 on an individualized approach to medication and delivery in chronic obstructive pulmonary disease (COPD).

Optimal management of chronic obstructive pulmonary disease goes beyond selecting the right medication. Increasingly, clinicians are tasked with individualizing the overall treatment approach, including tailored patient education as well as thoughtful selection of the medication delivery method. This 

panel of experts is going to provide a better understanding of the heterogeneity of COPD and will discuss how this should impact management of the condition. We’re going to review the recent clinical guideline updates and the advantages and disadvantages of various medication delivery devices.

I’m Dr. Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

Joining me for this panel discussion are Dr. Antonio Anzueto, a professor of medicine at the University of Texas Health in San Antonio and section chief of Pulmonary Critical Care at the South Texas Veterans Health Care System; Dr. James Donohue, professor of medicine at UNC School of Medicine in Chapel Hill, North Carolina; Dr. Byron Thomashow, professor of medicine at Columbia University Medical Center, medical director at the Jo-Ann LeBuhn Center for Chest Disease and Respiratory Failure at New York-Presbyterian Hospital, and chairman of the board of the COPD Foundation; and Dr. Barbara P. Yawn, adjunct professor of Family and Community Health at the University of Minnesota and chief scientific officer at the COPD Foundation.

I want to thank all of you for joining us. Why don’t we get right down to it?

There are classic symptoms associated with COPD. I learned about them in medical school. What are they? Have they changed? What’s going on here? Why are we even talking about this?

 The symptoms that we were taught in medical school are things like wheezing, shortness of breath, and chest tightness. And, at that time, when we were in medical school, we were so nihilistic. The main symptom of COPD was, they’re just going to die.

 No, it was just a symptom, unfortunately. But, we’ve learned so much more about it now.

 All right. Of course, we’re all going to die. The problem was, they were going to die sooner rather than later. That’s changed?

 It has. We’ve realized that we have a lot that we can offer these people. We identify them earlier, and we have a lot of therapies that can improve their quality of life and their ability to engage in activities. And so, it isn’t such a nihilistic approach any more.

 But, let me be very clear—there’s a difference between making people feel better and having a statistically significant impact on their life span. Have we improved their life span? You seem to imply that we have.

 I think the data suggest that maybe we haven’t.

 In my practice, I feel that we have. I saw a lady in 2005. Her FEV1 [forced expiratory volume in the first second of expiration] was 28%.

 It was very bad. She died in 2016. She was on oxygen. She was on a scooter. All the time, I would ask her, “Are you having a good time?” She would say, “I get around well.” She enjoyed her life. It was not until the end that she had all kinds of complications. So, today, I think that it is important to recognize that there are a lot of people that have not been diagnosed. Or, we diagnose someone with COPD because we don’t understand what they have. We just give a treatment. We don’t do a spirometry. We don’t try to understand what’s going on. I see patient after patient. They are labeled as having COPD, but they have perfect, normal spirometry. They have no risk factors. They have other conditions that need to be addressed.

 Well, we’re going to get into all of that. But, is it so bad? You wanted to say something?

 In terms of extending life, a couple of modalities, like low-flow oxygen, have a slight impact on survival. Cigarette smoking cessation has a profound effect. Others that are less widely used, like lung volume reduction, seem to have an effect. But, what people care about, of course, is quality of life. A lot of people would sacrifice duration for high-quality years. I think that’s the most important thing.

 A major problem is that the symptoms that are classic for COPD—progressive shortness of breath, cough, some sputum production&mdash;are self-diagnosed and self-treated far too often. A chronic cough becomes a normal smoker’s cough that is treated with over-the-counter medications. Progressive shortness of breath is often viewed as getting old or being out of shape or overweight. You’ve got 6 to 10 minutes to spend with your primary care physician, and you have multiple different medical issues to deal with. Sometimes, if the provider asks, “How’s your breathing?” the patient will say, “It’s OK,” because he’s cut back on his activity. It’s been a real problem. As opposed to chest pain or intractable headaches or terrible diarrhea, which gets people pounding on the desk for help, when you can cut back on your activity and be less symptomatic, you tend to make less of an issue of it. This is the reason why all of us tend to see these people a little bit later in their course, which is not when you should see them.

 It reminds me of claudication. You’re always taught to ask about claudication for peripheral vascular disease. Patients deny it because they’ve stopped walking.

 You don’t ask them just, “Are you having trouble with shortness of breath during activities?” You ask them, “What are you doing differently? What can you not do now, that you could do 5 years ago, without being short of breath? How many stairs can you go up before you’re short of breath?” And then, pulling it back and saying, “You know, this is not just caused by being out of shape.”

 But, Barbara, that’s one of the problems that I think all of us have with the Preventive Services Task Force recommendation on spirometry, which is dependent upon both risk and symptoms. If you don’t ask the right questions to get those symptoms, it often gets lost in the mix. I think we’ve all seen that.

 That is so critical. When a patient comes in, you don’t just say, “How are you doing today?” We know that, at least in Minnesota, the answer is always, “I’m fine.” They could be bleeding to death and they’re “fine.”

 Right. So, you need to ask the good questions. You develop 3 or 4 of them. “What can you do? What is your day like?” I’m amazed, when I look at thousands of medical records, as I have for research, that almost none of them comment on what the patient does daily. If you have no idea what your patient does, how can you ask the right questions? If you sit around all day and do nothing but click your TV remote, then you’re probably not very short of breath.

 I know you want to say something, but I’m just going to make a comment. The electronic medical record has not been our friend.

 Right. You’re not clicking the remote, you’re clicking check boxes.

 You have to be aware of the language, or the idiosyncrasies of language. For example, men with COPD are not very forthcoming. They don’t necessarily see shortness of breath or lack of doing things that they previously did as a sign of weakness. So, it’s very useful to engage the wife in the conversation, or the loved ones, to try to help bring the information out. Again, you have to manage the patient in context. In the rural South, for example, we ask about being able to walk down the driveway to the mailbox as a good sign of some activity. “Dad doesn’t do that anymore. He makes one of us go out and get it.” It’s things like that. Hunting—you know you wouldn’t ask about that too much in an urban area like New York, but you would ask about it in the South.

 Yes, that’s right. It probably would be different. But, if they don’t do that anymore, that’s something that’s kind of universally alike.

 We need to have something that is a common objective. Through the GOLD [Global Initiative for Chronic Obstructive Lung Disease] Committee, we use an instrument like a questionnaire. There may be 5 questions or 1 question. There is the mMRC [modified Medical Research Council] Dyspnea Scale. In my practice, when patients come and register, my nurse hands that to them while they’re waiting. They fill it out. I’m running a half hour late. When I see them, I say, “Listen, I’m sorry I’m late. Give me that piece of paper.” So, I have numbers. I have a CAT [COPD Assessment Test] score of 25. I have a score that is very high. They tell me that they are doing fine. I know they’re not doing fine. This will help me to decide on therapy and will help me to make a diagnosis.

