Transcript Chronic Obstructive Pulmonary Disease

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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
in the clinic
Chronic Obstructive
Pulmonary Disease
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What is chronic obstructive pulmonary
disease (COPD)?
 Abnormal inflammatory response to noxious particles or
gases
 Characterized by progressive airflow obstruction
 Variety of respiratory symptoms (chronic bronchitis) or
signs of emphysema
 Asymptomatic pts may meet spirometric diagnostic
criteria for COPD
 COPD treatable, preventable  but incurable
 4th leading cause of mortality  almost 100%  in ageadjusted mortality from 1970 to 2002 due to COPD
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
Which patient populations are at risk?
 ≈ 80 - 90% due to cigarette smoking
15% risk for clinically significant COPD among
smokers; may underestimate risk
 Effect of environmental (“second-hand”) smoke in
development of COPD less clear
 Genetic factors play role in susceptibility  best defined
being emphysema related to α1-antitrypsin deficiency
 Pts rarely ≤35 yrs  COPD develops only after
inhalational exposure of sufficient intensity & duration
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
Should clinicians screen asymptomatic
patients?
 Spirometry not recommended in the absence of
symptoms (USPSTF, ACP/ERS/ATS guidelines)
 Some organizations (GOLD) suggest screening pts with
risk factors (smoking + age > 35 y)  suggesting:
 Early detection = opportunity for pts to stop smoking
 Informing pts of abnormal spirometry (“lung age”) may
encourage smoking cessation
 Conflicting data re: any change in outcomes
 Likely ½ of patients with COPD have not been diagnosed
 Evidence does not support screening in general
population
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians consider a
diagnosis of COPD?
Hx of significant exposure to tobacco smoke
 esp with: cough
sputum production
dyspnea
decreased exercise tolerance
 Hyperinflation (e.g. hyperresonance, distant breath
sounds) may occur in advanced disease
Chronic bronchitis (≥90d cough + sputum in each of 2
consecutive yrs)
and
Emphysema (hyperinflation on exam, imaging to confirm)
 commonly assoc’d w/COPD but neither required for Dx
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What is the role of pulmonary function
testing in diagnosis?
 Spirometry essential for COPD Dx and classification :
 postbronchodilator FEV1/FVC ratio <0.70 considered
diagnostic threshold
 FEV1 percentage predicted classifies COPD as 
 mild (>80%)
 moderate (50%-80%)
 severe (30%-50%)
 very severe (<30%)
 Degree reversibility (FEV1 improvement after
bronchodilator or glucocorticosteroids) 
not recommended for Dx, DDx from asthma, or prediction
of response to long-term Tx
 Lung volume and diffusing capacity may support Dx
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What is the role of pulmonary
function testing in diagnosis?
 Arterial blood gases and pulse oximetry
 Determine candidates for long-term oxygen therapy
 Identify chronic hypercapnia
 May further characterize severity of COPD; suggest
presence of emphysema, or exclude other lung diseases
 Spirometry also for calculating BODE index
BMI; Obstruction (measured by FEV1); Dyspnea (Modified
Medical Research Council); Exercise (6-min walk test)
 Increasing BODE = increased risk for hospitalization and
poor long-term prognosis
 BODE index also used to evaluate for lung transplant
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians approach
drug therapy?
MMRC Dyspnea Severity Scale* for Calculation of BODE Index
Severity
Score Degree of breathlessness related to activities
None
0
Not troubled w/ breathlessness except w/
strenuous exercise
Mild
1
Troubled by SOB hurrying or walking up slight hill
Moderate
2
Walks slower than people of same age due to
breathlessness or has to stop for breath when
walking at own pace on level ground
Severe
3
Stops for breath after walking ≈100 m or after few
mins on level ground
Very
severe
4
Too breathless to leave house or breathless when
dressing or undressing
Continued…
Adapted from VA and DoD guidelines
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians approach
drug therapy?
