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Why treatment requires a multi-pronged approach
Physicians often struggle to help patients with chronic obstructive pulmonary disease (COPD) make and maintain the lifestyle changes and medication regimes necessary to manage it. No single approach is sufficient, so experts recommend a multi-pronged strategy to manage this complicated disease.
COPD is shorthand for a group of diseases that cause airflow blockage and breathing problems. While its most common cause is smoking, for a small number of people, the cause is genetic. It affects more than 15 million people, and poses a significant burden to the U.S. healthcare system. The Centers for Disease Control and Prevention (CDC) estimates the annual costs of COPD were $32.1 billion in 2010 with a projected increase to $49 billion by 2020.
Confirm the diagnosis with spirometry
COPD patients often present with symptoms including chronic cough, shortness of breath during regular daily activities, wheezing, excess mucus, and fatigue.
As a result, COPD and asthma are often used interchangeably, to the detriment of COPD patients, when they are not the same disease process, according to Keith Robinson, MD, an associate pulmonologist with Pulmonary Physicians of South Florida in Ft. Lauderdale. “I spend a good chunk of my time actually erasing diagnoses and giving patients the right term for what they have,” Robinson says.
Before discussing treatment options, it’s important to confirm the diagnosis with spirometry, the primary diagnostic tool for COPD. When patients who truly do have COPD receive a diagnosis it’s also often extra motivation to make the lifestyle changes to keep their disease from progressing, Robinson says.
The test is also important because even smokers who are symptomatic may still have normal lung function that doesn’t qualify as COPD. Those patients will still need education and intervention to prevent COPD from developing, but the treatment process may be different.
Once a diagnosis has been made, the next step is to get patients to stop smoking, says Philip Diaz, MD, a professor of medicine in the pulmonary, critical care, and sleep medicine division at Ohio State University Wexner Medical Center in Columbus.
“Getting off smoking is the best way to prevent the disease from progressing,” Diaz says.
Diaz relies upon a combination of pharmacotherapy-Chantix and Wellbutrin as key medications-and counseling to help patients quit. He finds it more effective to get patients to commit to a single quit date than to titrate slowly off.
Some people’s disease process can still progress even after quitting, but usually more slowly than if they continued.
Robinson also encourages physicians to prioritize the patients who are at the mild and moderate stages of the disease, because they can have the most impact on those patients’ disease process.
Create care teams for greater success
COPD, like many chronic illnesses, isn’t one that physicians can manage alone, says Ken Thorpe, Ph.D., a professor of health policy at Emory University in Atlanta. He says patients are better served when they have a care team that can make sure that none of the elements of their care are not overlooked.
He says that while physicians may do a good job creating treatment plans, things often fall apart in the execution. “A care team is really important. These patients are going to be in a physician’s office infrequently for a short period of time and the key is, what happens when they leave?” Thorpe says.
In addition to the physician, a care team might consist of a pharmacist and a nurse practitioner to manage medications, and possibly a care coordinator to help with transitions in and out of the hospital if the patient is acute. “Care teams are generally very diverse, because people with these chronic diseases often have other chronic diseases,” Thorpe says.
Thorpe also recommends a program created by the CDC known as the National Diabetes Prevention Program. The name is misleading, he says, because it’s really just a useful lifestyle program that offers education, exercise, nutrition, and behavioral advice for anyone with a chronic disease.
“It focuses on reducing the number of diabetics from pre-diabetics by generating weight loss behavior change but it has impact on a whole host of conditions,” he says. “Many physicians don’t know the benefit exists.”
Behavioral approaches to lifestyle changes
Once a diagnosis is confirmed, quitting smoking is only the first lifestyle change that COPD patients need to make to stay as healthy as possible. Exercise is especially important for COPD patients to manage their symptoms, Robinson says. It may seem counter-intuitive to recommend exercise to patients who are short of breath, but it is effective, he says.
This can be a challenge for many physicians, since patients often are reluctant to begin exercising. “If our patients weren’t really physically active as young adults, they’re not all that inclined to become active after they get a diagnosis of COPD,” Robinson says.
To encourage this behavioral change, his practice treats COPD patients as if they are struggling with an addiction, that addiction being a sedentary life. “We’re learning that COPD is a behavioral disease as much as an obstructive lung process,” Robinson says.
To overcome patients’ resistance, physicians in Robinson’s practice rely on motivational interviewing rather than just telling people what they should do differently. “We have patients reflect back on the activity or the lack of activity and ask them about what benefited them or what potentially might be the harm of not trying to change that behavior,” he says.
They also ask patients to reflect on what they have missed out on in life due to fear of shortness of breath or the embarrassment of being seen with an oxygen tank. They’ve also drawn upon scientific research that has found milder forms of exercise such as Tai Chi, yoga, and Pilates meet the same level of activity improvements as getting patients up on a treadmill for twenty minutes.
“More importantly, the mindfulness that they get out of [these exercises] and the awareness of their breathing becomes a foundation for those activities,” Robinson says.
Meditative breathing techniques can also help COPD patients, says Siobhan Bulfin, founder and CEO of Melon Health, a San Francisco-based healthcare consulting company that helps clinicians enable patients to self-manage chronic illnesses.
“With COPD we’ve focused on breathing techniques because we know that shortness of breath causes people with COPD a lot of anxiety,” Bulfin says. They teach physicians and nurses to walk patients through basic breathing techniques that can calm anxiety and restore breathing to a manageable state.
Practice empathy and offer hope
Along with its physical symptoms, COPD carries a lot of stigma, says Diaz. “I think some patients feel that they’re met with this idea that ‘you smoked, and you’ve done it to yourself,’” he explains.
Patients’ shame over their behavior and stigmas around smoking can prevent patients from getting treatment, which is unfortunate, Diaz says. “I tend to look at it more positively, that there’s always something that can be done. You can keep them out of the hospital, try to improve their quality of life, look into more advanced therapies.”
He does recommend setting realistic goals with patients, however. A person with COPD probably won’t run a marathon, but they might be able to play their favorite sport or get to the gym regularly.
Bulfin says they help patients create intrinsic rewards and make incremental changes. “An intrinsic reward is, ‘Oh I just did something I couldn’t do before,’ or ‘I just walked three times in a week,’” she says.
She says that for COPD patients with acute symptoms, improvement may be slow. With treatment, a patient may be able to walk to the end of their driveway every morning to pick up a newspaper, or maintain some basic mobility. But however small, every bit of progress is important.
Additionally, Robinson says, it can be productive when physicians show their human side with their patients by discussing their own failures. “In pulmonary rehab, we have a chance to [talk about our failures] often, by saying, ‘I failed you by choosing the wrong inhaler, let’s try a different delivery,’” Robinson says. “Or ‘maybe this class of medication isn’t making you feel well, let’s try a different class.’”
Another crucial, and often overlooked, area of patient support is for physicians to help patients meet with other COPD patients.
Belfin says her company has helped physicians be successful in getting COPD patients to engage in better medication adherence and lifestyle changes by connecting them to their peers. Melon Health does it through a HIPAA-compliant, online community where people with COPD can communicate with each other. It is overseen by a community manager nurse who can also advise and offer resources.
“Changing behavior and managing chronic illness is really hard, but it’s easier to do if you know that you’ve got other people to do it with,” Belfin says.
Whatever strategies a physician employs, Diaz emphasizes offering patients hope. “I think navigating these patients through their illness can really help them. Even though COPD is not something that can be cured, you can help them manage it.”