 The problem with that in primary care is that I have one of those questionnaires for depression, anxiety, and heart disease. There is a questionnaire for everything. I really liked what you said about the mMRC. There are only 5 categories. You can learn them pretty quickly. And pretty quickly, you learn that 2 is the most important. So, I just start by asking them, “How do you do with walking? Can you walk as fast as other people your age? Can you walk as fast as you could 2 years ago?” And something like that really goes back to one of those scores. And then, if I find that it’s abnormal, maybe I’ll pull out the CAT.

Assessing the Severity of COPD Symptoms

 First of all, I admire all of you, because this is a moving target. Chronic obstructive pulmonary disease (COPD) doesn’t just stay there, it changes. It morphs. It’s associated with all of these other comorbidities. It’s associated with heart disease, osteoporosis, a lot of respiratory infections, and with depression. How much of this is due to the COPD? How many people with COPD get these things because they are who they are? How do you begin to tease that out?

 We need to look at the individual, not look at the disease.

 That is the most profound thing I’ve heard in a very long time. You look at the individual, not the disease. This isn’t a textbook.

 The point is, it’s not that they have COPD or diabetes or heart disease. Those 3 conditions were produced by cigarette smoking. In your chart, your patient has 2 of the prior ones, and they will have COPD. You have not looked for it. You have not done the spirometry to make a diagnosis. Now, we understand that it’s not that an individual has a disease as a consequence of cigarette smoking. He or she has coronary artery disease, high blood pressure, COPD, osteoporosis, depression. We have to look at all of those conditions together.

 I completely agree with what Antonio said. You need to treat the person with COPD, not the COPD. The foundation did a survey with about 3000 patients a number of years ago, and 50% of them had 6 to 10 comorbid conditions. Another 20% had over 11. You can only envision how many medicines those people would walk away with by being prescribed with medications for the different processes. You need to treat the person, and that’s not a simple thing to do.

 I’m not sure that we have data on this. If you’re going to look at a person with COPD, and they have 10 medications, do we have a control group that is age corrected? How many medicines is somebody without COPD on at the same age? Do we know?

 There are some data that suggest that after age 65, the average person has 3 or 4 issues. Then, you get up to age 70. That number goes up. You get up to age 80, and we’re talking about 7 to 8 to 10 conditions. It is fewer medications for someone who does not have COPD, and this is mainly someone who has not been a long-term smoker.

I also want to point out that about 20% of people do not have personal smoking as their risk factor for COPD. We can’t forget about those very important people. You can’t only say, “Well, you’re a long-term smoker. You probably have COPD.” There are others that have the symptoms—all of the signs. You have to think about COPD in those people. Maybe they were around other smokers. Maybe they’re in an occupation where they are exposed to a lot of inhalation triggers. So, please don’t forget those people. If it looks like COPD, go ahead and evaluate it.

 We know very little about how COPD actually behaves in the nonsmoking population. If there are, for argument’s sake, 30 million people in this country with COPD, and 20% or 25% of them never actually smoked, that’s a lot of people. And yet, almost every study that has ever been done in COPD has eliminated people who never smoked. It’s a huge area, and we don’t know much about it.

 Worldwide, biomass exposure is the number 1 cause of COPD.

 Yes. I grew up in a rural area, where mothers cooked with woodstoves. They were exposed to that for 8 to 10 years. They never smoked. Now they’re in their 50s, and they have obstruction. So, like Barbara said, we need to remember other causes of this condition.

 I was a visiting professor in India last week. Half of the COPD there is caused by biomass, similarly, as Antonio was saying. In South America and Mexico, women get it. There have been a lot of studies about the phenotype of COPD in that nonsmoking population. One of the problems, in some of the societies, is that the women are not tall. They’re probably a little more vulnerable to COPD, in the sense of the lung growth and size. The natural history of that, when the exposure is removed, is being studied.

The common factors in all of these comorbid conditions are inflammation from cigarette smoking and people who are worried about dental plaque causing coronary artery disease. When you have an entire lung, a massive organ, full of inflammation, you can imagine the effects of that. Not only in practice, but also in clinical trials like the TORCH study, we power mortality studies on all-cause mortality. In the COPD patients, one-third will die of heart disease. Another third will die of lung cancer. And then, a third, maybe those who are a little bit older, will die of the COPD.

 Yes. So, it’s really important to look at the patients in the setting of their comorbidities. I still practice every day—as we all do on the panel, here&mdash;and the biggest problem is, again, the multiple medicines and the lack of affordability in the doughnut hole.

 I know that we’re going to get to it later, and that is an extremely important concept. From the studies that I just mentioned, like TORCH, we know that one of the most important causes of poor survival is nonadherence. That’s often a factor.

 Let me bring another important issue in—comorbidities. A group in Spain has looked at exacerbations and why patients won’t come back. They have a nursing staff. They go to the house. They do everything that they are supposed to do, and patients keep coming back. What they started doing is examining patients’ mouths. People who had more dental disease are the people who have more exacerbations and more problems. That’s something that we don’t do. I’m the only one in the clinic that uses tongue depressors. Nobody uses tongue depressors.

 I don’t know if that’s a marker or if there’s an ideologic relationship, but it’s fascinating.

 You have to look in their mouth. With this dental disease, you have to have them go to the dentist. So, I go back to my initial statement—we need to look at the individual.

COPD Comorbidities and Complications

 Let’s take a look at chronic obstructive pulmonary disease (COPD) for a moment. If you look at individuals, it’s a heterogeneous group. The disease seems to present in a heterogeneous way, right? You’ve got rapid versus low progression. You’ve got mild to severe symptoms and variability. How do you parse all of this out, Byron?

 Part of the problem is that for far too long, we’ve looked at COPD cases as the same and have treated it all the same. That’s clearly not the case. We would never, at this point in time, view all cancers as the same. We shouldn’t be viewing all COPD cases as the same. As you said, Peter, there are frequent exacerbated and infrequent exacerbated scenarios. There are eosinophilic exacerbators. There are the chronic bronchitis or bronchiectatic patients. The subsets deserve specific therapy that is aimed at them.

Earlier, Jim mentioned lung volume reduction surgery. Not all emphysema is the same. We’ve learned that for those patients who have upper lobe—predominant emphysema, if they meet certain criteria, they may very well be candidates for either a surgical procedure or perhaps a bronchoscopic procedure that can potentially improve quality of life and survival. We need to look at the individuals, and we need to move away from treating them all the same way. I think that’s going to be a part of the focus, going forward. I assume, Antonio, that GOLD [Global Initiative for Chronic Obstructive Lung Disease] is looking at that, as well?