Variable
Points on BODE Index
0
1
2
3
FEV1 (% predicted)
≥65
50-64
36-49
≤35
Distance walked in 6 min, meters
≥350
250-349
150-249
≤149
MMRC dyspnea scale score
0–1
2
3
4
Body mass index
>21
≤21

Points for each variable summed w/ possible range 0–10
 Higher numbers  worse prognosis
Adapted from VA and DoD guidelines
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What other lab tests should clinicians
order when evaluating COPD?
No tests other than spirometry routinely recommended
 May show flattened diaphragm and
hyperlucency
CT scan
 May show destruction pulmonary
parenchyma in pts w/ emphysema
ECHO
 May indicate possibility of cor pulmonale
from pulmonary HTN
α1-antitrypsin
 Consider measuring level in pts w/
 Use of vasodilators for pulm HTN in
testing
• COPD
< 40
COPD onset
off-label
andyears
of noold
proven
Exercise testing  Maybenefit
be usefulmay
in diff’l
Dx
of ptsexercise
w/
not
improve
• Absence of recog’d risk factor (e.g.,
dyspnea
whenorunclear
ifPH,
symptom
origin
tolerance
reduce
may
worsen
smoking, occupational dust exposure)
pulmonary
or cardiac
oxygenation
• Family Hx emphysema or α1antitrypsin deficiency, bronchiectasis,
liver disease, or panniculitis
 Chest X-ray




© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What other disorders should clinicians
consider in patients with suspected
COPD?
 Any condition that produces airflow obstruction
 Asthma
 Bronchiectasis
 Cystic fibrosis
 Bronchiolitis
 Upper airway obstruction (due to tumors of trachea,
tracheal stenosis, tracheo-malacia, vocal cord dysfxn)
 Less common Dx
 Other pulmonary conditions that cause dyspnea
(interstitial lung disease; pulmonary arterial HTN)
 Chest wall disorders (kyphoscoliosis)
 Cardiac causes (some may also coexist with COPD)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians distinguish
between COPD and asthma?
Spirometric obstruction, cough, wheeze, and
dyspnea common to both COPD and asthma
 Pts w/asthma…
 Usually develop symptoms at
younger age
 Less likely to be smokers
 Experience symptoms
intermittently, w/more
variability (may be seen with
monitoring daily peak flow)
 Pts w/COPD…
 Disease onset usually later
 Chronic productive cough
common
 Dyspnea more persistent
 Generally less consistent
response to drugs (inhaled
corticosteroids and
bronchodilators)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
Which smoking cessation interventions
are most effective? Stopping smoking reduces
decline in pulm fxn & mortality
 Urge all patients with COPD who smoke to quit
and to enroll in a smoking cessation program
 More structured smoking cessation programs 
effective in up to 30% of pts at 1y
 Typically include: 2 or 3 longer advice sessions
 Meds (e.g., nicotine prep’ns, bupropion, varenicline)
 Multicenter RCT of intensive smoking cessation program
including behavioral modif’n and nicotine gum vs. placebo: Over
5 yrs, mid-aged smokers in intervention group had slower rate of
decline in FEV1 (34 mL/y) than those in placebo group (63 mL/y)
 Follow-up: After 14.5y, all-cause mortality significantly lower in
smoking cessation group than in usual care group (8.83 vs.
10.38/1000 person-yrs; P=0.03)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians approach drug
therapy?
 Assess disease severity before initiating treatment
 Check FEV1 (note, however, that symptoms don’t
necessarily correlate w/ FEV1)
 Ask about baseline symptoms
 Ask about nature and frequency of exacerbations
 Use validated instruments for additional info
 Modified Medical Research Council (MMRC) Dyspnea
Severity Scale for Calculation of BODE Index
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians approach drug
therapy?
Step Tx for
pts w/COPD*
*ATS/ERS guidelines
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians approach drug
therapy?
