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Spirometry underutilized, but essential, in diagnosing COPD, asthma

SAN DIEGO — Clinicians should be taking steps to confirm the diagnosis of chronic obstructive pulmonary disease and asthma in practice, according to a presentation at the ACP Internal Medicine Annual Meeting.

To confirm such diagnosis, screening spirometry is crucial and should be implemented after symptoms and risk factors are assessed, Meredith C. McCormack, MD, MHS, assistant professor at the Johns Hopkins Bloomberg School of Public Health, said during the presentation.

Diagnosing and managing COPD

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, which outline approaches to diagnosing and managing patients with COPD, were recently revised in 2017, McCormack noted. The update recommended a multidimensional approach, building upon past guidance by adding that symptoms and history of patient exacerbation should be considered in addition to lung function, she said. These guidelines will help to reduce symptoms, reduce risk of exacerbation and improve overall quality of life, she added.

When treating patients with COPD, clinicians should consider both pharmacologic options, such as daily azithromycin and long acting bronchodilators, and nonpharmacologic options, such as smoking cessation, vaccination (influenza and pneumococcal), pulmonary rehabilitation and oxygen therapy, she said.

“Smoking cessation has multiple health benefits, but specifically it alters the natural force of COPD, slows the rate of decline in patients with COPD and has the greatest potential to reduce the risk of exacerbations,” she said. McCormack advised that clinicians consider the “5 A’s” for smoking cessation: ask patients about smoking — specifically those who quit, advise them to quit, assess willingness to quit, assist cessation efforts and arrange a follow-up. A combination of behavioral counseling and pharmacologic therapy is most efficacious, she said.

Pulmonary rehabilitation has multiple benefits, including improvement in exercise capacity, reduction of shortness of breath, reduction of hospitalizations, improvement in quality of life and reduction of anxiety and depression which are significant comorbidities of COPD, she said.

Diagnosing and managing asthma

When approaching treatment of asthma, clinicians should consider a patient’s symptoms, triggers and their response to triggers.

“Similar to COPD, spirometry is important in identifying airway obstruction to confirm the diagnosis for asthma,” McCormack said.

Pulmonary peak flow diary is another way to identify asthma, she said.

“An important thing to take away about asthma management is that inhaled corticosteroid treatment is by far the first line therapy for patients with asthma and our goal is symptom free and normal pulmonary function tests,” she said.

The least amount of medication that is needed to maintain control should be used in managing asthma, according to McCormack. To find that “sweet spot,” clinicians should titrate up if the patient is not well controlled and titrate down if the patient achieves stability, she advised.

“Another important feature of asthma management is to create a plan for the patient that will help them self-manage their own disease, such as an asthma action plan,” she said.

Overall, assessing symptoms, confirming diagnosis, reducing exacerbations, reducing environmental exposures, evaluating adherence to medications and considering comorbidities are the main goals for both COPD and asthma diagnosis and management. – by Alaina Tedesco

Reference:

McCormack MC. MTP 084: Clinical Approaches to Obstructive Lung Disease (COPD and Asthma). Presented at: ACP Internal Medicine Annual Meeting; March 29-April 1, 2017; San Diego.

Disclosure: McCormack reports being a consultant for UpToDate.