COPD Spotlight

February 15, 2021
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

January 22, 2021
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

COPD & COVID-19: An Interview With Dr MeiLan Han

As coronavirus disease 2019 (COVD-19) deaths and cases continue to climb in the United States, patients with conditions that can exacerbate COVID-19 severity, such as chronic obstructive pulmonary disease (COPD), have had to adjust to transitions in care delivery and maintenance.

Although the prevalence of comorbid COPD among those hospitalized with COVID-19 is lower than that of the general population, patients with COPD are 3 times more likely to die from a COVID-19 infection.

In an effort to protect these patients, telemedicine utilization has become paramount to ensuring individuals receive quality and timely care while adhering to pandemic guidelines.

However, as Meilan King Han, MD, a professor of internal medicine in the Division of Pulmonary and Critical Care at the University of Michigan explained, because patients with COPD knew they were at increased risk of COVID-19 complications, many experienced fewer exacerbations over the course of the pandemic due to less exposure from external triggers.

In an interview with The American Journal of Managed Care®(AJMC®) Han laid out how her practice has altered patient care to adapt to the ongoing pandemic and elaborated on challenges patients with COPD and their providers face when dealing with a highly contagious airborne respiratory virus.

Han is a physician and researcher with a focus on chronic lung disease and COPD. She is also a national volunteer spokesperson for the American Lung Association.

The following interview has been edited for length and clarity.

AJMC®: The CDC classified individuals with COPD as being at a higher risk of experiencing more severe COVID-19 symptoms. Nearly a year into this pandemic, what do we know about how these 2 conditions interact?

Han: I think it's really interesting because one thing that has happened is that many patients with COPD got the message that they were at increased risk and have been doing, I would say overall, a fairly good job of staying at home. What I would say, on the ground, at least in my own practice, as well as with talking to other physicians around the country, is that one odd thing that we're seeing is that patients with COPD in general are having fewer exacerbations of their disease than we would normally see. We know that in normal times, exacerbations would be due to things like normal colds, and other non-COVID-19 viruses. The interesting thing is that overall, we're seeing patients having fewer exacerbations simply because they're heeding the CDC guidance and staying at home.

Now, this does not mean that no one is getting sick. I have more recently seen several of my patients with both things like COPD as well as asthma become sick with COVID-19. The studies really do indicate that patients who are either older—which COPD patients tend to be, we know that the prevalence increases with age—as well as have underlying conditions such as COPD, truly are at increased risk for poorer outcomes. Certainly, I've had some of my own clinic patients, unfortunately, do poorly when they've contracted COVID-19. For every patient, there's still a wide range of disease severity, even within the group of patients who have COPD. But we know that as a group, they are at increased risk for more severe COVID-19.

AJMC®: What extra pressures or challenges do patients with COPD face during a pandemic that is wrought by a respiratory virus?

Han: We're seeing tons of challenges. One of them is just attaining regular medical care. Many patients with COPD live in rural areas, and they also tend to be, as a group, more socioeconomically disadvantaged. They're also afraid. What this means is that in a pandemic they're less willing to travel. They may not be able, for instance, to get someone to drive them because of the risk of that, and so they're having a harder time making it to in-person appointments when that's an option. They're also having a harder time doing virtual visits, because I'm finding a lot of them don't have the appropriate technical equipment that would require. We still are allowed to do phone visits, but it's unclear how long that those will continue to be reimbursed for.

I will also say, I've had one patient in particular that I did a video visit with who then was admitted to the hospital not long afterwards. And I wondered whether if I'd actually seen her, I would have realized perhaps how sick she was. But it's just difficult, even with video, to not be in the same room with a patient and observe how they're breathing and to listen to them and talk to them and watch them walk around. It's just not the same overall experience.

The other thing I'm finding a challenge is even how to do things like patient education. Normally, my nurses would go into the patients' rooms and would review inhaler techniques with them. We've never really tested this system out virtually. Like I said, many of my patients don't even have video as an option, so that's getting harder and harder.

The other problem that we've noticed is that many of the pulmonary rehabilitation centers closed during the pandemic. Many of them are back open, and are taking significant precautions, but these are intended to be shared spaces. Rehab is often performed in groups. So, getting patients in pulmonary rehabilitation has been hard.

