Management of Chronic Obstructive Pulmonary Disease and Asthma: Current Challenges

Educational Objectives

The goal of this program is to improve management of chronic obstructive pulmonary disease (COPD) and asthma. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate asthma and COPD from pulmonary conditions with overlapping symptoms.
2. Use combination therapy to treat patients with mild asthma.
3. Select patients with COPD for treatment with biologic drugs.

Summary

Chronic obstructive pulmonary disease (COPD) vs asthma: asthma has a larger genetic basis and is more associated with allergies and airway hyperreactivity; COPD is classically associated with smoking and air pollution; however, patients (especially adults) may have asthma-COPD overlap syndrome (ACOS); asthma diagnosis peaks in childhood and in adults 50 to 69 yr of age; asthma history — allergies, triggers, nocturnal symptoms, and exercise-induced symptoms are relevant; COPD history — smoking and asbestos exposure have synergistic cancer risk; exercise tolerance, quality of life (QoL), and exacerbations are relevant

COPD diagnosis: the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines emphasize the use of structured tools; the COPD assessment test (CAT) helps determine symptoms, number of exacerbations, and impact on QoL, and aids in diagnosis, staging, and management; new guidelines use the CAT score in place of forced expiratory volume in 1 sec (FEV1); the A and B categories focus on the degree of symptoms and have been retained; patients with ≥2 exacerbations over the past year are placed in GOLD E (high risk), and triple therapy for inhalers is recommended

Causes of COPD: genetic factors, eg, α-1 antitrypsin (AAT), have been identified; AAT testing is recommended for patients <60 yr of age with a new diagnosis of COPD or with minimal smoking history; testing is not required for patients with, eg, an 80 packs/year smoking history

Pulmonary function test (PFT): low-risk and high-yield; empiric therapy should be started if the diagnosis is clear; PFTs help distinguish asthma from COPD and identify mimics in cases in which the diagnosis is not as clear; spirometry (eg, FEV1, forced vital capacity [FVC]) is appropriate for asthma; full PFTs with diffusing capacity of the lung for CO (DLCO) should be done in cases of suspicion of, eg, interstitial lung disease; patients with curvilinear flow-volume loops which suggest obstruction and symptoms of obstruction, but with normal PFTs (ie, FEV1/FVC ≥70%), should be treated

Asthma, COPD, and obesity: obesity may worsen obstruction symptoms; PFT results suggest that weight loss may improve breathing; starting prednisone for obesity-related obstructive symptoms and wheezing in the absence of asthma does not help and can make obesity worse; obesity should be differentiated from obesity plus asthma; PFT outcomes affected by albuterol may not indicate asthma in all cases; COPD can sometimes exhibit albuterol responsiveness; a pulmonologist may be consulted in uncertain cases

Asthma and COPD mimics: a broad differential diagnosis (including considering no pulmonary issue) is required; vocal cord dysfunction — may be caused by surgery, intubation, or other trauma to the vocal cords; younger people may have stridor (not wheezing) triggered by anxiety or pain (may be reproducible); endoscopy to view the vocal cords may be done in consultation with an otolaryngologist; aspergillosis — a patient with worsening asthma symptoms and an extremely high immunoglobulin E (IgE) level may have allergic bronchopulmonary aspergillosis; vasculitis — rare and difficult to diagnose; may occur in patients (particularly older men) with newly developed asthma and systemic symptoms, eg, hematuria, weight loss; infections — consider, eg, Strongyloides, in patients who are immunosuppressed, coming from a pertinent area, with HIV, or recovering from transplantation; decompensated heart failure — examine for cardiac wheeze, signs of volume overload, and a prior echocardiography; bronchiectasis — primarily a concern for persons traveling to or from tuberculosis (TB)-endemic areas; check for scarred lung from TB or non-tuberculous Mycobacteria, eg, M avium complex

