PFTs are underutilized in suspected COPD cases. For a 65-year-old man with dyspnea, obesity, and a history of COPD, PFTs including spirometry with bronchodilator should be ordered to confirm airflow obstruction. PFTs revealed moderate COPD. Treatment includes smoking cessation, long-acting bronchodilators, and pulmonary rehabilitation. Regular reassessment of inhaler adherence and ability to use devices properly is important due to costs and side effects.

1. PFTs for GIM
When to Use Them
Katy Horan, MD
Federal Way GIM
August 30, 2018

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3. © 2014 Virginia Mason Medical Center
2014 Organizational Goals

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Disclosures
I’m biased in favor of PFT’s, of
course…

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Goals of this Journal Club
• Review Collins, et al article
• Discuss COPD management
• Review which pfts to order when
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6. © 2014 Virginia Mason Medical Center
Case #1
65 year old man presents with dyspnea
on exertion in the setting of obesity
BMI 37, hypertension, and diabetes.
He’s been told he has COPD.
Current medications include: Lasix,
amlodipine, atorvastatin, metformin,
losartan, aspirin, albuterol
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Case #1
Previous work up reveals echo with
preserved EF and grade I DD. No
pulmonary function tests.
Do you get pfts?
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The answer is…
Of course!
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Airflow obstruction in empiric COPD
Collins BF, et al. looked at presence of
air flow obstruction in patients with a
clinical diagnosis of COPD
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Collins BF, et al. Chest. 2015;147 (2)

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Population 2003-2007
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Intervention and Comparison
• Measured spirometry with
bronchodilator
• Compared against other factors
• Smoking in last year
• Sex
• BMI
• Co-mordities: ACS, CHF, DM, OSA, HTN
• Site of care (rural, urban, academic)
• COPD exacerbations
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Outcome
• 62% of patients receiving therapy for
COPD had airflow obstruction
• Obstruction is mandatory for dx of COPD
• Empiric dx of COPD more likely
correct
• Older, current smokers, 2 or more AECOPDs
• Empiric dx of COPD more likely
incorrect
• Co-morbid disease, obesity, CHF, DM, depression, OSA
• RR of COPD with 3 or more co-morbid disease 0.57
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Discussion
▪ Cost-hundreds of dollars
▪ Side effects: pneumonia (ICS),
urinary retention (MAs), role in CV
disease (MAs and BAs)
▪ Missed diagnoses/interventions
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Case #1
What pfts to order for our patient?
-spirometry with bronchodilator
-consider DLCO if you think the chance
of air flow obstruction is low
-consider lung volumes if FVC and SVC
are reduced—suggestive of restriction
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Case #1, part 2
PFTs reveal moderate obstruction.
He has 60 pack year history, quitting
10 years ago.
How do you manage him?
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Case 1, part 2 moderate COPD
Treatment
-smoking cessation-already done
—only treatment that has mortality
benefit in COPD or emphysema
—4x more improvement in QoL than
any medical treatment.
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Case 1, part 2 Moderate COPD
Treatment
Medications:
?daily symptoms?
?acute exacerbations?
If neither, short acting beta agonist
with spacer
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18. © 2014 Virginia Mason Medical Center
Case 1, part 2, moderate COPD
Treatment-medications
-if symptoms or exacerbation history, begin long
acting bronchodilator (LAMA or LABA). Reassess
for response ** in 4weeks. If no benefit, try
other class.
-next step up LABA/LAMA
-third step LABA/LAMA/ICS
-always dispense spacer for MDI (only 10% of
patients use MDI’s properly without spacer)
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A word about fluticasone/salmeterol
Data
-suggesting non adherence with FS vs. tiotropium
-non-adherence associated with higher costs
-Only 6% of discharging AECOPD patients are adherent at
80% at one month
—>Sulayman I, et al. AJRCCM. 2017
—>errors included blowing into discus, missed doses.
-consider once daily therapies for non-adherence
-consider pharmacy consultation
-poor lung function may make DPI more difficult
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ICS withdrawal
Data to support stepping off of ICS in
COPD without loss of control of symptoms
or exacerbation rate
—>Magnussen H, et al. NEJM. 2014
—>no change in AECOPD
—>drop in lung function
Benefits-decreased pneumonia risk,
decreased drug costs, simplification of
regimens
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COPD treatment-frequent flares
If failing ICS/LABA and LAMA, consider:
-daily azithromycin (hearing test, EGK)
—>Albert RK, et al. NEJM. 2011
—>reduction in median time to exacerbation 266 vs. 174
—>subsequent studies suggest benefit lost on smokers
-roflumilast (not for low BMI)
—>Calverley PMA, et al. Lancet 2009
—>reduction in AECOPD/year
—>improvement in FEV1 48mL
—>mean weight loss 2.17kg
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Case 1, part 3, nonmedical mgt
Pulmonary rehabilitation
-moderateCOPD and worse
-6-8 weeks of education and proctored
exercise
Lung cancer screening
Immunizations
Depression
Osteoporosis
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PFTs in Federal Way
Spirometry (FVC with or without BD)
Lung volumes (no weight limit)
DLCO
Neuromuscular testing
Oximetry
-please remind patients to hold inhalers
4 hours prior to testing if possible
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Ordering PFTs-decision support
Dyspnea
-FVC with bronchodilator and DLCO
Suspected COPD/emphysema
-FVC with BD, lung volumes, DLCO
Asthma
-FVC with BD
Cough
-FVC with BD
ILD/pulmonary fibrosis
-initial test: FVC, DLCO, lung volumes
Upper airway obstruction
-Flow volume LOOP (both inspiration and expiratory)
Neuromuscular weakness
-FVC sitting and supine, MIP/MEP
Pre-operative assessment
-FVC, DLCO
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Take-aways
• PFTs will be available at FW
• We underutilize PFTs in suspected
COPD
• Reassessment of inhaler use important
due to costs, side effects, and patient
ability to use.
• Medications are not the only COPD
management (exercise and cessation)
• With BID meds, ask about adherence
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