A COPD Primer

In 2012 we received a grant from the Veterans Health Administration Office of Specialty Care entitled, “Patient-Centered Model for the Management of Chronic Obstructive Pulmonary Disease.” The grant’s goals were to enhance the recognition and diagnosis of COPD and implement a Patient-Centered Model for the Management of COPD. As the work on that proposal progressed, we realized that providers did not have an up-to-date, comprehensive, easily read, “how to” manual for the management of COPD despite all the advances in COPD care that have occurred over the past 5 years. Consensus documents such as the VA-DOD Guidelines were abbreviated summaries that were rarely used. From those discussions, the concept for this volume, a COPD Primer, developed. The goal was to develop a practical book that concisely presented COPD to providers with sufficient background and explanation of the physiologic and scientific rationale for various management strategies without becoming an esoteric academic work. We hope that this COPD Primer has achieved that goal and will be a useful, practical text for practitioners and medical trainees alike. The COPD Primer begins with an examination of what COPD is; it is really a syndrome, a constellation of historical features and clinical, physiologic, and radiographic findings. However, those elements come together in many different ways to create multiple different COPD phenotypes that are only now being recognized and used to define specific management strategies. COPD research has progressed beyond the simple classification of “blue bloaters” and “pink puffers.” Next, the epidemiology and economic consequences of COPD are reviewed. Bill Eschenbacher presents an approach to the patient with respiratory symptoms with detailed discussions of pulmonary function testing and how airflow limitation/obstruction is identified by spirometry and the use of lung imaging to identify individuals with COPD. Michael Borchers and Gregory Motz summarize current evidence implicating genetics, proteolytic imbalance, oxidative stress, inflammation, occupational and environmental exposures, and innate and adaptive immune function in the pathogenesis of COPD and the implication of these findings to future treatments. The single most important intervention in the prevention and treatment of COPD is smoking cessation. Shari Altum, Katherine Butler, and Rachel Juran present a practical approach to smoking cessation utilizing motivational interviewing in combination with pharmacologic interventions. Then, they expand upon these concepts to provide practitioners with convenient, realistic suggestions to encourage patient self-management in all aspects of COPD care and overall health. Ahsan Zafar reviews the natural history, recently described COPD phenotypes, and gender differences that clearly illustrate the broad spectrum of disease that comprises the term, COPD. The cover illustration highlights Dr. Zafar’s creative and artistic talents. The extensive nonpulmonary aspects of COPD are reviewed by Ralph Panos in an examination of COPD’s multi-organ manifestations. Next, the effect of COPD on sleep and the overlap syndrome, the concurrence of COPD and obstructive sleep apnea, and its consequences are presented. Jean Elwing examines the effect of COPD on the pulmonary vasculature with a detailed discussion of the evaluation and management of pulmonary hypertension associated with COPD. COPD’s effects on psychosocial functioning and familial interactions are presented by Mary Panos and Ralph Panos. The focus of the Primer then shifts from manifestations to treatment with a discussion of stable COPD management. With the current plethora of devices for delivering respiratory medications, it is difficult for both patients and providers to sustain knowledge of their proper use. Aaron Mulhall presents a practical guide to correct inhaler use that reviews all the current devices. Folarin Sogbetun then reviews the management of outpatient COPD exacerbations and Nishant Gupta discusses the approach to the patient hospitalized with COPD. Because patients with COPD often see multiple subspecialty physicians in addition to their primary care providers, interdisciplinary communication and coordination of care is essential for their management; Sara Krzywkowski-Mohn reviews the interactions between primary and specialty care for the patient with COPD with suggestions for improved communication and care coordination. Finally, advance care planning including palliative care and hospice is reviewed