 When you take a look at COPD, I was taught that COPD was COPD. One size fits all. “Here’s how you treat it.” It’s probably been detrimental, right?

 I think it has been detrimental to assume that it looks the same in everyone and that you should start the same in every patient. In primary care, “frequently the same” means that you start with the same drugs that you start with in asthma, for example. And we really have to highlight that asthma and COPD are very different. The primary therapies are very different. We also need to start being honest about things. The diagnosis that I dislike the most is acute bronchitis. People keep having acute bronchitis. Maybe they’re having exacerbations of their COPD. We can’t just put a Band-Aid on what’s happening today. We need to be thinking about what this means in the context of the patient’s whole course.

 In addition to what Barbara was just saying, one of the things that has really been leading research is the idea that people achieve a certain level of lung growth. They come into adulthood, and some lose lung function at a predictable rate. Others, if they smoke, lose it more rapidly. It turns out that life events occurring in utero, in early life, or maybe even with asthma have a profound effect on what your lung function is by age 50. We have many people who have normal lung growth here, who then smoke and lose function. And we have this other very important group who never achieved anywhere near normal lung function. They have much less to lose, and they can have much more severe disease. We’re only beginning to touch on the natural history of this disease—trying to learn about these different patterns and trying to design therapies and remedies for them.

 And, again, I want to come back to this normalization of symptoms.

 Patients tend to pull back, right? They’re not going to tell you what’s going on unless somebody asks them about it, right?

Peter, the important thing now is that we have cohorts. We have data. We have patient information that we didn’t have 20 years ago, to better understand the disease. We look at COPD and genes. We are learning that it’s probably not about how many packs you smoke or for how long you smoke. We have Uncle Joe. He smoked. He was 90 years of age, and nothing happened with him. But, you know, Uncle Joe probably has good genes or something.

 We’ve all seen that story on the local news of the woman who’s 107 years old. They say, “To what do you owe your longevity?” She says, “Two packs of cigarettes and good scotch.” Everyone else who did that is dead at age 50, but she made it. That’s a bad role model, don’t you think?

 For many years, women didn’t get COPD. Maybe this was because of who we studied. But, women do get COPD. They get COPD at a younger age. It is more severe. It progresses more rapidly, in general. And so, you need to think about women and COPD as almost a phenotype. We need to be serious about identifying those women who are just as bad as men, who say, “Oh, nothing’s going on. I’m just fine. I’m just out of shape.”

 If anything, in my clinical experience, women are worse. They’re called upon to provide all of the support, and they can’t admit that they can’t do it. The kids have got to go to school and, “We’ve got to do this.” And, “You’ve got to do that.” They’re not going to give that up.

 That’s right. And so, we need to really be very supportive.

 That’s reminiscent of the scenario from a few years ago where a group of physicians were given patient characteristics and were asked, “Is this asthma or COPD?” And dependent on the gender with this characteristic, if it’s a man, it’s COPD. If it’s a woman, it’s called asthma. That can lead to changes. You might use a drug like a leukotriene antagonist in a woman. That’s not good for COPD, for example. Gender is extremely important.

 There’s even some evidence suggesting that women are more susceptible to some of these factors, whether it is cigarette smoke or biomass fuel. As Antonio was saying, biomass fuels are a staggering issue around the world. Much of that exposure is with women and children.

 Also, their comorbidities are at a higher rate. If you have all of these exposures, you are also more likely to get heart disease. Osteoporosis is certainly more common in women, especially in those who are postmenopausal. Depression and anxiety are also more common in women. So, comorbidities are, perhaps, even more important in women.

 I was trying to get at that, because depression is always listed in all of these bullet points with COPD.

 And osteoporosis is listed, all the time, in all of these bullet points. Is it causal? Is COPD causal for these two? Or, are they fellow travelers? Do we know?

 I don’t think we entirely know. I think that inflammation, as you commented on before, is very important. It affects all of these cases. I have to believe that depression and anxiety are made worse by the symptoms and the impact of COPD on your life, in addition to inflammation.

Examining the Heterogeneity of COPD

 When you take a look at this whole problem, not everybody out in the real practicing world is a pulmonologist or a pulmonary expert. In fact, primary care is where all of these people begin to encounter the health care system. So, is it just the physician? Is there a team involved? Who’s involved in the management of chronic obstructive pulmonary disease (COPD) out there in the texture of the real world?

 Health care providers, in general—from the person who is the first contact in the office, to the physician assistants, to nurse practitioners. Everybody’s a part of the team. As Barbara emphasized, we have to change our concept of, “Oh, I’m looking for COPD in a 75-year-old male who smoked.” Forget about it. You have to look for COPD in the 50-year-old woman who happened to smoke previously but doesn’t smoke anymore. She is coming in with a cough. You have a diagnosis with sinus, with allergies, and with this and that. You have to do a spirometry.

 Does this work in the real world, Byron? Do all of the primary care doctors get a team together to do this? If not, why?

 Well, I think Barbara could answer some of those questions. The thing I would stress is that most COPD exists in the primary care setting. Those of us who are pulmonologists, particularly those of us who work in academic medical centers, see a very skewed population. Most of the people that we see are frequent exacerbators who, after bothering their primary care physician enough, say, “Well, I’ll go see someone else.” I don’t see very many of the nonfrequent exacerbators until they’ve reached the point that they need to be evaluated for lung volume reduction surgery, or chronic oxygen, or lung transplant. So much of COPD is in the hands of primary care. Increasingly, with limited time that you can spend with your patients, I think we will be seeing more of a team approach that potentially involves more respiratory therapists and other things.

 Barbara, who else do you pull in? Respiratory therapists seem like a natural choice. Obviously, the primary care physician is steering the ship—at least at first. What other specialties do you want to pull into this team?

 In rural practice, which was where I was for many years, it’s great to have a respiratory therapist. There’s one over at the hospital, which is 20 miles away. Most primary care people do not have respiratory therapists in the outpatient setting.

 That’s what I was getting at. It’s wonderful to say, “I want all of these things,” but…

 Right, but you don’t have them. When you talk about a team, maybe my team was more likely to include the receptionist and my medical assistant. I couldn’t afford nurses, so I didn’t have very many RNs. Maybe there was 1 for every 15 or 20 doctors. And many nurse-practitioners and physician assistants in primary care are practicing independently, especially nurse-practitioners. They’re out all by themselves now. I think there is a great opportunity for education. As you know, most residents in primary care don’t get a lot of time with COPD. A lot of these other people have had no education in COPD at all. We have a long way to go, to help support what they’re doing.

