Therapeutic Strategies in the Management of COPD - Episode 2

The Complex Nature of COPD: Progression and Symptoms

Peter L. Salgo, MD: COPD is not just a snapshot at one moment. This disease has a beginning, and a middle, and it’s progressive. What is the progressive nature of this disease?

Frank C. Sciurba, MD, FCCP: This disease isn’t simple. It doesn’t have a simple answer. When you look at the graphics and the review articles, they say COPD progresses at “this rate,” which exceeds the normal rate of lung function decline. But the theme that I’m going to give during this session is that this disease is extremely variable. There are patients that have a rapid decline, and there are others that can maintain stability. It’s not just respect to lung function. COPD is a disease that affects the body. It results in deconditioning. It’s associated, intrinsically, with other processes like cardiac disease, osteoporosis, and depression. These also progress at variable rates. We need to understand the complexity of this disease and the variability to answer that question.

Peter L. Salgo, MD: Deconditioning, not just pulmonary deconditioning but totally physiologic deconditioning, is important, right? When you’ve got a heart patient, the first thing you tell that person is, “I want you to exercise better.” When you’ve got anybody with any sort of problem, you say, “I’d like you to get out there and walk and do things.” But if you can’t breathe, you’ve got an issue.

Frank C. Sciurba, MD, FCCP: Absolutely.

Fernando J. Martinez, MD: Look at some of the therapeutic guidelines. There are a lot of therapeutic guidelines. One of the common themes that you see in all of those is exactly what you said, Peter—you’ve got to make sure you keep active. “I know you’re maybe breathless, but activity is important. You’ve got to go out and keep up with this.” That’s become sort of our mantra in the COPD world, as well. Our primary care colleagues are particularly relevant in that respect because they’ve got credibility with that patient when they tell them that. So, that’s a crucial point.

Peter L. Salgo, MD: I can see the interaction now. Dr. Primary Care says, “Go out there and get active,” but the patient says, “What? Are you kidding me? I can barely stand up.” How do you get over that hump?

James F. Donohue, MD: That’s right. Well, in addition to the 2 major points that Byron said, in the pathophysiology of COPD, there’s a lot of inflammation. So, you have weakness of your quadriceps muscle. People always think of COPD, at least in the past, as a lone disease—a lung problem. But there’s more inflammation in the lung than there is, let’s say, in dental plaques. Everybody is worried about the connection between dental plaques and the heart. Inflammation has all kinds of systemic effects on bone marrow and muscle. That’s why it’s essential to really keep that patient moving. You do that quick test. Move them out of the chair and back. Patients with COPD can’t do it at all. They can’t even get up.

Byron Thomashow, MD: There’s one other issue, and it’s a new concept—we don’t start at the same place. There is something called the “Fletcher-Peto curve.” All of us have looked at this model, and there are things that are clearly wrong with it, including the fact that not everyone gets to age 20 at the same level of function. If you start with significantly less function, with some of the issues brought up before, you are far along on a curve, which isn’t a good thing. It’s not all the same, and I think that’s a point that needs to be stressed. COPD is not all the same, and we need to get away from treating all COPD the same. We would never treat all cancers the same, and I think that’s really important to point out.

Peter L. Salgo, MD: The other thing you pointed out is, there’s this conflation of normal aging and normal decrease in lung function.

Frank C. Sciurba, MD, FCCP: Yes, that’s crucial.

Peter L. Salgo, MD: I suspect if you really look at this carefully, you’re going to realize that COPD is associated with productive cough, wheezing, fatigue and chest tightness. Not all of that is a normal expectation of aging, right?

Frank C. Sciurba, MD, FCCP: But, not all COPD have all of those symptoms, nor do each of those components progress at different rate. That’s what adds to the complexity.

Peter L. Salgo, MD: The important fact is, if I’m looking at the normal progression of aging and lung function, I’m not looking at these particular symptoms.

