Patient Caregiver Connection: Novel Approaches to Optimizing Outcomes in COPD
Release Date: June 29, 2018
Expiration Date: June 29, 2019
Media: Internet - based
More than 15 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), and another 12 million have the disease but remain undiagnosed. Spirometry is an effective diagnostic modality, but is underused by health care professionals. Fortunately, a new approach identifies patients who are most likely to have an abnormal spirometry. In keeping with the National Institutes of Health COPD Action Plan that was released in 2017, the COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk, or simply the CAPTURE questionnaire, helps clinicians identify patients with COPD early. Across the United States and globally, most experts recommend relying on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD to manage the disease. While spirometry is clearly an essential diagnostic element, clinicians must also consider patients’ severe breathlessness and acute exacerbations, as well as step-up care. Patients may need inhaled or systemic corticosteroids, supportive care, and perhaps hospitalization. Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. Most patients with COPD use inhalers to control their disease. People with moderate to very severe COPD may benefit from nebulized treatments that allow them to breathe normally while taking medication.
During this Patient Caregiver Connection Medical Crossfire®, a multidisciplinary panel of expert faculty will introduce available tools, discuss guidelines, and suggest strategies to help improve care for people with COPD. This activity is enhanced by a patient’s own story and perspective, from diagnosis to daily challenges and advice for anyone experiencing COPD.
Acknowledgement of Commercial Support
This activity is supported by an independent educational grant from Sunovion Pharmaceuticals, Inc.
Instructions for This Activity and Receiving Credit
This activity is directed to pulmonologists, respiratory therapists, internal medicine and primary care physicians, geriatricians, and researchers; other health care professionals interested in the treatment of COPD are invited to participate.
At the completion of this activity, you should be better prepared to:
- Discuss the symptoms and risk factors for COPD, in addition to the importance of early recognition and routine spirometry in at-risk patients
- Explain the impact of disease severity and patient symptoms, needs, and preferences in providing individualized treatment with goals of slowing the decline of lung function, providing symptomatic relief, and managing disease-related exacerbations
- Review the efficacy and safety of new and emerging therapeutic options for patients with COPD
- Apply comprehensive knowledge to appropriately educate and counsel patients with COPD
Faculty, Staff, and Planners' Disclosures
Attending Physician, Collegeville Family Practice
Medical Director, Health Services, Ursinus College
Cofounder, Brookside Family Practice and Pediatrics
Assistant Medical Director, Health Services, Hill School
Disclosure: No relevant financial relationships with commercial interests
Chief, Division of Pulmonary and Critical Care Medicine
Bruce Webster Professor of Medicine
Joan and Sanford I. Weill Department of Medicine
Weill Cornell Medical College
New York-Presbyterian Hospital/Weill Cornell Medical Center
New York, New York
Disclosure: Grant/Research Support: AstraZeneca, GlaxoSmithKline, Boehringer Ingelheim. Speakers Bureau: Boehringer Ingelheim, Miller, NACE, Novartis. Consultant: AstraZeneca, GlaxoSmithKline, Boehringer Ingelheim, Proterix Bio, Genentech, Novartis, Pearl, Theravance.
Chief of Allergy and Immunology
Advocate Medical Group
Advocate Health Care
Disclosure: Consultant: AstraZeneca, Circassia. Speakers Bureau: AstraZeneca, Boehringer Ingelheim, Circassia, Novartis, Sunovion.
Pulmonary and Critical Care Medicine
Weill Cornell Medicine
New York, New York
Instructor of Practice, Nursing
College of Mount Saint Vincent
Riverdale, New York
Disclosure: No relevant financial relationships with commercial interests
The staff of PER® have no relevant financial relationships with commercial interests to disclose.
Disclosure Policy and Resolution of Conflicts of Interest (COI)
As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.
Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.
Off-Label Disclosure and Disclaimer
This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.