 What I’m hearing is that there are a lot of little silos here. There’s primary care, there’s the nurse practitioner, and maybe there’s some sort of respiratory therapist somewhere in the vicinity. Maybe there is not. By the way, where do the pharmacists fit in with all of this?

 Pharmacists could be very, very helpful, but they’re also extremely busy. You talk to them and they say, “Well, I really don’t have time to even talk to the people because I have to check through all of these prescriptions.” A lot of pharmacists, unfortunately, are still forced to stay back behind the counter. They really never encounter patients at all.

 We work with PharmDs in my intensive care unit. We’ve been doing it for over a decade. We have seen a dramatic change for the better.

 In primary care, we’re extremely envious of all of that. Sometimes, that’s why we send the patient off to our academic colleagues. We believe that you’re going to have more time with the patient. You’re going to have other resources to educate the patient and support the patient. It is very difficult, even when they get in the hospital nowadays. They’re in the hospital for 3 days, and they’re pretty sick during the whole time. It is difficult to get that education in.

 If we know that all of these specialties working together could be better than any one of them individually, and we think there’s real synergy here—whether it’s the pulmonologist plus the respiratory therapist, plus the primary care physician, plus the pharmacologist&mdash;what’s the path from here to get everyone to work together as a team?

 I think we need to engage in education with what we call “mid-level providers.” I love when they invite me to the nurse-practitioner or physician assistant meetings. I know that I will give a talk, and it will take me another hour and a half to get out of that room. The number of questions asked is unbelievable. They are on the front line every single day. People who are online say, “I have patients with ‘this’ disease. How do you do this?” So, there is a huge need to reach out to these individuals, to teach them. This is not only the case with COPD, but with many other conditions as well.

 You ask, “What do we need to do?” It’s not just that we would like to have a team. I’d love to have a team. I’d love to have that time. It’s called reimbursement. If you are not getting paid for all of these other things, it’s very difficult to take that chunk out of your salary, or whatever. So, health systems. Some of them have learned very well how to do this. They do it very well in the inner city or metropolitan areas. But, when you get out to the smaller practice, it’s not done so well.

So, telehealth. I’m going to put a plug in for telehealth. We always think that telehealth means a physician seeing a patient. Telehealth can mean a respiratory therapist educating a patient, a nurse educating a patient, or a social worker or a psychologist interacting with a patient. So, we can do this. We just have to be creative.

 The use of high-quality media educational materials could potentially have a much greater effect. We really all care about the patient here. That’s the focal point. All of the other interactions are secondary. But, what’s the best way to get to that patient in his or her environment? What kind of media do they seek? What kind of information do they seek? What’s the best way of communicating? I think that high-quality education, with all of the innovation that’s going on in our country, could be useful.

Now, one of the problems with COPD patients is that their literacy hasn’t been the highest in the world. They’re very similar to patients with diabetes. I was always involved in education. Between the National Institutes of Health and others, we used a lot of picture books. The patients didn’t have high literacy to read how to use therapies. And when you say that the patient is given 3 inhalers, and the pharmacist and doctors are too busy—nobody’s training them. You hand them information that they can’t read very well. It tells you about the need to use apps, pictures, videos&mdash;all of the various, sundry things to make sure that the patient successfully gets the necessary drugs and puts them into their body.

 I think we’re also quite unrealistic about believing that the patient hears everything that we say.

 They’re in my office for 12 minutes, if I’m really lucky. And in 12 minutes, I have to discuss 3 conditions with them. Do you think that they heard or were able to hear what I said after the first 30 seconds? Probably not. It is really difficult to absorb all of that and translate it into what it means for your life. So, there are opportunities for education in their home—recurrent education.

One of the things that I just learned about recently is something called VID Scripts. In this, you can record things that you tell patients multiple, multiple times—like how to use the inhalers. They can get it online, through YouTube. But, it’s me, their physician, recording it. Instead of watching Byron show them how to do it, and they’ve never seen Byron before, they go on YouTube and watch me. You can do this for all kinds of things in your practice. Also, I think we need to start using, as you said, social media.

Role of Primary Care in COPD Management

 We’ve been talking about patient education. Let’s take a step back. We’ve got to educate doctors.

 You’ve got the 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines, and you’ve got updates, right? What are the updates, first of all? And then, we’ve got to discuss how to bring this information to doctors’ and providers’ attention.

 They called for an update for COPD. I clearly understand that in the primary care setting, you are receiving many, many other guidelines—many other recommendations. So, the intent of this is, how can we simplify it for you? We emphasize to make a diagnosis with spirometry, and then ask about exacerbations and symptoms. Your therapy should be driven by symptoms and the risk of exacerbations.

We now understand the severity of the disease and know that the main decision-making tool, for deciding how you want to treat patients, is going to be driven by certain factors. If you have a person who has been in a hospital 2 or 3 times because of an exacerbation, it has to be very different from the individual who hasn’t had an exacerbation but has started to have symptoms. “I have cough every day.” “I have limitations.” The emphasis of the revised document has been to look at patients, ask about symptoms, and ask about exacerbations. That will help you to guide therapy.

 How does that differ? Before, was it suggested to look at the spirometry and go by the numbers?

 Right. Then, based on the spirometry, the patient would fall into a group. “This is what you should be doing.” Now we say, “Do your spirometry, but you have to make a diagnosis.” Put that aside for a minute and ask the patient, “Have you been in the hospital? Have you required antibiotics, and how many times within the last year? How are your symptoms? How limited are you?”

 So, the implication here, if I hear you right, is that the spirometry wasn’t tracking symptoms as well as we would like. Is that fair?

 Very poorly. So, why spirometry in the first place?

 To make a diagnosis. I think that is important. It’s not only the underdiagnosis. It’s the overdiagnosis. There are a lot of people who carry a COPD diagnosis who don’t have COPD at all. They’re potentially getting treated. So, I think we do need to define it.

I just want to come back, for a second, to your comment about the team approach. How to develop that, as Barbara says, is complicated. There is something happening now, though, that potentially allows us to begin to look at this. That’s the readmission issue, right?

are being penalized if their readmission rates in 30 days are greater than the national average. The first 3 core measures were acute myocardial infarction, congestive heart failure, and pneumonia. Several years ago, COPD and hip and knee replacement were added. So, hospitals that have readmission rates greater than the national average are penalized. That puts a significant financial burden on hospitals. It’s up to 1%, 2%, 3%, not just for the core measures, but for all Medicare hospitalizations. Many hospitals are now looking at that. It’s not just length-of-stay issues. It’s the readmission issues. Many hospitals have begun to develop programs that include more of a team approach, to try to prevent that from happening.