Other things that have been challenging include things like some of the treatments that many of our patients receive. Things like nebulizers, which are aerosol generating procedures, can be challenging, because if a patient has COVID-19, they could be aerosolizing COVID-19 particles to anyone that they might be sharing a home with, for instance. We had developed specific guidance for patients if they already become infected about trying to isolate when using nebulizers. The same thing goes for continuous positive airway pressure (CPAP) machines. Those also can generate aerosols and spread virus. So, if you have an actively infected patient they need to be sleeping alone, for instance, when using the CPAP machine. I think almost every aspect of life for COPD patients has been affected by the pandemic.

AJMC®: In your practice how has the pandemic altered care? Are you doing predominantly telehealth visits or phone visits with patients?

Han: I've been doing a mix depending on how bad the surge is. In Michigan, where I live, the surge was really bad in the spring, and at that point, the hospital encouraged us to move to almost all virtual visits. Things were much better in Michigan over the summer. I was able to get many of my patients back in for in-person visits and check their spirometry and tried to get issues sorted out in person.

We're now in the middle of a second surge. I have re-transitioned many of my visits back to virtual and we're kind of doing a mix. One thing that's been really challenging is just even doing pulmonary function testing on patients because this is also an aerosol generating procedure. Health systems have taken 1 of 2 approaches. Either they will test for COVID-19 first, or they will not test but the technicians and therapists that are doing pulmonary function testing have to wear full personal protective equipment (PPE) and will try to even do those in a negative pressure room if it's available. Even bringing people in when things were better was still more cumbersome than it typically would be.

Right now, I'm doing a mixture both in-person and virtual. The question on all my patients' minds right now is "When can I get the vaccine?" As we know the government and CDC have recommended currently individuals over 65 and individuals with conditions that would put them at increased risk [of COVID-19 complications should be vaccinated]. I think the majority of COPD patients would fall into that group that really should be prioritized for vaccination.

In Michigan and at Michigan Medicine, they started rolling that [protocol] out and scheduling this week, but then put a halt on it because we did not get a shipment of vaccine that we were expecting. I'm kind of just sitting here waiting to see what's going to happen with that. I know that at a national level, we've been told there's plenty of vaccines, but Michigan did not get an expected shipment this week. I really have yet to see any of my COPD patients receive the vaccine yet.

AJMC®: Are most of your patients eager to get the vaccine or are you confronting any hesitancy?

Han: I would say the majority of patients are eager to get the vaccine and are trying to sign up in as many places as they can think of; if they've seen physicians at 2 health systems, they're signing up with both health systems. They're signing up with multiple pharmacies. I have received some patients that have concerns. Patients, for instance, that might be on immunosuppressive medications, or have had other specific questions. Some younger patients, not my COPD patients, have had concerns or they may have seen in the media, for instance, things about pregnancy. But I would say for the most part, my COPD patients have been quite eager to be vaccinated.

AJMC®: How do you think the pandemic will affect treatment paradigms moving forward? Do you think there will be any long-term impacts?

Han: I do, and I'm hoping that they're for the better. I know that getting into the health system for care has always been a challenge for COPD patients, even outside the pandemic. I'm hoping that we can make at least some version of virtual [care] work for patients and figure out how to do that.

But in order to do so we've got to solve some of the technology problems. We need to figure out how to better deliver patient education virtually. We also need to figure out how better to deliver pulmonary rehabilitation, I think in a virtual format. Certainly, there are pulmonary rehab programs that are virtual that exist but trying to figure out how to help patients access that has been a challenge. Another thing that we've seen is, there are portable spirometers that are available. There are companies that manufacture these. They exist and the platforms exist to get these into the hands of patients, but how to bill for them, how to monitor, how to use that information, how to get that information into the electronic medical record, such as EPIC that we're on at the University of Michigan, and I think many health systems are on, those details have not yet been sorted out.

I think this is an opportunity to try to figure out all of these issues, such that we can better deliver care in a way that patients most need it in the future. Interestingly, before the pandemic The University of Michigan had as a goal to transition roughly 30% to 35% of all patient visits to virtual…just to increase access. I would envision that, in the future, I will have better ability to provide care virtually for patients, including patient education and rehab and mobile spirometry, if that makes sense for the patient.

But I don't think this means in-person visits will go away. I think in the future, we will probably be looking at a hybrid approach where patients might do virtual visits, for instance, alternating with in-person visits or perhaps, doing urgent add-on visits virtually if that's the most convenient for both the patient and the provider. My hope is that this will sort of improve options to optimize patient care moving forward because we've been forced to figure out how to deliver care in different ways during the pandemic.

