Targeting Treatments to Improve Quality of Life for Patients With Emphysema (AJMC TEST)

The treatments for chronic obstructive pulmonary disease (COPD) include drugs, rehabilitation, and invasive procedures, and not all options are right for all patients, explained Sohini Ghosh, MD, director of interventional pulmonology, Allegheny Health Network.

The potentially easiest option is to remove the offending agent causing emphysema, but some patients might be eligible for invasive procedures such as valve placement or lung transplant, both of which include rigorous workups to determine patient eligibility.

Overall, the goal of treatment and procedures is to improve the quality of life and day-to-day living of patients, Ghosh said during an interview with The American Journal of Managed Care^® (AJMC^®).

AJMC^®: How does emphysema impact the quality of life for the patient?

Ghosh: The biggest quality-of-life factor is really the shortness of breath and being able to do things on a day-to-day basis. What we hear from a lot of patients who are seeking further treatments is that they're just not able to do their day-to-day things. Previously, they can walk up the steps, and they're short of breath, but they could still do it. But now they're not able to do that, or now they're not able to walk to the restroom, or they can't leave the house because they're so short of breath. That's where the emphysema really affects the quality of life and day-to-day living.

The reason that we see that—whether it's from smoking or occupational hazards—is our lungs are made up of lots and lots of small little pockets, and those pockets collapse and expand collapse and expand when we take in breaths. But with the destruction with emphysema, from all the particles, those pockets become these really big pockets that can no longer fully collapse. Meaning that the air doesn't fully leave their lungs, and that air just gets stuck in their lungs. They have all this extra volume, and their lungs are actually too big for their chest wall, and that can cause compressions on our normal muscles.

The diaphragm is the big normal muscle that causes us to breathe in and breathe out normally. But when all this extra air is trapped in the lungs, it pushes the diaphragm down, so the diaphragm can't work normally. When it can't work normally, it can't compensate or can't work when someone is doing any exertion. For example, when me or you, we walk up the steps, our diaphragm is able to work a little bit better to exhale the air. With someone who has bad emphysema, when they're rest, they're fine, but as soon as they start walking, their diaphragm can't doesn't function normally, and they just get short of breath very, very quickly. That's where, with severe patients with severe emphysema, we really see their quality of life impacted.

AJMC^®: What are traditional treatments for patients with severe emphysema?

Ghosh: The number one treatment is to get rid of the offending agent that causes emphysema. If that’s smoking, to quit smoking. If that's an occupational exposure—if they're not able to get another occupation—at least make sure that they have proper protection. Then there's also certain genetic conditions that can cause COPD, and to identify those patients who have that, so they can be supplemented appropriately. That's foremost.

Then comes medical therapy, which is generally inhalers. There are 3 basic drugs that are included in inhaler COPD therapy. There's a whole different slew of drugs with different combinations of different drugs, but essentially, it's a maximum of 3 drugs. Those are used regularly either once or twice a day to try and prevent patients from having either flares of their COPD where they need more care, or just to control their daily symptoms. Then after inhalers, some patients may need oxygen. A really big part of it is pulmonary rehab. And that helps people not only get their strength up, but trains them to breathe in manners that they can kind of compensate for that air trapping that we had talked about previously. So those are the 3 basic cores of COPD: getting rid of the insulting agent, inhalers, and pulmonary rehab.

Then there's 2 kinds of traditionally more invasive procedures for COPD. One is the most invasive: lung transplant. That is probably the highest commitment and the most rigorous that any patient would have to go through. Not only is that a big surgery for a lung transplant, it's a completely huge lifestyle change with regards to exchanging COPD for the health condition of having a transplant. There's a whole lot of rigorous workup, very few patients qualify, and the number of donors are low. It is an option for select number of patients, but not everyone.

The less aggressive, but still quite invasive, procedure is lung volume reduction surgery, which is kind of where Zephyr valves pay into. Like we discussed, the problem with emphysema is that this air gets stuck in pockets of lungs, and it doesn't collapse like a balloon, it just stays inflated. Lung volume reduction surgery, or LVRS, was studied in the early 2000s to go in and surgically remove the most diseased portion of a patient's lung. Doing that allows the healthier lung to function better and to cause less of that compression of the diaphragm. That was studied in the early 2000s, and there are select patients who do benefit from it; however, it has fallen out of favor because these patients are already quite ill, and it requires a specific set of surgical skills, as well as a very specific patient population to put a sick patient under a big surgery like that.