 Overall Tx strategy includes smoking cessation, inhaled
meds, education, pulmonary rehabilitation & long-term
oxygen Tx in hypoxemic pts
 Cornerstone of pharmacotherapy  inhaled meds
(β2-agonists, anticholinergics, corticosteroids)
 Tx goal: symptom relief, particularly dyspnea, prevention
of exacerbations, improvement in long-term respiratory
health status
 Only smoking cessation convincingly reduces rate of
decline in pulmonary fxn; only smoking cessation
and long-term oxygen Tx decrease mortality
Dyspnea may respond to drug Tx at any level  but
most studies indicate effectiveness for symptomatic
pts w/FEV1 <60% predicted
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What is the role of inhaled bronchodilators?
Inhaled short-acting β2agonist (albuterol,
levalbuterol, metaproterenol, pirbuterol)
Dosage: 2 inhalations as needed, ≤12 inhalations/d
Side effects: Sympathomimetic symptoms (e.g., tremor,
tachycardia.
Notes: Generally used as needed.
Inhaled short-acting
anticholinergic
(Ipratroplum)
Dosage: 2 inhalations qid increase as tolerated
Side effects: Dry mouth, mydriasis on contact w/eye.
Notes: Use as maintenance Tx. Don’t use w/tiotropium.
Inhaled long-acting
anticholinergic
(tiotropium)
Dosage: 18 μg/d
Side effects: Dry mouth, mydriasis on contact w/eye.
Notes: Use as maintenance Tx. Don’t use w/ipratropium.
Inhaled long-acting β2agonist (salmeterol,
formoterol, aformoterol )
Dosage: depends on agent used.
Side effects: Sympathomimetic symptoms.
Notes: Use as maintenance Tx. Overdosage can be fatal.
Oral theophylline
(aminophylline:.
generic and brand-name
sustained and shortacting)
Dosage: Aim for serum levels betw 5 and 14 μg/mL
Side effects: Tachycardia, nausea, vomiting, disturbed pulmonary
fxn, insomnia. Overdose can be fatal.
Notes: Use as maintenance Tx. Use intravenously in emergency
dept. May improve respiratory muscle fxn.
Oral β2-agonists
(albuterol, metaproterenol, terbutaline)
Dosage: depends on agent used
Side effects: Sympathomimetic symptoms.
Notes: Use as maintenance tx. Rarely used bc side effects.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What is the role of inhaled bronchodilators?
 Begin treatment w/single bronchodilator
 No data avail to recommend one over another for initial use
 Base choice on pt preference, potential side effects, cost
 Educate pt on proper use (open-mouth technique not recom’d
for hydrofluoroalkane propellant-driven or anticholinergic
metered-dose inhalers)
 Step up to combination bronchodilator Tx  if add’l
symptomatic relief required
 inhaled combination LABA + long-acting anticholinergic may
improve FEV1 (unclear if better than monotherapy for dyspnea,
exercise tolerance, exacerbations)
Short-acting bronchodilators
preferred for 
Mild COPD, intermittent symptoms,
rescue treatment (for breakthrough
symptoms in pts on long-acting
meds)
Long-acting bronchodilator
monotherapy 
reduces exacerbation frequency
and improves overall resp health,
but no sig reduction
hospitalization or mortality
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians prescribe
corticosteroids?
Inhaled
corticosteroids
Fluticasone
Budesonide
Triamcinolone
Dosage: Fluticasone, 880 μg/d; budesonide, 800 μg/d;
triamcinolone, 1200 μg/d; all in divided doses.
Side effects: Skin bruising, oral candidiasis, rarely adrenal
suppression poss glaucoma, decreased bone density,
diabetes, systemic HTN, cataracts.
Notes: Can be used as maintenance Tx. In pts w/Hx frequent
exacerbations, high doses best studied. Pulmonary fxn
improved in 10%-20% of pts, but symptoms & exacerbations
reduced in larger percent. No effect on decline in pulm fxn.
Not approved by FDA for COPD.
