COPD GUIDELINES/SMOKING CESSATION
From Topics and Advances in Internal Medicine, University of California, San Diego, School of Medicine
| MANAGEMENT OF COPD: GUIDELINES FOR PRIMARY CARE —Andrew L. Ries, MD, Professor of
Medicine and Family and Preventive Medicine, University of California, San Diego, School of Medicine
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| Background: Global Initiative for Chronic Obstructive Lung Disease (GOLD) collaborative effort of World
Health Organization and National Institutes of Health (NIH) National Heart, Lung, and Blood Institute
(NHLBI)
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| Impact of disease: chronic obstructive pulmonary disease (COPD) fourth leading cause of death in United States;
increase in morbidity and mortality related to aging population and cigarette smoking; only ≈50% of clinically
significant COPD recognized; estimated 10% to 15% of people >55 yr of age have significant COPD; past 30
to 40 yr saw dramatic increase in COPD-related deaths, compared to other causes; trend expected to continue
for many years; as many new cases of COPD in women as men
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| GOLD objectives: to increase awareness of COPD among health professionals and general public; to stimulate
research and standardize practice; goldcopd.com provides—GOLD documents; Pocket Guide for healthcare
providers; guide for patients and families
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| Definition of COPD: disease characterized by airflow limitation not fully reversible (distinguishes from
asthma); usually progressive and associated with abnormal inflammatory response of lungs to noxious particles
or gases; burden of disease—underestimated; usually undiagnosed until clinically apparent and moderately
advanced
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| Four components of COPD management: 1) assess and monitor disease; 2) reduce risk factors; 3) manage stable
COPD (education; rehabilitation; pharmacologic and nonpharmacologic treatment); 4) manage exacerbations
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| Role of spirometry: gold standard for diagnosing and monitoring COPD; those involved in primary care should
have access to spirometry and familiarity with its principles
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| Classification of COPD: based on spirometry; forced expiratory volume in 1 sec (FEV1 ) from maximum inhalation;
forced vital capacity (FVC) denotes maximum volume expelled; reduced FEV1 /FVC ratio indicates flow
problem; COPD characterized by FEV1 /FVC <70%
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 | Stage 0 (at risk): normal spirometry; chronic symptoms (cough, sputum)
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| Stage I (mild): FEV1 /FVC <70%; FEV1 ≥80% of predicted (normal); with or without symptoms
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| Stage II (moderate): FEV1 50% to 80% of predicted
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| Stage III (severe): FEV1 /FVC <70%; FEV1 30% to 50% of predicted; (stage at which most patients clinically
recognized)
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| Stage IV (very severe): FEV1 <30% of predicted or FEV1 <50% with evidence of chronic respiratory failure
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| Reduce risk factors: exposure to tobacco smoke, occupational dusts, and chemicals; indoor and outdoor pollutants;
smoking cessation—single most effective and cost-effective measure at any stage
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| Managing stable COPD: stepwise increase in treatment with severity of disease as characterized by spirometry;
education—includes smoking cessation, improving skills in coping with disease, and pulmonary rehabilitation;
limitation of medications—unable to modify long-term decline in lung function (only possible with
smoking cessation); used to decrease symptoms and complications
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| Bronchodilator therapy: central to managing symptoms; given on prn or regular basis; principal options— β2
agonists; anticholinergics; theophylline; alone or in combination; long-acting inhaled bronchodilators more effective
and convenient, but more expensive; combining bronchodilators may improve efficacy and decrease side
effects, compared to increasing dose of single bronchodilator
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| Glucocorticosteroid therapy: inhaled steroids—regular treatment appropriate for symptomatic COPD with
FEV1 <50% of predicted and repeated exacerbations in last 2 yr; shown to reduce exacerbations, avoid hospitalizations,
and improve health status; long-term systemic steroids—should be avoided because of unfavorable
benefit-to-risk ratio
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| Rehabilitation programs: include education and training to improve exercise tolerance and reduce anxiety, dyspnea,
and fatigue
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| O2 therapy: long-term administration (>15 hr per day) to patients with chronic respiratory failure shown to increase
survival
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| Management by stage of COPD
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| All stages: smoking cessation; reduction of indoor pollution and occupational exposure; influenza vaccination
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| Stage I (mild): short-acting bronchodilators prn; regular treatment with ≥1 long-acting bronchodilators; rehabilitation
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| Stage II (moderate): short-acting bronchodilators prn; regular treatment with ≥1 long-acting bronchodilators;
inhaled glucocorticosteroids if repeated exacerbations; rehabilitation
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| Stage III (severe): short-acting bronchodilators prn; regular treatment with ≥1 long-acting bronchodilators;
inhaled glucocorticosteroids if repeated exacerbations; rehabilitation
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| Stage IV (very severe): short-acting bronchodilators prn; regular treatment with ≥1 long-acting bronchodilators;
inhaled glucocorticosteroids if repeated exacerbations; treat complications; rehabilitation; long-term
O2 therapy if respiratory failure; consider surgical options (lung volume reduction; lung transplantation)
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| Manage exacerbations: infection of tracheobronchial tree and air pollution most common causes, but ≈33% unidentified;
unnecessary to identify cause before treatment; therapy—inhaled bronchodilators; may add theophylline
and systemic (preferably oral) glucocorticosteroids; clinical signs of infection—antibiotic therapy
may be beneficial
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| Ventilation therapy: noninvasive intermittent positive pressure ventilation (NIPPV); used in respiratory failure
