Welcome to today's webinar, Practical Approach to the COPD Patient, Part 1 of 2. I'm Dr. Soler, and joining me today is Dr. Celli. It is a real privilege sharing the stage with you, Barb. Thank you, Xavi. I'm honored to be here with you, and we hope we can share this experience with our audience. This is our conflict of interest slide, and we prepare a case together from one of the real cases that Dr. Celli sees in his clinic. Jose is a 69-year-old retired roofer that came with a chief complaint of progressive dyspnea. Pertinent medical history is relevant for dyspnea on exertion over the three years, which he attributed to age. He stops for dyspnea while walking on level ground. He has occasional cough, no chest pain, no history of past exacerbations of COPD. His history of systemic hypertension is controlled in two drugs, and he's a smoker of 42-pack years. He stopped smoking two years ago. Physical exam is normal, except for a slight decrease in breath sounds. He had a chest X-ray done by his internist read as a slight hyperinflation and not cardiomegaly. Barb, based on this history, how you would approach Jose's medical problem? Very good, Xavi. This gentleman approached my clinic sent in by his internist with a history of also taking occasionally some inhaled medication that I assume was albuterol, which he picked up from his brother. Given that past medical history you just mentioned, we felt that the most appropriate test was to perform a spirometry. And indeed, on the next slide you will see that Jose had a spirometry after bronchodilators that showed an obstructive pattern with an FEV1, FEC of 0.51. When corrected by his age, gender, and height, he had a value of 15% predicted, which was clearly abnormal. In the middle panel, you see the gold staging of spirometric obstruction. And if you plot his number, which was 50% of predicted, he is at the borderline between a goal 2 and a goal 3. So we could say he has moderate severe obstructive lung disease. I want to call to attention that the spirometry I've just shown you is a post-bronchodilator spirometry as is required by the American Thoracic Society. Spirometry itself is a very good test. Not only does it tell you whether you are or are not obstructed, but its predicted value is that it relates to hospitalizations, to exacerbations, and it actually predicts mortality fairly well over time. If repeated over the years, a rapid decline in lung function, as shown in the panel on the left, is associated with increased mortality. So is associated with hospitalization. And in a very circular fashion, the presence of obstruction begets exacerbations, as shown in the middle, and the presence or incidence of exacerbation influences worsening of lung function. So it is advised not only to do it the first time that you see a patient, but it is very useful to follow as a way to know whether your therapy is appropriate or whether the patient is deteriorating over time. Thank you, Bart. So providing the results of that patient, which is moderate to severe obstruction, what else we should evaluate? There is a tendency to try to use only the spirometry in some cases to evaluate a patient's severity. But we have come to know that there are some other traits that are helpful, and of these the most important is whether you have dyspnea, that is symptoms, or whether you have exacerbations. In this case, because he had no history of exacerbation, we evaluated and quantified the severity of the shortness of breath. And for that, there are two tools that are widely used. The first one, which I personally favor and I use in this gentleman, is the Modified Medical Research Council Dyspnea Scale, which ranges from zero, where you only get breathless with a very severe exercise, almost normal, to four, people who get short of breath even with activities of daily living, as, for example, getting dressed. In this case, Jose complained that he became short of breath when he walked with people his same age, and he actually had to stop to be able to catch his breath. And as shown by the blue circle, that gave him an MMRC of two. And it is at that level where the threshold becomes very informative about outcomes in patients with obstructive lung disease. The alternative is to use the tool called COPD Assessment Test, or CAT for its abbreviation. This tool is a little more complex. It requires the calculation of the scoring for independent questions, but has the advantage of offering information regarding fatigue, sleep, and cough and phlegm. In this case, a value of 10 or higher is abnormal. And particularly for Jose, his absolute value was 12, which places him at an abnormal level of dyspnea, or in this case, symptoms. Well, now that we have the patient with medical information saying that he is moderate to severe COPD, that has a treatable trait, which is symptoms, what would be your recommendations for Jose? Based on the combination of a spirometry that showed moderate to severe obstruction, and to the fact that he has an MMRC of two and a CAT of 12, we have adjusted this to the gold management of COPD statement published in 2020. On the left upper panel, we see that the first thing we have to look into is whether the patient is smoking or not. In this case, he was not smoking, so there was no need to intervene. Whether he may or may not be a candidate for rehabilitation, this should always be considered. In his case, if he did not respond to therapy, it would be a very good choice. But importantly, from the point of view of initiating therapy, as was the case for Jose, the gold committee has established these quadrants called A, B, C, and D, in which the X-axis is quantified according