Practical Guidance to Improving COPD Management

As a pulmonologist, many patients referred to me have recently learned that their recurring respiratory infections or breathing troubles were, in fact, signs of chronic obstructive pulmonary disease (COPD).

While nobody wants to learn that they have an incurable disease, symptoms of COPD can be managed day-to-day (also see, “Explore What's Possible: Achieving Optimal COPD Management”). With effective therapy, patients can control their symptoms, reduce their risk of exacerbations, and improve their ability to lead a full life. Yet, despite these treatment options, COPD remains a public health challenge. This debilitating disease continues to be a major cause of chronic morbidity and mortality throughout the world and accounts for millions of deaths per year.¹

After decades of research and development, it’s time to use all the tools at our disposal to improve the outcomes of our patients with COPD. Now, more than ever, we must work together to slow COPD progression, treat symptoms and prevent exacerbations.

Utilizing validated tools as a base for the right treatment approach

Too often, people living with COPD ignore their symptoms because they aren’t aware that they are a result of their disease. For example, it is common for people to pass off shortness of breath as a sign of aging, weight gain or lack of exercise. Subsequently, the majority of patients aren’t diagnosed until they are already living with a progressed form of the disease.² One study in fact demonstrated that eight out of 10 people already had moderate or worse COPD at the time their diagnosis was confirmed by spirometry,² a common test used to assess lung function.³ Studies also reveal that approximately 70% of COPD worldwide may be underdiagnosed.⁴ These statistics highlight the urgent need to identify COPD at earlier stages to improve symptoms, help prevent loss in lung function and decrease risk for exacerbations.

Healthcare providers (HCPs) must do their due diligence to diagnose COPD. They must ask probing questions about respiratory symptoms, lifestyle, smoking history and occupational exposures. They must recognize that many patients are not completely open when discussing their symptoms and go beyond what our patients first tell us. They really need to listen to understand the whole story. If you’re a primary care provider and your patient has difficulty walking down the street or climbing stairs, or comes in with recurring respiratory infections, take notice that this may indicate COPD and perform spirometry.

Once spirometry is used to diagnose COPD, HCPs perform assessments to determine a patient’s level of breathlessness, the disease’s impact on their quality of life and the risk of future exacerbations. The Global Initiative for Chronic Obstructive Lung Disease proposes two validated tools for detecting the severity of COPD symptoms:

• The modified Medical Research Council (mMRC) dyspnea (shortness of breath) score. HCPs use this to identify the “grade” of their patient’s dyspnea on a scale of 0 to 4. The lowest grade, mMRC Grade 0, means the patient only gets breathless with strenuous exercise, and the highest, mMRC, Grade 4, means the patient is too breathless to leave the house or becomes breathless when dressing or undressing.
• The COPD Assessment Test (CAT). This helps HCPs understand the impact breathlessness has on a person’s everyday life. CAT uses a Likert scale format to assess the measure of health status impairment in COPD. It includes eight questions, ranging from coughing (one being “I never cough” and five being “I cough all the time”) to the patient’s ability to complete everyday tasks, like walking up the stairs.⁵

The results of these assessments can open the door for HCPs to ask questions that may encourage patients to speak up about how their disease is truly affecting them. I also encourage my patients to write down any changes they notice in their breathing or symptoms. This helps patients communicate more effectively with their HCPs, which in turn helps with treatment decisions. Understanding this information, as well as gaining insights into exacerbation triggers, can help identify treatments aimed at reducing the risk for another attack, which could result in additional loss in lung function. Understanding symptoms and exacerbation risk helps HCPs craft a management plan that addresses a patient’s personalized needs and goals. Without all the facts, it’s challenging for HCPs to recommend appropriate treatment options and optimize patient outcomes.

Avoiding exacerbations with appropriate pulmonary rehab and medication

Today, HCPs are shifting away from a one-size fits all approach to treating chronic diseases like COPD and looking for ways to elevate personalized care. With the right management plan, including pulmonary rehab and treatments, it may be possible to minimize the impact of symptoms and reduce the risk of COPD exacerbations, which occur when symptoms become severe and can leave behind permanent, irreversible lung damage.

We must help patients understand how to reduce their risk and deal with exacerbations as best they can. While attacks are not always preventable, there are ways to help patients avoid them and their negative consequences:

• Coach patients to recognize and avoid COPD triggers. These can include smoking, dust and fumes from cooking or cleaning products, viral infections and cold air.
• Recommend exercises like biking, swimming or walking, and participation in a formal pulmonary rehab program. Exercise can improve shortness of breath by improving aerobic conditioning. Exercise can also improve quality of life, anxiety and depression, and decrease the risk of further hospitalization for patients.
• Encourage patients to stay up to date on vaccinations — especially the flu vaccine, as people living with COPD are at higher risk of severe complications from flu.⁶ Research has shown that influenza vaccination reduces hospitalizations due to exacerbations by 52% and the risk of death by 70% in elderly patients with chronic lung disease.⁷
• Remind patients to seek care at the first sign of an exacerbation so that appropriate treatment can be started as soon as possible.
• Suggest people with COPD connect with others who can help them manage their disease. Whether they need help getting to appointments or with daily activities, it’s important to remind patients to surround themselves with people they can rely on.

For me, a critical part of every disease management plan is a Food and Drug Administration-approved COPD treatment. These treatments are aimed at improving lung function and decreasing exacerbation risk. No single treatment strategy works for everyone, so it’s important to partner with your patients to identify the right treatment for them. This may include a rescue inhaler that helps open airways in the lungs or a daily maintenance therapy, which can help keep a patient’s airways open throughout the day. Certain maintenance therapies may also decrease inflammation in the walls of the airways. If you’re prescribing a daily maintenance therapy, be sure to explain the proper usage and treatment schedule to your patients.

References

1) Global Initiative for Chronic Obstructive Lung Disease. 2020 Gold Reports. Available at https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf. Last accessed February 2020.

2) Mapel DW et al. Int J Chron Obstruct Pulmon Dis. 2011;6:573-581​.

3) Mayo Clinic. Tests and Procedures. Available at: https://www.mayoclinic.org/tests-procedures/spirometry/about/pac-20385201. Last accessed February 2020.

4) Diab N, et al. American Journal of Respiratory and Critical Care Medicine 2018;198:1130-1139.

5) Global Initiative for Chronic Lung Disease. 2019 GOLD Reports. Available at: https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. Last accessed February 2020.

6) Centers for Disease Control and Prevention. People at High Risk For Flu Complications. Available at: https://www.cdc.gov/flu/highrisk/index.htm. Last accessed February 2020.

7) Nichol KL, et al. Annals of Internal Medicine. 1999;130:397‐403.

If you’re looking for additional resources and information to share with your patients, there are helpful ideas, tools and resources on COPD.com.