Free NPACE Education - Updates in Managing COPD in Primary Care with Complex Case Studies

[Music] so congratulations on sticking through the the the asthma Marathon I just wanted to uh um append a couple of my answers one of your colleagues here actually works in an allergy clinic and so she she has more direct experience with the um biologics than I do and so for the question about um biologics and pregnancy specific speically what she said was that if a patient is already on a biologic and then they get pregnant they will they will continue the biologic like Zol a um mostly because of the risk of anaphylaxis so if it's a a patient who's already pregnant and then comes to you for zir therapy in that situation they would hold off until after the delivery because they really don't want to have to deal with the potential risk factor of um anaphylaxis and needing to use the EpiPen so that was the one major Point um thank you all for people who stayed behind and we had a great discussion um about uh questions one of the other things that came out is one way to think about um combination IC and formol therapy and kind of where asthma therapy is leading is don't ever ever ever ever ever ever ever give your patients short acting Bronco dilator even for the mild people please give them a inhale cortical steroid and rubber band it tell the patient to rubber band it together so take that IC inhaler take that short acting Bronco dilator put those two together put a rubber band around it so every time they need one they use the other that's a good way rubber band it in your own heads and rubber band it in your patients heads so those were the two key points I wanted to bring out so bigy breath we just have COPD to go through okay so COPD updates in um managing in primary care this I will say that the majority of the um the slide talk is similar however um the Gold group analogous to Gina they also did update their guidelines um during covid and we'll go through that I will emphasize what's different so we're again we're going to go through the same structure go over the um high yield assessments of how you want to understand your cop patients we'll talk about the guidelines and pickle in the gold juices and then we're going to talk about creating a comprehensive plan and managing these patients in your clinics I have no disclosures so in terms of in terms of nurse practitioners and PAs and the like um uh less than 10 less than 10% of COPD patients are actually seen by me a pulmonologist 90% of these patients are all your privileged to deal with um so COPD is a public health problem these stats actually the slide was uh before covid BC I did not change it because the statistics pretty much are the same um COPD is the fourth leading cause of death in the world um it's the third leading cause by 2020 responsible for 6% of deaths in 2012 and 6% and 30 million patients in the US 30 million people in the US actually have covid and actually have Co COPD and um we know that the incidence of COPD is rising um with age more than half of our patients will be 75 years or older by 2030 okay so um high yield definition bolded common preventable treatable with persistent respiratory symptoms and airflow limitation that is due to Airway and alv abnormalities and it is caused by significant exposure to noxious particles or gases so I don't have to belabor this we talked about this in the talk and in the questions uh my oak tree analogy is really awesome if I do do say so myself patients remember all right so the pictorial here is your lung parena the Airways or the branches of the tree are the kind of scaffolding they actually hold the lung tissue in a form of structure and COPD or airflow obstruction in the airway is caused by a lack of that scaffolding being intact so what you end up having is disrupted Alvar attachments as the leaves start falling off some parts of the Airways or or branches start sagging right so by analogous when um the Airways lose their scaffolding by disrupted attachment around the lung tissue those Airways will tend to collapse if the COPD Airways are inflamed with mucus and other stuff and inflammation inside then there's going to be a lot of sludge inside the Airways and the patients are going to have that chronic bronchitis uh presentation chronic sputum production okay so this is basically that same uh Cartoon in an actual histology here's your normal Airway um with you you have a nce wide open clear Airway with air in the middle and here you have all the lung tissue nicely arranged that lung tissue is the Alvi right so this is all your type one and your type two pneumocytes that make up those alvear walls this is a collapsed Airway it's it's lost some of its tethering the leaves have come off and the Airways themselves are very thickened and narrowed thickened and narrow Airway with a lot of inflammatory slug ludge and your patients waking up in the morning with a cough if they smoke they have a smoker's cough okay this is what empyema looks in an x-ray basically you've got that barrel chest um shape you've got flattened diaphragms a big heart but a lot of um dilated dilated apases of the lungs so this is empyema on x-ray this is empyema on autopsy I don't need to say anything there okay caus of air flow obstruction so here's a little cartoon from um Google image which basically shows you all of the different noxious particles and gases people can be exposing themselves to by smoking cigarettes I tell my patients if cigarettes were good for you if vaping was good for you if inhaling marijuana was good for you I would make my babies do it I don't make my babies do it I don't want you to do it okay smoking and secondhand smoking is basically the biggest cause of COPD but there are other causes in the world the wood smoke exposure is a big cause occupational exposures new data emerging data talks about how poor uh and and uh compromised early lung development can predispose you to lung disease including asthma including COPD even if you never smoked okay and then of course if you have alpha 1 antirion deficiency then basically you're going to have a lot of problems with your lung parena uh and therefore you will also develop empyema and that will uh is a genetic cause of COPD all right this is a book I love it's called a cigarette Century it was published a long time ago um but this book actually taught me that um cigarettes were basically the worst invention ever ever ever um cigarettes were first created and then a market was developed so the first cigarettes the Native Americans used to smoke for medicinal purposes they used the highly concentrated tobacco for religious ceremonies etc etc and they would smoke they would smoke small quantities and then somewhere down the road in the early 1800s some dude figured out well why don't I make a cigarette making machine I'm going to roll up the tobacco I'm going to wrap it up in a piece of paper and I'm going to roll it out and it took a few trials and by version 3 or 4.0 they diluted the the uh tobacco plant down into something that was less irritable to your lung and then they said voila here's the cigarette and they manufactured a product without a market it was like Steve jobes in the garage but bad okay and so that this first cigarette making machine produced 500 like in an hour okay and then after that it was Off to the Races a whole industry of advertising and marketing and science people used to smoke in the hospitals because cigarettes were part of the culture the reason I learned about this is my veterans tend to blame themselves for their smoking history but I tell them you the government gave you rations we used to put a penny or a nickel in a packet of cigarettes and you would get money back for buying cigarettes and we addicted your brain to nicotine when you were just a kid some of my patients started smoking when they were three years old okay so I thought that was totally strange until I read this book so if you like to read if you're on the beach pick up this book um great book so in terms of the pathogenesis of smoking cigarette smoke or other kind of um exposure will cause um inflammation in the lung that inflammation will eventually lead you to a COPD type pathology of air flow obstruction through various bad things that happen in your Airways oxidative stress and other proteinases that start um to cause bad things um the green is good so there's repair mechanisms antioxidants and other antiproteinases mechanisms um but excuse me but at the end of the day um eventually with enough toxic smoke exposure you're going to have some form of lung inflammation and chronic COPD pathology having said that only 20% of smokers end up getting COPD but 100% or in America at Le nearly 100% of patients with COPD have smoked okay so not everybody who smokes will get COPD but I will tell my patients your lungs you spared but remember that heart attack and that stroke you had and the peripheral vascular disease that's a reason to stop smoking okay so smoking is not free if if if it doesn't affect your lungs in my patients nearly everybody who smokes that that everybody who has COPD has smoked quite a bit okay so this is a a classic slide 1970s it's the Fletcher pedo which basically talks about how lung function declines this you you I nobody can give a COPD talk without showing you guys