Can emphysema be diagnosed without Pulmonary Function Tests (PFT) or spirometry in a patient using albuterol (bronchodilator) daily for Shortness of Breath (SOB) and currently undergoing chemotherapy with Inhaled Corticosteroids (ICS), without a Long-Acting Muscarinic Antagonist (LAMA)?

From the Guidelines

Emphysema can be diagnosed without Pulmonary Function Tests (PFT) or spirometry based on clinical presentation and history, especially in patients with a high suspicion of the disease and characteristic symptoms, as supported by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1.

Diagnosis Considerations

When diagnosing emphysema, a comprehensive clinical evaluation is crucial. This includes assessing symptoms such as shortness of breath, history of smoking or exposure to pollutants, and physical examination findings. Although spirometry is the gold standard for diagnosing COPD and emphysema, it may not always be necessary for a presumptive diagnosis, especially in the context of a patient already experiencing significant symptoms and using a bronchodilator like albuterol daily.

Treatment Approach

Given the patient's current use of albuterol (a short-acting beta-agonist) for shortness of breath and the absence of a long-acting muscarinic antagonist (LAMA) in their regimen, adding a LAMA such as tiotropium (Spiriva) 18mcg inhaled once daily would be the next logical step to provide more sustained bronchodilation and symptom relief. This approach is in line with recommendations for managing COPD, as LAMAs have been shown to improve lung function, reduce symptoms, and decrease the frequency of exacerbations in patients with COPD 1.

Considerations for Concurrent Chemotherapy and ICS Use

The patient's concurrent chemotherapy and inhaled corticosteroid (ICS) use are important considerations. Both chemotherapy and ICS can suppress immune function, increasing the risk of infections such as pneumonia and oral candidiasis. It is essential to instruct the patient to rinse their mouth after ICS use to reduce the risk of oral candidiasis and to monitor them closely for signs of respiratory infections. The use of ICS in combination with other therapies for COPD is recommended when there is a history of exacerbations, but it should be done with caution and careful monitoring due to the potential side effects, as discussed in the 2017 GOLD report 1.

Next Steps

If the patient continues to experience symptoms after the addition of a LAMA, considering a LAMA/LABA (long-acting beta-agonist) combination therapy could be the next step, but this should be done with careful consideration of the patient's overall condition, including their chemotherapy regimen and potential for increased infection risk. The decision to step up therapy should be based on the patient's response to current treatment, symptom burden, and risk of exacerbations, as outlined in the 2023 Canadian Thoracic Society guideline 1.

From the FDA Drug Label

The 8 trials enrolled patients with nonreversible obstructive lung disease (FEV 1 /FVC ≤70% and ≤12% or 200 mL improvement in FEV 1 in response to 4 puffs of albuterol/salbutamol) Two of the trials (Trials 3 and 4) conducted initially enrolled a population of patients with severe COPD (FEV 1 ≤50% of predicted) inclusive of those with chronic bronchitis and/or emphysema who had a history of smoking of at least 10 pack years

The diagnosis of emphysema cannot be made without Pulmonary Function Tests (PFT) or spirometry as the drug label mentions that patients were enrolled based on specific criteria, including FEV 1 /FVC ≤70% and response to albuterol/salbutamol, indicating that PFT or spirometry is necessary for diagnosis. 2

From the Research

Emphysema Diagnosis without PFT or Spirometry

• Emphysema is a type of chronic obstructive pulmonary disease (COPD) that can be challenging to diagnose without pulmonary function tests (PFT) or spirometry 3, 4.
• However, in patients using albuterol (bronchodilator) daily for shortness of breath (SOB) and currently undergoing chemotherapy with inhaled corticosteroids (ICS) without a long-acting muscarinic antagonist (LAMA), diagnosis may rely on clinical presentation and other diagnostic tools 5, 6.
• The use of phosphodiesterase-4 inhibitors, such as roflumilast, has been shown to reduce exacerbations in patients with COPD, particularly those with chronic bronchitis and a history of exacerbations 3, 4.
• Inhaled corticosteroids with combination inhaled long-acting beta2-agonists and long-acting muscarinic antagonists may also be effective in reducing COPD exacerbations and improving health-related quality of life 5.

Diagnostic Considerations

• A correct evaluation and accurate initial preliminary diagnosis of the patient's condition are crucial in guiding treatment changes 7.
• Clinical trials are not designed with clinical decision-making in mind, and treatment escalation should be introduced with caution as the disease progresses 7.
• The therapeutic response and its conditioning factors should be evaluated at each step before proceeding further 7.

Treatment Approaches

• Step-up and step-down treatment approaches for COPD involve a holistic view of progressive therapies, considering the complexity of the disease and the need for personalized treatment 7.
• The combination of roflumilast plus LAMA has been shown to exhibit the largest treatment effects in reducing exacerbations, and may be considered a first-line treatment option 6.
• However, the debate on de-escalation in pharmacological treatment involves the withdrawal of bronchodilators and inhaled steroids, and requires careful consideration of the patient's clinical scenario and comorbidities 7.