#356 Chronic Obstructive Pulmonary Disease (COPD) Update with Dr. Antonio Anzueto

September 26, 2022 | By Deb Gorth

Video

Brush up on your COPD skills and learn some new tips for diagnosis and management of this common respiratory condition from our expert Dr. Antonio Anzueto (University of Texas San Antonio). 

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Credits

• Writer and Producer: Cyrus Askin, MD
• Show Notes: Deborah Gorth MD, PhD
• Infographic: Kate Grant MD
• Cover Art: Kate Grant MD
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Associate Editor: Leah Witt, MD
• Showrunner: Matthew Watto MD, FACP
• Technical Production: PodPaste
• Guest: Antonio Anzueto, MD

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CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Case from Kashlak
• Epidemiology
• Diagnosis
• Workup
• Characterization of disease
• Treatment
• Outro

COPD Pearls

1. COPD demographics are evolving: one emerging phenotype is known as “Early COPD,” operationally defined as those less than 50 years old, with a 10-pack-year history of smoking, in conjunction with PFT and/or radiographic abnormalities (Maselli et al 2019); severe early-onset COPD predominantly affects women (66%) (Foreman et al 2011). 
2. Clinically, COPD is differentiated from asthma by responsiveness to bronchodilators and/or the presence of atopic allergic symptoms, but these diseases likely exist on a spectrum (Postma and Rabe 2015).
3. Iraq war veterans with exposure to burn pits have increased incidence of lung disease (Coughlin and Szema 2019). 
4. The criterion for airflow obstruction (which supports a diagnosis of COPD) is a ratio of FEV₁/FVC < 0.70; this ratio comes from the volume of air exhaled in the first second (forced expiratory volume in one second, FEV₁) divided by the total volume of air forcibly exhaled from the point of maximal inspiration (forced vital capacity, FVC) (GOLD 2022).
5. COPD is a treatable disease. The “COPD tripod” of treatment consists of medications, pulmonary rehab, and smoking cessation.
6. If the patient’s absolute blood eosinophil count is greater than 100/μL, consider prescribing  inhaled corticosteroids, and if greater than 300/μL corticosteroids are recommended (Agusti et al 2018 reproduced in Figure 3.1 in GOLD 2022). 
7. Start with an aggressive LABA/LAMA treatment, your patient is more likely to notice the symptomatic difference and be more likely to consistently take their medication (expert opinion).
8. If your patient is not using their short-acting rescue medication medication, you’re doing a good job treating their COPD (expert opinion). 

Chronic Obstructive Pulmonary Disease (COPD)

Epidemiology

Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory conditions worldwide, with a global estimated prevalence of 12% (Adeloye et al 2015).  Although the typical illness-script for a COPD patient is a man in their 70s or 80s, there is emerging evidence to suggest this may be evolving. For example, one emerging phenotype in COPD is known as “Early COPD,” operationally defined as those less than 50 years old, with a 10-pack-year history of smoking, in conjunction with PFT and/or radiographic abnormalities (Martinez 2018). COPD research has also identified that severe early COPD predominantly affects women (66%) (Foreman et al 2011). So, certainly not a disease process restricted to the “classic” demographic!

Dr. Anzueto notes that the pathophysiology & epidemiology of COPD is complicated, and in some cases, the seeds for a COPD diagnosis may be sewn in utero (Lange et al 2015, Soriano et al 2019) as smoke exposure and air pollution, in utero, have been attributed to the development of COPD. Additionally, exposure to respiratory toxins at any point in life can contribute to the development of COPD, particularly if one has the genetic predisposition to develop the disease. COPD is further complicated by the numerous phenotypes that are classically acknowledged, as well as some that are emerging (Corlateanu 2020). In their 2020 review of COPD phenotypes, Corlateanu and colleagues provide a table of accepted and emerging phenotypes. The former includes chronic bronchitis, asthma-COPD overlap, and frequent exacerbator – among others, while the later includes phenotypes such as the fast-decliner or the bronchiectasis-COPD overlap patient. 