Oral corticosteroids
Prednisone
Prednisolone
Dosage: Varying doses
Side effects: Skin bruising, adrenal suppression, glaucoma,
osteoporosis
Notes: Avoid use, if poss, in stable COPD. Pulm fxn
improved in 10%-20% of pts. Reduce to lowest effective
dose, including transition to inhaled corticosteroids, alt day
oral corticosteroids, or both. IV or oral corticosteroids
standard Tx & effective for acute exacerbations.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians prescribe
corticosteroids?
When pts w/mod/severe COPD (FEV1 <50% predicted)
remain symptomatic or have repeated exacerbations
while taking inhaled long-acting bronchodilators
 Inhaled corticosteroids + LABA = improved pulmonary
fxn and clinical outcomes > either agent alone
 Inhaled corticosteroid + long-acting anticholinergic +
LABA = improved QOL compared w/monotherapy w/
long-acting anticholinergic
 FDA advised against using LABAs w/o concomitant
admin of inhaled corticosteroids, due to safety concerns
 but recom’n didn’t apply to COPD
 Reserve oral corticosteroids for limited periods to treat
acute exacerbation  avoid ongoing use in stable
disease (limited benefits & high pot’l for side effects)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians consider adding
oral theophylline to inhaled drug therapy?
When pt has refractory symptoms even if receiving
inhaled bronchodilators and/or inhaled corticosteroids
 Start at low dose and titrate to effect  aim for blood
level 5-14 micrograms/mL
 Monitor serum drug levels frequently  narrow
therapeutic window, multiple interactions w/ other meds,
potential toxicity
 Side effects common, esp nausea and tachyarrhythmia
 Bronchodilator effects relatively modest
 Discontinue if symptoms don’t improve after several wks
 Do not use in treating acute exacerbations of COPD
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What immunizations should clinicians
administer?
 Annual flu vaccination: significantly reduces
exacerbations
 Pneumococcal vaccination: admin once to adults 19-64 y
who smoke or who have COPD; admin again after age 65
if previous vaccination given >5 y earlier
 If pt not vaccinated before age 65, then one-time
pneumococcal vaccination recommended
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What criteria are used to define a COPD
acute exacerbations?
Criteria and Classification of Acute COPD Exacerbation
Major criteria
• Increase in sputum volume
• Increase in sputum purulence (generally yellow or green)
• Worsening dyspnea
Additional criteria
• Upper respiratory infection in past 5 d
• Fever of no apparent cause
• Increase in wheezing and cough
• Increase in respiratory rate or heart rate 20% above baseline
Mild exacerbation = 1 major criterion plus ≥1 add’l criteria
Moderate exacerbation = 2 major criteria
Severe exacerbation = all 3 major criteria
(Adapted from Anthonisen NR, et al. Ann Intern Med. 1987; 106:196-204. [PMID: 3492164])
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians manage acute
exacerbations?
 Prompt recognition
 Possible adjustment bronchodilator and steroid Tx
 Initiation antibiotics
 Assessment of need for hospitalization
 Inciting factor for exacerbation typically unknown 
bacterial or viral infection or inhaled irritants
 Treatment should be guided by:
 Severity of exacerbation (if pneumonia suspected, obtain
chest X-ray to confirm)
 Degree of impaired pulmonary function
 History of exacerbations
 Response to previous treatment should guide therapy
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians manage acute
exacerbations?
 Antibiotics: esp in pts w/purulent sputum
 Improve peak flow, reduce mortality and treatment failure
 β-lactam/β-lactamase inhib, extended-spectrum macrolide,
2nd- or 3rd-generation cephalosporin, or fluoroquinolone:
for mod/severe exacerbation
 Tetracycline or trimethoprim-sulfa-methoxazole: for mild
exacerbations
 Prophylactic Abx may prevent future exacerbation 
requires better data before recommended; danger of
resistance
 Oral corticosteroids: for mod/erate severe acute exacerbation
 Dose not well-defined: 30-60 mg/d for ≤2 wks typical;
longer course increases risk for adverse effects
 Appears to reduce treatment failures
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians manage acute
exacerbations?