 But you know what hospitals say, right? “We get sicker patients. Our patients come back because ours are sicker.” That doesn’t fly.

No, it doesn’t fly because it’s not true.

Yes, amazing. The other thing is, we need to expand those programs. What percentage of COPD patients are actually in the hospital every year? Now, in your academic practice, it may be higher than it is in the primary care practice.

So, that may apply to 5% of my COPD patients. How do we expand and enhance that? The other thing I wanted to comment on is, you moved on to the GOLD guidelines. Primary care should love the new GOLD guidelines. We really haven’t ever done spirometry, repeatedly, to guide therapy. Now, you’re moving in with the GOLD guidelines, which should be right back into our wheelhouse.

 It’s validating all that you’ve been doing.

Something like that. We need to look at the patient. Decide what your patient needs, based on what you see right in front of you. What are their symptoms? What have they had to change in their life? Have they been to the hospital? Have they been to the emergency department? Have they had that crazy chronic or acute bronchitis diagnosed 3 times in the last 2 years? Again, this should be very comfortable for primary care physicians. Once they think of the possibility of COPD, they go ahead and make the diagnosis with the spirometry. We’re now back to the bread and butter of primary care. Ask the patient what’s going on. Look at the patient. Make a decision about therapy.

 Byron mentioned the issues of hospitalizations and readmissions. We looked at this in our institution. It turns out that half of the people who are admitted with COPD have never had a spirometry. And the ones who had a spirometry were normal. This guy was admitted 5 times, and we were like, “Gosh, you know, this guy has been admitted.” The guy had a 100% normal spirometry. What happened was, they put a diagnosis in the chart and nobody changed it.

 The other thing about the readmissions is, for whatever the index causes, they’re almost always related to one of the comorbidities.

Almost always, comorbidities play a role.

You put them in the hospital. You put them on oral steroids. Their diabetes is totally out of control. They end up back in the hospital, a week later, for their diabetes.

Key Updates to COPD Guidelines

A lot of what’s going on in the 2017 Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) guidelines puts some of the burden on the patient to self-manage their condition, a little bit, at home. They need to do what’s right. How important is lifestyle modification in chronic obstructive pulmonary disease (COPD)?

 Well, it was important for hiding the disease for a long time. We talked about that. Modifying your lifestyle, with things like smoking cessation and increasing your activities, is really crucial. That’s why I really like pulmonary rehabilitation.

But, doctor, I can’t exercise. I can’t breathe. How can you possibly tell me to exercise?”

 “Because I didn’t tell you to exercise. I’m going to talk to you about how we can increase your activity. Let’s talk about how many steps you can go up now before you have to stop. We’re going to practice so that you go up 1 more step a week without having to stop.”

“Oh, that’s exercise. I hate exercise. Come on, doctor.”

 “You do want to be able to get up to go to the bathroom. You do want to be able to get a drink and eat. You wouldn’t like to have to be in that chair and have somebody bring it to you all the time.” So, I do think you can talk about what they want to do. That’s one of the things I think we miss out on. What is it that the patient would like to do? We might formally call it goal setting. But, “What is it that you want to do that you can’t do? Is it going to get the mail? Is it going to the grocery store? Is it playing with a grandchild? Is it walking around the block? Is it being able to go get that beer from the refrigerator during the game? What is it?” And then, “Let’s work on that, as our goal.”

 I would love to have pulmonary rehabilitation. The city of San Antonio is the seventh-largest city in the country. Do you know how many pulmonary rehabilitation programs we have?

 Two. We have one by the military that we can send our veterans to. And there is one that is in the private sector—that’s a cardiopulmonary rehabilitation center. So, in reality, it doesn’t exist.

 Which is really terrible. The same thing exists in New York. We have a handful of rehabilitation centers. Rehabilitation does everything that you could possibly want it to do without any adverse effects. Yet, there are statistics that suggest that barely 3% of COPD patients either have pulmonary rehabilitation available or use it. It’s aggravating.

There’s a huge disconnect there, right?

 That’s why I think we need to say that it is one of the most effective therapies. It has very few adverse effects. It really improves quality of life. What can we learn from pulmonary rehabilitation? What can we learn about educating patients about increasing activity? Most of us have physical or occupational therapy available to us, because of all of the knee replacements and everything else. What can we do to use resources like physical therapy to help patients with activities? And, who can do some of the education for us?

 One of the issues that I think we need to deal with is isolation. One of the real benefits of pulmonary rehabilitation isn’t just the exercise. It’s the familial component to it. We’re in this together. Isolation, which is so much a part of the depression and anxiety in this disease, is something that, as we move forward, needs to be addressed. There won’t be pulmonary rehabilitation centers down every block. So, we need to figure out another way. But, we need to address the isolation issues.

 I like to work with the family on this. I pretty much throw out the idea of rehabilitation because we can never get it. We have it, but, again, it’s always prioritized to lung transplant or something else. Everybody can walk. Everybody wants to see their grandchildren. We really need to emphasize the outcomes that come with simple things like walking with the wife or kids, or what have you. In my environment, everybody has a dog. You want the patient to walk the dog. The dog will give them exercise. And, again, isolation is a phenomenally important feature.

If there is a center available, is it reimbursable to send patients there?

 The problem with the centers is that they are not reimbursed. The payers were paying 45 cents out of a dollar.

That was my question. If you get reimbursed for rehabilitation, why wouldn’t some entrepreneurs set these things up? And the answer is, they’re not getting reimbursed.

 I was part of the COPD Foundation. Many years ago, we lobbied very heavily for this, and we were able to get it. And somebody said, “Oh, this is not important.” They cut it out. They were missing the boat. This is the biggest thing that can have an impact. As Byron said, they go out and walk and do things. They are together, and they learn how to deal with life. One of my patients walked into my office and said, “What’s different about me?” She had been a part of a group. Somebody gave the patient these glasses that oxygen comes through. For her, it was very important not to have an oxygen cannula on her face. Having those glasses changed her life. She could get out. She could do more. She could learn from her peers, who deal with the disease day by day.

 As you know, cardiac rehabilitation has been reimbursed forever. There was a lot of push, by many of us, to get pulmonary rehabilitation approved and to get a national policy. It now exists. There are some states, like Oregon and Washington, that did not have pulmonary rehabilitation before. The problem is that, while it is more available, the reimbursements went from marginal to poor to almost 0. So, it’s very difficult. We now have a national program, but no centers are available.

