COPD: An Individualized Approach to Medication and Delivery - Episode 6
Peter Salgo, MD: 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)?
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Peter Salgo, MD: “But, doctor, I can’t exercise. I can’t breathe. How can you possibly tell me to exercise?”
Barbara P. Yawn, MD, MSc, FAAFP: “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.”
Peter Salgo, MD: “Oh, that’s exercise. I hate exercise. Come on, doctor.”
Barbara P. Yawn, MD, MSc, FAAFP: “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.”
Antonio Anzueto, MD: 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?
Barbara P. Yawn, MD, MSc, FAAFP: One?
Antonio Anzueto, MD: 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.
Byron Thomashow, MD: 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.
Peter Salgo, MD: There’s a huge disconnect there, right?
Barbara P. Yawn, MD, MSc, FAAFP: 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?
Byron Thomashow, MD: 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.
James F. Donohue, MD: 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.
Peter Salgo, MD: If there is a center available, is it reimbursable to send patients there?
Antonio Anzueto, MD: The problem with the centers is that they are not reimbursed. The payers were paying 45 cents out of a dollar.
Peter Salgo, MD: 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.
Antonio Anzueto, MD: 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.
Byron Thomashow, MD: 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.
Barbara P. Yawn, MD, MSc, FAAFP: 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.
Byron Thomashow, MD: 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.
James F. Donohue, MD: 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.
Transcript edited for clarity.