to improve blood gases and pH, reduce in-hospital mortality, decrease need for invasive mechanical ventilation
and intubation, and decrease hospital stay
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| Questions and answers: screening for COPD—generalized screening not recommended; target smokers for spirometric
screening; genetic screening—consider screening for α1 -antitrypsin deficiency in younger patient with significant
disease (particularly emphysematous variety); preoperative considerations—no absolute contraindication
to surgery; COPD increases risks, especially in surgery involving chest or general anesthesia; smoking cessation
important, even for 2 wk before surgery; aggressive bronchodilator therapy before surgery; COPD in
nonsmokers—>90% of COPD in smokers; other risks include environmental or occupational exposure; therapy in
emergency department—initiate systemic steroid therapy, intravenous (IV) or oral; avoid prolonged use; theophylline
therapy—effective adjunct, eg, for acute exacerbations, but use limited by narrow window between therapeutic
effect and toxicity; use of propranolol (Inderal)—risk of bronchospasm; more selective cardiac agents
preferable; anabolic steroid therapy—benefits in muscle and weight gain under investigation; potential toxicities
of concern; acupuncture—using nontraditional therapies to relieve shortness of breath not ruled out; evidence of
benefit lacking; pneumococcal vaccine (Pneumovax)—recommended on intermittent (not yearly) basis; lung-reduction
surgery—indications limited; study found patients with lowest level of function derived most benefit;
demonstrated how poorly patients with severe disease do with medical therapy (4-5-yr mortality almost 50%)
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| WHAT DOCTORS CAN DO FOR PATIENTS WHO CONTINUE TO SMOKE —David M. Burns, MD, Professor
of Family and Preventive Medicine, University of California, San Diego, School of Medicine
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| Smoking as process: smokers develop dependence with neurologic and behavioral aspects, making stopping difficult;
when cessation attempted without help, long-term success rate ≈3%; but rather than resigning themselves
to smoking, most smokers remain interested in quitting; ≈40% of daily smokers made serious attempt
to quit within last 12 mo
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| Role of physician: rather than counting on success of single attempt by individual patient, view as population issue
within practice; all smokers get consistent message to quit, and few more succeed with each cessation attempt;
physician’s recommendation to quit doubles cessation rate; efforts complemented by—larger environmental
forces, eg, restrictions on smoking, raising price of cigarettes
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| Who still smokes: while older patients more likely to have smoked at one time, many now former smokers; indicates
long-term success on population level; current challenge to curb ongoing exposure to toxins in midlife;
correlation between increase in educational level and decline in number still smoking; however, when smokers
provided with effective smoking modalities, rate of cessation similar at all educational levels
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| What works? everything works for someone (do not discourage any cessation attempt); nothing works for everyone
(no “magic bullet”); more intense treatment better; persistence more important than intensity (encourage
new attempt by offering alternative treatment, eg, this time, try gum rather than patch)
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| Whom should you treat? ask everybody whether they smoke; ask all smokers whether they want to quit (if not,
no need to explain details); ask those who want to quit whether they want help; refer those who want help;
what to say to those who say no—“this is the most importantt fight” (cessation long-term goal); ask again on
next visit
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| Five A’s physician can do: Ask—smoking status (staff records as vital sign); never too old, too young, too sick,
or too healthy; Assess—dependence; readiness to quit; Advise message should be clear, strong, personalized
(“I, as your physician, am telling you and I will help you”), and short; Assist—set quit date; patient tells
everyone (mobilize social support); counseling; medication; Arrange—schedule follow-up after quit date;
continue follow-up; relapse prevention and management
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| Treatments available: gold standard 6- to 8-wk intervention program with drugs (≈40% successful; ≈2%-3% of
patients willing); telephone counseling; self-help materials; nicotine replacement—transdermal patch easier
to use than gum; gum provides nicotine burst (combination provides background nicotine level, with gum for
cravings); nasal spray (rapid onset; irritation common; potential dependence); oral inhaler (rapid onset via
route similar to cigarette; causes irritation to back of throat); lozenge (requires 9-15 lozenges per day for 6
wk, not just for cravings); antidepressant—bupropion; depression associated with cigarette smoking; start 7
to 10 days before starting cessation attempt; more effective in combination with nicotine replacement; note
drug side effects and contraindications
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| Fitting smoking cessation into your practice: treat smoking as new vital sign; limit intervention to 45 to 90 sec;
focus on making change occur; list smoking as problem to follow; automate follow-up (letter goes out over your
signature, based on quit date placed on chart)
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| Questions and answers: safety of cessation therapies—nicotine replacement of concern in pregnancy; evidence
indicates probably safe in cardiovascular disease, but concern about potential complications limits use;
speaker unaware any additional risk from combination of nicotine replacement and bupropion beyond risks of
drugs used alone, eg, need for care in managing antidepressant therapy; concerns about nicotine replacement—
some patients fear toxicity, although much safer than cigarettes (less nicotine; eliminates ≈4000 carcinogens
present in cigarette smoke); long-term use as cessation aid has not been studied (risk of smoking considered
bigger problem than nicotine itself)
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Educational Objectives
| The goal of this program is to educate internists about guidelines for managing chronic obstructive pulmonary
disease (COPD) and recommendations on smoking cessation in daily practice. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Explain the purpose of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
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| 2. Employ the GOLD classification of COPD based on spirometry
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| 3. Manage therapy for COPD based on the GOLD stage of disease.