AJMC®: Is there anything that we haven't covered that you would like to discuss, or do you have any final thoughts you'd like to share?

Han: The best final wrap-up thought would be just encouraging patients who do have COPD to get vaccinated as soon as they are able. I have no reason at this point to believe that the vaccines are not safe or effective in the patient population that we're discussing. And I am strongly recommending that all of my COPD patients get the vaccine as soon as they can.

January 29, 2021
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

Dr Antonio Anzueto On the Benefits of Triple Therapy, Importance of Accurate COPD Diagnoses

Each year the Global Initiative for Chronic Obstructive Lung Disease (GOLD) releases a report on updated guidelines for chronic obstructive pulmonary disease (COPD) treatment and disease management. In the 2021 GOLD report, changes mainly reflected treatment recommendations for patients with COPD who develop coronavirus disease 2019 (COVID-19), explained Antonio Anzueto, MD, in an interview with The American Journal of Managed Care®(AJMC®).

In addition to recommendations on COVID-19, the updated report highlights new research on COPD therapies, diagnosis, and rehabilitation programs. In this interview, Anzueto discusses the benefits of triple therapy for COPD, adherence issues patients may face, and the importance of correctly diagnosing the disease.

Anzueto, a professor of medicine at the University of Texas Health in San Antonio and clinician practicing pulmonary and clinical care, also serves as a member of the GOLD Science Committee.

The following interview has been edited for length and clarity.

AJMC®: What are some of the key updates made to the GOLD 2021 report, and why are they important?

Anzueto: Probably the main update in the report is having a section related to how COPD patients should be managed in the COVID-19 area. In this document, we emphasize the need to continue their current appropriate medication, to do the evaluations and diagnostic procedures. We recognize there are limitations in the use of spirometry due to COVID-19 and the risk for contamination. But that doesn't mean patients should not continue their appropriate therapies, as well as the prevention measurements, such as smoking cessation and pulmonary rehab. We specifically also recognize that COVID-19 may not finish the day the patient starts feeling better, that patients may have some long-term effects as part of COVID-19. We have a section on follow-up assessment for COPD patients after they develop COVID-19. The main areas are related to the management of COPD patients during the COVID-19 pandemic.

AJMC®: What are the goals for this year's GOLD report?

Anzueto: I think one of the main goals is going to be to fully understand how the pandemic is impacting our COPD patients. More importantly, how the vaccine will be able to protect these patients. We're looking forward as the vaccination is being implemented in older individuals, individuals with comorbid conditions, to understand the efficacy as well as the safety of the vaccine to protect our patients with COPD or with chronic lung disease.

AJMC®: What are some of the benefits of triple therapy in patients with COPD, and can you discuss any potential risks of pneumonia?

Anzueto: I think it's important to recognize that COPD today is a treatable condition. It's crucial to make a diagnosis to know what the disease is. And once we recognize the diagnosis, the important thing is to implement pharmacotherapy for these patients. Since the 2000s, beginning in 2010 to 2015, the standard of care has become the use of inhaled corticosteroids [ICS]/long-acting β2-agonist [LABA] in a fixed combination and the long-acting anticholinergics. Since triple therapy has become available in a single inhaler—first as a once-a-day with a combination of fluticasone, vilanterol, and formoterol, and later on with a twice-a-day formulation of budesonide, formoterol, and glycopyrrolate—we clearly have better opportunities for the management of our patients with COPD.

We have recognized also, for the last 15 years, that patients who receive inhaled corticosteroids are at an increased risk to develop pneumonia. Further studies in that area clearly recognized that the individuals who are sicker, and individuals who have very low eosinophil counts, are the ones at an increased risk of developing pneumonia. The clinical trials in patients on the triple therapy, the ICS/LABA/LAMA [long-acting muscarinic antagonist], versus the dual therapy LABA/LAMA without inhaled corticosteroids, demonstrated that there is an increased risk of pneumonia.

What I tell my patients is, yes, the potential risks have increased for pneumonia, but I'm doing everything that I can to prevent pneumonia. I try to be sure patients get up-to-date on influenza vaccinations. I try to keep them up-to-date on pneumococcal vaccinations both for the conjugated vaccine as well as the polysaccharide vaccine and [make sure] they are given at the appropriate time. Today we also understand that the diphtheria, pertussis, and tetanus [DPT] vaccine should be included in the management of patients with chronic lung diseases.

