COPD, Sleep Apnea, and Asthma: American Thoracic Society Conference Highlights

Chronic Obstructive Pulmonary Disorder (COPD) at ATS

The most recent updated guidelines from the Global Strategy for the Diagnosis, Management, and Prevention (GOLD), issued in December 2011, recommend that clinicians incorporate symptom assessment tools into their decision making regarding treatment. Specifically, they advise using the COPD Assessment Test (CAT) every 2 to 3 months to identify “trends and changes,” rather than relying only on annual spirometry. The goal is to focus on improving quality of life, not just symptoms; the two do not always correlate. 

The higher the score on the 8-item CAT test, the worse the patient’s quality of life. Patients can even take the test online (http://www.catestonline.org/english/indexEN.htm) and bring it with them for their appointments. Tracking the score over time can provide insight into how quickly the disease is progressing. A change of 2 points is considered clinically relevant. Scores below 10 are considered low; 10-20, medium; 21-30, high; and greater than 30, very high, with specific management options recommended in each category.¹
 
Several presentations at ATS will document how clearly the CAT test indicates function and quality of life among COPD patients, some of whom don’t even show symptoms. A number of the abstracts have implications for the way COPD is treated.

CAT testing in smokers.  In one study, researchers gave the CAT to 342 heavy smokers, 68% of them currently smokers. None had yet been diagnosed with COPD, although several received the diagnosis during the study. Asymptomatic daily smokers with normal lung function had mean CAT scores of 8.6, while symptomatic smokers with normal lung function had mean CAT scores of 13.0, as did the participants who had GOLD II disease. Those with severe COPD or exacerbation scored an average of 20.9. Take-home message: Even patients with a smoking history who have normal lung function, as well as those with mild-to-moderate COPD, may have significantly impaired quality of life. Consider beginning treatment early and optimizing management.² 

CAT and exacerbations.  Several studies found links between CAT scores and exacerbations. In one, high CAT scores were associated with exacerbation frequency even in patients with mild airflow limitation. These patients also were less active indoors and experienced more gastrointestinal reflux disease.³  Meanwhile, among 161 patients who completed the CAT during an exacerbation and at least 5 weeks after, the CAT score at the time of the exacerbation correlated significantly with systemic inflammatory markers, providing a reliable indication of exacerbation intensity that could  guide treatment. The score was also a good marker to assess improvement in the weeks following exacerbation.⁴

Finally, a retrospective study of 39 patients with moderate-to-severe COPD found that CAT provided a clear marker for worsening disease and functional capacity. The authors recommended using it to determine “more effective interventions in the natural history of the disease.” ⁵

Screening for COPD. There is considerable debate as to the appropriateness of COPD screening, particularly in primary care offices where access to spirometry may be limited.⁶  After all, not every smoker develops COPD. A study that will be presented at ATS, however, found that smoking history, age > 55 years, and presence of exertional breathlessness reliably predicted patients at risk for COPD for whom spirometry is appropriate.⁷

Dyspnea in COPD. Dyspnea is the classic symptom of COPD, one that clinicians aim to improve with treatment. However, a study to be presented at ATS found that 44% of a cohort of 42,175 COPD patients had clinically significantly dyspnea regardless of their GOLD stage and current treatment. Take-home message: A significant percentage of patients are not being treated aggressively enough to manage their symptoms and improve their quality of life.⁸ 

Watch out for fatigue. More than half of COPD patients experience chronic fatigue. Yet there is disagreement on how to assess and manage fatigue in these patients, leading to significant underdiagnosis and undertreatment.⁹   A study that will be presented at ATS involving 101 patients with stable COPD found that 66% experienced fatigue, mainly those with more reduced lung function, shorter 6-minute walking distances, and greater dyspnea. These patients were also more likely to experience depression and anxiety than those without fatigue.¹⁰  Take-home message: Don’t ignore fatigue in your COPD patients. It could be contributing to other comorbidities and affecting quality of life, and it can be improved with proper management. Evidence-based approaches to improving fatigue in patients with COPD include pulmonary rehabilitation and nutritional support.¹¹