COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 10
Recommended strategies for measuring response and efficacy of chronic obstructive pulmonary disease treatment, especially during the COVID-19 pandemic.
Neil Minkoff, MD: Mr Hess, let’s pivot to you. We’ve gone through what the GOLD [Global Initiative for Chronic Obstructive Lung Disease] guidelines say. We’ve talked about how the guidelines may or may not be followed for a patient. When therapy has been chosen—Dr Lopes has covered the therapy—you’re now following the patient chronically. You’re seeing the patient at this point in this scenario. You have them on a regimen. How are you looking to see how they’re doing? How do you assess them? What tests do you do? How often do you try to do that assessment?
Michael Hess, MPH, RRT, RPFT:There are a couple of different ways we can go about it. We have some objective measures, like spirometry, pulmonary function testing, and the 6-minute walk test, which is a measure of exercise capacity. That gives us objective data to tell us what the physiology is doing. We also have things that are a little bit more subjective, which would fall under the category of patient-reported outcomes. These are symptom surveys like the St. George’s Respiratory Questionnaire, which many people may be familiar with. I believe we’ve mentioned the COPD [chronic obstructive pulmonary disease] Assessment Test, or the CAT. There are a couple of other ones out there. Those are where we can give a patient an interview and get a score back that looks at various domains of their symptom burden and where they are.
On top of both of those, one of the things I like to do the most is to simply ask how they’re doing because, as we mentioned before, there can be a big disconnect between the actual symptom burden and the subjective symptom burden, or how they are actually feeling after they’ve done all the adaptation and lifestyle modifications. One of the most rewarding aspects of my evaluations is when I am able to start somebody on a regimen, teach them how to use their therapies, then they come back in a month or 6 weeks and tell me, “Wow, I didn’t know how bad my breathing had gotten until it got better.” When we’re trying to run somebody into a new regimen, I like to see them about every month to 6 weeks.
Once somebody is a little bit more established and we’ve got their technique optimized and everything else going, we can usually go every 3 to 6 months or so. Some of the more cumbersome testing, like spirometry, can go a little bit longer, like annually. It is important to be checking in on people on a regular basis to make sure they’re doing well and they’re comfortable with the regimen because the more comfortable and satisfied they are, the more likely they are to adhere to it, and the better their subjective outcome is going to be.
Neil Minkoff, MD: Let me tweak the scenario a little bit. Let’s say the patient isn’t doing well, or you don’t think they’re doing as well as they could. In this scenario, they’ve come to you and they’re on a combination therapy. How do you start to reevaluate where they are? What testing do you do? How do you make recommendations for changes?
Michael Hess, MPH, RRT, RPFT: That’s where we start diving a little bit more into the quality of life interviews. There’s this idea of treatable traits, where there are certain things that we can specifically target in COPD therapy. For example, is somebody coughing very much? Do we need to figure out how to address that cough? Do we need to start looking at allergy control? Are they having reflux? Are they just short of breath? Do they need to go to pulmonary rehab and get “back into shape?” We start looking at what exactly we can modify. We also have to make sure we’re looking at inhaler technique because the tools don’t work if you don’t know how to use them. Then once we have eliminated all of that stuff, we can start looking at what we need to do to the medication regimen to optimize that.
Once we start getting well into the more severe phases of the disease, we can start looking at things like respiratory-assist devices, or noninvasive ventilation, or even some of the newer bronchoscopic interventions that are out there: the valves, coils, and the other therapies that can make minimally invasive changes to the lung physiology itself to get those people breathing their best and raising their quality of life.
Neil Minkoff, MD: Do you use PIF [peak inspiratory flow] as a way of helping to stratify that or to evaluate further?
Michael Hess, MPH, RRT, RPFT: Absolutely. I use that at every encounter because it does change over time as people age or as their concurrent conditions change. There are many factors that can impact somebody’s PIF, so it’s important to be checking that on an ongoing basis to make sure their regimen continues to be appropriate.
Neil Minkoff, MD: Dr Mahler, I have a similar question. You started talking about your approach and how you can help patients breathe even better with the 2-in-1 device and so on. Say that patient comes back. How are you evaluating their response, and what tools do you use?
Donald A. Mahler, MD: Basically, as Michael said, I ask the patient, “How are you doing?” A lot of times, they’ll say, “I’m fine.” And then I’ll say, “Tell me what activities you’re doing,” because a lot of people reduce their activity to minimize the unpleasant experience of shortness of breath. It depends on their activity. Some people are happy being very sedentary. Certainly, with the pandemic we’re experiencing now, we have a lot of patients who stay at home, are inactive, and are becoming deconditioned. A lot of them are gaining weight.
One of the other aspects in selecting the appropriate inhaler that I follow is a 3-step process. If it’s an initial visit or a follow-up visit, the first step is assessing their cognitive function. Are they able to think clearly? Are they able to follow instructions? If their cognitive function is impaired, then my assessment would be that a handheld inhaler is probably not appropriate. They would probably need nebulization as long as they have a family member or a caregiver able to set up that nebulizer kit or system. Then I’ll assess their manual dexterity, or whether they can handle the inhaler correctly. Do they have arthritis? Do they have Parkinson disease? Do they have muscle weakness that might impair their ability to actuate and load an inhaler? If their manual dexterity is poor, I would recommend nebulization.
For the final step, if I’m thinking about a dry powder inhaler or they’re already on one, I’ll have our respiratory therapist measure their peak inspiratory flow. If that is suboptimal and I’m going to use a handheld inhaler, then I would pick either the pressurized metered-dose inhaler or the slow mist inhaler because those are flow-independent and don’t require the patient to generate a high inspiratory flow to literally break up and pull the powder out of the device. The final step is patient preference. Sometimes people have been tried on different inhalers. They say, “Well, I like this one. I can use this one correctly,” and that will play a role in inhaler selection.
This activity is supported by an educational grant from Boehringer Ingelheim.