In a lot of the data on the risk of pneumonia and inhaled corticosteroids, the piece of data that is missing is the history of vaccination, especially pneumococcal vaccination. Clinical studies have demonstrated that pneumococcal vaccinations can give a significant protection especially to the serotypes included in the vaccine. I tell my patients, yes, you are at risk to develop pneumonia, but I'm trying to do everything that I can...This is a matter of risk/benefit. I believe that the benefit [of triple therapy] outweighs the risk primarily with the protection in reduction in exacerbations, improvement in quality of life, as well as improvement in lung function.

AJMC®: Studies on triple therapy have indicated it can result in a reduction in all-cause mortality when compared with dual and monotherapies. Is this finding a class effect?

Anzueto: I think it's hard to say if there is a class effect, if this is an effect of inhaled corticosteroids alone or this is an effect of the combination of medications. If we go back to 2000, there was a study called UPLIFT, and there were patients who were on ICS/LABA and they had the long-acting anticholinergic tiotropium added to the regimen. That study was versus placebo. There was a group of patients who were on ICS/LABA and placebo and patients who were on ICS and LAMA tiotropium. There was a significant reduction in mortality in the triple therapy group. I think, at the end of the day, there may be some effect with inhaled corticosteroids in the decreased mortality. But the benefit is being obtained and having the triple therapy, having the dual bronchodilators given together with inhaled corticosteroids, that would give the largest protection to the patients.

AJMC®: What are the main adherence challenges to triple therapy that your patients face?

Anzueto: For COPD, we have great medications available. As a matter of fact, 28 different medications have been developed over the last 15 to 20 years. And we can have the best medication in the world, but the patient cannot get it. That's a tremendous challenge. We are beginning to recognize that there are factors related to the individual, like their ability to generate enough inspiratory force to have a medication penetrate into the lungs, that is a very significant element, as well as coordination with the delivery systems, that [impact whether] they are able to get their medication. The GOLD committee has recognized, since 3 years ago we proposed in the algorithm of management that when the patient comes back to us for follow-up, and the patient tells us "I don't feel fine, I'm not doing well," before we jump into changing medication, adding or removing medications, we should address their ability to take the medication and their techniques. Having medications from different delivery systems—some dry powder, some are hydrofluoroalkane [HFA] formulation, some are soft mist, some are nebulized—these give us a very unique opportunity to tailor that delivery system to the patient's actual needs.

AJMC®: Can you elaborate on the role of critical errors in inhaler use and how these may impact patient outcomes?

Anzueto: When using the delivery systems and using the medication, certainly, there is a series of steps that the patient has to take in order to have the medication get into the lungs. Some of the challenges that we have are patients have to follow all those critical steps, because if they exhale too fast or inhale too slow, they don't follow those steps, they are at an increased risk of not getting the medication they need into the lungs.

One of the big challenges that we have today is trying to match the medication delivery to give them the appropriate medications…Some patients cannot do it in the powder form, it may be easy for them to do in an HFA form and vice versa. But it's very important, every time we assess our patients in our follow-up, to have them show us how they use the delivery system and remind them the appropriate way to use the delivery system.

AJMC®: According to the CDC, in 2011, about 5.4% of Texas residents surveyed had been told by a health care professional that they have COPD. In your experience, have you seen any trends in diagnoses in the state with the rising popularity of vaping or any external environmental hazards?

Anzueto: We have seen [trends] primarily from policies more related to cigarette smoking. We have seen a significant increase of patients diagnosed with COPD, because we are doing more spirometry [testing]. We're looking more at the management of their condition. So yes, we do see an increase in diagnosis of these patients.

AJMC®: Is there anything we didn't touch on that you'd like to include, or do you have any final thoughts you'd like to share?

Anzueto: It's very important to remind you that COPD is a treatable disease, but in order to treat it, we need to know what the patient has. One of the major concerns that I have is that many people have been labeled to have COPD never having [completed] spirometry, and if you do a spirometry test, they don't have COPD. So, the feeling that people happen to smoke, that doesn't mean they can develop or they're going to have COPD. Today, the gold standard is with the spirometry test… The important issue is we have to make a diagnosis of the disease because this is a treatable disease. If you make the right diagnosis, we have a tremendous opportunity to impact this patient's quality of life and lung function. Now we have seen with the recent publications of the triple therapy, you're not only reducing exacerbations, as well as improving quality of life and lung function, you may be reducing mortality, so we may impact the disease in ways we never suspected before.

