COPD: An Individualized Approach to Medication and Delivery - Episode 1
Peter Salgo, MD: Thank you for joining us for this MD Magazine® Peer Exchange® 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 MD Magazine® Peer Exchange® 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?
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Peter Salgo, MD: That was a symptom? It wasn’t a sign?
Barbara P. Yawn, MD, MSc, FAAFP: No, it was just a symptom, unfortunately. But, we’ve learned so much more about it now.
Peter Salgo, MD: 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?
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Peter Salgo, MD: 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.
Barbara P. Yawn, MD, MSc, FAAFP: I think the data suggest that maybe we haven’t.
Antonio Anzueto, MD: 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%.
Peter Salgo, MD: I read that somewhere. That was bad.
Antonio Anzueto, MD: 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.
Peter Salgo, MD: Well, we’re going to get into all of that. But, is it so bad? You wanted to say something?
James F. Donohue, MD: 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.
Byron Thomashow, MD: A major problem is that the symptoms that are classic for COPD—progressive shortness of breath, cough, some sputum production—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.
Peter Salgo, MD: 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.
James F. Donohue, MD: Yes.
Barbara P. Yawn, MD, MSc, FAAFP: 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.”
Byron Thomashow, MD: 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.
Barbara P. Yawn, MD, MSc, FAAFP: 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.”
Peter Salgo, MD: You bet.
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Peter Salgo, MD: 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.
James F. Donohue, MD: No, it hasn’t.
Peter Salgo, MD: Right. You’re not clicking the remote, you’re clicking check boxes.
Barbara P. Yawn, MD, MSc, FAAFP: That’s true.
James F. Donohue, MD: 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.
Peter Salgo, MD: It probably would be different.
James F. Donohue, MD: 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.
Antonio Anzueto, MD: 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.
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Transcript edited for clarity.