this slide and this slide in the green is basically um the physiology of your Airways so you're born assum your born healthy you have an A you you get to Peak airf flow in your Airways in your mid 20s and then guess what after that time and age works against you so after your mid 20s aging is you know what lung function declines over time this isn't a non-smoker okay if you smoke and you smoke lung function declines more rapidly you see that that Cliff you're falling off that Cliff if you quit smoking the data shows that the longer you remain smoke free you can never regain the function that you lost the lung empyema will never come back the lung tissue won't come back but as you age your lung as you age your lung starts aging normally again your lungs kind of forget that you smoked if you remain smoke free for about 10 years so you can at least normalize your aging pattern again okay and then if you smoke and then you have a lot of exacerbations then your lung function is worse than falling off a cliff it just plummets to the ground all right so this is a great slide to kind of talk to your patients about how quitting smoking is a good idea because every cigarette does chew away at that tree and drops your leaves off and over time you actually may feel feel like the next guy who never smoked because you're you're at least not aging as well the one thing I don't like about this diagram is that emerging data you know we look at this diagram and we we look at this diagram and you we think well in general everything's heading in the wrong direction right but what we know is with good treatments adherence to those inhalers and staying out of the hospital with COPD flareups and pneumonia there are patients there's a subset of patients that actually can have an improvement in their spherometer and this 1970 graph never really learned that it's only now in the mid 2020s that we're seeing a lot of patients with good therapies at least have improved air flow so it is possible to have your fv1 improve okay so that's that's the good news all right so I love this study this study was a European respiratory Journal study in 2013 and it took uh took place across 17 European countries study investigators basically called patients with moderate to severe COPD who had been living their daily lives at home who did not have a COPD flare up for three months prior and they basically just asked them questions over the phone and they said tell me about your symptoms and what these patients by and large were affected by mostly was breathlessness then fleem then cough wheezing and chest tightness were present but not so much so your Cardinal symptoms of COPD often patients will always complain about being dmia being dnic and just dnic some of them may or may not have cough and Flem production but a majority are these top three Cardinal symptoms breathlessness fleem and cough this study when they interviewed these patients this is the other thing this was practice changing for me and this is practice changing for my house staff those people I was telling you about that all they want to do is keep adding on inhalers on their patients and I say no no no go back and make sure these patients know how to use their inhalers this also this study is responsible for the way I teach my students now okay what they asked these the the study subjects was well when does your COPD bother you most the majority of patients when they reported breathlessness cough chest tightness Flem and wheezing their symptoms are affecting them early morning and morning so if they don't control their COPD early morning or morning then the cow's out of the barn and the rest of the day is horrible for them so how has this been practice changing for me I will tell my patients before you wake up and get out of bed before your toes touch the ground take two Puffs of your albuterol rescue before you get up before your toes touch the ground take a neb treatment go shower come back take your control or medication all right some of my met veterans were ahead of me on this by years they already do this okay but this is practice changing if you have a patient who's having some bad days in good days don't add on more therapy tell them to use their rescue inhaler more and tell them to use it first thing in the morning or early morning okay and by early morning some of my guys wake up at 5 4 5 o'clock in the morning okay so practice changing this is also practice changing for me this is what I tell my patients we tell our patients that their rescue therapy and COPD is for emergencies an emergency they take to be a real emergency so they never use their Albuterol and so lower the expectations tell them as needed or when needed make it okay for them to use their albuterol rescue so a lot of my patients would come in really in distress but have never really tried using their albuterol because they misunderstood my Direction so when I say it now I say use your controller and then use your emergency or use your as needed as an add-on it's an add-on it's meant for you to be used I'd rather you not be a bump on a log I want you to push yourself I want you to vacuum the house I want you to wash the dishes I want you to take a walk and if you have to use more Albuterol that's fine that's what it's there for so practice changing for me what this study also found was that COPD is a very variable disease and that's normal even for patients who are controlled Monday might be a bad day Tuesday Wednesday might be good Thursday might be really bad for no specific reason and what they found was overwhelmingly patients did not modulate their rescue inhaler use according to to good days and bad days so recognize and reinforce they're going to have good days and bad days for no reason that's just COPD it's okay for you to use your albuterol inhaler so this is the mmrc scale it's a measure of breathlessness I don't really use this I think it's too crude of a measure and most of my patients are going to rank high anyway it doesn't tell me much I use the cat score I love the cat score the cat score is a validated questionnaire how many of you guys use or have heard of the cat score not enough not enough so the cat score is great to establish a baseline it's great to see if your patients are using their inhalers well it is predictive of impending COPD flare up it is predictive of recovery from a COPD flare up and so what it is is basically 40 points um eight questions on a fivepoint lyer scale and patients have to tell you I never cough or I cough all the time they comment on their fleg production they comment on their chest tightness so the top three questions are your symptoms your Airway symptoms okay and then the next thing here is uh breathlessness when you walk up a hill or flight of stairs the next question is being limited with activities the next questions is whether they're confident leaving the home despite their lung condition the next question is sleep and whether they sleep soundly and the next question is having lots of energy do any of you guys ask your P patients about whether they're okay leaving their house because of their COPD does anybody ask that question okay I want you to put a pin on that oh one person back there put a pin in that why is anxiety or confidence leaving the home so important put a pin in that we will get back to that okay this is important because it gives you the whole holistic picture of your patient and their symptoms of COPD energy is a COPD symptom sleep is a COPD symptom confidence is a COPD symptom not just the airway symptoms of the top three questions practice changing change your practice use a cat score if you can okay so basically pfts are the gold standard what you have here on the left is normal patient maximally expires to their Peak value in COPD their Peak value is down so early COPD this is these are the few updates that I'm going to just show you um number one is that even healthy smokers patients who are smoking and if they have normal spirometry we don't say that they're fine we call them early COPD we call them we put put a little label on them because the science is suggesting that um the smoking is kind of causing slow Airway remodeling which you guys know about from the previous talk can you code this as anything right now is it actionable clinically no but um something to think about all right and the reason I talk about this is because um there are patients that smoke and that they have normal lung function um but about a quarter of them actually have abnormal CTS so this is kind of to help you counsel your patients who are smoking who don't have COPD just to help you tell them well listen you know what we know from the data that there you might you might have early COPD I just can't see it on spirometry so this is more a smoking cessation counseling slide for you okay okay so actual COPD though forgetting about patients with early theoretical Maybe in the future developing COPD actual COPD is vastly undiagnosed we have patients out there living their lives and they've gotten spirometry that's been abnormal but nobody's doing nothing about it in Denmark 78% of patients were undiagnosed even with an abnormal COPD I wager to think in the US it's probably worse okay um so that's pretty much my updates and my assessments for uh like emphasis for you for the first