AJMC^®: What is the benefit of the Zephyr valve over traditional surgery?

Ghosh: The concept is very similar in that it is to get rid of the most diseased portion of the lung, but it's done without surgery. It's done minimally invasively. It's a procedure that is done by a flexible bronchoscope under general anesthesia. There's no cutting of the skin; the scope goes in through the mouth into the lungs, and one-way valves are deployed into, ideally, the most diseased portion of the lung. These one-way valves allow air to leave that portion of the lung but not extra air to go in.

For example, if we're going into the right upper lobe, we're going to put in how many of our valves are needed into those airways to prevent air from going into there. That will eventually lead to collapse or atelectasis of that lung. When that right upper lobe, for example, of the lung collapses, that allows the rest of the lung on the right side to work better. So, it creates the same physiological response but in a much less invasive manner.

AJMC^®: Are there certain individuals who are better candidates for the Zephyr valve procedure?

Ghosh: Yeah, so this procedure does require a pretty extensive outpatient evaluation. The two most important things are that patients have quit smoking and are otherwise optimized on their COPD therapy. Then there's also another requirement that we look at, which is they're called their FEV₁, or their forced expiratory volume. That's a measurement taken on pulmonary function testing to determine the severity of their COPD or emphysema. That's the basic parts of qualifying for it; however, there is a pretty extensive outpatient evaluation looking at heart function, looking at the degree of air trapping, looking at their CT scan to see how damaged the lung is, and to see if the lobes are appropriate for the type of valves, as well as some blood work. Once a patient has a certain FEV₁, and has quit smoking, we can evaluate them in clinic with the rest of the evaluation, and if they qualify, based on the rest of the outpatient evaluation, then we would pursue on with the procedure.

Not everyone who has COPD is going to be eligible for this procedure. That's why there's that extensive outpatient evaluation. However, if anyone is interested, we can evaluate them to see if they would benefit.

AJMC^®: What is the plan of action in the cases of patients whose emphysema or COPD worsens after the Zephyr valve procedure?

Ghosh: Say, a valve is placed, and a patient does well, and we follow them up as an outpatient, regardless of the patient, we plan to repeat pulmonary function tests as well as their quality-of-life scores in a follow up. The biggest benefit of this procedure is really to target quality of life, and to improve a patient's day-to-day activities. If we're seeing someone in follow up, and either their breathing tests are not improved or their quality of life has not improved, then we would look to figure out what is the issue. Are the valves working appropriately? If they are working appropriately, then to look for something else. If the valves aren't working appropriately, then we would troubleshoot to see if there's something that we need to adjust. But the biggest goal of the procedure is really to improve the quality of life and day to day of these of these patients.

AJMC^®: We’re heading into winter and flu season: in general, are patients with COPD affected worse by the flu because this is a respiratory condition?

Ghosh: It definitely can. A lot of it depends on their reserve. A patient who has healthy lungs, they get the flu, they might just have fever and really not that much pulmonary issues because their lungs are otherwise healthy. In someone who has COPD, their reserve is a lot lower, so they are likely to get a lot sicker from a lung standpoint, just because they're not able to compensate appropriately. If they're already on oxygen and their lungs have a little bit of a hit, they're more likely to end up hospitalized or in the [intensive care unit] than someone who doesn't have lung disease.

AJMC^®: What proportion of COPD patients typically get the flu vaccine, and has awareness of the COVID vaccine increased awareness of the flu vaccine?

Ghosh: I don't have any specific data with regards to what vaccination rates are. I do know that in the past couple years, we have seen flu rates be a lot lower than they have in the past. That's primarily been due to masking. It's a little hard to say what's going to be coming up this next winter as most masking rules are no longer in place.

From a personal standpoint, I can tell you that, unfortunately, the majority of my patients are not vaccinated for the flu. I'm hoping now with this COVID vaccine and the fact that there might be a booster coming up patients might be willing to have both at the same time. I am worried, however, that because there have been lower rates of flu the past couple of years, the public is going to artificially think it's because the flu is not out there. I don't have any data on what the flu rates vaccination rates are, but I can subjectively say that they're not as high as I would like them to be.