Other mimics: occupational and environmental lung disease — occupation and environment (eg, pets, including birds) are relevant; lung cancer — may be misdiagnosed as asthma or COPD; interstitial lung disease — common mimic; subacute, insidious shortness of breath and cough is a classic presentation of idiopathic pulmonary fibrosis (common in older adults and former smokers); full PFT may be done; reactive airway disease — wheezing after COVID-19, respiratory syncytial virus (RSV), or influenza infections may indicate occult asthma in adults; obtain PFTs after recovery from the acute infection; reactive airway dysfunction syndrome presents as acute wheezing and bronchospasm with exposure to an irritant (eg, construction dust); for postviral wheezing, use supportive care (similar to mild intermittent asthma)

Referral to a pulmonologist: should be made when PFTs or chest computed tomography (CT) do not produce a diagnosis, if there is a need for advanced testing (eg, methacholine challenge or bronchoscopy), a mimic is suspected, or diagnostic help is needed

Management: an inhaler chart should be kept in the clinic; the GOLD criteria algorithm links symptoms to treatment; patients in GOLD group E (eg, patients requiring hospitalization) should use a long-acting beta agonist (LABA) plus a long-acting muscarinic antagonist (LAMA) combination or triple therapy (LABA, LAMA, and inhaled corticosteroids [ICS]); LAMA alone is adequate for patients who are less symptomatic; patients who are symptomatic with LABA plus LAMA therapy should have ICS added for triple therapy; triple therapy — has a mortality benefit for patients not doing well on LABA-LAMA therapy; a newly available inhaler contains fluticasone furoate, umeclidinium, and vilanterol (Trelegy) for once daily use; triple therapy may slightly increase cardiovascular (CV) risk; patients with COPD are at higher risk for CV disease from tobacco smoke; an individualized risk-benefit assessment should be made for each patient; the benefit of triple therapy outweighs the risk for most patients; COVID-19 — guidelines support continuing inhalers, including ICS, in patients with acute COVID-19 taking nirmatrelvir-ritonavir (Paxlovid)

Comorbidities: common in patients with COPD; consider a 6-min walk test, depression screening, or a sleep study; CV risk factors and bone mineral density (especially in patients taking high-dose steroids) should be assessed; lung cancer screening in eligible patients may be done with low-dose computed tomography (CT); Bhatt et al (2023) found that adding dupilumab for patients with COPD, eosinophilia, and elevated IgE levels decreased the number of exacerbations, which demonstrates the convergence of asthma and COPD therapies; anti-IgE therapy should be considered in patients with high eosinophil levels with COPD who are frequently hospitalized for exacerbations

Acute COPD exacerbations: guidelines have not changed; short-acting inhalers (eg, albuterol, ipratropium bromide [Atrovent]) are effective; no significant benefit from combination inhalers have been seen; inhalers can be continued during hospitalization or exacerbations; 5 days of prednisone 60 mg is recommended, plus 5 days of either azithromycin or doxycycline for anti-inflammatory effects; other needs (eg, supportive care, bilevel positive airway pressure) should be evaluated

Management of mild intermittent asthma: the GOLD guidelines (2017) recommend using LABA-ICS as needed for mild intermittent asthma; Beasley et al (2019) found that an as-needed LABA-ICS combination reduces exacerbations and time to first exacerbation without significant adverse effects; the anti-inflammatory effect of ICS is more beneficial than short-acting β2 agonists (SABAs, eg, albuterol) for chronic maintenance therapy; LABAs (eg, formoterol) act quickly and provide longer relief; the 2019 guidelines recommend against using a SABA inhaler alone for safety reasons

The Global Initiative for Asthma Guidelines (GINA; 2019) recommendations: adults with asthma should receive symptom-driven or daily ICS-containing controller treatment; 2021 and 2023 updates state that budesonide-formoterol may be used as single maintenance and rescue therapy (SMART); the decision to step up or step down therapy should be based on an assessment of symptoms and environmental conditions; step 1 is low-dose ICS-formoterol (as needed); low-dose maintenance therapy (ie, ICS-formoterol twice daily) should be tried next; an increased dose or addition of a LAMA (tiotropium) or monoclonal antibody therapy may be done if treatment is not effective; pulmonology consultation — required for severe asthma requiring intensive care unit stay or intubation (predictor of fatal asthma), and for consideration of IgE therapies (eg, omalizumab, benralizumab) for uncontrolled asthma