History

COPD is a clinical diagnosis (made with support of spirometric data) and commonly presents with shortness of breath (often worse with exertion), and a productive cough. Some common mimickers of COPD include asthma, congestive heart failure, bronchiectasis, and upper airway abnormalities like vocal cord dysfunction. COPD is differentiated from asthma both by responsiveness to bronchodilators and the presence of atopic allergic symptoms, but these diseases likely exist on a spectrum (Postma and Rabe 2015). Dr. Anzueto recommends asking about a patient’s sensitivity to strong odors (perfumes or cleaning products) which suggests airway hyperreactivity. 

Personal smoking history is the typical cause of COPD (Ford et al 2013), but other exposures such as air pollution and second-hand smoke can also contribute. Iraq war veterans with exposure to burn pits have increased incidence of lung disease (Coughlin and Szema 2019). 

Severe obesity, sometimes secondary to a more sedentary life due to dyspnea, can also further exacerbate dyspnea and deconditioning (and in some cases contribute to co-existing obesity hypoventilation syndrome covered in Episode 269).

Diagnosis

The diagnosis of COPD is a clinical one, made in the setting of appropriate exposures (eg personal smoking history), symptoms, and supported with spirometry. While pulmonary function test (PFT) reports can often be intimidating (author’s personal option), focusing on a couple values make them more approachable. The criterion for airway obstruction (which supports a diagnosis of COPD) is an FEV₁/FVC ratio < 0.70; this ratio comes from the volume of air exhaled in the first second (forced expiratory volume in one second, FEV₁) divided by the total volume of air forcibly exhaled from the point of maximal inspiration (forced vital capacity, FVC) (GOLD 2022). In COPD, the airway obstruction is fixed meaning that the obstruction is present even following bronchodilators. Dr. Anzueto reminds us to make sure that the demographics on the PFT report match the demographics of the patient (“predicted” values are based on age, sex and height so these must be entered accurately for interpretation) and that the study quality was adequate (look at the flow volume curves to see if the efforts were reproducible and good quality). 

Dr. Anzueto discussed the continuum that can exist between asthma and COPD–patients who have a robust bronchodilator response may fit the asthma-COPD phenotype which should prompt more investigation into possible allergens that may be targeted. It can also make short-acting bronchodilators a more useful tool for symptom control.

Work up

Besides spirometry, additional evaluation can be helpful to rule out other causes of dyspnea and tailor treatment. Consider a CBC w/ differential to look for eosinophils or IgE levels; these patients may be eligible for biologic therapy if symptoms are not controlled with first-line inhalers. An alpha-1 antitrypsin level should be offered to those with a diagnosis of COPD (or bronchiectasis).. The Alpha-1 Foundation offers free and confidential testing for alpha-1 antitrypsin deficiency. Dr. Anzueto often also gets an aeroallergen panel to assess whether there is an allergic component to concurrently treat (expert opinion).

Dr. Anzueto often gets full PFTs (distinguished from spirometry by the addition of lung volumes by plethysmography, and a diffusing capacity for carbon monoxide (DLCO)) and a CT chest to look for other lung abnormalities if there is a concern for another pulmonary process. Around 50% of individuals with early COPD have no emphysematous changes on CT scan (Oh et al 2020) and many of these patients have a component of interstitial lung disease (Washko et al 2010). 

Lung cancer screening: Low dose chest CT scans should be offered if the patient meets criteria (ages 50 to 80 years with 20 pack-year smoking history who currently smoke or quit within the past 15 years) (USPSTF). Lung cancer screening must be done yearly while a patient qualifies for screening–the decision to start (and stop) should be made via shared-decision making factoring in the individual’s preferences and willingness to undergo curative lung resection surgery if an early-stage malignancy is identified.

Consider evaluation for sleep apnea in patients with lower resting oxygen saturation (or elevated serum bicarbonate), especially if the history or physical exam suggest this diagnosis. If a patient is hypercapnic, noninvasive ventilation can reduce readmission (Murphy et al 2017).