 We are going to have to substitute. We’ve mentioned telehealth. We mentioned walking your dog. But, I think that online communities are a real possibility for this isolation. In rural Minnesota in the winter, you don’t go out and walk your dog because it’s too cold. It’s too icy. You’re going to fall and break your hip. So, these online communities are extremely important. The COPD Foundation has one of these, and there are others that can be developed. I really encourage the health care community to do this. The other group that I think about, when I think about isolation, is the caregiver group. We forget that many people who have COPD that’s a little more progressed have to have a caregiver. That makes them isolated, frequently, too. They need that support.

 The COPD Foundation has created a program called COPD360social. We have over 35,000 members, and we’re getting over 250,000 unique hits a month. So, these are people who want help. They want to join. It’s something that we all need to push forward on.

 The other thing with rehabilitation and walking is, we do have medicines that work. The patient needs to have access to them. In all of the big trials that we do with developing new medicines, we improve exercise performance. This is not like asthma so much. But, it is still pretty good. If we can get people to be adherent, they might surprisingly be able to do a little more. So, we try to encourage them with that, Peter.

COPD: Lifestyle Changes and Pulmonary Rehabilitation

 Let’s talk a little bit about these treatment decisions. What have we got? We’ve got the short-acting bronchodilators (SABAs), the long-acting bronchodilators (LABAs), the long-acting muscarinic antagonists (LAMAs), and inhaled corticosteroids (ICSs). How do you make decisions about these things? What do you use, and in whom?

 This is very, very complicated, because we do have a lot of choices. A lot of them are “me-toos.” The 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines really have made it very nice and simple. I think everybody needs a short-acting rescue medicine like albuterol or ipratropium. Or, you could use the 2, together.

 That’s a SAMA [short-acting muscarinic antagonist], or a SABA, or even in combination. In asthma, if it’s the only thing that you have, you can pretreat yourself before you walk, and you could get something out of it. Most people start with a long-acting bronchodilator—a 12-hour or 24-hour bronchodilator. That could either be an anti-muscarinic agent, or a long-acting beta agonist, or&mdash;what I really like to use, to make life really simple&mdash;both, as the first drug. What everyone has used for years are inhaled steroids and long-acting beta agonists because that’s simple. That’s a really good asthma therapy, first-line. Then, all of these patients are wheezing.

 Yes, but that revolutionized the lives of our patients with asthma and chronic obstructive pulmonary disease—the ICSs in the first-line setting. You’re right, Barbara. But, anyway, we think about the one-size-fits-all approach. That’s what I was saying. It’s a simple story. It’s simple marketing. Use Advair or Symbicort.

 Her blood pressure’s gone to 280/150. What just happened here?

 As you pointed out, it’s a real problem. It is not a one-size-fits-all approach. And when you look at therapy for COPD, it is frequently this combination of a long-acting bronchodilator and ICS. That is not the appropriate first therapy.

 I like to think of this as a hierarchy. There is the short-acting bronchodilator. Then, you add a long-acting, or, both classes of the long-acting bronchodilator. And then, there are indications for going on, to add other medications. It is not automatic. Then, you just add ICS, if they’re still not doing well.

 Now, one of the things that Byron taught me was that if you give a long-acting bronchodilator or a muscarinic drug, you could actually shrink lung volumes, over time. This is, if you will, and forgive me for the oversimplification, a chemical lung volume reduction. That improves function. So, where does that fit, here? Are they saying that? Is that what you’re hearing?

 OK. So, the 2 bronchodilators—the LABA/LAMA combination, which I happen to like a lot. The most important thing is that the shortness of breath is driven by the air trapping&mdash;the hyperinflation. That’s why I like it. If they don’t respond to one, the other one is there. There’s no escalation in adverse effects when you put the 2 together. So, anyway, that’s a nice combination. Now, what about the inhaled steroid/LABA? That’s another very nice combination. Or, even as triple therapy. GOLD gives us nice guidelines. There’s an asthma/COPD overlap. We see people with a lot of eosinophils as markers of allergic inflammation&mdash;300 cells per cubic millimeter. Those are people with severe disease and, most importantly, people who have a lot of exacerbations. They are the frequent flyers. They need that steroid. So, to make it pretty simple&mdash;monotherapy with a long-acting agent and, maybe, dual bronchodilators. And then, either add a triple or just ICS/LABA.

 I think that the message, here, is that COPD is a treatable disease. It can be treated. These bronchodilators have changed the natural history. They have improved lung function and quality of life. So, the foundation is long-acting bronchodilators. Most of the time, I’m now using the fixed combination, because you give 2 different mechanisms for the price of 1.

 And, there’s no increase in adverse effects.

 That’s a really important message that I don’t think primary care hears all the time. You’re using 2 long-acting bronchodilators, but they are different mechanisms of action. So, yes, you use them together and they’re synergistic.

Overview of COPD Medications

 The poor primary care physician hears about all of these different devices. We’ve got the metered-dose inhaler (MDI), dry powder, soft mist. And then, we’ve got these devices versus nebulizers. So, parse this out for me.

 We have the different devices, and a very well-quoted meta-analysis (from many years ago), by Myrna Dolovich, that says they’re all pretty much the same. However, now, in an era of personalized medicine and phenotyping patients with studies, that’s not exactly true. Coming back to Barbara and my favorite topic, women have been really ignored in this dilemma. A lot of women of short stature cannot generate an adequate inspiratory flow to disperse the dry powder drug. They’re not getting it. So, we have to take patient factors into account—the severity, the social, economic, and what have you. For most people, who are reasonably healthy, it’s a toss-up between a dry powder, [an] MDI with a spacer, a Respimat, and you don’t need to go on. But, for those maybe cognitively impaired people, or people who are home bound with severe disease, you would consider the nebulizer. The nebulizer, with its multiple drugs, is paid for by Medicare, for that population. That’s an extra dimension that impacts it. So, you must use the right device.

The In-Check device hasn’t really come in to family medicine too much. The In-Check measures the peak inspiratory flow that the patient can deliver. Usually, you need about 60 liters to get the drug—a dry powder, like an Advair, Breo Ellipta, or Trilogy kind of device. It turns out that many, after an exacerbation, can’t do it. That’s one of the reasons for relapse. We’ve studied that in a number of centers. They are too weak. And the only reason I mentioned women is because of the height, again. They’re often the ones who have more difficulty and more severe conditions. So, we try to titrate or select the right device for the individual patient.

 There are different kinds of nebulizers, right?

 Before we talk about the nebulizers, I hate to spoil the party, we’ve got wonderful devices. We have reasons for adherence, with that. I don’t decide what device I give to my patient. It’s the payer. So, my patients who are on medication A get a letter. It says, “You’re switched to medication B.” Well, guess what? Medication B is a completely different delivery system.

 Then, the patient comes back and says, “Listen, I hate this. I cannot breathe with this.” For me to get it back to medication A, it takes 2, 3 hours on the phone. Normally, I do that when I write my notes. But, it’s payers who are switching patients back and forth.

