COPD: An Individualized Approach to Medication and Delivery - Episode 11

Implications of COPD Device Misuse

Peter Salgo, MD: What are the potential consequences to patients of using this stuff wrong?

Antonio Anzueto, MD: It doesn’t work.

Barbara P. Yawn, MD, MSc, FAAFP: They don’t get it in to where it needs to be.

Antonio Anzueto, MD: You’re not taking the medication right, so it doesn’t do what it’s supposed to do.

Peter Salgo, MD: But to go beyond that, the clearer implication is that you’re not going to get the medicine right. It’s not going to work.

Barbara P. Yawn, MD, MSc, FAAFP: You end up in the emergency department. You end up in the hospital. You end up with exacerbations. You end up limiting your activities further and further and potentially have more rapid disease progression because of all those negative consequences.

Peter Salgo, MD: And if the patient thinks he or she is doing it right, and it’s not working, there’s depression and there’s dissatisfaction.

Barbara P. Yawn, MD, MSc, FAAFP: Yes.

Peter Salgo, MD: There’s a certain amount of hopelessness. “I think I’m doing it right and it’s not working. I must be hopeless.”

Barbara P. Yawn, MD, MSc, FAAFP: Well, “I’m hopeless” or “My doctor’s an idiot.” I mean, whichever one.

Peter Salgo, MD: It’s a close call.

Barbara P. Yawn, MD, MSc, FAAFP: I’ve heard that before. I remember sitting in the Chicago airport watching this woman exhale while she pushed her MDI [metered-dose inhaler] button. She was saying, “My doctor doesn’t know what they’re talking about. This doesn’t help at all.” And 3 hours later, because we were delayed, after the fifth time she took it wrong, I couldn’t stand it. I said, “Excuse me,” and I showed her how to do it. And about 3 hours later, when we finally got on the plane, she said to her daughter, “You know, this stuff really does work.”

Peter Salgo, MD: That’s a N of 1.

Barbara P. Yawn, MD, MSc, FAAFP: It is a N of 1. But, it is the kind of thing that, if we can take the time and figure out how to do it, our patients are really, really going to benefit from. In our office, we use the phlebotomist or the lab person. At the beginning of the day, they’re crazy busy. But there are times, during the day, when things are a little slower. Most of them love adding another skill to what they can do. So, think outside of the box of who can do this.

Peter Salgo, MD: Do doctors consider that?

Byron Thomashow, MD: One of the gaps in chronic obstructive pulmonary disease care is that we have got limited classes of medicine. Only 1 medicine, of a new class, has actually been approved in the last 10 or 15 years. That doesn’t mean our therapies haven’t gotten better. The combinations, the new versions of the older medicines, clearly work. We have therapies that can help people. But if you don’t use them, or if you don’t use them correctly, you have no shot.

Peter Salgo, MD: If the doctor is sitting in the office and believes that he or she gave the right drug with the right delivery device, and the patient comes back and is not better, is the doctor, in your experience, considering that the patient is not using it right? Is that something, in the differential?

Barbara P. Yawn, MD, MSc, FAAFP: Unfortunately, it’s frequently not. The first knee-jerk reaction is, we better add something else. Instead, it should be adherence and inhaler technique and exposure.

Peter Salgo, MD: Show me how you’re using it.

Barbara P. Yawn, MD, MSc, FAAFP: Right. Show me how you’re using it. Tell me about how you’re able to use it, and how often. “I know this is hard, with your 10 medicines. How often do you find that you forget?” So, you deal with adherence and inhaler technique. And then, of course, you look at triggers like, “Are you still smoking?” Or “Is somebody else smoking in your house?” Then you can make huge strides forward with no added side effects and no added cost to the patient. It makes a huge difference.

Peter Salgo, MD: Is it fair to say that if you had to pick one take-away, we’d say to make sure that the patient is taking the drug the way you think the patient is taking the drug. And then, if the drug isn’t working, check?

Antonio Anzueto, MD: Invest in education.

Peter Salgo, MD: Education.

Antonio Anzueto, MD: Invest in patient education. That could be the best.

Byron Thomashow, MD: We talked about the fact that some 25% of people with COPD may never have smoked. They may have some of these other exposures, and there are certainly some genetic issues. But cigarette smoking remains, in the United States, to be the primary cause of this disease. We don’t do a great job of getting people off of cigarettes. Now, part of that is that the average is 8 to 10 attempts at quitting. Providers don’t like to fail. So, each time they fail, we tend to get less enthusiastic about pushing forward, because we’ve got a lot of other things we need to do. It is still the only thing that we have found, which changes the course of the disease. Yes, there’s oxygen, but clearly, the data that cigarette smoking cessation affects the course of the disease is clearer than anything else. I just want to stress that.

Barbara P. Yawn, MD, MSc, FAAFP: And there are some data suggesting that there are some time points at which you’re more likely to be successful: the patient is in the hospital with an exacerbation, they’re in the emergency room, they’re getting their prescription for oral steroids and antibiotics in your office. And by the way, could we add a smoking cessation therapy to this? So, it’s just like with myocardial infarctions [MIs]. When do they stop smoking? Right after their MI. Well, with an exacerbation or an adverse event, this is a good time to try again.

Peter Salgo, MD: I remember a news anchor who had an MI. He got on the air after he recovered, and he said, “I always thought I should exercise. I never thought I had the time. I do, and I just woke up.” So, it’s the same critical teachable moment, right?

Barbara P. Yawn, MD, MSc, FAAFP: Right.

James F. Donohue, MD: One other thing that I’d like to emphasize, in terms of the personalization of medicine, is that with the communication and education, we need to be good listeners. Many of us, as physicians, have always used an authoritative type of approach, telling people what to do. And then, we’re not successful. We really need to be detectives, as to why that is. And so, we need to be able to better communicate with our patient, in their context, and have a conversation with them, not as doctor—patient, necessarily, but as 2 people who are having a conversation as to why our therapy is not successful. Perhaps we could even use intermediaries. In the South, we’ve had trouble, at times, talking with different groups of people. I’ve used members of the clergy, for example, and members of the family to help me understand what is wrong and why things aren’t working. It’s all about the patient. That’s really the only thing we’re here for.

Peter Salgo, MD: We do have to move on, but it goes without saying: This is an addictive drug and quitting an addiction isn’t easy.

Antonio Anzueto, MD: It’s very hard.

Peter Salgo, MD: It is hard. Simply looking at a patient and saying, “Stop smoking,” is not going to cut it.

James F. Donohue, MD: It’s not going to get it. Why isn’t it working?

Barbara P. Yawn, MD, MSc, FAAFP: No, but offering, again, repeated support. And you’re right, you have not failed until the 30th time that you’ve tried.

James F. Donohue, MD: And finding that moment, that Barbara mentioned, when the patient is in a teachable predicament or situation and exploiting that to their benefit.

Transcript edited for clarity.