PER Pulse™ Recaps
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Step Up Efforts to Identify COPD Early
Experts in the field of chronic obstructive pulmonary disease (COPD) have a message for American clinicians: It’s time to step up efforts to identify COPD, the third leading cause of nonaccidental death in the United States,1 much earlier.
This chronic, progressive disease is associated with systemic inflammation and creates a smoldering decline in lung function that is not self-evident for many patients. It frequently culminates in abrupt symptomatology, such as coughing and shortness of breath. According to Fernando J. Martinez, MD, and Alanna Kendig, NP, of Weill Cornell Medicine in New York, New York, patients who are aware of their risk factors often have symptoms but ignore them. These are the 12 million individuals with undiagnosed COPD.2 These patients might think, “It’s just normal aging or a smoker’s cough.” Often, they seek treatment only at the urging of their significant other.
Early diagnosis allows intervention during a window of opportunity to slow disease progression and ultimately, preserve patient independence. This has galvanized a concerted global push to diagnose COPD in individuals in their 30s and 40s.
COPD has numerous risk factors, and most clinicians are aware that smoking is a leading cause. However, clinicians should also have a high index of suspicion when patients have indoor, outdoor, or occupational air pollutant exposure. This means that industrial workers, bakers, people who work in dusty environments, and individuals who reside in densely populated areas need to be screened.
Most clinicians also recognize the importance of spirometry, but many offices have been unable to afford the equipment (which is coming down in price). For this reason and others, spirometry is underused in primary care.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is promoting a new tool called CAPTURE (COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk). Written at a sixth grade level, it screens patients with 5 questions about smoke and pollution, seasonal change and its impact on COPD, fatigue factors, and acute respiratory illnesses within the past 12 months. Michael Foggs, MD, chief of Allergy/Immunology at Advocate Medical Group of Advocate Health Care in Chicago, Illinois, said, “The CAPTURE questionnaire helps clinicians identify patients who are at moderate or high risk for COPD and refer them patients for definitive testing.” The combination of peak expiratory flow measurements plus the CAPTURE data are very useful, with approximately 90% sensitivity and approximately 78% specificity.3
The panelists also discussed comorbidities; 60% of patients with COPD have 1 or more chronic diseases, and after age 70, the number jumps to 90%.4 Patients with comorbidities have markedly worse outcomes, require more treatment, use more resources, and need more medication. Individuals with COPD also often experience depression, anxiety, mood disorders, and sleep problems.References
- Wheaton AG, Cunningham, TJ, Ford ES, Croft JB; Centers for Disease Control and Prevention (CDC). Employment and activity limitations among adults with chronic obstructive pulmonary disease—United States, 2013. MMWR Morb Mortality Wkly Rep. 2015:64(11):290-295.
Chronic obstructive pulmonary disease (COPD). April 2018. CDC website.
cdc.gov/copd/index.html#3. Accessed March 30, 2018.
- Martinez FJ, Mannino D, Leidy NK, et al; High-Risk COPD Screening Study Group. A new approach for identifying patients with undiagnosed chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017;195(6):748-756. doi: 10.1164/rccm.201603-0622OC.
- O’Kelly S, Smith SM, Lane S, Teljeur C, O’Dowd T. Chronic respiratory disease and multimorbidity: prevalence and impact in a general practice setting. Respir Med. 2011;105(2):236-242. doi: 10.1016/j.rmed.2010.07.019.
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Individualizing Care in COPD: Critical!
Patients who have chronic obstructive pulmonary disease (COPD) require individualized treatment plans. Often, the primary care provider and his or her treatment team provide basic care for these patients. Experts in the field recently reviewed important considerations when providers see COPD patients and offered clinical pearls for management.
Using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as a basis, these experts reminded clinicians that COPD occurs along a continuum. Patients who have fewer symptoms obviously require less care, but those who have more severe symptoms and especially those who experience exacerbations need very aggressive care. The cornerstone of that care is the handheld inhaler.