section um think about telling your patients to use their rescue more COPD is highly highly variable between Monday through Friday for no reason whatsoever okay the timing of your of their symptoms are early morning um help them learn and use their inhalers um correctly and for your smokers tell them that we know smoking is causing early damage we just can't see it in spirometry but if we look the right way in a CAT scan we're seeing Early Air trapping and gas trapping all right so let's go straight to the guidelines now the guidelines did change um and I'm going to talk you through how many of you guys by the way were here in 2019 in this room okay so okay all right so some so for a few of you guys some of the slides are going to be repeat but hopefully review so I look at COPD holistically um I think about confidence I think about energy I think about fatigue I think about sleep so when I think about all of my to-do items for COPD I kind of put everything on there I think about what their spherometer and I I risk assess them and I will talk about how you risk assess them I do they smoke or not what is their cat score how many exacerbations have they had six months to a year I write down their pfts if I can get a six-minute walk I want to see if they desaturate after walking 6 minutes I have some Imaging I know what their alpha 1 tripson level is if it's diminished then I may need to think about repleting the alpha 1 if I can get an ABG especially on my severe COPD patients I'd like to document that I think about all their comorbidities their heart failure their apib their hypertension their cancers um everything I you know there's mental health stuff I think about echocardiograms their heart function bone densities I also try to check at least on my patients with moderate and severe COPD I like to have imunoglobulin levels checked you guys can order these it's probably a special order but you should be able to do this do this on your moderate and severe patients you'll check IGG total and then you'll check their subclasses igg1 ig2 ig3 and ig4 if the immunoglobulins are low then these patients may be getting respiratory infections because their immune system is depressed and you can give them imunoglobulin replat and then they will have less lung infection they will have less COPD flares and less bad Airway remodeling so IG is something good that you can get total IGG and IGG subclasses make sure their vaccinations are done their pacle vaccinations their influen of vaccinations and their covid shots and boosters okay I write down the treatment plan document whether they need oxygen have they ever done pulmonary rehab will they do pulmonary rehab refer to pulmonary rehab I always document end of life go goals of care and Health Care proxy issues why is all this stuff important because COPD is not a bullet to the head I talk to my patients just like I'm talking to you COPD is not cancer there's no therapy that's going to put your Co your can like COPD in remission you don't get to walk away from your COPD if you like you if you cure your cancer you get screenings but you're you're done with cancer right with COPD it is a slow slow torturous decline some of my patients with endstate COPD who I have put on hospice have graduated hospice past one year two years I put one guy on hospice two or three times and he is still alive it's been six years so tell your patients life with COPD can be good set reasonable expectations but make sure that you have this talk with them okay especially your severe copers and you know who they are case of Mr g 65 years old he's actively smoking now half a pack a day 70 pack years has all the Cardinal symptoms of cough sputum production we um his cat score is high what's the threat threshold so anything above 12 on the cat score means they're having more COPD symptoms anything below like 12 I consider controlled COPD so his COPD is uncontrolled he's short of breath walking 150 ft he can't climb stairs he had a COPD admission three months ago and he's had at least two ER visits several prazone bursts and antibiotics doesn't use oxygen he has heart failure anxiety depression diabetes hypertension so his inhalers he's using albuterol alone and only uh and and 15 others per day now remember this is not asthma put the asthma things aside but he's using albuterol alone and his other meds his resting oxygen is 94% when he walked he dropped down to 88% and he was symptomatic he was short of breath so I fill out that same checklist so in high so in the italicized it's basically me kind of writing my soap note here and putting in all the data and then we're going to go through together how we stage him how we risk assess him how we do his pfts and how we'll develop a treatment plan according to his according to our new guidelines is everybody with me and how I'm walking you through this all right so I haven't yet documented any pulmonary rehab or family stuff or end of life stuff um but that's where we're at all right so in 2017 there was a huge change in the way gold conceived of how we assess our patients so it used to be that gold said we have to know somebody's fev1 because fe1 impacted patients risk of illness and their mortality okay and so for primary care doctors you were kind of Shackled because you guys couldn't really do much without getting an fev1 according to the guidelines but you and I know how hard it is sometimes to get pfts okay maybe they're not at the site that you work at maybe you don't have like reliable in office barometry maybe you refer them but it's months before you see the patient back again or they never show so see the spherometer information may be missing from what you have but the patients right in in front of you and you want to treat them so the data also said that guess what spherometer is is less important than the patient's own information and their history of exacerbations and I can tell I can tell you that I have two patients with the same exact bad numbers on their spherometer however the guy that's doing well and is not in the hospital with recurrent pneumonias um and he's using his inhal and he's not smoking his Outlook is vastly different than the different guy with the same exact bad spirometry numbers but he's smoking he has heart failure he was intubated three times right so patient specific factors and a history of Admissions and intubations is more important than the fe1 and it used to be in Risk assessing gold made you factor in uh fe1 now they don't so this was the refined tool and basically if you and they separated it so if you have the spirometry then you can stage them if the uh fe1 is above 80 and their ratio is low they have mild COPD if their fe1 is below 30 they have very severe COPD and in the middle you've got your goal two goal three as specified there so that's how you would factor in your spirometry if and when you have it at the beginning or whenever you get it but in terms of risk assessing the two things that matter are the two things that you can do the first time you see your patient with COPD you ask them what's your you look at their cat score and if it's below 10 they're here if it's above 10 they're here okay and then on the y axis here you ask them well how many times have you been having a flare up did any of these flareups take you to the hospital and if it's zero or one they're lower and if it's at least one leading to a hospitalization or at least two exacerbations in the year then they're higher risk and then it's just a ma matter of triangulating them so my guy with a bad fev1 a very severe gold state COPD who's living his life well he's walking he's quit smoking his last flare up was maybe two years ago and he has low symptoms that severe gold stage 4 COPD patient maybe gold a and I will treat him differently than a different patient with gold very sever gold state COPD but maybe he's had multiple admissions to the hospital including the ICU and when I give him his cat score it's 20 and he might be a gold d right so you just see how that works differently and so that's how you risk assess so for our patient then Mr G his flow volume Loop is really severely obstructed and his F1 over fvc is below 70 so you know he has obstructive lung disease his fev1 is below 30 so that's gold stage four very severe and then when I risk assess him he's had admissions to the hospital and his cat score was 20 so he's gold stage four D risk so I'll fill that in there all right so I filled in so I filled in that information here and here and now let's talk about treatment because this is a psycho uh pharmac this is a pharmacologic conference all right so Airway inflammation and Bronco dilation again this is where that oak tree analogy really helps with the patients you can use it for asthma you can use it for COPD what I tell my patients because I live in New England and Winters here are horrible I tell them that Airway their airways like the roads so to Bronco dilate I'm going to widen the roads I'm going to give them a Bronco dilator to clear out the snow that's obstructing the road I'm going to give you an anti-inflammatory all right another analogy if if you so choose so patients get confused they they use the INF inflammation stuff for the Bronco dilation and vice versa just a reminder here you've got different ways to Bronco dilate in COPD in COPD