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The best practices for treating COPD, particularly in light of the changing restrictions imposed by COVID-19
Even before COVID-19 began causing respiratory distress around the globe, experts say the United States was experiencing a respiratory crisis. More than 16 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), according to the National Heart, Lung, and Blood Institute, and many millions more may be living with it undiagnosed. Experts have been weighing in on the best practices for treating COPD, particularly in light of the changing restrictions imposed by COVID-19.
“COVID-19 is only highlighting the crisis we have faced previously and helping us ask how do we better treat our patients with these chronic respiratory diseases,” says Laren Tan, M.D., director of the Comprehensive Program for Obstructive Airway Diseases at Loma Linda University Health in California.
Tan says that prevention should be the most important goal for physicians treating COPD, as “we don’t want progression of disease.”
Best practices for diagnosis
Prevention starts with an accurate diagnosis, according to MeiLan Han, M.D., a professor of medicine in the Division of Pulmonary and Critical Care at the University of Michigan in Ann Arbor. She says there are problems with both overdiagnosis and underdiagnosis here in the U.S.
“Many primary care providers don’t order pulmonary function testing,” she says, referring to the spirometry test, the best way to make a COPD diagnosis.
Unfortunately, in the time of COVID-19, pulmonary function tests pose a health hazard because they generate aerosols, which makes the tests challenging to carry out.
Han laments that there is no standard questionnaire to help diagnose COPD as there are for other chronic disorders, such as diabetes, high blood pressure or high cholesterol, other than the COPD assessment test (CAT).
“[Due to COVID-19] it’s as though we’re going back to an earlier stage in medicine where we (don’t) even have the technology of the stethoscope and (have) to focus on what the patient is telling you, what you can hear in their voice and the way they’re talking and breathing,” says Madelyn Rosenthal, M.D., assistant professor of pulmonary and sleep medicine, and codirector of the Martha Morehouse Pulmonary Rehabilitation Program at The Ohio State University Wexner Medical Center in Columbus, Ohio.
She says the difficulty of diagnosing COPD makes it important to do a thorough history of exposures beyond tobacco, including “any environmental exposures such as chemicals, toxins, coal burning stove with poor ventilation, etc.”
Because many symptoms of asthma, bronchitis and COPD overlap, Rosenthal says physicians should “make sure you know what (patients’) triggers are.”
Diagnosis is also made more challenging by the shift to telehealth due to COVID-19. Though telehealth does allow for continuity of care, many physicians agree that it is not ideal for working with patients who have COPD.
Andrew Martin, M.D., chair of the Deparment of pulmonary medicine at Deborah Heart and Lung Center in Browns Mills, New Jersey, shared his experience regarding a patient who called in asking for a refill on an inhaler because of increased shortness of breath. He felt he couldn’t determine the man’s condition over the phone and insisted the patient come in to the office. In person, he realized the man was experiencing heart failure. “Telehealth is good for follow-ups but I don’t use it for an initial visit or evaluating unless I know the patient really, really well,” Martin says.
Once a diagnosis is confirmed or known, physicians can begin to make or continue a treatment plan. Martin’s motto is, “Protocols are nice, but they are no substitute for paying attention.” He treats each patient with COPD as an individual case. “Doctors are not paid to check off boxes and click algorithms—spend time with your patients, ascertain whether they are doing normally or abnormally for themselves, or if disease is progressing,” he suggests.
The most important step in treatment is helping patients cease smoking if they are still smoking, Martin says. That could mean getting them on a medication proven to help, such as bupropion or varenicline, or adding in a nicotine replacement option.
“Smoking itself needs to be thought of as a chronic disease with all kinds of bad health outcomes,” says Benjamin J. Seides, M.D., M.P.H., director of interventional pulmonology at Northwestern Medicine in Winfield, Illinois. “There is nothing we can do for (you) that is as beneficial as quitting smoking, no matter what stage of COPD you have,” adds.
He opts for a harm reduction model. “My philosophy is that if you need to usenicotine replacement for the rest of your life, then use it, because it’s way better than the alternative.”
Medications and treatments
After handling smoking cessation, Martin turns to three common types of medication to prevent flare-ups and exacerbations: inhaled steroids to reduce inflammation, long-acting bronchodilators to open airways, and anticholinergics to reduce mucous secretions.
A more recent formulation with fluticasone furoate, umeclidinium and vilanterol offers all three medications in one inhaler, which can improve patient adherence and even outcomes, says Seides.
As research varies on which patients should be taking inhaled steroids, which are linked to an increased risk for pneumonia and other infections, Han recommends checking the blood eosinophil levels for high-risk patients, which will give a more accurate sense of who needs to be on steroids.
For more extreme cases where lungs have been severely affected due to emphysema, some patients may qualify for valve placement, Han says. “Emphysema destroys the natural elasticity of the lung, so it’s like a really old rubber band. By taking diseased tissue out you provide more room for the diaphragm to move the lung up and down, and the valve helps the lung de-gas,” she says.
Yet another new treatment is currently in phase three clinical trials, known as targeted nerve denervation, explains Seides. “(It’s) a bronchoscopic therapy where you burn the vagus nerve to reduce vagal tone to the lungs, which helps treat the chronic bronchitis phenotypes.”
Lastly, Tan encourages physicians to remind their patients of basic lifestyle behaviors such as exercise, at whatever capacity they are capable and healthy diet.
When patient adherence is an issue, David Hatfield, D.O., chief medical officer of Hatfield Medical Group, a family practice in Arizona, likes to give his patients a vision of what their health can look like months down the road if they stick to their treatment plan. “Remind them that while COPD is not curable, it is reversible.”
He also encourages learning more about the barriers to patients’ ability to stick to a plan.
“Maybe they have a friend that took a medicine that didn’t sit well with them and now they don’t want to try it,” he says. “Listen to them, understand their concerns.”
Reimbursement and revenue
Keeping patients with COPD healthy also goes a long way toward improving quality metrics that may affect a physician’s reimbursement. Medicare penalizes physicians whose patients are readmitted to the hospital within thirty days of a discharge.
“The minority ends up costing the majority of health care utilization. The goal is to reduce that utilization, especially during COVID-19,” says Tan.
Han’s health system established a transition-of-care clinic that follows up with anyone who has been hospitalized for COPD exacerbation or flare within 7 to 14 days of discharge. Smaller practices could hire a care coordinator, Hatfield recommends.
Moreover, helping patients with COPD stay healthy can minimize what Tan calls the downstream costs of health care on clinic staff, who could be doing less calling and follow-up.
“No outcomes, no income,” Hatfield concludes.