February 15, 2021
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

Dr Gerard Criner Offers Insights on Early COPD Diagnosis, Next Steps for Triple Therapy

Although chronic obstructive pulmonary disease (COPD), is among the leading causes of death in the United States, many challenges remain when it comes to diagnosis, treatment, and management. Now, with coronavirus disease 2019 (COVID-19) threatening to damage even healthy lungs that become infected, pulmonologists are concerned the disease could lead to an uptick in COPD diagnoses or other lung related-issues in the long term, said Gerard Criner, MD, FACP, FACCP, an interview with The American Journal of Managed Care® (AJMC®).

Criner is a professor and chair of the Department of Thoracic Medicine and Surgery at the Lewis Katz School of Medicine at Temple University. As an active clinical investigator in advanced lung diseases, primary COPD, pulmonary fibrosis, and respiratory failure, Criner offered his thoughts on the next steps for triple therapy, challenges in diagnosing early COPD, and lessons learned from the COVID-19 pandemic.

The following interview has been edited for length and clarity.

AJMC®: Triple therapy can be associated with increased risks of pneumonia. An analysis of IMPACT trial data showed an increased incidence of pneumonia in patients in Asia compared with those outside of Asia. An additional analysis comparing Western Europe and North American regions found an inhaled corticosteroids (ICS) class effect of increased pneumonia incidence in North America but not in Western Europe. What factors contribute to these findings?

Criner: That finding isn't a first finding. That's been demonstrated before in Asian populations. They have a higher increase of pneumonia with ICS use compared to trials that have been done outside of Asia, such as in the United States or in Western Europe. There's a number of factors [contributing to] that.

It might be something to do with the environment, with the prevalence of other types of infections such as tuberculosis that may cause bronchiectasis, or more structural airway abnormalities that lends to colonization with organisms that may predispose to pneumonia. Some might be due to host factors. Childhood illnesses may be different in one part of the world than the other one.

There also could be environmental causes that could contribute to it. It may just be as simple as that some patients in Asia are leaner than patients in non-Asian populations. It could be the relative dose of steroids that the patient receives could be greater because their body mass is lower. It could be just that the clinical care is different, that the use of x-rays in the diagnosis of pneumonia might be more frequent in Asian populations because the clinical paradigm there might be to consider pneumonia based on clinical parameters or the use of radiographs [compared with] other cultures. The exact reasons aren't known.

AJMC®: The IMPACT and ETHOS trials found beneficial effects of triple therapy vs dual therapy on mortality. But this was only in symptomatic COPD patients who had a history of frequent and/or severe exacerbations and who were previously receiving maintenance therapy with triple therapy, long-acting beta2-agonists/ICS, or single or dual long-acting bronchodilators. The GOLD 2021 report stated, "Future analyses or studies may help determine whether other specific patient subgroups demonstrate a greater survival benefit." In your opinion, which patient subgroups ought to be studied next? What are the next steps for research into triple therapy?

Criner: The 2 studies that you just mentioned that showed that there was a survival advantage, those were prespecified analyses, but they weren't the primary outcomes of the studies. The FDA and other regulatory bodies have not approved the use of triple therapy to improve survival in patients who were in those studies. I think that's the first place to start: an approved indication for the use of inhaled triple therapy for patients with COPD. We would like to see that as approved therapy. I think that it's not a stretch now that the 2 studies that you mentioned and the pooled analysis from the TRINITY and TRELEGY studies also showed an improved survival in a pooled analysis of those studies.

We believe that it's true, it's a class effect; that in the appropriate patients, triple therapy improves survival. Those studies, as you mentioned, [were conducted on patients who] were highly symptomatic, people with frequent or severe exacerbations. The other patient groups that would benefit from this are people who aren't as symptomatic, who are still with severe exacerbations.

Should triple therapy be something that every patient who's hospitalized receive on exit from the hospital and remain on therapy for a period of time? Those are the patient groups I think we need to study, people that have severe exacerbations, [who] are hospitalized but may not be as symptomatic. How long should they be placed on triple therapy? I think we also need to solidify the patient groups that were studied in ETHOS and IMPACT to get an approved indication for triple therapy.

