New COPD Guideline: Act Early, Treat Aggressively

Chronic obstructive pulmonary disease (COPD) is the 2^ndleading cause of disability, and the 3^rdleading cause of death in the United States in 2014. It's also very common. Approximately 16 million Americans have COPD, but more than half are unaware of it. It's inevitable that retail health providers will see patients who have COPD, whether they are aware of their condition or not. Often, these patients appear because they have acute minor illnesses—illnesses that can mushroom into emergency situations quickly.

COPD creates persistent respiratory symptoms and airflow limitations due to airway and/or alveolar abnormalities. It's preventable and treatable disease. Fewer American are smoking these days—in 2015, 15.1% of adults were current smokers, compared to roughly 21% in 2005—but the millions of Americans who have smoked since their teens are still at risk for COPD.

The most comprehensive and respected guideline for COPD is the Global Strategy for the Diagnosis, Management, and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD). In March 2017, the GOLD guideline was revised to make several significant changes.

GOLD 2017 now includes:

A refined COPD assessment, separating spirometric assessment from symptom evaluation.Many clinicians are willing and able to assess patients based on their symptoms. Fewer are trained or have the equipment to do spirometry. The new guideline allows clinicians to classify COPD based on the patient's symptoms, and refer them for diagnosis confirmation using spirometry. Retail healthcare providers should suspect COPD in any patient who presents with persistent shortness of breath, chronic cough, chronic sputum production, or wheezing. They also need to monitor patients who are exposed to high levels of air pollution, have family histories of COPD, and/or are 40 years old or older.

Specific pharmacologic escalation strategies based on patient classification, and a new concept of therapy de-escalation based on symptoms and exacerbation risk. The guideline includes a flowchart that suggest intervention based on the severity of the patient's COPD.

A section on comprehensive nonpharmacologic therapies.Patients who have COPD need more than medications. This updated guideline covers education and self-management, pulmonary rehabilitation, and nutritional support. Patients need to incorporate lifestyle changes into their routines, and once the disease progresses, surgical procedures like lung reduction or lung transplantation may be needed.

Emphasis on comorbid conditions' impact on COPD management.COPD ranks as the third most frequent cause for hospital readmission within 30 days, causing 800,000 hospitalization annually. The majority of COPD readmission are related to underlying comorbidities, which is why the 2017 revision of GOLD emphasizes comorbidities. All comorbid conditions magnify COPD disability and complicate disease management.

COPD in the Retail Clinic

When retail healthcare providers see COPD patients, they should monitor comorbidities, refer patients when problems arise, and adjust medication when current treatment appears to be failing. Even if patients have comorbidities, clinicians must manage COPD in the same way and as simply as possible—simple regimens improve adherence.

Immunization is a critical preventive measure. The GOLD guideline recommends pneumococcal vaccine, which may reduce mortality. They also recommend influenza vaccine, which may reduce acute COPD exacerbations. With the recent increase in cases of pertussis across the country, vaccinating against this illness is also reasonable.

Choice of inhaler is important, because many patients struggle with inhalers. GOLD 2017 emphasizes ensuring patients use inhaler devices correctly and addressing poor adherence/correcting inhaler technique early. The guideline highlights initiating treatment with either a long-acting muscarinic antagonist or a long-acting β₂-agonist. If symptoms or exacerbations persist, it steps up to combination treatment. One change is new: GOLD 2017 acknowledges the growing indecision about high-dose inhaled corticosteroids as evidence confirming their side effects accumulates.

Inhalers are drug-device combinations (DDCs), and clinicians need to ensure patients can use them appropriately. Available DDCs require some degree of eyesight and hand coordination, but older individuals often have difficulty with vision, dexterity and grip strength. Clinicians need to consider each patient's limitations and select the appropriate device. Manufacturers market 3 main types of inhalers: meter dose inhalers (MDI), dry powder inhalers (DPI) and a newer Soft Mist™ technology. In addition, a new type of DPI called the Ellipta® inhaler was introduced in 2013 (FDA, 2015). Each has pros and cons.

Guideline-based treatment for COPD has proven benefits. It improves lung function, symptoms, exercise tolerance, and quality of life. It also reduces the number of exacerbations and hospitalizations.

References

Centers for Disease Control and Prevention (2016). Chronic obstructive pulmonary disease (COPD). Updated September 16, 2016. Available at https://www.cdc.gov/copd/index.html. Accessed March 3, 2017.

Centers for Disease Control and Prevention (2016a). Current cigarette smoking among adults in the United States. Updated December 1, 2016. Available at https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm. Accessed March 1, 2017.

Robinson K, Thomashow B. Preventing COPD rehospitalizations: Acute and post-acute comprehensive care to enhance quality and improve clinical outcomes. February, 2015. Available at http://www.medscape.org/viewarticle/839472. Accessed March 6, 2017.

Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary.Eur Respir J.2017 Feb 24. doi: 10.1183/13993003.00214-2017. [Epub ahead of print]