you've got your Al uol typee drugs which is your beta 2 agonists they relax the smooth muscle okay you've got anticholinergics like ipratropium and also called atrovent and they also relax the smooth muscle of the airway and then you've got the antimuscarinics which also prevent smooth muscle um contraction but they do so kind of at the level of the synapse between the neuron and the muscle just a review there all right so Bronco dilators in stable COPD and this is evidence level a so short acting Bronco dilators help improve your symptoms they increase your fe1 and you can use this um uh as needed or PRN you can even use these in combination and generally gold says combination therapy is better so if you have like a coment which is short acting muscarinic um hopium with short acting Al butol you can absolutely do that um either way combination may be better um than either one alone in improving symptoms improving your fe1 again I do I have my patients on just atrovent I'm I'm sorry just albuterol absolutely um that's because I have them on a long acting muscarinic and so I don't use a combination rescue um but it depends on how you want to work it and how your formulary is and how your patient is is um long acting Bronco dilators and long acting muscarinic improve lung function um the llamas are the it's called like the main ones would be tiotropium or spy Rea all right llama that's a llama it's a muscarinic so again because I do this talk after asthma it's okay if you guys are getting confused a little bit because it's everything's coming at you and you're think it's not the same there's similar words and similar letters but lot masas are long acting muscarinic the more most common one is like tiotropium there's a Clum and umum there's mixtures and all kinds of inhalers um how many of you guys use spa or tiotropium for your copers great great so in COPD that's first line in asthma it was like step five it was like an adjunct right so um in COPD long acting muscle kinic is your first line so for you guys seeing your patients who are having poor cat scores who are um in and out of the hospital and they're just on Albuterol alone you need to give them a long acting Bronco dilator called a llama like Spa llamas are actually better than long acting Bronco dilators in in reducing exacerbations okay you and now this is one major difference between as and COPD this came out in the question remember long acting Bronco dilator use alone a laa alone in cop in a laa alone in asthma somebody can sue you for doing that because that can cause asthmatic catastrophe in COPD using a llama I'm sorry using a laa alone is okay and in fact there are inhalers out there that are just long acting Bronco dilators just be really sure your patient doesn't have asthma too and we can talk about that later so in terms of Bronco dilators again the long acting Bronco dilators this is llamas this is the tiotropium or the u u mums or the glyco Pilates these reduce hospitalizations they reduce exacerbations and again this is the other major point I'm going to hone this in so you get sick of me saying it these single use long acting muscarinic one inhaler is better than using IC lava okay another big difference between asthma and COPD here in COPD the general trend is actually to try to move away from inhaled corticosteroid gold really believes in Long acting muscarinic or long acting lava you can do a llama you can do a laa you can do a llama laa even even for your higher risk you know D patients all right so those are differences so Spa improves the effectiveness of pulmonary rehab so patients going into exercise they need that Bronco dilation because the main pathology here is air flow obstruction so in terms of inhaled steroids all right so inhal steroids IC and LOB they're better together in a combination drug like that ADV or like the simoc cour or the duera all right rather than giving somebody separately a flow vent and separately a foro so one is better than two so a combination inhaler is better and there's also this whole discussion in the guidelines about triple therapy so the triple therapy all of my patients who are like severe or like moderates COPD or severe COPD and they're poorly controlled I have them on IC a llama and a laa but my formulary I have to give them two inhalers not just one there is something out there you guys know Trilogy how many of you guys have you okay Trilogy so Trilogy it's like $1,000 per per inhaler so in the VA we can't give patients Trilogy it's just too expensive uh routinely we have something called bre tree which is cheaper okay the go guidelines again basically they recommend triple inhalor therapy three in one because one single inhaler is better patients tend to not do things correctly so in terms of this is an update meaning mostly emphasizing that gold really wants you to reserve the use of inhal cortical steroids in patients who really really really need it so those that have had a COPD exacerbations those that have had at least two COPD exacerbations per year those that have eosinophils in their sputum and those that have some asthma okay so you can also the same way you kind of phenotype eosinophils and Asthma you can phenotype COPD as well so IC really should be for your patients with COPD asthma overlap or patients who are poorly controlled with their COPD and have had to go to the hospital and do it okay so other adjunctive therapies would be macrolides like aiyin aiyin um is an antibiotic but it also has an anti-inflammatory effect so usually for this what I do for these patients is I give them um like a lower dose 250 milligrams Monday Wednesday Friday Thrice weekly and that's a great adjunctive agent um agent for patients who are already on Triple inhaler therapy who already have a nebulizer who already are doing things correctly add on that adjunctive just make sure their QTC isn't prolonged okay and um and and if and make sure you know their hearing is okay uh because too much as if Romy can cause hearing impairment but the data is actually when you use a higher dose of like 500 or more so that's why if you do 2503 times a day you're fine I don't send my patients to hearing tests and what we know is that aomy decreases their risk of flaring up by about 30% another another adjunctive therapy that you probably cannot write for yourself is anybody writing for doares or raflum malast oh okay you are all right um are you guys working in pulmonary clinics yeah so this is mostly a Pulmonary Clinic site um and so refer to your pulmonary colleagues um your NPS and MDS and PAs working in Pulmonary Clinic um this is basically a phosphodiesterase inhibitor um specific indications for gold three and gold four COPD p patients who have chronic bronchitis um and recurrent exacerbations um you will end up get starting them off on a dose of doares a lower dose for four weeks as long as they can tolerate you'll increase it to a maximum dose okay all right so this is what I did for my patients with COPD I sort of have in my mind the constellation of inhalers regimens out there and there are a lot and it's confusing and so what I recommended to your group three or four years ago was look look at your formulary make a list of what you have that's first line Second Line divide it up into the different classes and then have like a standard um approach according to the guidelines so here I've divided up into your short acting Bronco dilators your long acting Bronco dilators your inhal cortical steroids alone this is your triple therapy your Cadillac uh uh Trilogy or your Tesla and then this is your bread stre okay um this is your combination IC laas that's out there on the market these are your llama laas all right this is your and these factor in in the guidelines and I love Lama labas they're awesome and then there's your long acting uh Bronco dilators there's um the ellipta the toras pyas uh SE may be off the market and then there's combination and this slide is updated as of like last month um okay okay so again similar themes from asthma I'm not going to belabor this correct inhaler use is not common it's pretty much the same slide and review you I hope you remember this in your dreams all right spacers improve drug delivery so tell p give them a spacer this is a smaller one that we have at the VA but this when you put the inhaler at the back of the spacer and they breathe through the spacer the heavy particles like settle into the spacer and then the lighter particles get inspired all the way down into the lungs you'll have better drug delivery and with your inhal cortical steroid if it fits in a spacer it's great because they get less oral thrush um so I've already talked with you about my like peanut butter and the sandwich and fluff on top analogy it works with COPD better than asthma now um I tell them your controller your is your every day you must use it every day and then because COPD is a variable disease you must use your your rescue when you need it okay now let's talk about the guidelines so these guidelines are different for those of you that were here in 2019 in this room these are newer slides for you because the guidelines did change from before covid times all right so you already know I've already sorry I've already explained to you what the xaxis here is this is basically cat score less than 10 means good COPD