with a discussion of how end stage COPD affects not only the patient but also their family and social network. This COPD Primer incorporates the knowledge that we have learned over the past several years during the development and implementation of a patient-centered model for the management of COPD. It was written with the explicit goal of assisting both the practicing provider and medical trainee in the care of patients with COPD. Chronic obstructive pulmonary disease (COPD), Chronic bronchitis, Emphysema Preface 17 1 Introduction and Definition of Chronic Obstructive Pulmonary Disease COPD 20 1.1 Definition of Chronic Obstructive Pulmonary Disease (COPD) 21 1.2 Diagnostic Criteria 25 1.3 Staging Disease Severity 26 1.4 COPD is a Syndrome 27 1.5 Genetic Factors 27 1.6 Clinical Symptoms and Differential Diagnosis 28 1.7 Imaging 29 1.8 Treatment 29 1.9 Conclusion 30 1.10 Summary Points 30 References 30 2 Epidemiology and Economic Consequences of COPD 33 2.1 Introduction 33 2.2 Epidemiology 34 2.3 Economics 40 2.4 Conclusion 42 2.5 Summary Points 43 References 43 3 COPD Recognition and Diagnosis: Approach to the Patient with Respiratory Symptoms 50 3.1 Introduction 50 3.2 Patient Presenting with Respiratory Symptoms 50 3.3 Initial Screening Evaluation for a Patient Presenting with Respiratory Symptoms including Dyspnea 54 3.4 COPD 57 3.5 Asthma 60 3.6 Interstitial Lung Disease 61 3.7 Summary Points 62 References 62 4 Pulmonary Function Testing: Spirometry: Presence and Severity of Airflow Limitation/Obstruction 64 4.1 Introduction 64 4.2 Reasons for Spirometry Testing 65 4.3 Spirometry Screening for COPD 66 4.4 Limitations of Spirometry 66 4.5 Three Phases of a Spirometry Test 67 4.6 Displaying the Results of Spirometry Testing 68 4.7 Acceptability and Repeatability Criteria of Spirometry Testing 70 4.8 Measurements from Spirometry Testing 71 4.9 Patterns of Spirometry Impairment or Limitation 71 4.10 Interpretation of Spirometry Results 73 4.11 Summary Points 83 References 83 5 Radiology: Use of Lung Imaging to Help in the Identification of Patients with COPD 85 5.1 Introduction 85 5.2 Chest Radiographs 85 5.3 Computed Tomography (CT) Scans 86 5.4 Other Advanced Imaging Techniques in COPD 91 5.5 Summary Points 92 References 93 6 Pathogenesis of COPD 95 6.1 Introduction 95 6.2 Chronic Bronchitis 96 6.3 Emphysema 96 6.4 Smooth Muscle 96 6.5 Fibrosis 97 6.6 Pathogenesis of COPD 97 6.7 Airway Inflammation in COPD 101 6.8 Cytokines and Chemokines in COPD 108 6.9 COPD as an Autoimmune Disease 109 6.10 Systemic Inflammation 110 6.11 COPD Exacerbations 112 6.12 Summary Points 113 References 113 7 Smoking Cessation 123 7.1 Introduction 123 7.2 Smoking Risks 124 7.3 Factors Associated with Cessation 124 7.4 Screening Recommendations 125 7.5 Using Physiological Data When Addressing Smoking 129 7.6 How to Present Spirometry Results to Promote Smoking Cessation 129 7.7 Readiness for Change 130 7.8 The 5 A’s Model 135 7.9 Motivational Interviewing 140 7.10 Interventions 142 7.11 Other Nicotine Sources 144 7.12 Conclusion 147 7.13 Summary Points 147 References 148 8 Fostering Patient Self-Management of COPD 150 8.1 Introduction 150 8.2 Clinician Skills 150 8.3 Stages of Change 152 8.4 Patient Self-Management Skills 153 8.5 Self-Management Tasks 154 8.6 Self-Management Programs 161 8.7 Shared Decision-Making 165 8.8 End-of-Life Discussions 168 8.9 Integrated Care Teams 169 8.10 Conclusion 169 8.11 Summary Points 172 References 173 9 Natural History, Phenotypes, and Gender Differences in COPD 178 9.1 Natural History of COPD 178 9.2 Factors Influencing Lung Function in COPD 179 9.3 Role of COPD Exacerbations and Progression of Disease 184 9.4 COPD Phenotypes 187 9.5 Gender Differences in COPD 194 9.6 Conclusion 199 9.7 Summary Points 200 References 200 10 COPD Is a Multi-Organ Disorder: Systemic Manifestations 208 10.1 Introduction 208 10.2 Inflammation in COPD 208 10.3 COPD Mortality 208 10.4 Cardio- and Cerebral-vascular Disease 209 10.5 Lung Cancer 211 10.6 Pulmonary Fibrosis 214 10.7 Hematologic Manifestations 217 10.8 Musculoskeletal 219 10.9 Diabetes 222 10.10 Conclusion 222 10.11 Summary Points 223 References 223 11 Sleep and COPD: The Overlap Syndrome 231 11.1 Introduction 231 11.2 Smoking, Sleep, and COPD 232 11.3 Prevalence of Overlap Syndrome 233 11.4 Predictors of Overlap Syndrome 234 11.5 Screening and Diagnosis 235 11.6 Ventilation and Ventilation Perfusion Matching 239 11.7 Polysomnography 239 11.8 Mortality and COPD Exacerbations 241 11.9 Conclusion 244 11.10 Summary Points 245 References 