Nuances in the Overall Treatment Approach for COPD

Peter L. Salgo, MD: What is the overall treatment approach to COPD (chronic obstructive pulmonary disease), and how would that be in contradistinction to asthma, per se?

Byron Thomashow, MD: I think Frank just said it. The mainstay of therapy for asthmatics who need more than a short-acting occasional beta-agonist is inhaled corticosteroids. That’s not the case in COPD. One of the complexities is, not just for primary care doctors but for us, as well, sometimes differentiating between asthma and COPD. We talked a little bit about spirometry. To really get a feel of whether or not this is asthma or COPD, you often need to do post bronchodilator spirometry. That’s rarely done in the primary care setting. So, it ends up being important to look at the history. Asthmatics tend to start earlier. There’s an atopic component to it. It’s much more intermittent. In COPD, it’s a later onset. There’s more smoking. There are other issues that you need to look at, but it’s more than just happenstance. We need to try to make those diagnoses because the therapies do differ.

Peter L. Salgo, MD: I don’t want to hammer primary care doctors.

Byron Thomashow, MD: No.

Peter L. Salgo, MD: They’re out there. They’re on the front lines. I don’t want their job. They’re very good at it. I wouldn’t be, I suspect. But the ability to do a post bronchodilator spirometry doesn’t seem that imposing. Is it that hard to do?

James F. Donohue, MD: It’s not, but many of us have studied this in the community. The quality of the tracings, when you don’t do a lot, isn’t very good. They don’t go long enough. The recommendation changes, but I would say if you have access to a spirometer, you don’t have to do it, yourself, if you’re only doing 1 or 2 a month, but make sure you know where your pulmonologist or your allergist, or even the hospital lab, is. You should get them at the appropriate time.

Peter L. Salgo, MD: I didn’t ask this before, but I meant to. When do you pull the trigger? When do you call a pulmonologist? When is this not within the wheelhouse of the primary care setting?

James F. Donohue, MD: If someone has unexplained dyspnea, of course, or a cough, or an abnormality on an X-ray, or those kinds of things, and also to help you with therapy, or for someone who’s refractory and is not getting better, those are the kinds of things that we often would consult.

Byron Thomashow, MD: I think that an argument could be made that if you’ve had a hospitalization for COPD in the last year, if you have 2 or more exacerbations that need steroids, if the lung function is going down more rapidly, if you’ve got a sleep disorder, if you’ve got an unclear diagnosis, the question of whether or not it’s one of these overlaps, or if you have someone on what you would call a “maximum inhaled regimen” and they’re still struggling, you should consult with a pulmonologist. COPD should be able to be taken care of in the primary care setting. It’s where it lives, and we’ve struggled doing that.

An argument could be made that GOLD (Global Initiative for Chronic Obstructive Lung Disease) is the single most important program that has existed in COPD, worldwide, in the last 20 years. But while GOLD has had tremendous impact with investigators and academic centers, it has struggled making an impact in primary care. For us to ultimately make a difference, we need to do it in primary care. That’s where people live. What we do here is not neurosurgery. If you have somebody who has really got very advanced disease, who needs to be evaluated for lung volume reduction surgery, or one of Frank’s bronchoscopic procedures, or a lung transplantation, that’s different. But under normal circumstances, a good primary care doctor should be able to do what we do with COPD.

Peter L. Salgo, MD: And before we go on to pharmacologic interventions for COPD, I don’t want to skip over the non-pharmacologic options that people have that are not exclusive. They’re probably overlaid on all of this, right? What is involved in the strategy of treating COPD, other than with drugs?

Byron Thomashow, MD: Frank has already talked a lot about exercise. Pulmonary rehabilitation works. Pulmonary rehabilitation does just about everything you could possibly want it to do. It’s a shame that only around 2% to 3% of COPD patients around the country have access to it. That’s simply unacceptable. But you need to understand that even if you have access to pulmonary rehabilitation, that it lasts x-amount of time. People need to understand that an exercise program needs to go on forever if you’re going to really make a difference. The hooker is, and I think people don’t understand sometimes, pulmonary rehabilitation is not just about exercise. There are many factors in COPD including depression, anxiety, and isolation that tend to develop. Pulmonary rehabilitation tends to address some of those issues. So, pulmonary rehabilitation and exercise, influenza vaccines, pneumococcal vaccines, pertussis vaccination, lifestyle changes. The one thing we absolutely know that changes the tenure of COPD is smoking cessation. I understand it’s beating a dead horse. We’ve already talked about the fact that people don’t like to hear about it. They know it’s an issue. Many people with COPD never smoked, at all, but it does make a real difference.

Peter L. Salgo, MD: It’s important, right?

Byron Thomashow, MD: Yes.

Peter L. Salgo, MD: If you find the big etiologic agent, you hammer it. You’ve got to.

Frank C. Sciurba, MD, FCCP: The other component that is intrinsic to pulmonary rehabilitation programs is nutritional assessment.

Byron Thomashow, MD: Yes, that’s absolutely correct.

Frank C. Sciurba, MD, FCCP: Most often, weight loss with obesity. But at times, patients are actually undernourished. They need nutrition to increase their muscle mass. The increased metabolism and the work of breathing can cause weight loss. So, it can go in either direction, and we need to address that.

Transcript edited for clarity.