Therapeutic Strategies in the Management of COPD - Episode 11
Peter L. Salgo, MD: Let’s take a little time, now, to help the primary care physicians to better understand some of the basics here. In other words, you’re sitting across from a patient and you say, “You’ve got COPD. I want you to use this inhaler or device.” How do you pragmatically, and clinically, work through this with the patient? How do you discuss this choice?
James F. Donohue, MD: First of all, you have to understand, particularly, in my community practice, that the literacy is about the level of diabetes. It’s not very, very high, in general, in COPD. So, you have to take that into account. As a matter of fact, that was a huge problem when vendors would change from a dry powder, for example, to a metered-dose inhaler without any direction.
Fernando J. Martinez, MD: Literacy among whom?
James F. Donohue, MD: The patients. Many patients with COPD, maybe not in New York but, certainly, in the Carolinas, have low literacy with this condition. We did picture books for the American College of Physicians, just like we do in diabetes, to try to help. We also use the principle of, “keeping it simple.” You can use 1 device for all of these different options, combined into 1, so you don’t have to teach about 3 different devices, and we’re beginning to have that, now. That would make it a little bit easier. Or, there are the fixed-dose combinations that we have been talking about. Then, the family doctors are really good at looking at 1 disease in the setting of 7 others. So, they’re already doing that. But just think about COPD. Think about what Byron, Frank, and Fernando have been talking about here. This is an important component of the illness and the personalized medicine approach.
Byron Thomashow, MD: You can’t simply prescribe a medication. You have to show people how to use the inhalers. Then, you have to use a teach-back phenomenon, so that you know they’re using it correctly. It’s become very complicated because, as everyone knows, insurers are now deciding what medicines people will be on. I’m increasingly finding, for people in whom I’ve taught how to use an inhaler, that 2 months later, their insurance has switched them to another inhaler. First of all, you could argue that not all drugs of the same class are the same. If I’ve got a 25-year-old asthmatic, it may not matter what LABA/ICS they’re on. But if I’ve got a 75-year-old guy with atrial fibrillation who is tolerating a LABA, they may not tolerate another LABA. Beyond that, in COPD, where inhaler knowledge is particularly important, this constant switching of different inhalers is problematic, at best.
Fernando J. Martinez, MD: In the last 2 to 3 years, what I’ve seen as the most dramatic component of my practice has been the incredible influence that payers have on what’s available, what you can use, and the complexity that it raises to our clinics. I’m sure that the primary care physicians are dealing with this in a much more difficult fashion because they get it across multiple diseases. But just in airway disease, it is brutal.
Frank C. Sciurba, MD, FCCP: Terrible.
Peter L. Salgo, MD: It also occurs to me that if Byron’s right, you’ve got to teach someone how to use this device. You just don’t throw it across the table and say, “Good luck.” Then, they’ve got to come back and show you that they know how to use it. That takes time.
Byron Thomashow, MD: This is increasingly going to be a team approach to care. I think we all agree with that. We need to take advantage of respiratory therapists who we generally underutilize. We need to take advantage of pharmacists. Pharmacists need to begin to show people how to use these things. Or, it’s not going to work.
Fernando J. Martinez, MD: I agree.
Peter L. Salgo, MD: What about other therapies out there? You alluded to this earlier, that there is some stigma attached to the disease. “You did this to yourself. You’re a smoker. You’re bad.” Then, you say, “Let’s make this really public. You need oxygen.” How do you introduce that and have people accept it and say, “I feel great on this. Maybe this is worthwhile.” What is the technique for doing that?
Frank C. Sciurba, MD, FCCP: Interestingly, the philosophy in the use of oxygen is exactly the opposite of the use with bronchodilators. Oxygen has been proven to prolong survival, when it’s necessary. And so, we now feel that we have to prove that it prolongs survival to use it. The reality is, oxygen is probably one of the best drugs for patients who have symptoms and a drop in their oxygen level in making them feel better. If you have low oxygen levels at rest, it is absolutely necessary. Multiple studies have shown that it prolongs survival. In patients who only drop their oxygen with exertion, a big study from the National Institutes of Health showed that it doesn’t prolong survival if it only occurs during exercise. But that says nothing about the fact that every rehabilitation program in the country would think it’s insane to exercise a desaturating patient without giving them oxygen. They feel so much better and do so much more. Oxygen helps people. You have to get the stigma eliminated, at least in that patient and their family’s mind. Then, hopefully, the rest of the world will follow.
Peter L. Salgo, MD: It’s always been somewhat amusing to me that people have less trouble smoking in public than using oxygen in public.
James F. Donohue, MD: That’s right.
Fernando J. Martinez, MD: That’s a good point, actually.
Byron Thomashow, MD: But it’s also complicated. Every time someone comes into my office pulling a green canister, that should have gone out of use 40 years ago, behind them, some of the devices, particularly some of the portable concentrators, really work very well, especially in COPD, where the oxygen demands are not like the pulmonary fibrotic population. Most of the time, the portable concentrators work fairly well. But a lot of insurers don’t cover them. It’s a problem.
Peter L. Salgo, MD: What about the more invasive stuff? Byron, early on, you were working with some of the early studies on lung volume reduction. The question is, what is the role now?
Byron Thomashow, MD: Lung volume reduction surgery, when you pick the appropriate candidate for the surgery, works. It can improve quality of life, exercise capacity, and survival, the second thing since oxygen. And yet, at least in this country, and to a large extent around the world, it is rarely used. The results, at my center, have been remarkably good. I would suggest that, in part, it’s because we’ve been able to keep the team together for a very, very long time. There’s a lot of interest, now, in some of these less invasive bronchoscopic procedures. Frank’s been a leader in that. Some of them are going to the FDA within the next year, and my hope is that they will be added as an option.
Frank C. Sciurba, MD, FCCP: Without going into detail on these, these are reasons why you need to refer to a specialist. While maintenance therapies can be delivered by an attentive primary care doctor, they’re not going to be able to address these much more esoteric and complex issues. Patients with obstruction, with a FEV1 (forced expiratory volume of 1) below 50%, predicted, need to be referred to Byron, Fernando, and Jim to evaluate them for lung reduction surgery and, when and if the FDA approves these less invasive approaches, the consideration of coils and valves to reduce lung volumes in COPD.
Peter L. Salgo, MD: What about so-called “noninvasive ventilation?” That’s a term which a lot of people haven’t even heard of. What is it?
Frank C. Sciurba, MD, FCCP: That’s CPAP (continuous positive airway pressure), and BiPAP (bilevel positive airway pressure) with newer ventilator devices. AVAPS (average volume assured pressure support) have been used mainly for sleep apnea and in the acute setting for COPD to prevent intubations. But particularly in Europe, there’s data showing that these devices, when used appropriately, particularly in patients with carbon dioxide retention, can prolong survival and dramatically improve quality of life. More studies need to be done, but we probably need to start considering the right patient to use these in.
Byron Thomashow, MD: I think the take-home message with all of this, not just recognizing that we need more, and better, and different types of medicines, is that the medicines that we have now can work. And if you add exercise, rehabilitation, the vaccinations, and smoking cessation, and, then, the considerations of some of these more invasive options, there’s actually a lot we have to offer. So, the nihilism that existed from this disease simply shouldn’t exist any longer.
Transcript edited for clarity.