Therapeutic Strategies in the Management of COPD - Episode 1
Peter L. Salgo, MD: Thank you for joining us for this MD Magazine® Peer Exchange® on therapeutic strategies in chronic obstructive pulmonary disease (COPD). COPD is an increasingly common diagnosis associated with significant morbidity and mortality in the United States and worldwide. The cornerstone of COPD management includes an emphasis on lifestyle modifications as well as therapeutic interventions to increase survival and improve quality of life. I am pleased to be joined today by a panel of experts in pulmonary disease to review the current treatment landscape as well as to discuss evolving treatment strategies in COPD.
I am 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 discussion today are: Dr. James Donohue, a professor of medicine and former chief of the Division of Pulmonary and Critical Care Medicine at the University of North Carolina at Chapel Hill; Dr. Fernando Martinez, chief of the Pulmonary and Critical Care Medicine Division at Weill Cornell Medicine and New York-Presbyterian Weill Cornell Medical Center; Dr. Byron Thomashow, professor of medicine at Columbia University Medical Center, medical director for the Jo-Ann F. LeBuhn Center for Chest Disease and Respiratory Failure at New York-Presbyterian Hospital, and chairman of the board for the COPD Foundation; and Dr. Frank Sciurba, visiting professor of medicine and education director for the Emphysema/COPD Research Center, of the Division of Pulmonary and Critical Care Medicine, at the University of Pittsburgh.
Thank you, all of you, for joining us. We have a lot to cover, so why don’t we get going? I want to discuss, right away, COPD—the 10,000-foot view. I don’t think people really understand how common this is. When I was in medical school, COPD was something some people got. But it’s much more common than that.
Byron Thomashow, MD: Over 16 million Americans have now been diagnosed with COPD. Evidence suggests another 12 to 14 million probably have the disease but haven’t been diagnosed. It’s the third leading cause of death in this country, is the second leading cause of disability, and the cost of caring for COPD, in this country, now, stands at over $50 billion per year. But despite those staggering statistics, it’s important to stress that COPD is almost always preventable and almost always treatable. Although, I think most of us would agree we need better treatments and, ultimately, we need to figure out a way to find some cures.
Peter L. Salgo, MD: Some of those numbers are not just staggering, but they’re shocking, in the sense that I don’t think doctors appreciate them. How can this be this common, have this much of an impact on this country, and most doctors don’t understand it? They don’t know about it.
James F. Donohue, MD: Well, it’s not high on a doctor’s differential diagnosis. That’s why there is so much work from the Foundation, the National Institutes of Health (NIH), and everyone who is trying to increase awareness of it. In fact, many of the patients that we’re now seeing around the world haven’t even smoked. It’s biomass smoke, particularly in women. I was visiting Mexico and, then, last month I was in India. Biomass fuel is a cause. There are many different causes. But, still, in the United States, it’s cigarette smoking. We really have to increase public awareness.
Peter L. Salgo, MD: There’s a number that I saw—about 1 out of every 4 people with COPD never smoked. Now, does this mean that it’s biomass? Or, is it that it’s etiologically indeterminate? We just don’t know.
James F. Donohue, MD: In the United States, the number of smokers is in the high 80% range.
Peter L. Salgo, MD: That still gives you 20%.
James F. Donohue, MD: Right, but in India, half of the women were exposed to biomass and never smoked. So, it’s just something to be aware of. As we’re a nation of immigrants, more and more folks are coming here. It’s particularly the women who have had single room dwellings with cook stoves that are not vented.
Byron Thomashow, MD: I think that Jim’s point is worth stressing. Most of us, in the field, have struggled for years with 2 issues. One is the blame issue.
Peter L. Salgo, MD: I was going to get to that.
Byron Thomashow, MD: I think that that has colored this whole disease state for reasons most of us don’t understand. You have similar risks with cardiac disease and vascular disease. But, the blame issue is important, and I think that has hindered our progress. Also, I think that for a long time, there’s been a nihilism that existed among our colleagues, whether on the pulmonary side or the primary care side, that there just wasn’t much that they could do. If you put those 2 issues together, those are some of the things we’ve been trying to move against.
Fernando J. Martinez, MD: I think Byron has summarized, very succinctly, the answer to your question. Those, I think, are the 2 key reasons that we have these staggering numbers. People are surprised when they hear about it.
Peter L. Salgo, MD: I have a particular theory about why there’s this blame game with COPD and not with heart disease and vascular disease. My theory is that you can see it. In other words, people with COPD are obviously struggling. You can have heart disease because of an etiologic agent—diet, exercise, smoking. But your ticker can’t be seen until you have a myocardial infarction. Here, folks are struggling every second. It’s easy to point a finger. And, what’s the other thing? The other thing is, it’s expensive, right? What percent of the people who are sent out after a hospital admission for COPD bounce back within 30 days? I heard it was 20%.
Fernando J. Martinez, MD: At least 20%. It’s a major driver of health care costs. It’s incredible when you see those numbers and you contextualize it. When you put it within the context of some of the other diseases, it has an amazing impact.
Frank C. Sciurba, MD, FCCP: The other thing is, the perception that it’s a simple disease and that they know everything about it.
Peter L. Salgo, MD: You mean it’s not?
Frank C. Sciurba, MD, FCCP: For the number of patients admitted to the hospital where they don’t consult pulmonary, you wouldn’t think of doing that with an advanced cardiac disease. So, I think that’s the purpose of this group, here right, now. We are here to show you there’s a lot going on. We’re going to show it to you.
Fernando J. Martinez, MD: There are a lot of good things going on.
James F. Donohue, MD: I have a comment on the balkanization of health care where people come into the hospital with COPD. Maybe they’re seen by the emergency room physician or, on the ward, by a hospitalist. Those physicians do a great job, but they don’t want to assume long-term care. That 30-day relapse has a lot to do with the medicines people are sent home on, the frequency of follow up, and a huge penalty for Medicare.
Peter L. Salgo, MD: I was about to say, that’s expensive, right?
James F. Donohue, MD: Right.
Peter L. Salgo, MD: If you come back within 30 days, that admission is not covered.
James F. Donohue, MD: That’s right. That’s the good news because that means that the heavy hands of the health industry, the hospitals and those who have big bucks, are now investing in this topic.
Transcript edited for clarity.