I can’t tell you how often that happens. And what’s really disturbing is that, often times, we’ll get a letter from the insurance saying, “That drug is not covered. Here is a list of compatible drugs.” A number of them are completely different classes of drugs. They’re not even the same drug. So, it’s not generic versus brand.

 Who’s drawing up the list? That raises an interesting question. Who says that they’re equivalent? Who’s drawing the list up?

It’s the formularies for the insurance companies. It’s increasingly an insurance company issue. I think we all agree that these medicines work. Everything that Jim said is absolutely correct. If you don’t know how to use your device, it’s worthless. And if they’re completely changing the device in between your visits, and they don’t know how to use it, it’s worthless.

 And, they get it in the mail. Many years ago, I had access to the Respimat delivery and I brought it to my group. They were smart pulmonology guys. They believed that they were very smart. I put it in the middle of the table and I said, “How does this work?” Nobody could figure it out.

So, my patients would get it in the mail. It’s a different delivery. Then, they would call. They would ask, “What am I supposed to do with this?” “I need to chew the pills?” “I need to do this?” This is the big challenge that we have today. There are no equivalent devices, so we have to emphasize education. “You’re going to get this medication, with this device, and this is what you have to do.”

 With that particular device, you have to put it together and, “Do this.” The little trick that I was taught is to put on the prescription “AAP”—assemble, activate, and prime. The pharmacist is supposed to do that, because putting it together is not easy. We’ve all broken some of those devices by putting them together incorrectly. Our patient is not going to figure it out.

 I must tell you that my kids’ pediatrician, many years ago, said, “You’re going to use a nebulizer,” for reasons which we need not go into here. But, she sat down with me, knowing that I was a physician, anyway, and showed me how to set it up, assemble it, and prime it. It made a world of difference.

 Oh, it makes a huge difference. In primary care, even for the ones that are not that complicated, teaching patients how to do inhaler technique is not part of many visits. And the other problem is, once you teach a patient, even if they’re lucky enough to get the same device for 3 or 4 months in a row, their technique will fall off. So, you have to review technique.

COPD Medication Delivery Options

 Nebulizers versus various other hand-held devices—is there a distinction? Do patients do better with one? Do they do better with the other?

Many patients like nebulizers. They’re very simple to use. You don’t have to go through the hand dexterity issues. Until literally a couple of months ago, there was no nebulized LAMA [long-acting muscarinic antagonist] available. At this point in time, LAMAs are the mainstay of therapy, They are generally combined, but are certainly the mainstay of therapy. The problem, even now that we have a nebulized LAMA, is that, as you’ve heard, chronic obstructive pulmonary disease management is more than 1 thing. We don’t still know whether you can mix that LAMA with a LABA [long-acting beta-agonist]. We don’t know whether we can mix the LAMA, and the LABA, and the steroid in the same nebulizer. Until we’ve defined those issues, nebulizer therapy for COPD will still not be the primary mode of therapy, because we can’t deliver the group of medicines that we want.

 It’s limited for patients who have reasons—mentally, physically. They’re the ones who are primarily getting nebulizers.

 It also occurs to me that it’s harder to get on an airplane, carry these things around, and plug them in. Yes?

 Well, we can take oxygen on the airplane. We have the POC—portable oxygen concentrator. That was a big effort that was led by the pulmonary community, a few years back. So, yes, you can use them. The small ones have not been approved, until now. We have a LAMA with an eFlow, which is a low-volume type of device.

 Does it make a difference, in terms of patient adherence—a nebulizer versus another delivery system? Do patients like one versus another?

 Well, I think a lot of patients will tell you they really like a nebulizer. They want a nebulizer. But, if they’re using one of the older nebulizers, that’s 10 to 15 minutes per drug. Suppose they have 3 different drugs. That’s 30 to 60 minutes to take your medicine. Can you take them with you? Well, maybe you can, on the airplane. But, how about for rescue therapy? If you need a quick reliever, it’s not so easy, at the grocery store, to pull out a nebulizer and use it. So many people are going to need to have both, including an MDI [metered-dose inhaler], because that’s what most of the rescuers, short-acting, are. And if they need a nebulizer, this is fine at home. But, it also takes some effort to put the medication into the nebulizer. So, someone that’s got cognitive impairment is going to need support, whether they need a nebulizer or another device.

 Do the insurance companies like nebulizers, or do they like the other devices?

 Nebulizers, because of Medicare, under Part B and D. They’re paid for by Medicare. We call that, at times, Medicare Advair, for example. That would be a long-acting eformoterol plus budesonide, which is compounded. Or, you could use the pediatric .25. So, we do a lot of that. We didn’t have the LAMA. As Byron just mentioned, we’re going to have 2 of those coming. One will be in a new nebulizer—one of the ultra-efficient ones. But, we don’t know how that will work out. So, the main reason that I use those nebulized drugs is based on economic reasons. Now, the severe is all the of the things that Barbara mentioned with a caregiver, at times&mdash;cognitive impairment. The other thing is that for the nebulizer, all you have to do is tidal volume breathing. To get a dry powder, as I mentioned, you have to have a really big peak inspiratory flow rate. It takes training to use the MDI with a spacer. And the Respimat, once you figure out how to do it, is very easy.

 Do we have data as to patient outcomes—nebulizers versus other hand-held devices?

 The meta-analysis is from 2005 and 2007, and they’re all the same. That was the basis of that initial report, from the American College of Chest Physicians, Peter. But, again, we need to individualize the therapies that we’ve been hearing about all the way through, in their own environment. Some people will clearly do well with it. Plus, the cost factor.

I think that’s actually true. My only issue with the nebulizer, first of all, is that everybody is an individual. You need to define therapy for the individual patient. But, the problem, to date, is that we still don’t know about mixing these things together. That leads to Barbara’s concerns about 2 hours of nebulizer use per day, which is not practical. Once we have newer agents and data showing that you can mix them safely, and that they’re effective together, safely, that will change some of these things.

 So, you make 1 cocktail (one therapy) burst, and then you’re done?

Sort of like the coffee pot system, right? You wake up in the morning and you say, “This is the day that I want the combination.” You put your combination in, unless Jim knows more than me?

 No. This is funny. When I was in India, I asked them why they invited me. It turns out that I think I was involved in the development of the 7 nebulized therapies that are out there for COPD, going way back. I’m old enough to have been on the original ipratropium. But, Byron is exactly right. A lot of companies try to get by the patent rights by altering the formulation, just a twitch, for drugs like albuterol and formoterol. Exactly as Byron says, we consider the osmolality changes, the tonality changes, and you might have an ineffective product or a harmful product. So, it’s a serious issue. There is no research. Because it takes 30 minutes, if you’re taking 3 drugs, you’re tempted to throw them all in a soup and then give it. But, you don’t know what you’re giving.

