Recognizing and managing COPD exacerbations in primary care: A conversation with Dr. Barbara Yawn

Welcome to Inside Family Medicine, where you hear from leaders and peers in your specialty while learning about new tools and resources. I'm your host, Emily Wick, a member of Team AAFP Today. Dr. Barbara Y is joining us to talk about the role family physicians play in recognizing and managing chronic obstructive pulmonary disease or COPD exacerbations in primary care.

Dr. Y is a family physician and clinical researcher with over 45 years of experience, including 14 years practicing full-time in rural Minnesota. Dr. Yan has recently retired as Chief Science Officer at the COPD Foundation. And is an adjunct professor in the Department of Family and Community Health at the University of Minnesota in Minneapolis.

She holds a medical degree from the University of Missouri. Columbia School of Medicine completed her residency in family medicine at the University of Minnesota and earned a master of Science in clinical research design and statistics from the University of Michigan. Her research interests include asthma.

And COPD management, women's health, and improving diagnostic processes in primary care. Thank you so much for joining us, Dr. Yan. Thank you for having me.

I wanna start out by asking you, as we like to ask all guests, why you chose family medicine as your specialty. Well, it was a long time ago when family medicine was just coming to the fore.

Before that, we'd all been just gps, but now there was family medicine residencies, and as I went through medical school, I enjoyed taking care of people in all the different rotations. But I realized it wasn't so much fun to take care of just their kidneys or just their lungs. I really wanted to take care of the whole person, and that meant family medicine.

I also really enjoyed maternity care and taking care of children and babies, so that was family medicine. And then when I got out into rural practice, I realized how much it meant to take care of someone in the context of their. Family and their community. So that's family medicine. Yes. You get to do a little bit of everything, especially when you're in those rural settings.

You really get get to do full, full scope.

Yeah. So I know we're talking about COPD today, and according to the COPD Foundation where we mentioned you served as the Chief science Officer, more than 16 million people in the US are living with COPD. That is a big number, and millions more are undiagnosed. So what are the most critical early warning signs of COPD and COPD exacerbations that family physicians should be trained to recognize during visits?

Well, one of the issues is you have to think of the diagnosis. If you don't think COPD could be a problem, you're never gonna make the diagnosis because patients tend to ignore or deny a lot of their symptoms. They don't wanna be sick. They don't want to have their smoking or other things have caused medical problems, so they won't tell you about some of their symptoms.

And also the symptoms are gradual in their onset frequently. So over five years, someone is. Suddenly breathless when they walk out to the mailbox or up a flight of stairs. But that happens slowly, so they may not even notice and they change their activities.

So I think we have to be suspicious and have to ask.

Do you have problems with getting short of breath or out of breath? Do you find there are things you can't do now that you could do five or 10 years ago? Do you have problems with chronic cough? Those are the kinds of questions you need to ask, and you also really need to be suspicious when someone keeps coming in for bad colds.

Oh, yeah. I get three bad colds a year. Well, that's not usual. Most people get it the most one cold a year, and so it may be these are exacerbations of the COPD. They don't even know they have, so you have to think about it and you have to ask questions because the patient will say. I wasn't worried because I'm getting old.

I'm outta breath because I'm outta shape and I'm overweight and I don't do activities. So they have lots of excuses for those symptoms and just won't tell you unless you ask and are interested and then follow up. I think that's why family physicians are so well positioned to notice it or to flag some of these concerns because you see these patients over the course of decades, I mean the, or their whole lifetime in some cases.

And so you know when something changes and something's different, you can say, I don't think that's right. Well, yes, except they don't always. Tell you, and you don't always know. Remember, you see the patient frequently sitting only in the exam room. You didn't see them get short of breath walking down the hall to get into the exam room.

And you know, they put on their best face while they're there. And if they don't want you to know about something, they will do lots of things to get around it. They're not being deceptive, they just wanna put their best face forward. So. You do need to engage them and talk to them. One of the things I find really interesting is asking them what's their daily routine, because then you get some idea of what they really do.

