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Keith Loria is a contributing writer to Medical Economics.
A look at how physicians can help patients manage their respiratory health
Because COVID-19 is a respiratory virus, individuals with chronic obstructive pulmonary disease (COPD) or asthma fall into higher-risk categories for getting the disease.
Approximately 10% of American patients 40 or older have COPD. It is associated with high morbidity or mortality, and it is one of the leading causes of death in the United States.
COPD exacerbations lead to higher medical costs and increased emergency department (ED) visits and hospitalizations.
“It is important to diagnose COPD early so we can appropriately [treat] our patients to help keep them healthy and prolong survival,” said Karen Wetherell, M.D., medical director of Village Medical in Glendale, Arizona. “Underlying lung disease is a risk factor for having serious complications from respiratory infections [such as COVID-19] and influenza, so we need to be actively engaged with our patients.”
Asthma is another significant inflammatory disorder that needs to be actively managed by primary care providers. According to the Centers for Disease Control and Prevention, 1 in 13 Americans — more than 25 million — have this challenging respiratory condition.
If a patient hides symptoms or lifestyle choices from their physician, the conditions could go undetected and lead to more serious issues later in life.
COPD and asthma both can be mild and in the background at times for many people. But when patients have an exacerbation, it often is severe or even life-threatening. That’s why it’s important for physicians to talk to patients ahead of time about how to prevent flare-ups.
Starting the conversation
David Beatty, a general practitioner with more than 30 years’ experience in Essex, England, says both asthma and COPD are underdiagnosed. Once a patient receives a diagnosis, there should be a discussion with their physician about the condition and how best to treat it, he says.
“COPD is far easier to manage at the mild or moderate stages,” he says. “Once severe COPD is established, the response to treatment is not so good.”
Whether it’s COPD, asthma or another respiratory health condition, Wetherell notes that establishing a good rapport with patients and getting to know them helps physicians get the conversation started.
“Having a long-term relationship with our patients and monitoring our patients on a regular basis has proven to keep them healthier and reduce visits to the [ED] and hospitalizations,” she says. “As a matter of fact, visits with the primary care provider on a more frequent basis — for example, every 90 days — has proven to reduce exacerbations, ED visits and hospitalizations by as much as 30% to 40%.”
One of the ways to discover respiratory problems is for physicians to ask patients about exposures that increase their risk for lung disease, such as smoking.
“This helps us evaluate our patients and intervene early,” Wetherell says. “Ask detailed questions. For example, ‘How often are you coughing during the day?’ and ‘How much mucus do you have?’ and ‘Are you short of breath when you climb stairs?’ This helps us determine how lung disease might be impacting their quality of life, including their ability to work, sleep and perform activities of daily living.”
Stephen Buksh, M.D., an internist with Northeast Tarrant Internal Medicine Associates in Euless, Texas, notes many of the triggers of worsening respiratory health are related to behavior and lifestyle management that can be managed by a patient with proper education. Such triggers include smoking, exposure to allergens, air quality, protection of airways occupationally and during hobbies involving fumes or bad air quality, as well as exposure to viral or bacterial pathogens from other contagious persons.
“It takes time to talk and educate patients to best manage COPD and asthma,” he says. “It’s also important to show the value of rescue versus maintenance inhalers, and their proper use along with when to seek help during exacerbations — earlier is always better.”
Ben Tanner, a physician assistant at Envision Physician Services in Las Vegas, says that emphasizing how powerful prevention can be is critical for patients in these cases.
“It can be very empowering to patients when you let them know there are steps they can take to help avoid exacerbations,” he says. “Most of them already know how bad a flare-up can be, so if they realize they can potentially prevent it if they take the right measures, they’ll probably be pretty motivated to do that.”
He also finds it helps to educate the patient about other healthy lifestyle measures that may reduce their chances of getting a flare-up. For example, reducing intake of refined sugar and other refined carbohydrates lowers inflammation in the body, which can reduce the likelihood of getting a flare-up.
Tanner notes one of the main things patients should know to prevent worsening or exacerbations is to avoid smoking. It also helps to avoid secondhand smoke and any other irritants, such as exhaust or other noxious fumes.
“Eating an anti-inflammatory type of diet — which includes avoiding excess sugar and [consuming] plenty of vegetables and fruits — also helps; asthma flares or COPD flares are essentially an increase in inflammation,” he says.
Preventive treatment includes steroid inhalers, which keep inflammation in the lungs at bay.
A team approach to care
During follow-up or preventive visits, a physician should always ask the patient about any problems with breathing, Buksh says. This is especially important for patients with established diagnoses that affect breathing such as asthma, COPD, heart failure, interstitial lung disease, obesity and anemia.
“The physician should spend time explaining that lungs are directly affected by poor air quality so that patients can alter their habits or take measures to protect their lungs,” he says. “Develop a team approach to chronic lung disease care. Include a pharmacist and nurse or respiratory therapy driven care management program.”
He explains that pharmacists assist with patient adherence by monitoring refill frequencies and education regarding use of maintenance medications, whereas care management nursing and respiratory therapists can ensure patients have appropriate appliances such as nebulizers or CPAP machines or oxygen, either portable or in-home units.
The past year has brought much more attention to respiratory health amid the COVID-19 pandemic, since respiratory failure is the prime concern and cause of death with severe COVID-19 infection.
Because of that, Buksh says, more people have purchased pulse oximeters and are more aware of their oxygenation. Devices such as smart watches have added features to monitor oxygenation as well, which has led to many patients paying closer attention to respiratory symptoms and respiratory health.
Thankfully, COPD and asthma care have improved significantly with advances in the technology of inhaled medications. However, Buksh notes that affording them has become a significant challenge.
“As a physician, I must be more aware of formulary structure and changes along with the difficulties of patients not being able to afford inhalers that were once the key to the stabilization of their chronic lung disease,” he says. “I am hopeful that pharmaceutical companies and insurers of all types will work together to make sure patients have access to affordable inhaled medications, recognizing that exacerbations and hospitalizations are much more expensive to the system than maintaining control of these chronic lung diseases [such as] asthma and COPD.”