Key components include smoking cessation, rehab and symptom management
Division of Pulmonary, Critical Care and Sleep Medicine - January 2018
RODNEY J. FOLZ, MD, PHD
Chief, Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center; Scott R. Inkley, MD, Chair in Pulmonary/Critical Care and Professor of Medicine, Case Western Reserve University School of Medicine
Chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis, is the third-leading cause of death in the United States. But with no cure for the disease, pulmonologists need to approach COPD as “a chronic, lifelong disease that must be managed regularly,” says Rodney J. Folz, MD, PhD, Chief, Division of Pulmonary, Critical Care and Sleep Medicine at University Hospitals Cleveland Medical Center.
Overall, COPD patients with the best outcomes are with those who are enrolled in a comprehensive COPD management program consisting of several critical components.
Management of symptoms. “With the right medications, patients can be more active and enjoy overall improved quality of life, Dr. Folz says. However, “though most COPD medications will help patients breathe better, medications do not improve or reduce mortality from COPD or slow the loss of lung function,” he says. “They improve symptoms and, in some cases, help improve performance measures, such as breathlessness and lung function parameters.”
For those reasons, pulmonary specialists should 1) customize treatments for COPD patients based on their symptoms, exacerbations and air flow limitations and 2) know which patients are at highest risk for exacerbations and follow up regularly.
Smoking cessation. “Because tobacco is a major cause of COPD, effective smoking cessation programs are key,” Dr. Folz explains. Nicotine replacement products “reliably increase long-term smoking abstinence rates,” according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, which offers universal guidelines for managing COPD. But pulmonologists shouldn’t underestimate their role in patient smoking cessation. According to GOLD, “counseling delivered by physicians and other healthcare providers significantly increases quit-rates over self-initiated strategies.” There is also a direct correlation between the intensity of that counseling and cessation rates.
Healthy patient visits. If pulmonologists or primary care doctors only see patients when they are having an acute incident, they miss an opportunity to discuss managing comorbidities, educate patients on treatment regimens and teach them how to properly use their inhaler, Dr. Folz says. He stresses the importance of scheduling periodic healthy visits with all COPD patients, and using these visits to help patients develop a COPD action plan – an “if-then” plan for COPD exacerbations.
Unfortunately, patients don’t always report exacerbations to their doctors, so an action plan alerts them to the significance of their symptoms and the importance of early intervention. “A COPD action plan allows patients to get a head start on medications and try to limit the impact of the exacerbation until they can see their doctor,” Dr. Folz says.
Cardiovascular disease prevention. Cardiovascular co-morbidities, including heart failure, ischemic heart disease, arrhythmias, peripheral vascular disease and hypertension, are more prevalent and severe in patients with COPD. So, in addition to closely monitoring COPD patients for co-morbidities, be proactive in implementing an aggressive CVD prevention program. “Look at patients’ cholesterol levels, focus on nutrition and a heart-healthy diet, and make sure patients get good exercise,” Dr. Folz says.
Screening for other conditions/diseases. Adults 50 to 80 years old who were 30-pack-a-year smokers and currently smoke, or recently stopped smoking, are eligible to undergo low-dose CT screening to help detect early stage lung cancers. These cancers can often be resected, giving patients their best chance for a cure.
Dr. Folz also recommends ordering bone density screening for osteopenia and osteoporosis, as weak bones put COPD patients at higher risk for fractures. And, it’s critical to survey patients for depression – and treat it appropriately. “Patients with both depression and COPD are more likely to have COPD exacerbations and end up in the ER or hospital,” Dr. Folz says. They also have poorer control over their COPD, and they may not adhere to their medication regimens as well or be as active as a non-depressed person, he notes.
Pulmonary rehabilitation. According to a Cochrane Database Systematic Review, “pulmonary rehab is shown to be the most effective therapy strategy to improve shortness of breath, health status and exercise tolerance.” It’s also appropriate for most COPD patients, especially those with moderate to severe disease.
Pulmonary rehab helps patients exercise safely, develop stamina and engage in enjoyable activities, Dr. Folz says. They will receive one-on-one education about how to use inhalers, which medications to use (or not) and breathing techniques for when they’re feeling short of breath.
“UH’s Pulmonary Rehabilitation Program at the Ahuja Medical Center includes a pulmonary support group in conjunction with the American Lung Association Better Breathers Club,” Dr. Folz notes. The program even offers yoga for pulmonary patients.
Patients get the most benefit from rehab programs that last six to eight weeks. Strongly encourage patients to participate in pulmonary rehab and to continue what they learned when the program ends.
Coordination with GPs. Managing care for COPD patients must be ongoing, joint effort, involving both the patient’s general practitioner and pulmonary specialist. “Because of the large population of people with COPD, there are not enough specialists to handle the full population of patients,” Dr. Folz says. “It’s going to fall on GPs to help manage and care for these patients.”
PROACTIVE DIAGNOSIS AND TREATMENT
Healthy, aging individuals do not have shortness of breath with exertion, Dr. Folz notes. Don’t let your patients write off these symptoms to old age. If a patient complains about a cough or shortness of breath, or gets winded with minimal activity, use pulmonary function testing (spirometry) as a way to quickly and objectively diagnose COPD, Dr. Folz says.
For questions about the latest advancements in the treatment of COPD, please email Dr. Folz at Rodney.Folz@UHhospitals.org.