For example, one of my patients when I said, well, tell me about what you do every day. Well, I get up and it takes me about an hour and a half to get ready for breakfast. Why? Well, you know, I get really kind of short of breath and I can't do too much when I'm getting dressed. It takes me a while and then I have breakfast, and then I go in and sit in my recliner and I make sure I take my water with me because I don't wanna have to get up and walk.

Back and forth to the kitchen 'cause it gets short of breath and don't wanna drink too much water. 'cause I don't wanna have to go to the bathroom too many times 'cause I get short of breath. Just some of those things. You don't see those in the medical record all that often because we think we're in a hurry and that doesn't take that long.

And you find out a huge amount of information by a simple question like, tell me about your average day.

Yeah. Yeah, that's great advice right there. How do the AAFP and other guidelines shape our approach to diagnosing COPD exacerbations and preventing future ones in primary care settings? Well diagnosing COPD exacerbations most of the time seems pretty straightforward.

If you know the person has COPD and they're acutely getting more short of breath, they've got more cough, they're producing more sputum, the sputum is suddenly kind of green or yellow. That's probably A-C-O-P-D exacerbation. But they're not always that obvious. And if the patient doesn't think about what it is, they may not tell you.

They may just start using their rescue inhaler or their other medicine or stop their activity and wait till they're really very ill. They can't sit up, they can't talk in full sentences. That's when they need to call nine one one. They needed to call you way back, and you need to tell them. Look, if you're having more shortness of breath, cough changes, especially if it turns yellow or green, you need to give my office a call because we need to think about changing therapy and acutely the recommendations are that you're going to start corticosteroids.

Systemic corticosteroids oral, for example, like an oral burst, 30 to 50 milligrams a day. Probably need more in the 30 range for like five to seven days. You may add antibiotics depending on the particular situation, if they're sputum is suddenly yellow or green, and. Very copious and they have a fever.

You are going to definitely think about antibiotics. Most of the time. If you catch it early, you can treat it as an outpatient.

If not, and they get more short of breath or they go to the emergency room, then you're gonna check things like pulse ox, and you have to decide. Is this COPD or could it be congestive heart failure?

Could they have a pulmonary embolus? Do they have pneumonia? That's when you need to use other tests like chest x-ray for the pneumonia. You may use BNP for heart failure. You can use the D dimer. Just looked for I and. Things like that, but those are usually people who've gone to the emergency room or certainly once they get in the hospital.

The family physician's role is yes, to treat it acutely, but our most important role, I think, with exacerbations is seeing the patient shortly after that 5, 7, 10 days after you start the burst, or if they went to the ED or the hospital after their discharged. And talk about, okay, what happened before this exacerbation started?

What was the cause of the exacerbation? Were they having trouble taking their medicine? Did they run out? Could they not afford it this month? Did somebody start smoking around them? Did they start smoking again? Do they not up to date on their immunizations? So they got. COVID or they got pneumonia or they got influenza.

So those are the kinds of things that we do that are really, really important. Yes, you treat the acute exacerbation, but it's the follow-up that is really our special role. So the family physician we know is the medical home. You're gonna help them manage their care and navigate what they need to be doing.

But when should a family physician also consider referring a patient with COPD to a pulmonologist? Yeah. And that's really kind of a personal decision for both the patient and the family physician. Family physicians have. Different levels of comfort with COPD. Sometimes when you're very young and starting, most of your patients are aged about 30, so there aren't very many people with COPD.

As you get older, your patients tend to get older, and if you have more experience, you may be able to take care of the patients longer. But I am most comfortable thinking about referrals, certainly. After a hospitalization for COPD or after multiple exacerbations, like two or three in a year, something else is going on.

I need to have checked. As I said, the adherence, the inhaler technique are those problems that we could take care of hopefully before we send them on. But once we get to the point. I think their inhaler techniques good. I've got them on whatever is my highest level of therapy for most people. That's triple therapy, which is an inhaled corticosteroid, an antimuscarinic, and an anti or beta agonist therapy.

