This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my great friend, Dr Paul Nelson Williams, who I should mention is America's primary care physician.
We're going to talk about COPD in older adults. We had two great guests on this podcast. We learned that as people get older, their lungs get older as well. And on balance, that means the thoracic cage has some changes. There is less elastic recoil and the respiratory muscles don't work as well. In most people that ends up looking like a more obstructive pattern if you were to get spirometry. But Paul, does that mean that we can diagnose every older adult with COPD just because they have abnormal spirometry?
Paul N. Williams, MD: I feel like we probably shouldn't. We get very tied up in the FEV1/FEV < 0.7 in making the diagnosis, and once you're there, everything else falls by the wayside. But Dr Witt in particular talked about how you need symptoms consistent with the history and the exposure. You asked about COPD-asthma overlap syndrome, and she talked about getting a childhood history. So when you're dealing with presumed COPD, a lot of times it's one of those anecdotal diagnoses that hangs on forever without the diagnosis actually having been formally made. Getting a good history, making sure you're doing your due diligence, and doing the basics can go a long way.
Watto: It's the post-bronchodilator FEV1 to FEV ratio< 0.7, and we're still using that for older adults. You might slightly overdiagnose COPD, but you have to look for the clinical history and the symptoms to make the diagnosis. When we're thinking about how to treat these patients, you need to know which classification they fall into. We used to use spirometry and go by the FEV1 but that was actually really poor in predicting the symptoms people would have or whether they would have an exacerbation. So, we have the modified Medical Research Council (mMRC) scale. It's a kind of grade. You decide which grade the patient fits into or you can give them the eight-question COPD Assessment Test (CAT) score.
Based on that, you can determine severity — either low- or high-severity symptoms. You also figure out whether they've had an exacerbation (eg, needed to be treated with antibiotics or steroids) or if they've been hospitalized for COPD. Patients who have been hospitalized or have been treated for an exacerbation are automatically in the E group, which is the exacerbation group. Those patients should jump right to a combination therapy when you're treating them. Paul, which medications are we really pushing in COPD now? Is it the inhaled steroids?
Williams: Not for most patients. There is a role for some, but it's a little bit more nuanced. To start with, it seems that the long-acting muscarinic receptor antagonists (LAMAs) are the safe backbone of therapy. For patients who are having mild symptoms or not having a lot of exacerbations, you almost can't go wrong there. If someone is coming to you with a high frequency of exacerbations or pretty severe symptoms, then a LAMA-LABA (long-acting beta-2 agonist) combination makes a lot of sense. And you can always de-escalate if you need to. So it's okay to change therapy after you start or adjust if you need to. But the LAMA is the very basic background therapy.
Watto: I love the point that our guest made, that you can step up and step down therapy. And she even does a check 6-8 weeks after starting them on an inhaler to see if they improved. If they didn't, she'll step up therapy and see them back again within a certain time period. If they're still not better, then maybe the combination isn't working, and she might go back and try something else. It's good to know that it can be fluid because I think most people just get slapped on an inhaler, and then unless the formulary changes, nothing is changed.
Williams: She also reiterated that it's worth making sure you got the right diagnosis. If you're starting them on therapies for COPD and their COPD is not improving, maybe that's not what you're dealing with. I thought that was a really helpful point to keep in mind because it's easy to keep pushing and going nowhere.
Watto: There are so many inhalers and different devices, and they're all patented. That's probably on purpose so that they can remain expensive. So, how can we navigate this and help patients? Is there a resource or an app of some type that we can point our patients to?
Wiliams: The COPD Foundation has educational videos on how to use inhalers correctly. I'm just as guilty as anyone of not having full mastery of how to use inhalers, which means I can't teach it effectively. This episode prompted me to look at the videos myself, even watch them with some patients and reinforce that you have to be able use the inhaler for it to actually be effective. So, just going back and being sort of foundational again, and making sure you get those basics right, is going to help your patients the most in the long run.
Watto: That's why on boards the right answer is almost always "make sure they have correct inhaler technique," because it is just so commonly not done correctly. And the app is really great because you can toggle between a provider view and a patient view, and the videos are embedded right in there. It's really great.
In this podcast we went way into depth on COPD, so I would highly recommend people check it out at this link.
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Cite this: Matthew F. Watto, Paul N. Williams. COPD: Tips on Primary Care Management - Medscape - Dec 20, 2023.
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