Therapeutic Strategies in the Management of COPD - Episode 3
Peter L. Salgo, MD: In this particular age, we’re talking about cutting research budgets. When you cut down from $100 million, you’re going down to even less than spitting in the ocean, which brings us to this whole evidence-based approach, which, of course, requires evidence. It requires research. It requires money. Then, we come back to the critical thing that you guys mentioned earlier: this diagnosis is often not made. And when it’s made, it’s made late. Why? And what does this do to your ability to manage this?
James F. Donohue, MD: It’s not on people’s radar, but we’re really working hard, as Byron just said. With the COPD Foundation and NIH (National Institutes of Health), I can remember screening people at minor league baseball games. The thing that’s really pushing things now is that pharmaceutical companies are advertising COPD drugs on television. Byron nicely told us about the effects of nihilism. What drives patients in to see the doctors is a therapy. So, yes, for years, it was very, very delayed. People get sedentary for all of the reasons that we’ve heard. They assume that the shortness of breath is related to hitting middle age, getting old, and being obese. But now, because there are effective therapies, not great but they’re effective, it’s driving people in. I think that this will move people along. But traditionally, the last thing that doctors thought of was COPD. Cardiologists send me more patients than anybody else. Cardiologists have run some of the big trials. Cardiologists are integral with the deaths due to heart disease. And, the same goes for the pulmonary doctors. We need to learn a little cardiology so we treat our patients appropriately.
Peter L. Salgo, MD: But nobody gets to a cardiologist unless he or she is referred. This is the same with a pulmonologist. So, in terms of the diagnosis here, can a primary care physician make this diagnosis?
James F. Donohue, MD: Yes.
Peter L. Salgo, MD: How easy is it?
James F. Donohue, MD: You think about the cardinal symptoms of COPD: dyspnea getting progressively worse and, then, maybe a cough, where every cough is abnormal, no smokers cough, limitations in exercise, those kinds of symptoms. Fatigue is a terrific symptom. Who would have thought about COPD? Appropriately so, you’re looking for diabetes. You’re looking for hypothyroidism. You’re looking for anemia. I think all of those things can increase awareness. I think it’s important to remember that we do have some drugs now, for better or worse. But, we need better screening. I’m going to defer to Byron to talk about the important role of spirometry in the diagnosis, but somebody has to think about doing it. So often, there is no spirometry, and that’s the key thing.
Peter L. Salgo, MD: I’m going to get to spirometry in a second, but let’s be even more basic. Should there be the ability to do spirometry at every primary care doctor’s site?
Fernando J. Martinez, MD: I think all of us would agree that there should be that capability. But that clearly doesn’t take place at this point. There’s no question about it.
Peter L. Salgo, MD: Is that right?
Fernando J. Martinez, MD: Yes. In fact, depending on the studies you read, even people who have had a diagnosis of COPD were on some type of a COPD therapy. A quarter of them have had spirometry testing at some point in life. With support of the NHLBI, who has been very supportive of the COPD National Action Plan, there were a couple of projects that I’ve been involved in with Byron. Some of what he and I have been involved in dates back to the COPD Foundation and John Walsh, founder of the COPD Foundation, and some of the things that John did years ago.
When you think about diagnostic components in COPD, the primary care clinician is the key person. They’re the person who sees that patient first. It would be ideal for that individual to think, “There’s old age, and shortness of breath, and coughing. That is not necessarily a normal thing.” And so, part of what we try to do with the NHLBI and COPD Foundation is address how you can generate an approach that a primary care clinician could easily do that would help them with decision making. “You know, there’s probably something going on here. Additional testing is probably warranted.” And so, this is this whole capture approach. That was an NHLBI initiative that has been going on for several years.
Peter L. Salgo, MD: Capture is an algorithm, right?
Fernando J. Martinez, MD: Capture is an algorithm for this very simple approach of providing information to the primary care clinician that COPD is likely. There are a couple of components that are really interesting. Primary care clinicians were involved in the development of this whole process. And so, when we asked them, “If you’re a primary care clinician and I want to give you a very simple approach, with simple questions, how many questions do you want?” “How many questions is practical for you to ask a patient?”