control and Cat score above 20 means uh not good COPD control needs action cat score above 10 and then on the y axis you basically have their history of exacerbating um in the y axis above is more than two two or more outpatient or at least one leading to admission and this is zero or one moderate not leading to admission so if you're basically not having a lot of symptoms not going into the hospital at all or maybe just once in the last year you could get away with with just having a Bronco dilator if you escalate you're going to need a long acting Bronco dilator so this is probably a short acting that you use when needed this is a long acting if you have higher admission history um and lower symptoms you're going to use the Llama which is like that tiotropium or one on on that list I showed you and then Group D and this is the major change because gold three years ago before covid actually said it was okay to use IC lavas it was okay to introduce patients to inhal steroid here and so the major change is is they really don't want us to use inhal steroids unless we absolutely have to so if they're still going to the hospital a lot just give them a long acting muscarinic educate them about how to use it educate them about their nebulizer and their short acting as well work work on all of their other stuff their sleep their energy their mental health their exercise tell them to Bronco dilate first thing in the morning but modify all the basic stuff before you add on another therapy gold really wants us to save llama labas for Group D and save uh IC inhal steroids and long acting for Group D all right all right this is the other update slide and right now if you guys are zoning out a little bit I understand it's been a long morning and there's a lot of acronyms which I find really obnoxious especially if you're not a pulmonologist llamas lavas ics's SAS Sabas all sorts all right so I'm going to go over this in theory we'll go over some cases so it's more Crystal Clear if it's clear as mud right now I understand I empathize I commiserate all right so this is a new slide what they want you to do in terms of following up and escalating treatment is they want you to go off the patient's symptom so this is new um they want you to see is the patient predominant symptom of poor cop control really their dpia or is it that they are having frequent exacerbations either way you have to escalate their therapy if it's dnia then they again they really want you to move from just using either the long acting alone or the long acting muscarinic alone they want you to use the Lama laaba alone the combination Lama laaba in fact they go so far as saying if you have them on an IC steroid and they haven't had a lot of exacerbations they're just complaining of shortness of breath to you get them off of the IC laa because the inhale cortical steroid gives them pneumonia and so put them on a combination okay Lama laaba and then they say if if this if this doesn't work then maybe think about spacers inhaler device add junks like aiyin or doares and investigate other causes if your patients are basically coming to you with having a lot of exacerbations and they're only on the single inhaler either a laa or a ll they're saying put them on both okay so put them on a combination if they if they're doing okay on followup again they want you to really taper down and if they're not doing well they really emphasize this triple inhaler therapy now Trilogy all my patients come to me and they see these awesome commercials and you've got these patients golfing or doing like you know weird things on the pharmaceutical commercials and then they'll say Trilogy ask your doctor about Trilogy everybody wants Trilogy in my clinic but they come to the VA for their care they don't have Private health insurance I told you Trilogy costs $1,000 um so I can't give them trilogy but I I basically give them the triple inhaler therapy I just give them the Llama separately and then I'll give them the IC lava separately so they'll carry two controllers and one inhaler and as long as I teach them how to do it I'm pretty okay with them doing that there are some patients that insist they want the triple inhaler and in that situation I'll have to do other hoops and jump through and I'll try to get them the single inhaler therapy so if they have just that triple in one the three in one then they'll carry the three in one as the controller and they'll carry the albuterol short acting as the rescue so the trelly triple inhaler is in their bedroom and the albuterol is in their pocket okay my my patients are mostly men they don't carry purses so they don't have a spacer which is not great okay and then if things don't work out then you know and if my patients are having a lot of exacerbations I will definitely put them on aithon and I will consider doares as well that's like fourth line and Fifth Line when you're going deep into your uh toolbox all right so let's go back to Mr G to kind of get things a little clearer for you guys all right so we said Mr G was gold stage four severe right his feev 1 was 26 we know he doesn't have any features of asthma but his cat score is high and he was I think he was in the ICU and he had several COPD flareups so for him he fits in this gold D box so for him he could get a spy Rea or a spy he could get a llama also tiotropium also Spa he could get a llama laa combination Bronco dilator uh which is like the one that I have in my formulary is tiotropium olodaterol which is called um St Alto all right or you could give them the IC laa and to be completely honest and what happens in the real ground is basically when my patients are like group cish and definitely Group D I am using an IC laa my patients need a steroid inhaler gold really just wants you to be thoughtful about giving them to these patients okay so we'd put Mr G on Group D therapy and then on followup Mr G still complains of shortness of breath so at this point like I said I would consider um re-educating him about spacer use um I would add on my adjunctive therapies like a ziyin or dollares if he exacerbates I'm definitely adding him on these medications okay so let's just review some basic clinical pearls key points about stable seal op you really want to prioritize long acting Bronco dilators llama alone or lava alone combination is better than either single and then you want to consider steroids if they have a history of high eils or if they're Group D okay do not use steroids inhal steroids alone for monotherapy and COPD okay monotherapy IC is asthma not COPD all right so let's go let's go now to this this case one when we'll do this together a 55y old man in the emergency room for one week history of new cough cop sputum chest tightness he smokes uh 25 years half a pack a day trying to quit he's Physically Active he does get short of breath never been to the Ed never hospitalized this is his first Ed visit he was nebulized with coment discharged home with prazone and antibiotics he comes to you he feels better now his cat is like five that's awesome the prazone helped he's not using any inhalers and you did everything you dotted your te's and crossed your eyes and full h&p everything everything looks great it checks out so let's do it what are we going to do now he's okay now discuss smoking sensation this sounds familiar let's screen for COPD B C is initiate a short acting Bronco dilator as needed D initiate a long acting Bronco dilator and do several things above so in terms of this I will walk you through this so the answer is pretty much do several things above okay so if the patient isn't having symptoms don't bother screening them but really do a good investigation for screening so screen for COPD in patients who complain of symptoms if they just smoke um and they have no symptoms then I I would refrain from screening them I think that's just a healthc care cost issue and going back to our case we don't in of this emergency room patient that we're looking at we don't know what his spherometer is that's to be decided but his cat score was five he recovered and he only had that one one and only emergency room visit so he's gold a um and he's he's he's gold a because he's kind of less risk so your options then with my cheat sheet that I developed for myself is Bronco dilators and stable COPD you could give them a short acting uh llama you could give him a sama which is a short acting antimuscarinic you could give him a Saba like albuterol short acting Bronco dilator beta Agonist or you could do a combination which is a comet okay that's a respimat which is a different kind of uh device but it works really well so again just a reminder that combination short acting is fine that's probably better than either or but all of these are great options for you you've got many options for him so basically the answer is e do all of several things above I would discuss smoking sensation hey buddy your smoking not good for you there's a risk of you know early COPD so stop smoking he was symptomatic I would screen him for his COPD initiate a short acting Bronco dilator um PRN okay I would not at this point commit him to a long acting Bronco dilator I would just start off with a short acting and that would be fine for COPD short acting alone is fine so do everything and follow up okay does that make sense good