacterial resistance (B) and hearing test impairment (C)

Acute Exacerbation Management:

• Offer inhaled SABAs, with or without SAMAs, as the initial bronchodilators for the treatment of acute exacerbations (B)
• Consider administering systemic corticosteroids (not more than 5-7 days) to improve FEV1, oxygenation, and shorten recovery time and hospitalization duration in patients with acute exacerbation (B)
• Consider administering antibiotics for 5-7 days to shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration in patients with acute exacerbation (C)
• Do not use methylxanthines (theophylline) for the management of patients with acute exacerbation (D)
• Initiate noninvasive mechanical ventilation as the first-line modality for respiratory support, in the absence of absolute contraindications, to improve gas exchange, reduce work of breathing, reduce the need for intubation, decrease hospitalization duration and improve survival in patients with acute respiratory failure (A)

5. Nonpharmacologic Interventions:

• Offer smoking cessation interventions in all patients with COPD (A)
• Advise patients to increase their level of physical activity, as it is a strong predictor of mortality (A)
• Offer pulmonary rehabilitation in all patients with relevant symptoms and/or high risk for exacerbation to improve dyspnea, health status, and exercise tolerance in stable patients (A), to reduce symptoms of anxiety and depression (A), and to reduce hospitalizations in patients with recent exacerbation (B)
• Consider offering lung transplantation to improve quality of life and functional capacity in patients with very severe COPD (progressive disease, BODE score > 7, ineligible for lung volume reduction surgery) and at least one of the following: (C)
  • History of hospitalization for exacerbation associated with acute hypercapnic respiratory failure (PCO2 > 50 mmHg)
  • Pulmonary HTN and/or cor pulmonale despite oxygen therapy
  • FEV1 < 20% of predicted and either DLCO < 20% or homogenous distribution of emphysema

Preventative Measures

• Offer influenza vaccination in all patients with COPD (A) to reduce serious illness and mortality (B)
• Offer SARS-CoV-2 vaccination in all patients with COPD (B)
• Offer pneumococcal vaccination (PCV15 or 20) to all adults aged 19-64 years with COPD who have not previously received conjugate vaccination, or if previous vaccination status is unknown (B) 
  • If PCV15 is used, it should be followed by PPSV23 > 1 year later. (E)
  • If PCV20 is used no dose of PPSV23 is recommended. (E)
• Offer Tdap vaccination to protect against patients pertussis in adult patients with COPD not vaccinated in adolescence (B)

If you enjoyed this newsletter, please consider forwarding it to a friend or colleague who would enjoy it too.

If a friend sent you this, get the next newsletter by signing up here.

Who’s Pathway? We’re a global community of clinicians working to democratize medical knowledge and make practicing evidence-based medicine more accessible, fun, and not so overwhelming.

Warm regards,

- The Pathway Team

Pathway Medical Inc. | All rights reserved | Unsubscribe