Characterization 

There are subjective and objective ways to characterize dyspnea and COPD severity. Dr. Anzueto suggests using a six minute walk test to quantify functional dyspnea. Two patient-reported measures to quantify dyspnea are the Modified Medical Research Council (mMRC) dyspnea score or COPD assessment test (CAT). The mMRC score goes from a scale of 0 (dyspnea only with strenuous exercise) to +4 (too dyspneic to leave the house or breathless when dressing)  (Mahler and Wells 1988). The CAT score is a more comprehensive 8-question graded questionnaire, with multiple translations available on The COPD Assessment Test website (Kim et al 2013). 

Either the mMRC or CAT can be used to classify COPD severity according to the ABCD assessment tool; more than one hospital admission and mMRC > +2 (walks slower than people of the same age because of dyspnea or has to stop for breath when walking at own pace) are the parameters that delineate the ABCD groups (GOLD 2022, Fig 2.4)

Treatment

COPD is a treatable disease. The “COPD tripod” of treatment is medications, pulmonary rehab, and smoking cessation. If pulmonary rehab is inaccessible, encourage physical activity like walking. 

The two mainstays of COPD treatment are long acting muscarinic antagonists (LAMAs) and long acting beta agonists (LABAs). Treatment typically starts with LAMAs (aka tiotropium, glycopyrronium, aclidinium, and umeclidinium). If the patient is symptomatic, it may be appropriate also to add a LABA (aka salmeterol, formoterol, indacaterol, and olodaterol). Short acting bronchodilators (albuterol or ipratropium) are rescue medications only.  Dr. Anzueto suggests that if you start with aggressive LABA/LAMA treatment, your patient is more likely to notice the symptomatic difference and be more likely to consistently take their medication (expert opinion). He also reminds us that if your patient is not using their short-acting rescue medication medication, you’re doing a good job treating their COPD. Most of these medications are inhalers, which are subject to user error, but using a spacer or nebulizer and coaching proper inhaler use (as demonstrated in these videos available on the National Jewish Health website) can improve efficacy.

If the patient’s absolute blood eosinophil count is greater than 100/μL, can consider prescribing  inhaled corticosteroid, and if it is greater than 300/μL corticosteroids are recommended (Agusti et al 2018 reproduced in Figure 3.1 in GOLD 2022). This recommendation is balancing the benefit of steroids versus the risk of pneumonia. This treatment can be removed once the person stops having frequent exacerbations.

In people who are hypoxemic at rest, supplemental oxygen improves mortality (when used for the majority of the day (MCWP 1981). Vaccinations (influenza, COVID-19, PPSV23, PCV13, and Tdap) (GOLD 2022, p46) and smoking cessation are also critical for mortality benefit. Smoking cessation can be difficult to achieve but is extremely important! This topic is covered in depth on episode # 252 Smoking Cessation Unfiltered. Until recently, a mortality benefit had not been seen with inhaler therapy; however the 2021 ETHOS trial demonstrated reduction in all-cause mortality when participants with COPD were treated with budesonide, glycopyrrolate, and formoterol) compared to treatment with glycopyrrolate/formoterol fumarate (Martinez et al 2021).

Links

1. Seinfeld El Paso Joke, evidence that Dr. Watto’s Seinfeld episode references are accurate
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2022 guidelines
3. The COPDGene study website 
4. National Jewish Inhaler videos 
5. Alpha-1 Foundation
6. The COPD Assessment Test website
7. Pulmonary rehab locations/education
8. The COPD Foundation

Goal

Listeners will learn the latest updates in the diagnosis, characterization, and management of chronic obstructive pulmonary disease.

Learning objectives

After listening to this episode listeners will…  

1. Reflect on the diagnostic criteria for COPD.
2. Appreciate the burden of illness for both patients and society as well as disparities related to COPD.
3. Recognize the role of spirometry, labs and imaging to better assess COPD.
4. Develop an understanding for the heterogeneity of COPD and the value of phenotyping.
5. Revisit key therapeutics and learn about new approaches to COPD management.

Disclosures

Dr. Anzueto reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

 Gorth D, Askin CA, Witt L, Anzueto A, Williams PN, Watto MF. “#356 Chronic Obstructive Pulmonary Disease (COPD) Update with Dr. Antonio Anzueto”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list 26 September, 2022.