the next case so 69y old man he's an ex-smoker increased cough shortness of breath and fleem going on six months now no fevers chills hemoptisis or weight loss he does get short of breath after climbing several flights of stairs and he's been using an aerol six times a day his lab work is normal and a chest x-ray I'll show you he had spirometry that showed air flow obstruction and this one basically showed fe1 of 54 so he's goal stage two his chest x-ray looks like this his cat score is 16 um and you can kind of look at the breakdown on your own time and see which symptoms are more but his cat score is bad it's above 10 so let's pull our plan here so remember this guy is only on uh short acting albuterol six times a day we know he has COPD we've known for six months we haven't done anything about it and he's sick so continue present management no repeat pfts and refer to pulmonary not necessary why put him through that you already know he has COPD and don't refer to me you guys can take care of him start a maintenance inhaler IC laa who wants to start a maintenance inhaler in him IC laba good I've done my job good no do not do that it's he's not an asthmatic I he's a copier we want to really reserve the IC laa only if he needs it oop sorry so start a maintenance uh uh inhaler long acting Bronco dilator or llama good I hear mutterings of yes and then start a maintenance inhaler IC alone no that's most right exactly asthma so my I think I said that we should do D but we'll see if we're correct so llamas all right this is a picture of spy Rea how many people recognize this guy right here the handy Haler can you raise your hand yeah that is the most annoying Creation in mankind right you get a box of pills each pill is individually wrapped you have to struggle to open that damn pill then you have to open up this funny looking egg shaped thing then you put the thing in there then you have to puncture it then you don't even know if you're getting any nonsense nonsense nonsense nonsense how many people have this have access to this kind of inhaler okay perfect so this is a respimat this is awesome you get a box the cartridge is separate and then the plastic part is there you put the cartridge in you slam it on the table and then the cartridge is loaded in then when you open the inhaler what you do is you you rotate it once it clicks in you hear the click and then they open the little cap they hold the inhaler to their mouth they press the button and the nice beautiful thin clear Mist comes through and it goes straight down so much much easier than this nonsense egg shaped thing and this respimat technology not only can you get it for a long acting llama you can get a a coment respimat the Sama Saba you can get a Lama laaba in this respimat so you can get St Alto um at least on my formulary so if I change somebody if if I escalate the regimen it's easy for me I'm like you don't have to do anything I'm just giving you a different inhaler with a different color cap but I know it's got more drug in it so llamas the uplift trial basically said that spa or tiotropium improves ex uh rate of exacerbation improves quality of life okay and it actually helps prevent the decline of your F1 and it's very very safe over 10 years of data on that inhaled steroids cause pneumonias they CA cataracts they cause fractures they cause thrush try to avoid if you can lots of side effects okay so for this patient that I was talking about he doesn't have asthma don't give him an IC alone all right a combination llama laa isn't is probably not an option he doesn't need to escalate side effects with the IC laa you can actually give him a long acting Bron Bronco Dil alone okay you can actually give him a llama llama alone okay so if you don't have Spa now in my hospital I don't actually have access to the ellipta line of things but if you do you might you might have access to CB or to dorsza or something but the bottom line is you have options for either a long acting alone or a muscarinic alone or a long acting Bronco dilator alone and I personally would go with the llama all right so this is another case gold state and then we'll move on I promise so gold state copd2 um oh this is the same case gold two so this patient has more symptoms and he's sort of risk B which is why we gave him either the long acting Bronco dilator uh beta Agonist or the antimuscarinic so I emphasize this with your asthma lecture last time I said giving a patient a long acting Bronco dilate alone will cost you a lawsuit don't do that in asthma okay it's totally um uh uh uh not a good idea but in 2017 it's okay to do that with IC so just reassuring you that laas are safe in combination okay in asthma long acting Bronco dilators are safe okay so the torch Tri Tri basically said it's okay for you to do in your COPD patients just make sure that they don't have asthma there was a minor risk of some cardiovascular events but that was really related to the fact that the patients had pre-existing cardiac disease it wasn't the inhaler itself all right so just a reminder that long acting Bronco dilators either one laas or llamas are okay combination is always better so for him we said basically option D was correct start a maintenance inhaler either a llama or a lava I highlighted my preference so let's switch away from kind of basic uh evaluation of COPD and just a brief run through of of COPD exasperations as my patient would call it not exacerbations you might have a normal period and then you have one exacerbation and you're fine again you might have normal period you have an exacerbation you never get well and then you need additional therapy or you might have a trajectory where you just have multiple exacerbations uh close together in time okay this is actually a study for you guys and I am going to go through this in detail I was very excited when I presented this three years ago and it's still um uh relevant because it's for Primary Care this is basically what happens to COPD patients in a general uh pulmon AR I'm sorry in a general Primary Care Clinic so and the question they asked is what is the effect and severity of COPD exacerbations at Baseline and what is the risk and death of future exacerbations in a primary care population so the think of all of the COPD patients you guys have seen in your career in your clinics and Clump them all together and this trial will be applicable to your experience so about a 100,000 patients were followed um up to uh at Baseline which is the first year of their followup and up to a Max of 10 years and then they basically used information from the database in the UK and they linked it with hospitalizations and death so this study was possible because the UK has the National Health Service so they have everything in the computer and they have outpatient data uh deaths and hospitalization all Linked In One EMR imagine that all right okay so in their cohort this average Primary Care cohort average was 68 years old over 50% of them smoked the majority of them are kind of moderate gold two patients a smaller subset of severe and very severe patients and look at this most of the patients never really have COPD flareups so most of the patients that you guys are actually following are kind of relatively stable copers all right about 20 % have one uh COPD P COPD flare up that's treated out of the hospital and then 10% have about two per year 133% have three per year so this really helps you know this is not my perspective on COPD I see a different subset so I just wanted to highlight this okay so it's interesting when they actually looked at Baseline and during the first year and then they looked at followup and I think that the major the median followup was over 5 years about a quarter of those patients never ever exacerbated in primary care they were actually managing their disease and they never had an exacerbation some of these patients had their first exacerbation during this study okay so that's about 38% about 60% had COPD now this is the thing this is the money shot this is what I want to actually emphasize to you guys just when I talk talk about like air airway Remodeling and injury remodels the Airways and causes worse disease well I'm going to talk you through this graph because what this is showing you is there's a dose response relationship because one exacerbation carries a risk of a future flare up carries a risk of a future admission and carries a risk of death so comp compareed to reference one exacerbation causes you is a 1.7 times increased risk of future COPD outpatient flare up it causes a 1.2 times risk of getting admitted and the risk of death probably no difference it's just one but let's say your patient has three exacerbations their risk of a flare up is now almost three times their risk of an impatient flare is 1.89 and their risk of death is now 1.25 okay so if your patient has one severe exacerbation all right this bottom row their risk of getting another uh COPD flare up is more than three times higher their risk of having another admission is 3.6 Times Higher the risk of death is 1.8 so with every one exacerbation your risk of having a flare up risk of getting aitt risk of dying is more so in practice what does all this mean I tell my patients if you had a COPD flare up then I worry about you for the next like two to three months I worry