Gerard J. Criner, M.D.
Patients who are diagnosed with COPD often have many questions about their disease, its treatment and prognosis. Why am I always short of breath? Will I have to use oxygen? Will I die of this disease? Pulmonologists looking for evidence-based answers to these and other questions attended the May 18 symposium, “Seven Questions Every COPD Patient Wants Answered.”
“The purpose of today’s symposium is to use seven questions frequently posed to clinicians by their patients to give you evidence-based guidelines to answer those questions appropriately,” said session co-chair Gerard J. Criner, M.D., who is a professor of medicine and director of pulmonary and critical care medicine at the Temple Lung Center at Temple University School of Medicine in Philadelphia.
To answer the question, “Why am I so short of breath?” Bartolome R. Celli, M.D., said the relationship of the lungs, brain and peripheral muscles must be understood.
“It appears that for people who have any disease of the lungs, there is only one response,” said Dr. Celli, who is a professor of medicine at Tufts University School of Medicine in Boston. “The brain wants more oxygen and the respiratory apparatus increases frequency, while the tidal volume decreases because, anatomically, air spaces in the injured lung can’t exchange gases very well. It is this synchrony between what the brain wants and what the machine can do that produces shortness of breath.”
Dr. Celli emphasized that the structure and function of the lungs can be changed and dyspnea improved. “The king of all therapies to reduce shortness of breath is rehabilitation,” he said. “If pharmacotherapy improves the dyspnea scale by one unit, rehabilitation will improve it by two units.”
He also highlighted evidence that low-volume reduction surgery improves dyspnea and quality of life by decreasing central drive, increasing lung elastic recoil, delaying dynamic hyperinflation and improving diaphragm function.
In answering the question, “How to get rid of mucus stuck in my throat?” Victor Kim, M.D., began by emphasizing that mucus overproduction predisposes patients to airflow obstruction, and data suggest chronic mucus hypersecretion increases COPD morbidity and mortality.
Dr. Kim, who is an assistant professor of medicine at Temple University School of Medicine, focused on both pharmacologic and non-drug therapies to reduce mucus hypersecretion and overproduction, and to improve clearance.
“I think we can all state that we should try to maximize inhaled therapy, and that corticosteroids and antibiotics are not routinely recommended for those with chronic bronchitis and chronic phlegm production,” he said, adding that cough suppression is not recommended because coughing expectorates phlegm, and mucolytics may be beneficial for patients not on inhaled steroids.
Evidence suggests that there is a strong relationship between COPD and fatigue, said Victor M. Pinto-Plata, M.D., in his presentation on answering the question, “Why am I so tired?”
But evidence also shows a strong correlation between fatigue and conditions associated with COPD, including depression, deconditioning and hypoxemia, said Dr. Pinto-Plata, who is the medical director of the Pulmonary Physiology Laboratory and Respiratory Therapy Department at St. Elizabeth’s Medical Center and Tufts University in Boston.
Dr. Pinto-Plata cited research that 7 to 42 percent of all COPD patients experience symptoms of major depression. His evidence-based recommendations for treatment focused on pulmonary rehabilitation, which improves muscle function, mitigates dyspnea, reduces symptoms of depression and increases energy.
“Patients are from Earth and doctors are from Pluto,” said Barry J. Make, M.D., in describing the differences between what patients want and what physicians perceive when answering the question, “Which inhalers should I really use?”
Dr. Make said that for physicians to make patient-centered therapy choices, they must understand the patient’s goals, whether it is to reduce shortness of breath, be more active or live longer.
“Our goal is to personalize medicine by starting with the patient’s goals,” said Dr. Make, who is the co-director of the COPD program and director of pulmonary rehabilitation and respiratory care at National Jewish Health in Denver.
Physicians want to talk about medicines to improve lung function, but patients don’t care about that, he said. They care about improving quality of life and shortness of breath, and being more active. The physician and the patient together should pick the appropriate medications based on evidence showing improvement of symptoms matching the patient’s goals.
“Agreeing with your patient about what the outcomes are before they start a medication is very important,” Dr. Make said.
When it comes to questions about patient use of supplemental oxygen, Roger D. Yusen, M.D., M.P.H., said data concerning outcomes in COPD patients are spotty and depend on disease severity. An NIH study currently underway may help answer the question, “Do I really need to use this oxygen?” according to Dr. Yusen.
“In patients with very severe COPD and cor pulmonale, long-term oxygen therapy compared to no long-term oxygen therapy improves survival,” he said. “And, again with very severe COPD, continuous oxygen therapy compared to nocturnal oxygen therapy improved survival.”
However, Dr. Yusen noted that supplemental oxygen does not appear to improve survival in patients with moderate hypoxemia, though data come from a small number of trials with limited sample sizes. More answers will likely come from the LOTT study currently underway.
Dr. Yusen, who is an assistant professor of medicine at Washington University School of Medicine in St. Louis, described the National Heart, Lung, and Blood Institute’s Long-Term Oxygen Treatment Trial (LOTT). The randomized, controlled trial being conducted in 14 centers around the country, “will be the largest supplemental oxygen study ever conducted,” he said.
Dr. Criner, the session co-chair, addressed COPD exacerbations in answering the question, “What should I do if I get into trouble?” He reported that frequent acute exacerbations are associated with rapid decline in lung function, increased fatigue and weakness, and increased exercise intolerance. Research also indicates that COPD patients hospitalized for acute exacerbations “are more likely to die from their disease,” he said.
The quicker patients are treated for exacerbations, the better their outcomes, though one study reported that COPD patients with exacerbations only seek medical treatment 18 percent of the time, Dr. Criner said.
COPD exacerbations are best prevented through smoking cessation, self-management education plans, influenza and pneumococcal vaccinations, and, when appropriate, regular therapy with long-acting bronchodilators or inhaled corticosteroids combined with long-acting beta-agonists.
As far as evidence-supported treatments for COPD exacerbations, Dr. Criner began with antibiotic use and reported that extremely ill patients with acute exacerbations had lower incidences of treatment failure on antibiotics, while less-sick patients hospitalized with no fever did no better on antibiotics than control patients in trials.
“This challenges the dictum that patients hospitalized with a COPD exacerbation all need antibiotics,” Dr. Criner said.
He also addressed treatment with corticosteroids, pulmonary rehabilitation and the use of a support person to aid patients in therapy.
In perhaps the most difficult question of all to answer, “Am I going to die from COPD?” Fernando J. Martinez, M.D., M.S., examined the mortality of COPD, reporting that currently the disease is the fourth-leading cause of death in the U.S. and that mortality rates associated with COPD are rising.
Dr. Martinez, who is a professor of internal medicine and director of pulmonary diagnostic services and co-medical director of lung transplantation at the University of Michigan Health System, said that if asked the question, he would have to reply, “maybe.”
“The disease of COPD is much more complicated than we once thought and a large percentage of our patients who aren’t dying from COPD per se are dying of other things,” Dr. Martinez said, adding that heart disease, cancer, stroke and diabetes are the leading diseases related to COPD mortality.
Data suggest that the more severe the COPD and the more exacerbations, the more likely it is that respiratory disease will play a significant role in a patient’s death. What is needed is a comprehensive approach to determining mortality.
“The evolving data that we’re getting can be incorporated into a kind of multi-component fashion where you will be able to markedly improve your ability to answer that question for individual patients,” he concluded.