 PPIs may prevent exacerbations in older patients
 Mucolytics may help prevent in pts w/ chronic bronchitis
(effect seems absent in pts using inhaled corticosteroids)
 Frequency of exacerbation in past year  predicts
frequency of exacerbation in following year (overall 43%
sensitivity, 87% specificity)
 Best predictor of future exacerbations: ≥2 in past yr (also
baseline FEV1 <50% predicted, Hx GERD heartburn)
 If outpatient mgmt of exacerbation inadequate 
hospitalize pt for poss intubation + mechanical ventilation
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
How should clinicians manage acute
exacerbations?
 Indications for hospital assessment or admission
 Marked increase in intensity of symptoms (e.g., sudden
development of resting dyspnea)
 Severe underlying COPD
 Onset new physical signs (e.g., cyanosis, periph edema)
 Failure of exacerbation to respond to initial medical mgmt
 Significant comorbid conditions
 Frequent exacerbations
 Newly occurring arrhythmias
 Diagnostic uncertainty
 Older age
 Insufficient home support
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians recommend
pulmonary rehabilitation? For all symptomatic
Pulmonary rehab = multidisciplinary program
 Exercise training
 Education
 Psychological and nutritional counseling
pts w/ COPD
 part of overall trmt
plan as drug trmt
optimized
Benefits
 Components beneficial individually  but
comprehensive, integrated appear most
effective
 HC team provides pulmonary rehab thru
structured program to groups of pts w/COPD
 Patients
Patients with
mostsevere
likely to
COPD
benefit:
require
program
lasting
mos
to achieve benefit
 Impaired
QOL ≥6
from
COPD
Improved exercise
ability
Improved healthrelated QOL
Reduced dyspnea
Reduced future
hospital admissions
 Patients
w/ mild-to-moderate
COPDactivity
could Reduced mortality
 Breathlessness
& anxiety limiting
benefit
from
program
 Willing
to shorter
undertake
intensive edu’n and exercise program
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What other adjunctive measures should
clinicians consider?
Adjunctive therapies commonly used 
but little evidence supports effectiveness
 Relaxation techniques  to reduce anxiety due to
shortness of breath
 Pursed-lip breathing and diaphragmatic breathing  to
reduce shortness of breath
 Nutritional interventions  to achieve ideal body weight
and improve performance of daily activities and exercise
 Chest physiotherapy, percussion and vibration, and
postural drainage  to enhance sputum clearance and
alleviate shortness of breath
 Limited usefulness w/o excessive sputum prod’n and
inadequate bronchial clearance
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians prescribe
oxygen therapy?
 Periodically evaluate pts w/ mod-to-severe COPD 
to determine if supplemental oxygen needed
Criteria for Initiation of Long-Term Oxygen Therapy
 Room air PaO2 ≤55 mm Hg or between 55 and 60
mm Hg w/ cor pulmonale; signs of tissue hypoxia
(e.g., polycythemia); or SaO2 ≤88% or 89% w/ signs
of tissue hypoxia, OR
 Nocturnal hypoxemia w/ SaO2 ≤88% (use oxygen
only at night), OR
 Exercise hypoxemia w/ PaO2 ≤55 mm Hg or SaO2
≤88% (use oxygen only with exertion)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians prescribe
oxygen therapy?
PaO2 measurement after 30mins breathing room air 
most accurate clinical standard for initiating Tx
 Use pulse oximetry (sensor that measures Hgb
oxygenation)
 To qualify pts for long-term oxygen Tx
 To adjust oxygen flow rates after initial Dx, over time
 To allow pts to self-adjust rate of oxygen flow w/
Inexpensive pulse oximeters (instruct pt in use,
keeping SaO2 above and near 90%)
 For pts titrating oxygen flow at different altitudes
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians prescribe
oxygen therapy?