Fernando J. Martinez, MD: One of the points that you just raised is, and this is really a crucial point for our primary care colleagues because I’m sure you guys have seen this, there is an association between COPD and aging. That is important. You’re absolutely correct to point out that it is recognizing those particular symptoms that will enhance…

Byron Thomashow, MD: I think that’s really critical. We’re going to talk about diagnosing this disease. At this point, we’re still using spirometry to make the diagnosis. There are some flaws with that, and we can talk about that. But part of the problem with the Preventive Services Task Force recommendation is that you do it in people who are at risk with symptoms. And the problem is, particularly with this disease, that progressive shortness of breath is often self-diagnosed. Cough is often self-diagnosed. “I’m getting old.” “I’m out of shape.” “I’m overweight.” And in the 5 to 10 minutes you may have with your primary care physician, if you ask the wrong question, you may get the wrong answer. “How’s your breathing?” If you’re not doing much, your breathing may not be bad at all. You need to ask the right questions. Maybe a better question is, “How’s your breathing compared to a year ago?” “Can you do what you could do a year ago?” “Can you do what you want to do?”

Fernando J. Martinez, MD: Dr. Sciurba, you’ve been advocating for this for years. I’ve heard you make that comment so many times in the past.

Frank C. Sciurba, MD, FCCP: One last comment is that these other manifestations of COPD, the deconditioning, the weight gain, these attributes that are associated with it, are the things that don’t just go away by giving a drug. Even though you’re going to learn about new drugs that have an impact, the things that matter the most are motivating your patients to exercise and lose weight. That really is the trickiest and most important role, and primary care physicians probably do better with this than specialists.

Peter L. Salgo, MD: Particularly with the comorbidities of COPD, heart disease is one of them, lung cancer is another. Respiratory infections, those may be associated. But are they etiologically associated? In other words, is there a common etiologic agent? COPD doesn’t give you lung cancer. COPD doesn’t give you heart disease, right?

Byron Thomashow, MD: You could argue the opposite. COPD is an independent risk factor for many of these other diseases, separate from the cigarette smoking. We may not understand it, but it’s true.

Fernando J. Martinez, MD: You guys have been doing this in lung cancer and osteoporosis for years.

Frank C. Sciurba, MD, FCCP: Something that we, and others, have found is, independent of tobacco smoke or other risk factors, if you have COPD, you’re more likely to have osteoporosis, cardiovascular disease, depression, or lung cancer. It’s the inflammatory, systemic effect of this disease that has an impact on other organ systems. It’s the same disease. They’re all interacted and they’re all related. It’s not just one organ at a time.

Byron Thomashow, MD: But isn’t it true that not all COPD predisposes to lung cancer, for example? It’s more the emphysematous type? It gets very complicated.

Frank C. Sciurba, MD, FCCP: It’s the holes in the lung that are the risk factor.

Peter L. Salgo, MD: As I said, things just got a lot more complicated, which brings us to the COPD National Action Plan of the National Heart, Lung, and Blood Institute (NHLBI). What is the COPD National Action Plan?

Byron Thomashow, MD: So, in February of 2016, NHLBI held a town hall meeting in Washington that many of us were at. They brought together investigators, and patients, and patient families, and a number of organizations like the ATS (American Thoracic Society), the AARC (American Association for Respiratory Care), and the COPD Foundation. Out of that town hall meeting came the first national COPD action plan. There’s been a national action plan for asthma for years, and many people who work in that field will tell you it was the major force behind much of the progress that we’ve made.

Fernando J. Martinez, MD: It was transformative.

Byron Thomashow, MD: It was transformative. Now, the difference is, as you guys know, that came from Congress with some money. NHLBI deserves a tremendous amount of credit for pushing this forward, but the money issue is not so clear. There are 5 points to the program. They involve awareness, prevention, therapies, data collection, and pushing the importance of research. I think it’s important to touch on that, just for a moment. And, again, NHLBI deserves a tremendous amount of credit. But I think all of us would agree that COPD continues to get the short end of the stick, from a research standpoint. NHLBI provides around $100 million in COPD research funding. That sounds like a lot of money. It’s the equivalent to spitting in the ocean. In HIV, and cardiovascular disease, and cancer, the number is $2 billion to $3 billion a year. You get what you pay for.

Transcript edited for clarity.