So triple. LABA llama ICS. When I get to there and they're still having either breathlessness or they're having exacerbations, that's when I really want another opinion, and the pulmonologist is probably the person I'm going to get that from. Although I don't wanna forget there. Other things that can cause these, like depression that I'm having trouble treating, or heart disease that I need the cardiologist's opinion for.

So there are several things that would make you consider. A consultation or referral. I like to separate those two because referral I think means well, I'm gonna send them off and I may never see 'em again. That doesn't happen usually, so it usually is collaborative care, a consultation. We're going to take care of this patient together, and so when do I want someone else helping me take care of this patient?

What are the current best practices for treating and preventing COPD exacerbations, and how do corticosteroids and antibiotics fit into that treatment landscape? Well, the corticosteroids and the antibiotics, especially systemic corticosteroids, are what you use acutely. You use a burst of the corticosteroids.

There are some indicators, as I said, for adding the antibiotics. For example, the sputum. Changes color, there's a lot more of it. They have a fever. They've had repeated previous exacerbations that required antibiotics. Those are something you do acutely, but that only treats it after the fact. We want to talk about treating it and preventing it from happening again.

So that's when we talk about the therapies for COPD, and as I said, they sort of start in a step. Wise fashion. Usually you start with a bronchodilator and that could be a LAMA long-acting antimuscarinic. If that's what they need and they're not having too many symptoms, that's great. As they get more symptoms, you need more bronchodilation.

That's when you go to LABA plus lama, dual bronchodilator therapy. If they start having more exacerbations, the dual bronchodilator therapy can help prevent exacerbations. But if it's not enough, you're then gonna think about adding inhaled corticosteroids on a daily basis, and that's when the eosinophilia comes into account.

People know about, well, I'm supposed to check eosinophils. Why do I do that? Well, you do that because people with higher eosinophil counts and the numbers are not quite absolute. But if they're more than 300 cells per milliliter, that's someone who probably is gonna respond to inhaled corticosteroids. If it's 100 to 300, well they may, and it's a clinical decision if it's less than a hundred.

They probably aren't gonna respond to the inhaled corticosteroids, and that's when you may need to think about some of the other therapies that we can talk about in a minute as the newer therapies. And that's when I probably would like a referral because. Where do I go next?

Yeah. And before we talk about some of those newer therapies, which I think will be really helpful for our listeners, I'm curious how family physicians can use shared decision making to personalize COPD treatment plans, especially following an exacerbation.

Yeah, and following exacerbation is a great time. We know that, for example, after someone has a heart attack, they're much more likely to wanna stop smoking and do other things. And I think it's the same after a lung attack. And I like to call them lung attacks because I think that resonates with patients.

They know what a heart attack is. This is a lung attack and it's. Just as serious and so shared decision making is not something I think we should be frightened of. It doesn't mean it's gonna take an hour and a half or 30 minutes or whatever for this visit. You can do it fairly quickly and it's kind of interesting.

You can use the share as kind of your guideline. S stands for seeking the patient and their family's opinion and what do they think? Think about participating and trying to make better decisions to prevent what just happened from happening again. Then you help them explore and compare the options for therapy, and then you assess what they want.

What are their preferences? What are their goals? And then you reach a decision based on what is available and what are their goals. For example, the woman says, I really need to stop smoking because my daughter-in-law said if I don't stop smoking, I can't see my grandchild and she's due in three months.

What do I do? And so. You've got a perfect in, they're ready to help. The same with adherence. You know, I don't like taking this ICS stuff because my sister-in-law says that athletes get into big trouble with steroids, so I'm afraid of them. That's very helpful to understand what their preferences and fears are, because then you can address that hopefully.

Then after, uh, assessing and then reaching this mutual decision, it's reevaluate. Don't forget to evaluate and reevaluate can the patient do their part? Of what we suggested, will their insurance company let us do what we suggested and then reevaluate, make a follow up appointment and ask about those shared decisions again, because if you ask, they know you think it's important and they're going to believe it's important.

