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Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

Pearl 1: Diagnosis and Empiric Therapy

• COPD label without spirometry is very common
  • of patients are diagnosed empirically and do NOT receive spirometry
  • You cannot without spirometry
• “History and physical examination are poor predictors of airway obstruction and its severity” - from 2011 from  ACP, ACCP, ATS, and ERS 
  • 1 in 3 .
  • Despite not having obstruction on PFTs, 1 in 4!
• A note on defining airflow obstruction (AFO):
  • Historically (and currently, by GOLD), defined as post-bronchodilator FEV1/FVC < 0.7 or by FEV1 < 80% of predicted. 
  • However, there are concerns that this can ignore normal, age-associated decreases in FEV1/FVC and lead to overdiagnosis. 
  • The are now recommending using the lower limit of normal (defined as the 5th percentile) to define AFO.
• Empiric initiation of maintenance inhalers for COPD generally shouldn’t be done
  • However, in patients with radiographic evidence of emphysema/COPD and with symptoms consistent with the diagnosis, it’s probably ok to start maintenance inhalers so long as outpatient PFTs are ordered for confirmation

Pearl 2: The Initial Visit–Blood Work and Initial Treatment Choices

• Blood work in COPD:
  • 1) Every new diagnosis of COPD should be checked for
  • 2) Every COPD patient should have a CBC with diff checked at least once to . Specifically, do not interpret eosinophils when they’re taking systemic steroids or have an acute infection.
    • The idea behind this is that COPD patients with higher eosinophils may have an allergic or inflammatory phenotype that an ICS will directly treat and therefore reduce exacerbations.
      •   differ between studies and individual’s practice patterns, but there’s evidence that peripheral eosinophils predicts 
        • a patient's risk of exacerbation and 
        • More likely to . 
    • On the other hand, patients without high eosinophils don’t have an inflammatory phenotype and so are only getting the risk for immunosuppression and pneumonia with ICS use. 
      • is associated with an
      • Data supports that if eos are , patients may have a higher rate of PNA and so at higher risk of harm from ICS use.
• Simplify inhalers by remembering that there are only 3 classes of medications:
  • 1) Beta agonists 
    • Generally end with “-�DZ�”
    • E.g. formoterol, salmeterol
  • 2) Muscarinic antagonists
    • Generally end with “-���ܳ�”
    • E.g. tiotropium, aclidinium, the umeclidinium
  • 3) Inhaled corticosteroids 
    • Generally end with “-�DzԱ�”
    • E.g., fluticasone, beclomethasone
• The most widely used staging/grouping schema (see infographic) is described by , which uses a combination of spirometry, symptom burden, and history of exacerbations over the last year to determine grade and group. 
  • COPD grade informs prognosis 
  • COPD group informs initial therapy. 
    • Memorization of specific cutoffs isn’t necessary, and can be looked up.
• The way you assess symptom burden matters. 
  • COPD is
  • Consider using a standardized instrument to assess your patients-  a significant number of symptomatic patients will otherwise. 
    • The modified medical research council (mMRC) score has been used quite broadly due to its simplicity, but .

    • Contributors

      Luke Hedrick, MD – Author/Host

      Shreya Trivedi, MD, ACP Member – Author/Host

      Kai Saukkonen, MD – Expert Discussant

      Richard Schwartzstein, MD, FACP – Expert Discussant

      Rebecca Omlor, MD – Expert Discussant

      Ali Trainor, MD – Author/Host

      Aaron Troy, MD – Producer/Author

      Reviewers

      Nick Mark, MD

      Lakshman Swamy, MD

      Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

      Release Date:  June 22, 2022

      Expiration Date: June 22, 2025

      CME Credit

      This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the �ܼ�����ˮ��̳ and Core IM.  The �ܼ�����ˮ��̳ is accredited by the ACCME to provide continuing medical education for physicians.

      The �ܼ�����ˮ��̳ designates this enduring material (podcast) for 0.75 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

      ABIM Maintenance of Certification (MOC) Points

      Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.75 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

      How to Claim CME Credit and MOC Points

      After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.