that your risk of having another flare up is high and I'm going to watch you all right so I'm going to skip the specifics of Miss C for time but I'm just going to tell you that I'm just going to point out that women are a different breed for many reasons women have under diagnosed COPD more than men we're treated more suboptimally we present with different symptoms we're younger we smoke less we have issues of socioeconomic status a lot of anxiety depression we are more than likely to smoke more than our male counterparts and a lot of Occupational so um you can look in your s you can look in your slides for that case but the case was intended to emphasize the fact that it's a woman instead but I'm going to move ahead so I can answer your questions the causes of exacerbations 80% of the time is are infections the impact of exacerbations we know is Healthcare quality costs go up hospitalizations economic costs lung remodeling costs quality of life costs accelerated lung function decline higher mortality with COPD exacerbations so this is the laundry list of exacerbations there's like 15 or whatever but the main big one I want to show you is that exacerbations beget exacerbations beget exacerbations you will have a frequent exacerbator because you were not able to break that cycle so the highest risk of exacerbation is a previous exacerbation exacerbations cause exacerbations okay I'm going to skip Mrs C and move ahead so management of exacerbations I'm not going to belabor this I think most of us um have know Bronco dilators this is your uh dubs nebulizers albuterol nebulizers you'll need your prednizone um and antibiotics duration of steroids this is really important this is also very very important we used to PE put people like by and large on these tapers 60 for a few days 40 for a few days 30 for a few days 20 for a few days 10 for a few days and God knows what we don't really need to do that there's only a few small percentage of patients where you need to do that most of the time I would say like 90% of the time this is should be practice changing for you you can actually do a burst we can you can do a 5day births 40 milligrams times 5 days and that's it if they exacerbate again give them another 40 of five days try to refrain from the burst because remember in your primary care perspective most of your patients are having one maybe two outpatient flareups okay in your entire cohort a 100,000 patients I presented to you so really avoid the prazone tapers and then covid covid covid this is a very beautiful looking sexy slide about what happens to patients with covid in general um but I will synthesize it by saying I do nothing different just like an asthma with covid I'm telling my patients keep taking your the ones that are in the at at home recovering right now I'm following all the NIH guidelines for covid if they need um you know the COPD patients are older with more comorbidities so maybe they might actually need that regeneron infusion right the antibody infusion um if they need you know Pax lvid obviously yes but then for the COPD side of things I'm not reflexively giving them a prazone burst I'm actually telling them take your paid drink your hot teas go to sleep take your inhalers take your nebulizers and call me if things get worse um so not changing anything if they're higher risk if I'm more concerned about it sure give them four give them five days of a prazone burst but you know what wait you know then that would be fine in the outpatient setting if they come admitted to the hospital they're going to be on dexamethasone anyway for covid right that's your hospital treatment for covid so that kills two birds with one stone it's going to treat the covid it's going to help with them with their COPD so for your outpatients at home living with their spouses or their family members whatever just counsel the same thing you've been counseling them um and you can tell them to call you if they have anything worse from a COPD perspective and and again I'm just going to highlight continue usual COPD maintenance therapy and this is a slide from um the blue journal in pulmonary so comprehens comprehensive plan this is the thing now remember back in the beginning of the talk I I asked why does anybody ask about confidence leaving home does anybody ask about confidence leaving home you don't one person does um uh so why do we think about confidence leaving home it's a marker for anxiety level right so this is a audience participation question COPD is a lung disease true or false who says true COPD is a lung disease true okay who says COPD is not a lung disease ah no brave souls out there so COPD is not a lung disease this is me the pulmonary doctor telling you COPD is not a lung disease COPD is a total body disease because I ask you about your sleep I ask you about your energy level I ask you about your confidence leaving home and I will tell you why okay comorbidities and risk of mortality in patients with COPD this is from the Bode collaborative group published 2012 so uh 10year anniversary of this paper I love this paper this is practice changing I have a copy of the picture I'm going to show you next on my wall all right these study coordinators what they did was they look looked at a sample of a cohort of Co patients and they said what other diseases do you guys have patients men and women and then they said which one of these diseases that travels with COPD negatively influence influences survival all right and this is why I love it this is the COPD Galaxy okay this is this is like Star Wars in pulmonary medicine all right what you have here is the statistically significant Bo of the G Galaxy all right colorcoded by the type of comorbidities in this cohort they found 80 different disease States traveling with COPD red is cardiovascular green is pulmonary blue is like a mishmash of like diabetes BPH uh renal failure Etc um breast cancer anxiety Etc all right so a lot of the patients had hyp lipidemia but big so the size of the planet is how many patients have that disease but it is not in the center of significance it's not really in the Galaxy it's in the universe right so hypertension travels your with your patients but it does not affect mortality doesn't affect survival uh hyper that's hyper lipidemia hypertension also prevalent but it crosses the line of significance so yes it's present but no it doesn't affect survival they only found found 12 specific disease states that they thought were statistically significant of the 12 specific disease states which one is the closest to the primary outcome the center star of death which one anxiety say it with me now loud and clear anxiety anxiety anxiety anxiety anxiety the center star of death for a COPD patient is anxiety okay this is Association so I'm supposed to say Association doesn't include causality there's no mechanism I can tell you no molecule no absolute esin theil count that's going to draw a line here but this is what I think happens my patients with COPD who can't walk 150 uh feet they're running out of space to breathe they're air trapping right and then when they get anxious they're breathing fast so they take so imagine yourselves take a deep breath in but don't blow out now take another breath on top of that and don't blow out take another breath on top of that so when you're anxious you're trying to take four five six seven breaths on top of breaths on top of breaths these patients will exacerbate they'll have a very very bad day very very quickly and they end up in the hospital and they end up on cycles and cycles of COPD exasperation therapies PR razones anti antibiotics Bronco dilators they get so many Bronco dilators they come to your clinic and they're shaking like a leaf they're they're jittery okay they don't need all that stuff anxiety anxiety anxiety what you need to do is if they're in that stage you need to figure out how you can calm them down to calm them down don't use Adavan or benzo diazines that's contraindicated I know you want to do that don't do Adavan they have breathlessness right they have that breathlessness you might actually give them a lowd dose morphine a low dose short acting uh you can get you can give them a liquid morphine you could give them a small like oxycodone okay now this subset of patients what I'm talking about is your gold stage fours okay but in your moderate lesser State cops use taichi use mindfulness use exercise use holistic ways of talking to them educate them that anxiety and mental health is the foundation for their control this is very practice changing and so that's my theory is that you know air trapping makes things worse when you air trap and you're breathing on top of breathing on top of breathing you're running out of air and then you worsen your VQ mismatch your oxygen level drops and you go to the hospital and you go into that cycle which doesn't do you any good instead what you needed was some deep breathing slow deep breath threats to reduce the air trapping improve the VQ mismatch so this is a practice changing slide this is the slide that will stand the test of time because it's the COPD comorbidome Galaxy of death all right all right smoking sensation I don't have to belor this it's important the benefits of cessation I think I mentioned this is that up to 20% of patients up to 20% of your smokers