If you reach a decision and then you never follow up on it, well it must not have been very important, so. We won't bother. So I think that shared decision making is what we do all the time. We just might cut it a little short here and there and you don't want to, but I find that using the share just helps me remember there are five steps.

Let's make sure I did them and you could do them quickly. Yeah, that's definitely an ongoing conversation.

Yeah. As you mentioned, certain treatments are gaining traction for COPD. What are they, and how should family physicians identify patients who might benefit from these advanced treatments? Yeah, I think that we'll talk about the most unusual one first, and that would be the surgical interventions, endotracheal or into bronchial valves and lung reduction surgery.

Those are for people with emphysema that. You've tried all the drugs and they aren't helping, and the way that you find out a patient has emphysema most of the time is through imaging. And the perfect time for that is when you're doing lung cancer screening. Remember, most of these patients have smoked and most of 'em are can candidates for lung cancer screen.

So when you do that ct, you ask the radiologist, please tell me about emphysema, about end bronchial thickening, about anything you can with the lungs. And they're looking at the lungs for the masses. They can look for all those things too. They can tell you about. Cardiac size, for example, and heart failure.

So ask those questions. If they have that problem, that's a clear referral, in my opinion, to a pulmonologist, and then they can take it from there. The other therapies are things like azithromycin, that's antibiotics taken daily or maybe three times a week. They don't work well in people who smoke. Or are smoking recently.

But otherwise they can make a huge difference for certain subgroups of people. There's the PD in four inhibitors. They've been around for a little while. They're for people with chronic bronchitis, meaning they have kind of wet emphysema. They cough a lot and they bring up a lot. Sputum and they can be helpful.

A lot of family physicians don't start them because they have a fair number of side effects, but if you start them very slowly, over a period of three or four weeks, they can be, again, very helpful for a subgroup. The newer ones are things like. The biologics. There's two biologics approved right now for COPD, dupilumab and Mepolizumab.

They're very different. Dupilumab treats two of the cytokines IL 14 and 13, and it actually helps with things like mucus plugs, which you can also see on the lung cancer screening It. With inflammation and it actually helps with bronchial constriction. So it does three things. It is an injection and if you've used it for patients with asthma, 'cause it's been available for asthma for a long time, then maybe you're comfortable in trying it with your patients with COPD.

But a lot of family physicians are not. The other one is the mepolizumab. Not quite as easy to administer. It works by blocking eosinophils, actually all the way back to the bone marrow. And if you don't have eosinophils coming out with inflammation, then you don't get all those cytokines inflammatory cytokines.

That cause all the problems. So both of those can work. Now, there are certain qualifications these patients for both of the biologics have to have elevated eosinophil counts. And whether that's one 50 or 300 depends on the medication and sometimes the insurance company, but those. Most of the time require prior authorization, and it's one of the things that our pulmonary colleagues probably do much better with their office staff than my office staff.

So again, one of the things they can help us do as well as all the staff they have for education that I may not have and pulmonary rehab. I really wanna stress that pulmonary rehab has. Basically no risk. Whatever. It works very well to lower the chances of the next exacerbation, improve quality of life, improve exercise capacity, and usually is associated with a fair amount of education, the patient.

So it works well. And now with Telerehab, even in rural areas, we can have much better access to pulmonary rehab.

It is clear that managing COPD can be complex and family physicians certainly play a critical role as you've shown us. You've shared so much great information with us today. I would love for you to just share one or two main points that you're really hoping our listeners take from our conversation.

Well, I think first of all, make sure you've got the right diagnosis and then second, all when there's an exacerbation, don't just give the steroid burst. And that's it. Go back and figure out why did this exacerbation happen? What can we do to prevent the next one? And don't forget inhaler technique and adherence, which are two of the things we are really good at doing.

Well, thank you so, so much for joining us, Dr. Yan, and sharing your expertise. And to our listeners, if you'd like to learn more about choosing family medicine or you'd like more resources around CPD, you can see the links in the show notes. If you enjoyed today's episode, let us know by dropping a line to a AAFPnews@ AAFP.org.

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