245 12 COPD and Pulmonary Vasculature 251 12.1 Introduction 251 12.2 COPD Associated Pulmonary Hypertension 252 12.3 COPD Associated Venous Thromboembolic Disease 259 12.4 Summary 260 12.5 Summary Points 261 References 262 13 COPD’s Effects on Psychosocial Functioning and Familial Interactions 268 13.1 Introduction 268 13.2 Depression 268 13.3 Anxiety 273 13.4 Panic Attacks 276 13.5 Cognitive Impairment 278 13.6 Social Interactions 280 13.7 Effect of COPD on Caregivers 281 13.8 Conclusion 282 13.9 Summary Points 282 References 283 14 Management of Stable Chronic Obstructive Pulmonary Disease 294 14.1 Management of Stable COPD 294 14.2 Guidelines for the Management of COPD 299 14.3 Pharmacologic Treatment of COPD 302 14.4 Nonpharmacologic Treatment of COPD 305 14.5 Management of COPD-related Nonpulmonary Co-morbidities 307 14.6 Summary Points 307 References 307 15 Practical Guide to Correct Inhaler Use 311 15.1 Introduction 311 15.2 Inhaler Education and Errors in Inhaler Technique 312 15.3 Inhalation Delivery Systems 314 15.4 Reminders to Increase Adherence 324 15.5 Conclusions 325 15.6 Summary Points 325 References 326 16 Management of Outpatient COPD Exacerbations 331 16.1 Introduction 331 16.2 Definition and Differential Diagnosis 332 16.3 Prevalence 332 16.4 Etiology 333 16.5 Presentation 334 16.6 Natural History 334 16.7 Consequences 335 16.8 Outpatient Management of COPD Exacerbations 335 16.9 Management 337 16.10 Prevention of COPD Exacerbations 344 16.11 Risk Factors for Relapse 345 16.12 Conclusion 346 16.13 Summary Points 347 References 347 17 Inpatient Management of Acute COPD Exacerbations 354 17.1 Introduction 354 17.2 Definition and Risk Factors 355 17.3 Risk Factors for COPD Exacerbations 355 17.4 Etiology of COPD Exacerbations 356 17.5 Triage to Home Versus Hospital for Management of Exacerbations 357 17.6 Hospital Management of COPD Exacerbations 359 17.7 Hospital Discharge and Follow up 368 17.8 Conclusion 369 17.9 Summary Points 369 References 370 18 Primary Care and Interaction with Specialty Care for the COPD Patient 376 18.1 Introduction: A Healthcare System in Crisis and New Models of Care 376 18.2 The Patient Centered Family Medical Home Model 377 18.3 How Does the PACT Team Differ from Traditional Roles/Responsibilities? 378 18.4 General Roles of the PACT Team 380 18.5 Care Management of the COPD Patient PACT Roles and Responsibilities 380 18.6 COPD and PACT 383 18.7 Summary Points 385 References 386 19 Integrating Supportive, Palliative, and End of Life Care for COPD 388 19.1 Introduction 388 19.2 COPD Disease Course and Management 389 19.3 Patient and Caregiver Burden 390 19.4 Prognostication of Duration and Quality of Life in COPD 392 19.5 Advanced Care Planning Discussions Between Providers and Patients with COPD and Their Families 393 19.6 Timing and Content of Discussions 395 19.7 Symptom Management 398 19.8 Bereavement 400 19.9 Effectiveness of Palliative Care 400 19.10 Conclusion 401 19.11 Summary Points 401 References 402 Index 408 In 2012 we received a grant from the Veterans Health Administration Office of Specialty Care entitled, "Patient-Centered Model for the Management of Chronic Obstructive Pulmonary Disease." The grant's goals were to enhance the recognition and diagnosis of COPD and implement a Patient-Centered Model for the Management of COPD. As the work on that proposal progressed, we realized that providers did not have an up-to-date, comprehensive, easily read, "how to" manual for the management of COPD despite all the advances in COPD care that have occurred over the past 5 years. Consensus documents such as the VA-DOD Guidelines were abbreviated summaries that were rarely used. From those discussions, the concept for this volume, a COPD Primer, developed. The goal was to develop a practical book that concisely presented COPD to providers with sufficient background and explanation of the physiologic and scientific rationale for various management strategies without becoming an esoteric academic work. We hope that this COPD Primer has achieved that goal and will be a useful, practical text for practitioners and medical trainees alike. The COPD Primer begins with an examination of what COPD is; it is really a syndrome, a constellation of historical features and clinical, physiologic, and radiographic findings. However, those elements come together in many different ways to create multiple different COPD phenotypes that are only now being recognized and used to define specific management strategies. COPD research has progressed beyond the