Peter L. Salgo, MD: If I’m a primary care physician?
Fernando J. Martinez, MD: Correct.
Peter L. Salgo, MD: I want 3, 4, or 5.
Fernando J. Martinez, MD: Jim?
James F. Donohue, MD: The same.
Fernando J. Martinez, MD: Dr. Sciurba?
Frank C. Sciurba, MD, FCCP: Ditto.
Fernando J. Martinez, MD: So, when Byron and I were involved in this, we said, “This is going to be a challenge because these guys only want 3 to 5 questions. We’ve got to come up with 3 to 5 questions.”
Peter L. Salgo, MD: But just to stop you, they have 3 to 5 questions for COPD, and 3 to 5 questions for prostate…
Fernando J. Martinez, MD: Depression…
Peter L. Salgo, MD: Pretty soon, they’re up to an hour-and-a-half discussion, and they’re only getting paid for 7 minutes.
Fernando J. Martinez, MD: That’s exactly what they said. They said, “You’ve got to be practical.” We’ve got to do this for a whole series of chronic diseases, all of which have therapy, some of which are good, and some are not as good. And so, we said, “I’ve got to come up with 5 questions.” And then, there’s a matter of, how do you ask these questions? Dr. Sciurba is always saying that you have to ask the questions in relation to what the person has stopped doing. That stuck in my mind for years. And so, throughout this whole process, we actually came up with a concept. After a very rigorous approach, we came up with an instrument that has 5 questions.
Peter L. Salgo, MD: I did not know this.
Fernando J. Martinez, MD: It’s incredible. And, you know what? Since it was done in a very rigorous fashion and involves patients from the beginning, it will include very complex data sets. I learned a lot about how you ask questions. It was very clear that you can’t just ask, “Are you short of breath?” The question has to be, “Are you short of breath with this activity?” And, “Are you doing less?” Another item that came up, that I was surprised to see, was fatigue.
James F. Donohue, MD: Right, integral.
Fernando J. Martinez, MD: Integral. It was a key question. John Walsh was very clear in this, as well—seasonal changes in symptoms. John, who was the head of the COPD Foundation for years, had severe COPD. As he looked at that question, he said, “Yes, that’s exactly right. Nobody ever asked that question.” And so, we ended up with 5 really simple questions. A peak flow meter is something that primary care clinicians use all the time. It’s very cheap. They know how to do it. You know what? It looks really good in identifying people that likely have COPD.
Peter L. Salgo, MD: Is that what capture is about?
Fernando J. Martinez, MD: That’s what capture is about. Literally, this week, Byron and I just started a large validation study across 85 primary care centers across the United States with the NHLBI. This is an NHLBI/COPD Foundation initiative.
Byron Thomashow, MD: The only thing that I would stress is that for other questionnaires, and I know Fernando was involved in a number of other questionnaires in the past, none of them were really developed with this degree of structure to them. It’s really interesting because most of the prior questionnaires basically found old, active or former smokers. The question, “Do you smoke?” or, “Did you smoke?” didn’t even make the cut here.
Fernando J. Martinez, MD: Amazing.
Byron Thomashow, MD: Which is really fascinating. It may give us the first chance of finding some of the 20%, 25% of people with COPD, more around the world, who never smoked at all.
Peter L. Salgo, MD: And it’s not a pejorative.
Fernando J. Martinez, MD: Oh, it’s very worded to not be pejorative.
Byron Thomashow, MD: It has been checked out and we’ve already validated it. We’ve actively gone through the process and are doing it in Spanish. The hope is that this validation study will lead to a real change. But I do want to stress one other thing. The goal of this, from the beginning, was to better determine who primary care should send for spirometry.
Fernando J. Martinez, MD: Correct.
Byron Thomashow, MD: That remains the goal. But it’s interesting. You can have patients in primary care who have symptoms that are classic for COPD but don’t meet your classic spirometry criteria for having COPD. But, they may have a lot of COPD on their CAT scans. The question really is, ultimately, is spirometry the best answer for this? Or, is it only one piece of a puzzle that ultimately, for us to make a difference, we need to move on from?
Transcript edited for clarity.