Other management tips: counsel patients on the basics, eg, smoking cessation, pulmonary rehabilitation, trigger avoidance, exercise, vaccination (eg, influenza, COVID-19, pneumococcal polysaccharide vaccine [Pneumovax]); the RSV vaccine is recommended for persons >60 yr of age

Acute exacerbation of asthma: recommendations are unchanged; albuterol every 20 min-1 hr is the mainstay; SMART therapy (LABA-ICS) may be used for quick relief (≤6 times/day); prednisone therapy is used for 10 to 14 days for acute asthma exacerbation (vs 5 days for COPD); supportive care, triage, close guidance, and return precautions should be provided

Biologics for asthma: monoclonal antibody agents target different parts of the airway epithelium; IgE levels and a complete blood count with differential (to assess eosinophils) should be checked in patients with an allergic phenotype; monoclonal antibodies are effective in patients with high IgE and eosinophil levels and frequent exacerbations; however, patients with COPD or asthma without allergic phenotypes do not benefit; select conditions (eg, steroid-refractory asthma) may be exceptions; clinical data indicate different biologics reduce exacerbations to a similar degree, and all are steroid sparing; consultation with pulmonology and allergy-immunology may be done for drug selection

Readings

Amrol DJ. 2023 GOLD Guidelines for chronic obstructive pulmonary disease. NEJM Journal Watch. 2023; pNA5687. DOI: 10.1056/NEJM-JW.NA56877. View Article; Beasley R, Holliday M, Reddel HK, et al. Controlled trial of budesonide–formoterol as needed for mild asthma. New England Journal of Medicine. 2019 May 23;380(21):p2020–2030. DOI: 10.1056/NEJMOA1901963. View Article; Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with type 2 inflammation indicated by eosinophil counts. New England Journal of Medicine. 2023 July 20;389(3):p205–214. DOI: 10.1056/NEJMOA2303951. View Article; Cagle SD, Landrum LS, Kennedy AM. Chronic obstructive pulmonary disease: Diagnosis and management. American Family Physician. 2023 June;107(6):p604–612. View Article; Jordan TS, Spencer EM, Davies P. Tuberculosis, bronchiectasis and chronic airflow obstruction. Respirology. 2010;15(4):623-628. doi:10.1111/j.1440-1843.2010.01749.x View Article; Kritek P. 2023 GOLD guidelines for chronic obstructive pulmonary disease. NEJM Journal Watch. 2023;Volume pNA56004. DOI: 10.1056/NEJM-JW.NA56004. View Article; Markowitz SB, Levin SM, Miller A, Morabia A. Asbestos, asbestosis, smoking, and lung cancer. New findings from the North American insulator cohort. Am J Respir Crit Care Med. 2013;188(1):90-96. doi:10.1164/rccm.201302-0257OC. View Article; Mosnaim G. Asthma in adults. New England Journal of Medicine. 2023 September 14;389(11):p1023–1031. DOI: 10.1056/NEJMCP2304871. View Article; Mümmler C, Milger K. Biologics for severe asthma and beyond. Pharmacology & Therapeutics. 2023 December;252:p108551. DOI: 10.1016/J.PHARMTHERA.2023.108551. View Article; Rajan S, Gogtay NJ, Konwar M, et al. The global initiative for asthma guidelines (2019): change in the recommendation for the management of mild asthma based on the SYGMA-2 trial – A critical appraisal. Lung India. 2020 Mar-Apr;37(2):p169–173. View Article; Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD Executive Summary. Am J Respir Crit Care Med. 2017;195(5):557-582. doi:10.1164/rccm.201701-0218PP. View Article; Yu Y, Cao W, Xiao Y, et al. Budesonide/formoterol maintenance and reliever therapy in childhood asthma: Real–world effectiveness and economic assessment. Pediatric Pulmonology. 2023 October. DOI: 10.1002/PPUL.26647. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Santhosh was recorded at Primary Care Medicine: Principles and Practice, held October 4-6, 2023, in San Francisco, CA, and presented by the University of California, San Francisco, School of Medicine. For information on future CME activities from this presenter, please visit meded.ucsf.edu/continuing-education. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

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The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

FP721601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.