simple classification of "blue bloaters" and "pink puffers." Next, the epidemiology and economic consequences of COPD are reviewed. Bill Eschenbacher presents an approach to the patient with respiratory symptoms with detailed discussions of pulmonary function testing and how airflow limitation/obstruction is identified by spirometry and the use of lung imaging to identify individuals with COPD. Michael Borchers and Gregory Motz summarize current evidence implicating genetics, proteolytic imbalance, oxidative stress, inflammation, occupational and environmental exposures, and innate and adaptive immune function in the pathogenesis of COPD and the implication of these findings to future treatments. The single most important intervention in the prevention and treatment of COPD is smoking cessation. Shari Altum, Katherine Butler, and Rachel Juran present a practical approach to smoking cessation utilizing motivational interviewing in combination with pharmacologic interventions. Then, they expand upon these concepts to provide practitioners with convenient, realistic suggestions to encourage patient self-management in all aspects of COPD care and overall health. Ahsan Zafar reviews the natural history, recently described COPD phenotypes, and gender differences that clearly illustrate the broad spectrum of disease that comprises the term, COPD. The cover illustration highlights Dr. Zafar's creative and artistic talents. The extensive nonpulmonary aspects of COPD are reviewed by Ralph Panos in an examination of COPD's multi-organ manifestations. Next, the effect of COPD on sleep and the overlap syndrome, the concurrence of COPD and obstructive sleep apnea, and its consequences are presented. Jean Elwing examines the effect of COPD on the pulmonary vasculature with a detailed discussion of the evaluation and management of pulmonary hypertension associated with COPD. COPD's effects on psychosocial functioning and familial interactions are presented by Mary Panos and Ralph Panos. The focus of the Primer then shifts from manifestations to treatment with a discussion of stable COPD management. With the current plethora of devices for delivering respiratory medications, it is difficult for both patients and providers to sustain knowledge of their proper use. Aaron Mulhall presents a practical guide to correct inhaler use that reviews all the current devices. Folarin Sogbetun then reviews the management of outpatient COPD exacerbations and Nishant Gupta discusses the approach to the patient hospitalized with COPD. Because patients with COPD often see multiple subspecialty physicians in addition to their primary care providers, interdisciplinary communication and coordination of care is essential for their management; Sara Krzywkowski-Mohn reviews the interactions between primary and specialty care for the patient with COPD with suggestions for improved communication and care coordination. Finally, advance care planning including palliative care and hospice is reviewed with a discussion of how end stage COPD affects not only the patient but also their family and social network. This COPD Primer incorporates the knowledge that we have learned over the past several years during the development and implementation of a patient-centered model for the management of COPD. It was written with the explicit goal of assisting both the practicing provider and medical trainee in the care of patients with COPD.-- Provided by publisher The Copd Primer Begins With An Examination Of What Copd Is; It Is Really A Syndrome, A Constellation Of Historical Features And Clinical, Physiologic, And Radiographic Findings. However, Those Elements Come Together In Many Different Ways To Create Multiple Different Copd Phenotypes That Are Only Now Being Recognized And Used To Define Specific Management Strategies. Copd Research Has Progressed Beyond The Simple Classification Of “blue Bloaters” And “pink Puffers.” Next, The Epidemiology And Economic Consequences Of Copd Are Reviewed. Bill Eschenbacher Presents An Approach To The Patient With Respiratory Symptoms With Detailed Discussions Of Pulmonary Function Testing And How Airflow Limitation/obstruction Is Identified By Spirometry And The Use Of Lung Imaging To Identify Individuals With Copd. Michael Borchers And Gregory Motz Summarize Current Evidence Implicating Genetics, Proteolytic Imbalance, Oxidative Stress, Inflammation, Occupational And Environmental Exposures, And Innate And Adaptive Immune Function In The Pathogenesis Of Copd And The Implication Of These Findings To Future