Break the cycle of COPD exacerbations

Getting to know a chronic obstructive pulmonary disease (COPD) patient well is not a good sign, pulmonologist Sandra Adams, MD, MS, told attendees at the University of Texas San Antonio's second annual Updates in Hospital Medicine conference in October.

“No offense, but we don't want to see them again,” she said, before offering her advice on how to prevent COPD exacerbations and have “zero repeat offenders,” as her talk at the conference was titled.

“There's a lot that's new and upcoming in COPD, especially what we can do to reduce the risk of them coming back [to the hospital],” said Dr. Adams, who is a professor of medicine at UT Health in San Antonio. “Even if we just reduce the risk of them having outpatient exacerbations, that's a big deal.”

New concepts in the field include pre-COPD, which is defined by normal spirometry in the presence of symptoms. Many patients won't report these symptoms on their own, but they do if asked the right way, Dr. Adams noted.

“I ask things like ‘Do you mow your yard?’” she said. “If three years before … they were able to mow their yard in 30 minutes, and now it takes an hour, that tells you they reduced their activity. They may not be short of breath at all, and it's because they've reduced their activity level.”

Patients with pre-COPD may have air trapping, hyperinflation, and emphysema on CT. “Maybe if you do pulmonary function tests, they have reduced diffusion capacity, or they have a rapid decline in FEV₁,” Dr. Adams said. “Many patients with pre-COPD will go on to develop COPD, and we need to start treating their symptoms aggressively to try to reduce exacerbations.”

Another new patient population to watch out for are those with PRISm, or preserved ratio impaired spirometry. “PRISm is interesting. It's probably somebody who has COPD but also has some interstitial lung disease or [had] some problem as a child, multiple recurrent pneumonias or something like that,” she said.

Patients with PRISm have a normal postbronchodilator ratio of FEV₁ to forced vital capacity (FVC). “But their FEV₁ is low and their FVC is proportionally low,” said Dr. Adams, adding that these findings are cause for concern. “They do almost as poorly as the patients with known and documented COPD, and in some cases even worse because their [pulmonary function tests are] restrictive.”

To assess such patients, and anyone with COPD, use the Modified Medical Research Council Dyspnea score, but also consider exacerbation history in the past year. “If they've only had one outpatient exacerbation, that's lower risk for future exacerbations than if they had two or more outpatient or one inpatient,” she said. “So when they come in to see you, it's important to ask, ‘Have you had [oral or a shot of] steroids in the last year?’”

When a patient's history or symptoms indicate that they are high risk, take preventive action, just as you would in a patient with cardiovascular risk factors, Dr. Adams recommended. “We shouldn't just say, ‘Well, they have these risk factors. [An acute exacerbation] is expected.’”

She noted that a COPD exacerbation could also be called a lung attack. “It should make us cringe like it does when somebody has a heart attack. We're so used to seeing it over and over and over again, but we can actually break the cycle.”

Patients with few symptoms and low exacerbation risk can be treated with just a bronchodilator, but those with more symptoms should get a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA). If they're having exacerbations despite that therapy, then it's time to add an inhaled corticosteroid, Dr. Adams said.

If a first exacerbation happened without the patient being on LAMA/LABA therapy, it's worth holding off on triple therapy, because growing evidence shows that inhaled corticosteroids increase pneumonia risk. “It's real wishy-washy data, but there's more and more of a signal that inhaled steroids in COPD—not in asthma—are associated with the risk of pneumonia. So if they don't need it and can get by on LABA/LAMA, then that's what we should do,” she said.

Triple therapy is indicated for COPD patients with significant features of asthma, an absolute eosinophil count of 300 cells/microliter or higher, frequent and/or severe allergy symptoms, a “huge” bronchodilator response, or very episodic symptoms, she added.

Ideally, the three drugs should come in a single inhaler. “If you have to use two inhalers, it's OK, but the patient really needs to buy in to using the inhalers,” Dr. Adams said.

She also offered some advice on optimizing use of inhalers. “The problem is our patients' insurance will sometimes say, ‘OK, this month, you're getting this one’ and two months later, they change and you're getting a different one,” Dr. Adams said. “Talking to patients about inhaler technique is important.”

Have patients demonstrate their technique if possible, and watch out for pitfalls such as failing to remove the cap, doing more than one puff at once, and not breathing in slowly and then holding one's breath.

If patients aren't able to follow these protocols, there are alternative strategies, noted Dr. Adams, who showed a video of her dog being treated with an inhaler. “When you have somebody that's older or younger, or of the canine variety, who cannot take a deep breath and hold it, you can actually do five tidal breaths with that spacer [and a mask],” she said.

Dr. Adams also reviewed some nonpharmacologic interventions proven to reduce COPD exacerbations. Technically, smoking cessation is not one of them, but it can be worth a try. “It makes sense, and so we should be doing that,” she said, noting that she prefers to focus on the health benefits of cessation (e.g., a 50% lower risk of heart disease after a year) rather than warning about the risks of continued smoking.

Postdischarge pulmonary rehab has been proven to reduce readmissions, she noted. “And vaccines are critical, absolutely critical. Influenza is the one that's been studied the most, but COVID, [respiratory syncytial virus], pneumococcal, and even shingles.”

Prescribe oxygen therapy if a patient is hypoxic, and consider whether they could be a transplant candidate. “Don't forget about referring to lung transplant that population that is really severe, but actually the rest of their body is OK, just their lungs are failing,” said Dr. Adams.

Overall, remember not to fall for the big myth about COPD, she reminded the conference attendees. “The myth is that a COPD exacerbation is a nuisance, with no serious consequences. The reality is it's a big problem, associated with poor quality of life and progression of lung disease … and can be prevented.”