 Peter, your original question was, do we have data to determine whether one is better than another. The answer is, no. You cannot compare. These are apples and oranges. Even though you read through the meta-analysis, who are the people who were nebulized, who were mentally impaired, and who were incapable? We need to go back to identify, “Well, these patients will benefit from nebulized therapy. This patient is more active. The patient is more ambulatory.” We can give many of the other devices that we have, today.

Why don’t we just give a quick warning on what to watch out for with a couple of the new nebulizers? They are only indicated for 1 drug. You have to be very careful. Not only would you have to spend 30 minutes, you may have to have 2 or 3 nebulizers, and that’s not practical.

 I was asking about that before. There are different kinds of nebulizers, right? There’s the ultrasonic, there’s the compressor, and something called a mesh nebulizer. So, not only do you have to deal with the other issues that we’ve discussed, but you’ve got to use the right nebulizer. And now you’re telling me that some of the drugs are incompatible with some of the nebulizers?

Yes. I think it’s the reason that primary care frequently asks, “Pulmonologists, would you like to help us? We don’t know what’s going on.”

 This is so important. Really, to have the ‘keep it simple’ commentary, you’d like to have 1 type of dry powder inhaler for everything. It cuts down on teaching time. However, glycopyrrolate will come with an eFlow. It feels like cystic fibrosis, though. Each new inhaled antibiotic, and other different drugs that have been developed, all come with their own delivery system. It becomes very, very expensive, and extremely difficult. But, the thing that’s interesting is that the field is changing rapidly. There’s a revolution. Antonio has talked greatly about inhaled antibiotics, in the intensive care unit, with ventilator-associated pneumonia. So, the field is going to be very, very wide, with antibiotics, in particular, and other types of inhaled therapies for the field of COPD. And they’ll all have their own devices.

Benefits and Limitations of Nebulizers in COPD

 Whether it’s a hand-held device or it’s a nebulizer, somebody’s got to teach the patient how to use it. How comfortable are physicians in teaching patients—going over technique?

 Well, primary care physicians are not. We’re not usually the ones that do it. In the study that I think a lot of people quote—about looking whether it was physicians, residents, nurses, or respiratory therapists&mdash;physicians were the worst at even knowing how to use all of these different devices, let alone teaching about them. Most of us have nurses who do this. The problem is, they don’t have enough time. There is, in theory, reimbursement for this. It’s very minimal, and it takes a lot of extra paperwork. So, it just doesn’t happen. We really have to make people feel accountable for this. This is just as critical as diagnosing and prescribing the right medicine.

 The foundation has an app, which is free in the app stores. We’re presently in the process of adding things to that app—anxiety scores, depression scores, exacerbations. Most importantly, we’re going to be adding the ability to look at the different devices. You can sit there, take out your iPhone, and show the patient how to use it. That hopefully will become available, later this year.

 Does the patient have access to the app, too?

 So, the patient can take out the patient’s iPhone and compare it.

 I use a lot of YouTube. When I see the patient, I show them the placebo device and say, “Go to this place. Put this in YouTube. Just watch that.” I have many patients that do that, and they say, “Oh, yes, I watched that.”

 I think it’s very, very helpful. But if you do not watch the patient do it, you cannot be sure that they understood and incorporated what they saw. And one of the things that we all have to do is medication reconciliation. That’s basically required, at every single visit. So, if you’re going to do medication reconciliation and they’re on an inhaler, do the observation. And people say, “Whoa, wait a minute. They’re going to take an extra dose of medicine.” Who cares? There is no COPD medicine that demonstrates that taking 1 extra dose a day is going to do anything bad. So, we really need that nurse to observe the technique when they do the medication reconciliation.

 I agree, completely, with what Barbara just said. But it comes back to your conversation from the beginning, Peter, about the comorbidities. Anyone who prescribes 10, to 12, to 15 medicines for a patient, who thinks that they’re going to fill 10 to 15 medications, is fooling themselves. Even if you’ve got a drug plan with a co-pay, if you start multiplying 10 to 15 times the co-pay, it’s a lot of money. And it’s particularly a problem in the COPD world, because people have the option of cutting back on their activity level. They don’t feel that they need the medicines. It’s the wrong approach, and is one that we need to fix. But there isn’t a simple answer.

 That’s the kind of self-normalizing that we were talking about before. We all know about this study that I was taught, years ago—they tried giving medical students, as a test, 1 dose of a placebo, once a day, for a year. They said, “Just do this. Take this placebo, once a day.” And at the end of the year, they collected the untaken pills. It was about 30%. For 1 pill, once a day, this is crazy.

 And in COPD, it’s, unfortunately, exactly the opposite. It’s about 30% adherence, 70% you would get back.

 I’m sure it goes down as you multiply the number of pills?

 Right, because of the cost and all kinds of things.

 We do have some advantages with new technology. For example, we now have 3 drugs in 1 inhaler. The first one is on the market, and 2 more, that I’ve been involved with, are coming. It gives you the LAMA [long-acting muscarinic antagonist], the LABA [long-acting beta-agonist], and the inhaled steroid, either once or twice a day, depending on which product you choose. That’s very nice. I think that cuts down on a lot. The costs have been in the ballpark of the duals. Then, you also have a product line. For example, one company uses the same type of device for all products. That also could be a help.

 It would be a huge help, wouldn’t it? I mean, you’ve got a DPI [dry powder inhaler], a metered-dose inhaler (MDI), a soft mist, and you do them all in different ways. How can you keep track of it?

 That’s the razor blade business model, right? You give them the razor and sell them the blades. You lock them into a product line.

 And in this case, if I hear you correctly, that’s not necessarily a bad thing?

 Well, it certainly shouldn’t be, if they have the full line. Unfortunately, they don’t, yet, have the full line.

COPD: An Individualized Approach to Medication and Delivery

EP 1: Assessing the Severity of COPD Symptoms

EP 2: COPD Comorbidities and Complications

EP 3: Examining the Heterogeneity of COPD

EP 4: Role of Primary Care in COPD Management

EP 5: Key Updates to COPD Guidelines

EP 6: COPD: Lifestyle Changes and Pulmonary Rehabilitation

EP 7: Overview of COPD Medications

EP 8: COPD Medication Delivery Options

EP 9: Benefits and Limitations of Nebulizers in COPD

EP 10: Patient Education - Improving COPD Medication Adherence

EP 11: Implications of COPD Device Misuse

EP 12: Issues with Reimbursement in COPD Care

EP 13: Future of COPD Management: Precision Medicine