Treatments. The Single Most Important Intervention In The Prevention And Treatment Of Copd Is Smoking Cessation. Shari Altum, Katherine Butler, And Rachel Juran Present A Practical Approach To Smoking Cessation Utilizing Motivational Interviewing In Combination With Pharmacologic Interventions. Then, They Expand Upon These Concepts To Provide Practitioners With Convenient, Realistic Suggestions To Encourage Patient Self-management In All Aspects Of Copd Care And Overall Health. Ahsan Zafar Reviews The Natural History, Recently Described Copd Phenotypes, And Gender Differences That Clearly Illustrate The Broad Spectrum Of Disease That Comprises The Term, Copd. The Cover Illustration Highlights Dr. Zafar’s Creative And Artistic Talents. The Extensive Nonpulmonary Aspects Of Copd Are Reviewed By Ralph Panos In An Examination Of Copd’s Multi-organ Manifestations. Next, The Effect Of Copd On Sleep And The Overlap Syndrome, The Concurrence Of Copd And Obstructive Sleep Apnea, And Its Consequences Are Presented. Jean Elwing Examines The Effect Of Copd On The Pulmonary Vasculature With A Detailed Discussion Of The Evaluation And Management Of Pulmonary Hypertension Associated With Copd. Copd’s Effects On Psychosocial Functioning And Familial Interactions Are Presented By Mary Panos And Ralph Panos. The Focus Of The Primer Then Shifts From Manifestations To Treatment With A Discussion Of Stable Copd Management. With The Current Plethora Of Devices For Delivering Respiratory Medications, It Is Difficult For Both Patients And Providers To Sustain Knowledge Of Their Proper Use. Aaron Mulhall Presents A Practical Guide To Correct Inhaler Use That Reviews All The Current Devices. Folarin Sogbetun Then Reviews The Management Of Outpatient Copd Exacerbations And Nishant Gupta Discusses The Approach To The Patient Hospitalized With Copd. Because Patients With Copd Often See Multiple Subspecialty Physicians In Addition To Their Primary Care Providers, Interdisciplinary Communication And Coordination Of Care Is Essential For Their Management; Sara Krzywkowski-mohn Reviews The Interactions Between Primary And Specialty Care For The Patient With Copd With Suggestions For Improved Communication And Care Coordination. Finally, Advance Care Planning Including Palliative Care And Hospice Is Reviewed With A Discussion Of How End Stage Copd Affects Not Only The Patient But Also Their Family And Social Network.this Copd Primer Incorporates The Knowledge That We Have Learned Over The Past Several Years During The Development And Implementation Of A Patient-centered Model For The Management Of Copd. It Was Written With The Explicit Goal Of Assisting Both The Practicing Provider And Medical Trainee In The Care Of Patients With Copd. Ralph J. Panos, William L. Eschenbacher ; Managing Editor, Magdalena Wierzchowiecka ; Language Editor, Dylan Richards. Includes Bibliographical References And Index. Also Available In Print Form. Mode Of Access: Internet Via World Wide Web. Frontmatter Contents Preface 1. Introduction and Definition of Chronic Obstructive Pulmonary Disease COPD Ralph J. Panos 2. Epidemiology and Economic Consequences of COPD Ralph J. Panos 3. COPD Recognition and Diagnosis: Approach to the Patient with Respiratory Symptoms William L. Eschenbacher 4. Pulmonary Function Testing: Spirometry: Presence and Severity of Airflow Limitation/Obstruction William L. Eschenbacher 5. Radiology: Use of Lung Imaging to Help in the Identification of Patients with COPD William L. Eschenbacher 6. Pathogenesis of COPD Michael T. Borchers and Gregory Motz 7. Smoking Cessation Shari Altum, Katherine Butler and Rachel Juran 8. Fostering Patient Self-Management of COPD Shari Altum, Rachel Juran and Katherine Butler 9. Natural History, Phenotypes, and Gender Differences in COPD Muhammad Ahsan Zafar 10. COPD Is a Multi-Organ Disorder: Systemic Manifestations Ralph J. Panos 11. Sleep and COPD: The Overlap Syndrome Ralph J. Panos 12. COPD and Pulmonary Vasculature Jean M. Elwing 13. COPD’s Effects on Psychosocial Functioning and Familial Interactions Mary E. Panos and Ralph J. Panos 14. Management of Stable Chronic Obstructive Pulmonary Disease Ralph J. Panos 15. Practical Guide to Correct Inhaler Use Aaron M. Mulhall 16. Management of Outpatient COPD Exacerbations Folarin Sogbetun 17. Inpatient Management of Acute COPD Exacerbations Nishant Gupta 18. Primary Care and Interaction with Specialty Care for the COPD Patient Sara M. Krzywkowski-Mohn 19. Integrating Supportive, Palliative, and End of Life Care for COPD Ralph J. Panos Index