Alanna Kendig, NP, of Weill Cornell Medicine in New York, New York, indicated that clinicians prescribing therapy need to look at a triad of factors: device cost, patient dexterity, and the patient’s ability to use the device. With the broader array of devices now available, these are serious concerns. Clinicians must ensure that patients know how to use their inhalers and also have a spacer, Kendrick said.
Michael Foggs, MD, chief of Allergy/Immunology in at Advocate Medical Group of Advocate Health Care in Chicago, Illinois, said, “Clinicians need to look at an acute exacerbation as tantamount to a myocardial infarction in a person with coronary artery disease.” A patient experiencing an exacerbation will need aggressive therapy and, often, antibiotics for 5 to 7 days.
These experts discussed 3 levels of medication:
- Bronchodilators that dilate airway smooth muscle and improve airflow
- Anti-inflammatory medications
- Evolving medications
Most COPD patients generally don’t need inhaled steroids except during periods of exacerbation, according to the experts, who summed up the progression of treatment: Use bronchodilators for breathlessness. If breathlessness becomes persistent, add a long-acting muscarinic agent in combination with a long-acting beta-agonist. If anti-inflammatories are needed, steroids or phosphodiesterase 4 inhibitors are the next step. All are available in handheld inhalers, and clinicians need to be aware that various types of inhalers are used differently.
A long-acting muscarinic agent, glycopyrrolate, is also available via nebulization. Patients find nebulization convenient because they can breathe at tidal volume with little effort or inspiration.
Recently, the FDA approved triple therapy delivered in a single inhaler for patients with frequent exacerbations.
As with many conditions, monoclonal antibodies that target specific IL-5 mechanisms are new to the condition. Two of these, benralizumab and mepolizumab, are among the first of these biologics.
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Educating the COPD Patient: Change Your Behavior to Change Patient Behavior
For patients with chronic obstructive pulmonary disease (COPD), patient education holds the key to better quality of life, continuing independence, and avoidance of exacerbations. These patients see their healthcare providers frequently, and every visit offers an opportunity to reinforce patient education.
Michael Foggs, MD, chief of Allergy/Immunology at Advocate Medical Group of Advocate Health Care in Chicago, Illinois, identified 3 areas of behavioral change that could improve outcomes for COPD patients.
- Patients should be provided with a fundamental understanding of COPD, leading to lifestyle changes and medication adherence.
- Clinicians should offer slightly longer encounter times and use of physician extenders to help them incorporate education into every visit.
- Hospital systems and managed care organizations should recognize the importance of allocating adequate time for educating patients and staff.
These experts remind clinicians that patients who have multiple exacerbations and whose activity is seriously limited need more attention and aggressive interventions. COPD can be socially limiting, but with good care, many patients can regain or extend their independence.
Choosing an inhaled medication generally starts with deciding which drug the patient needs (eg, bronchodilator, anti-inflammatory, or both). Next, the prescriber (ideally, with the treatment team) looks for a device that the patient can use without difficulty, which requires determining the patient’s insurance coverage, dexterity, and ability to understand multiple steps.
A cornerstone of the educational process involves assessment of the patient’s ability to use an inhaler. Clinicians need to demonstrate how to use the specific device, use the teach-back method to make sure patients understand, and review inhaler use at every visit. Engaging the entire clinical team, including the dispensing pharmacist, increases the likelihood that the patient will use the inhaler correctly.
For some patients, especially those who have low inspiratory capacity or difficulty with inhalers, nebulizers present an effective alternative.
Every patient who has COPD can benefit from 2 things: pulmonary rehabilitation—a comprehensive, 26- to 28-week program that helps them understand their disease and make lifestyle modifications—and, if appropriate, smoking cessation. Clinicians need to address both interventions at every visit if the patient has not yet completed them and encourage patients to take every possible step to self-manage their disease.
Finally, the experts stated that patients need a consistent, reliable source of care so that if exacerbations occur, they don’t have to go to an emergency room or urgent care clinic.