In COPD and Pulmonary Hypertension, Potential Care Gaps Warrant Further Research

A series of posters presented at the 2023 American Thoracic Society International Conference focused on advancing care for patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH), with studies highlighting areas with room for improvement when it comes to caring for patients with pulmonary conditions.

Focusing on the Patient Experience

Patients with COPD experience declines in quality of life due to clinical symptoms, but also psychological distress from the stigma associated with the condition, according to one abstract.¹

The study aimed to validate the COPD-related Stigma Scale (COPDSS), a 24-item survey designed to measure COPD-related stigma and its effect on patients.

“COPD-related stigma contributes to psychological distress,” said presenter Seoyoon Woo, PhD, RN, assistant professor at the University of North Carolina School of Nursing. “Other disease-related stigma has been well-studied, like mental illness or HIV, but COPD-related stigma is not researched, and a stigma scale is needed.”

The cross-sectional study evaluated the factor structure of the scale and its reliability, validity, and sensitivity in 271 patients with COPD who completed the COPDSS online. The scale showed adequate to high internal consistency reliabilities, as measured by Cronbach’s α, and confirmatory factor analysis indicated that one higher order (COPD stigma) with 4 subscales (social stigma, felt stigma, anticipated stigma around oxygen, and smoking-related stigma) fit the data well.

Considering there has been limited research on stigma and COPD, consistent measurement of such factors could fill a knowledge gap and allow for more personalized care, and the COPDSS may hold potential as a measure of COPD-related stigma. Most of the population was female and Caucasian, and research in diverse populations may be needed, the authors noted.

Another poster explored the association of supplemental oxygen use and symptoms, health status, and mood in patients with PH.²

Supplemental oxygen is often used as a supportive therapy for PH, as it reduces pulmonary vascular resistance and can ease symptoms. However, the symptom profile and health status in those who use supplemental oxygen is not well researched.

In the study, which was a secondary analysis of a cross-sectional study of 176 adults with PH, participants were stratified into 2 cohorts: oxygen use (n = 115) and no reported oxygen use (n = 61).

All participants completed surveys related to physical and mental health status. These included sociodemographic information, Pulmonary Arterial Hypertension Symptom Scale (PAHSS) to gauge symptom severity, the Pulmonary Arterial Hypertension Symptom Interference Scale (PAHSIS) for the degree to which symptoms interfere with life, the Medical Outcomes Study Short Form (SF)-36 to determine health status, and the Profile of Moods State (POMS) to gauge patient mood.

Patients using oxygen were significantly older and showed higher PAHSS and PAHSIS scores. They also showed worse SF-36 and POMS scores compared with patients who reported no oxygen use.

“For those that were using oxygen, they had a higher symptom severity, more interference with their symptoms, worse health status, and worse mood states around depression,” said Lea Ann Matura, PhD, RN, associate professor at the University of Pennsylvania School of Nursing.

A notable limitation was a lack of data on how participants used their supplemental oxygen, which varies from patient to patient. The patient population was also 86% female and mostly non-Hispanic White, potentially limiting its generalizability.

More research is needed to determine who may benefit from supplemental oxygen and the effect on symptoms, health status, and function.

Addressing Potential Care Gaps in Respiratory Conditions

One poster examined the incidence of obstructive sleep apnea (OSA) in patients with severe and very severe COPD to determine the effect screening for OSA may have in this population.³

“We know that sleep apnea, if it’s untreated, there is a high risk of mortality compared to the patients in treatment,” explained presenter Kristina Hansen, former ICU nurse and PhD student at the University Hospital of Southern Denmark, Vejle Hospital.

COPD and OSA occurring simultaneously is known as overlap syndrome, and these patients experience more severe oxygen desaturations during sleep vs those with either COPD or OSA alone. When treated with continuous positive airway pressure (CPAP), they have a lower mortality risk compared with patients who are not treated, so identifying patients with overlap syndrome who may benefit from CPAP is important.

Patients with COPD and no prior diagnosis of OSA were screened with an at-home cardiorespiratory monitor, and the researchers found that patients had a high rate of OSA and/or nocturnal oxygen desaturation. Of 67 participants with COPD, 38 (57%) were shown to have symptomatic OSA and/or nocturnal desaturation. These findings suggest that screening for OSA should be standard for patients with severe or very severe COPD.

Another area where unmet care needs are present is the treatment of women with advanced COPD, according to the final poster presented during the session.⁴

COPD is a condition that carries a significant symptom burden, and women report an increased number of exacerbations, higher symptom burden, and lower quality of life than men with the condition. As COPD progresses, palliative care (PC) is recommended to improve quality of life, the authors noted.

“When I did an integrative review, I found that most studies were focused on white males,” said Jessica Madiraca, a PhD student at the Medical University of South Carolina, who presented the poster. “I really wanted to focus on whether women have different needs, and what are those needs?”

The Global Initiative for Chronic Obstructive Lung Disease recommends early integration of PC and using it as disease progresses to improve QOL. “Thus, the primary objective of this study is to explore the unmet care needs, identify barriers to care, and knowledge of PC services of women with advanced COPD,” wrote Madiraca, et al.

Participants in the study (n = 30) completed questionnaires related to quality of life, COPD symptoms, and PC, if applicable. Preliminary results found that women with advanced COPD reported unique care barriers to accessing resources, such as medications or oxygen. Another commonly reported theme was stigmatism, as well as emotions such as anger and embarrassment due to the stigma around COPD. None of the participants were receiving PC, and most had never heard of it.

The findings suggest there are unmet care needs among women with advanced COPD and that further research into barriers to care is needed. PC may be underutilized, and emotional support resources are lacking.

Overall, presenters emphasized the need for more research on the patient experience and possible care gaps to optimize the treatment of patients with COPD, PH, and other lung conditions.

References

1. Woo S, Reich JC, Pond RS. Validity and reliability of the Chronic Obstructive Pulmonary Disease-Related Stigma Scale using confirmatory factor analysis. Poster presented at: American Thoracic Society International Conference; May 20-24, 2023; Washington, DC. Accessed May 22, 2023. https://cattendee.abstractsonline.com/meeting/10703/Presentation/9124

2. Matura L, Proana M, Iroegbu. The association of oxygen use and symptoms, health status and mood in pulmonary hypertension. Poster presented at: American Thoracic Society International Conference; May 20-24, 2023; Washington, DC. Accessed May 22, 2023. https://cattendee.abstractsonline.com/meeting/10703/Presentation/9126

3. Hilberg O, Gantzhorn EK, Jensen HI, Loekke A, Hansen KK. The effect of screening for obstructive sleep apnea in severe and very severe COPD - an exploratory clinical study. Poster presented at: American Thoracic Society International Conference; May 20-24, 2023; Washington, DC. Accessed May 22, 2023. https://cattendee.abstractsonline.com/meeting/10703/Presentation/9123

4. Madiraca J, Lindell KO, Phillips S, Coyne P, Miller S. Exploring the unmet care needs of women with advanced chronic obstructive lung disease (COPD). Poster presented at: American Thoracic Society International Conference; May 20-24, 2023; Washington, DC. Accessed May 22, 2023. https://cattendee.abstractsonline.com/meeting/10703/Presentation/12309