to the CAT or MMRC, with values higher than 10 or 2 or higher displaced to the right, and exacerbations on the vertical axis, which would qualify a patient as being C or D. In this case, as shown by the blue circle, the patient was a category B because he had higher levels of dyspnea and CAT, but did not have exacerbations. This allows you to make an initial choice of therapy based on the gold schema. This is again depicted on the X-axis by symptoms, on the Y-axis by exacerbations, and being a group B patient, a long-acting bronchodilator is indicated. And this is exactly what he was placed on. It is very important to note that even though COPD is considered a disease that is poorly responsive to bronchodilator, this is actually a myth. In order to prove that, I've taken here this manuscript from Don Pashkins and co-workers of the uplift trial, in which 6,000 patients, very close to it, 5,700 of them, with severe obstruction with a mean FEV1 of 1.1 liters, were given two bronchodilators and then tested one hour later. What you see on the graph is the histogram response of a post-bronchodilator spirometry. The value of 100 is considered to be the clinically meaningful response that has association with improvement in symptoms. In the red square, you can see that the majority of patients, even though they had severe COPD, responded to the bronchodilators with a value that was higher than the MCID. That is to say, most patients, the vast majority of COPDers, when given bronchodilators, will respond to it with values higher than 15% to their administration. Actually, it is important to look at two aspects of the spirometric response, and this is the purpose of this slide from the same manuscript. In the left panel, we have on the x-axis the two qualifying responses in flow. For the Europeans, an increase of 15% would be a positive response. For the American Thoracic Society, it is 12% and 200 milliliters. Overcoded for that Ably study that I spoke about, you have patients with moderate COPD in yellow, severe COPD in green, and very severe COPD, FEV1, less than 35% in purple. Notice that the more severe you have your obstruction, the less likely it is that you will have a positive response in terms of flow of FEV1. That is because the less amount of air you have in your lungs, the less likely it is that you'll meet that pre-established threshold. On the right side, in the same maneuver, we have plotted the force vital capacity, the mirror image of the residual volume. That is to say, a reflection of the volume left in your lungs. When you are hyperinflated, you have a small vital capacity. As you deflate, the vital capacity goes up. I want to point out to you here that the response was greater in terms of inflation or deflation in the most severe patients. Those are the purple bars in the graph. In other words, FEV1 measures flow, that is volume over time, whereas vital capacity measures volume. And the level of inflation in your lungs is a big determinant of dyspnea. So bronchodilators not only increase your flow, but in the more severe cases actually deflate you, thereby having a dual action on the response. And this helps explain in great part why patients with COPD feel less dyspneic with exercise when they use their bronchodilators. The next slide shows the actual response to one-year therapy of a long-acting bronchodilator administered to Jose over that time. In the middle panel, I'm sorry, in the left panel, you see the pretreatment curve as I showed to you at the beginning. In the middle panel, you see the response after the one-year therapy. Please note that the vital capacity went up almost one liter, and so did the FEV1, and the ratio tended to normalize. This was a superb response, and Jose felt he could keep up his spears now and was able to actually help and play with his grandchildren, a thing he could not do before. I don't want to finish this portion without reminding everyone that, as I told you at the beginning, therapy for COPD should be based on the one hand by the degree of obstruction and on the other hand by the traits of dyspnea or exacerbations. In this case, without exacerbation, we concentrated on the dyspnea. But it is extremely important that in the management cycle, we continue to monitor both the spirometric response, as I showed you, and the perceptive response, as was discussed in this case. It is with that combination of elements that you may guide your therapy as this disease is chronic, and you have to make sure that over time, you're monitoring all these functions. Thank you so much, Bart, for summarizing the patient that you saw in your clinic. Just as conclusions, COPD is a preventable and treatable disease. An important and very common symptom is dyspnea. Diagnosis should always be confirmed with a spirometry. If the patient's predominant treatable trait is dyspnea with no history of COPD exacerbations, the cornerstone of treatment is lung acting bronchodilators. Bronchodilators improve airflow, lung function, but also reduce hyperinflation, the resting lung volume, which positively impacts dyspnea and exercise capacity. Thank you very much for listening to this webinar. Bart, thank you so much for joining me today. And do you have any other final comments before closing? Well, it is my pleasure, Xavi, to have been here with you and with our audience. We hope we've been clear, but if you have any questions related to this presentation, please write to webminar at chestnet.org. Thank you again, and we hope we can repeat this at some point in the future. Thank you very much. Have a good day.

webinar

COPD

spirometry

dyspnea

bronchodilators

Chronic Obstructive Pulmonary Disease