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| 4. Integrate smoking cessation into routine clinical practice.
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| 5. Counsel patients on therapies for smoking cessation.
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Discussed on This Program
Aminophylline (theophylline ethylenediamine) [Phyllocontin, Truphylline]
Bupropion HCl [Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban]
Nicotine inhalation system [Nicotrol Inhaler]
Nicotine nasal spray [Nicotrol NS]
Nicotine polacrilex (nicotine resin complex) [Commit lozenge, Nicorette, Nicotine Gum]
Nicotine transdermal system [Nicoderm CQ, Nicotrol]
Pneumococcal vaccine, polyvalent [Pneumovax 23]
Propranolol HCl [Inderal, Inderal LA, InnoPran XL]
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To locate lectures of related interest, or to see a complete listing of Audio-Digest CME Programs, including written
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Suggested Reading
Anczak JD et al: Tobacco cessation in primary care: maximizing intervention strategies. Clin Med Res 1:201,
2003; Booker R: Spirometry in primary care. Practitioner 249:180, 182, 184 passim, 2005; Burns DM: Epidemiology
of smoking-induced cardiovascular disease. Prog Cardiovasc Dis 46:11, 2003; Doherty DE et al:
Chronic obstructive pulmonary disease: epidemiology, pathogenesis, disease course, and prognosis. Clin Cornerstone
Suppl 2:S5, 2004; Eakin EG et al: Validation of a new dyspnea measure: the UCSD Shortness of
Breath Questionnaire. University of California, San Diego. Chest 113:619, 1998; Freeman D et al: Questions
for COPD diagnostic screening in a primary care setting. Respir Med 99:1311, 2005; Hurd SS et al: COPD:
good lung health is the key. Lancet 366:1832, 2005; Kunik ME et al: Surprisingly high prevalence of anxiety
and depression in chronic breathing disorders. Chest 127:1205, 2005; Lindberg A et al: Prevalence of chronic
obstructive pulmonary disease according to BTS, ERS, GOLD and ATS criteria in relation to doctor's diagnosis,
symptoms, age, gender, and smoking habits. Respiration 72:471, 2005; Martinez FJ et al: Is it asthma or
COPD? The answer determines proper therapy for chronic airflow obstruction. Postgrad Med 117:19, 2005;
Petty TL: Benefits of and barriers to the widespread use of spirometry. Curr Opin Pulm Med 11:115, 2005; Reed
MB et al: The effect of over-the-counter sales of the nicotine patch and nicotine gum on smoking cessation in
California. Cancer Epidemiol Biomarkers Prev 14:2131, 2005; Ries AL et al: Effects of pulmonary rehabilitation
on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern
Med 122:823, 1995; Ries AL et al: Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized
trial. Am J Respir Crit Care Med 167:880, 2003; Ries AL: Pulmonary rehabilitation and COPD. Semin
Respir Crit Care Med 26:133, 2005; Ries AL: The importance of exercise in pulmonary rehabilitation. Clin Chest
Med 15:327, 1994; van Schayck CP et al: Comparison of existing symptom-based questionnaires for identifying
COPD in the general practice setting. Respirology 10:323, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
For this issue, the faculty reported nothing to disclose.
Drs. Ries and Burns were recorded at Topics and Advances in Internal Medicine, sponsored by the University of
California, San Diego, School of Medicine, March 3-9, 2005, in San Diego. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation in the production of this program.
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