who don't want to quit smoking who may not have COPD on spherometer you can tell them listen you have a 20% chance of actually like never of actually if you have mild COPD your F your COPD function can actually improve we can reverse the clock a little bit Back in 1970 they did not this this chart is not exactly very very accurate even though it's classic okay so there are there are physiologic respiratory Airway measurement benefits of quoting smoking and that means regaining some F1 function so pulmonary rehab is important education is important self-management is important vaccinations are important oxygen use I'll just summarize by saying that the Medicare criteria is still active relevant um that if the patient um desaturates below 88% or has a po2 less than 55 with core pulmonal um you definitely want to give them oxygen the main issue here is this lot trial I'm going to skip over that um which basically says you know back in the day about five or six years ago if my patient desaturated with walking if they desaturated below 88% I would give them exertional oxygen now I don't have to do that and if the patient doesn't want oxygen when they're walking around that's fine I don't pressure them the only true indication for your COPD patients to need oxygen is if they desaturate below 88% at rest then we know oxygen prolonged survival exertional oxygen alone is not uh necessary or indicated to prolong survival I still prescribe oxygen for exertion if my patients want it and there is some symptomatic benefit but in terms of the primary care Heart Primary hard outcome of improving survival oxygen is indicated for only uh resting hypoxemia below 88% and I'm going to stop there same thing um there's some additional resources about inhalers and how to use them and let's get to questions okay we've got quite a few hopefully we'll get to them all uh is there a remote possibility that COPD advances more quickly after each exacerbation due to Saba overuse uh yeah because you're you're sort of thinking about the asthma lecture I don't think so I think that what we what I what what I tell patients is that lung inflammation and exacerbations beget more exacer ations um so frequent frequent Saba use in my experience the patients generally tend to have more jittery side effects um and it the and without the use of um inhal cortical steroids or some long acting control they're just never getting under control um there's no data that I know of right now that um sabba use frequent SAA use alone remodels Airways in the same way um as in asthma thank you what scale should we use in patients with cognitive impairments or those that cannot answer the questions for on the cat uh good question um a caregiver or um I you know oftentimes I use my patients wives most of my veterans are male and so I'll use a caregiver or somebody else um if you C if you if you cannot elicit that information then use your subjective judgment to kind of assess what's bothering you the most um the cat works best if the patient is filling it out themselves um but I've had patients that don't have their reading glasses or during covid we were on the phone so I would just H kind of generally ask them those questions and fill it out myself so I ask you to use your own judgment okay uh you mentioned COPD patients using albuterol first thing in the morning are we not as concerned with COPD patients and albuterol overuse yeah so the data at least the reason I say that is that a lot of my patients wake up and they say that their morning fleem morning cough is really bad um and if they're having more bad days than good I'm telling them that it's okay for them to use their albuterol first I think I would consider albuterol overuse if like every single day for um a consistent period of time whether it's one or two weeks they're using their albuterol you know every single day four to six times but my recommendation for them to use it first thing in the morning is so that they open up their Airway all that fleem that's trapped in there from the night they can cough up and get out and then when they take their controller medication more of it sort of goes in um and I think this is a strategy my patients actually taught me and then I saw it years later in that in that trial that I presented okay we have a couple of questions about immun immunoglobin therapy like the indications and treatments for them yeah so imunoglobulin therapy really the indications is if they're having recurrent if if your patient comes to you with pneumonia and you can't explain why if a patient has a stroke or is an alcoholic and they black out and then they aspirate it or if they have a stroke and they have swallowing difficulty and they have aspiration pneumonia that's probably you know separately related but you can still check IGG levels on them but the indications for treatment really are if you check the levels and they're low and if they have recurrent infections um then I would go ahead and consult whoever you need to consult um in your system to get them um IVIG therapy it's usually uh IVIG therapy I think it's usually monthly it might be bi-weekly but the allergy doctors would decide that okay any indication for using IGG as a a marker for treatment um so yeah if if total IG is low and then if you have your subass is are low um uh but yes if total IGG is low then that would be an indication to consider IVIG therapy okay does llama or lava help with idiopathic pulmonary fibrosis uh with oh great idiopathic pulmonary fibrosis so usually patients with idiopathic pulmonary fibrosis if they just have idiopathic pulmonary fibrosis they will have a restrictive lung disease which is a totally different bucket than air flow obstruction so I don't put patients on um long acting um but for but I would I might give them a short acting albuterol uh because they can take that and if they feel any benefit from it that would be fine keep in mind that pulmonary fibrosis is a totally different disease process and um sometimes from diagnosis to death if it's like a serious case of fibrosis that's developing we're talking four or five years so once I've diagnosed it and I have them on pulmonary fib rosis therapy and I have them on oxygen I really am giving them my heart is you know I'm giving them whatever I can give them and a little bit of Albuterol is not going to hurt it's cheap and relatively risk-free okay can we diagnose someone with COPD uh with symptoms alone without spherometer you can have a clinical presumption but in terms of the gold standard for diagnosis you do need a spherometer okay initially uh with covid-19 we were told to avoid steroids y uh any contraindications in using them now no I mean back so we had this discussion offline so early on March 2020 we had no idea what the heck we were doing with covid um and so I remember when I did the virtual covid um Talk for npace somebody was asking me about beeside steroids and was that okay for COPD and this was I gave the virtual conference October 2020 and there was a clinical trial about simoc cour so I couldn't answer that question um but now it's June of 2022 and um we know that steroids are okay so if you're in the if you're in the home whether it's asthma or COPD continue your usual therapy if you're in the hospital you're going to be prescribed dexamethazone and that is a treatment for covid inpatient okay okay if a patient is on a llama and IC and is stable yeah would you then suggest taking them off of the IC and then yes starting a lava yes absolutely absolutely so if you if it so if a patient is on a on a on a llama and IC usually you don't want a patient on usually you would typically have like the patient on an IC and laa and so you can step down um and move the IC laa away or you can put them on a llama laa and just get the IC component out that would be actually favored by by gold okay and someone has a question about the powder formulations but I think you spoke about the spera in the yeah powdered formulations are just very hard some powdered formulations actually make some of my COPD patients cough more that's mostly because um they're not using a spacer or it's because the inhaler do itself camp be inserted into a spacer and then that dry powder it's and oh the other thing is you know the dry powder might settle on their throat and tickle the back of their throat and they'll cough or what also happens is that um the the dry powder a lot of COPD patients for example with um wixell how many patients here know wixel yeah yeah so wixel is the cheap version of ADV right it's the same exact drug wixel is the generic it's just not in a very pretty formulation purple discus ad is horizontal wixel is vertical and then the main thing with wixel this discus is when you take the breath in you have to generate a flow rate that's pretty fast so to suck up that dry powder and many patients with COPD may not be able to do that so they don't have enough of that with that initial breath and then they may not be able to do that inspiratory breath hold and hold it apparently 6 to 10 seconds six to 10 seconds is a long time for a COPD patient so that makes dry powders challenging for some people thank you so much we have two additional questions and we can talk to her offline uh because we have to uh end right now Dr s thank you so much for your presentation [Music]