 When long-term oxygen Tx
indicated 
 Use ≥15h/d, ideally 24h/d
 Follow-up w/in 3 mos initially
 yearly thereafter
 In pts who don’t qualify for
continuous Tx 
 Use to reduce dyspnea
during exercise (in those w/
exertional desaturation)
 Use during sleep (in those
who desaturate at night)
 Long-term home oxygen
Tx: improves survival in
select group of pts w/ +
severe hypoxemia
 Doesn’t improve survival
in pts w/ mild-to-mod
hypoxemia or w/ only
arterial desaturation at night
 Unclear if nocturnal
oxygen in pts w/o daytime
hypoxemia benefits
mortality, health-related
QOL, or daytime fxn
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians refer patients to
a pulmonologist?
When to Consider Referral to a Pulmonary Specialist*
 Disease onset before 40 years of age
 Frequent exacerbations (≥2/yr) despite adequate treatment
 Rapidly progressive course of disease (decline in FEV1, progressive
dyspnea, decreased exercise tolerance, unintentional weight loss)
 Severe COPD (FEV1 <50% predicted) despite optimal treatment
 Need for oxygen therapy
 Onset of comorbid cond’n (osteoporosis, HF, bronchiectasis, lung CA)
 Diagnostic uncertainty (e.g., coexisting COPD and asthma)
 Symptoms disproportionate to severity of airflow obstruction
 Confirmed or suspected α1-antitrypsin deficiency
 Patient requests a second opinion
 Possible candidate for lung transplant or lung-volume reduction surgery
 Very severe disease and requires elective surgery that may impair
respiratory function
*Adapted &modified from ATS/ER and VA/DoD guidelines.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians consider
surgical therapies?
 Lung volume-reduction surgery
 Improves exercise capacity, lung fxn, dyspnea, QOL
 doesn’t improve survival vs. medical Tx alone
 May improve survival for subgroup w/upper lobe
emphysema and low exercise capacity
 Consider if pulmonary rehab completed and patient
meets the following criteria:
• Evidence of bilateral emphysema on CT scan
• Postbronchodilator TLC > 150% predicted and RV >
100% predicted
• Max FEV1 ≤45% predicted; and
• Room air PaCO2 ≤60 mm Hg and PaO2 ≥45 mm Hg
 Unlikely benefit + high risk if FEV1 ≤20% predicted + either
homogeneous emphysema on CT scan or CO-diffusing
capacity ≤ 20% predicted
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
When should clinicians consider
surgical therapies?
 Lung transplantation
 Improves pulmonary function, exercise capacity,
QOL, and possibly survival
 Consider if pt BODE index 7-10 and ≥1 of following:
• Hx hospitalization for exacerbation associated w/acute
hypercapnia (PCO2 >50 mm Hg)
• Pulm HTN, cor pulmonale, or both despite O2 Tx
• FEV1 <20% predicted + either CO-diffusing capacity <20%
predicted or homogeneous distribution of emphysema
 Survival single lung transplantation for pts w/COPD
≈83% at 1y; 60% at 3y; 43% at 5y (double-lung
transplant survival similar/ slightly higher)
 Chronic allograft rejection prevalence as high as
50%-70% among survivors (at 5 yrs after transplant)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What do professional organizations
recommend with regard to prevention,
screening, diagnosis, and treatment?
4 guidelines provide comprehensive approach to Dx and management
of COPD (all drawing from variety of sources: RCTs; cohort and casecontrol studies; public policy org recommendations; expert opinion)
 Global Initiative for Chronic Obstructive Lung Disease, updated
2009
 American College of Physicians / American Thoracic Society/
European Respiratory Society, updated 2011
 VA and DoD, updated 2007
 National Institute of Clinical Excellence, updated 2010
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.
What measures do stakeholders use to
evaluate the quality of care for patients
with COPD?
 Centers for Medicare & Medicaid Services 2010
Physicians Quality Reporting Initiative
 Percentage of patients ≥18y w/ Dx of COPD who had:
 Spirometry evaluation documented
 FEV1/ FVC ratio <0.70, and symptoms such as
dyspnea, cough, sputum, or wheezing who were
prescribed inhaled bronchodilator
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 154 (7): ITC4-1.