AJMC®: Can you elaborate on some of the limitations of using the forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio to diagnose COPD?

Criner: COPD is more than just an airways disease. There's a lot of symptomatology, morbidity, and mortality that's outside of what can be measured from the FEV1, such as comorbid clinical conditions and important changes COPD [has] on musculoskeletal strength activity. That's one limitation: that any spirometric measure, just not the FEV1/ FVC, is important in characterizing the burden of disease that patients with COPD have. Besides that, the FEV1/FVC just measures the degree of airflow obstruction. We know that some patients can have significant smoke-related or other host factor–related (such as environmental pollutants, etc) changes in lung function and can develop emphysema that may not be reflected by airflow obstruction. That definitely is a trait that patients have that importantly contributes to their outcome.

There are also patients where an absolute cut point of FEV1 to FVC does not identify the burden of their disease or their likelihood of developing COPD later. There are people who surround the border, the threshold variable for FEV1/FVC, which is currently 70%. Patients can still have significant symptoms in outcome; that's been shown in several studies now, where patients can have preserved spirometry and still be symptomatic with COPD-like symptoms and respond to treatment and have a differential outcome. There are several limitations to just using a threshold variable of obstruction identified by the FEV1/FVC ratio.

AJMC®: What are some of the challenges involved in early COPD diagnoses or designating individuals as having pre-COPD?

Criner: There's ups and downs about trying to do that. One of the things that we would like to do is identify patients who have an earlier phase of COPD or a predilection to develop COPD, patients who are at risk, and be able to intercede before they get fixed airflow obstruction. The problem is that not everyone who has symptoms of mucus hypersecretion, or cough, or shortness of breath go on to develop COPD. You don't want to label patients with a disease when they don't have a disease or even a path to develop the disease. Because the stigma and the consequences and the likelihood of overtreatment for that patient group could be worse than having the label of the disease to begin with.

I think, overall, we need better ways to detect patients who are predisposed to develop COPD, that currently we don't have. Patients' symptoms aren't robust enough to do that. Radiographic imaging carries another risk for people who use it at a younger age. That may increase the cost of care, but also, needless exposure to radiation isn't something that we want to do. We don't have a specific and straightforward biomarker that can indicate patients who are at risk for COPD, like we have for patients who may be labeled prediabetic based on a biomarker such as glycosylated hemoglobin.

There's clearly more work that needs to be done to enhance our ability to capture patients who are at risk for developing COPD, before they have intractable airflow obstruction that exists. Currently, we don't have that, but we need to work hard to try to discover that.

AJMC®: Reports of COPD exacerbations have decreased since the pandemic due, in part, to reduction in external exposures. Is there anything that pulmonologists can learn from the lockdown and implement going forward when it comes to improving disease management?

Criner: We've seen that both in clinical trials and also in clinical practice that patients developing acute exacerbations of airflow obstruction, whether they have COPD or asthma, are both less. At our institution so far this year, we've only seen 2 documented cases of influenza, which is markedly different from what we see in any other year. Prevention of aerosol contact with one individual for another one is something that has been the only good benefit that I can see of COVID-19, with social isolation, wearing masks, and better hand hygiene. I think we can learn a lot from that, that [during] peak seasons of the year where populations are at risk, perhaps using those preventative measures would be something that could be very important to lessen the morbidity and mortality associated with viral and bacterial infections that occur throughout the winter months when people are in closer quarters.

AJMC®: It's been proven now that COVID-19 can result in both short- and long-term lung damage. Do you anticipate any long-term impacts of COVID-19 on otherwise healthy lungs that could potentially lead to an uptick in COPD diagnoses or other lung-related issues?

Criner: Yes, unfortunately, I think we will see that, and we have been seeing that. The true magnitude of that problem isn't really clear right now. We thought that, based on the prior experiences with severe acute respiratory syndrome [SARS] 1, that incidence might be 1% to 2% at most, that the likelihood of persistent problems would not be greater than SARS 1. But it appears that it probably is slightly greater. How greater, it isn't known.

For the most part, obstructive airways disease doesn't seem to be as prevalent as parenchymal inflammatory disease with fibrotic changes or with persistent ground glass opacities, which appear to be much more apparent. But I think we'll know a lot more in the next 6 to 12 months [regarding] how many patients have this problem, what the nature of that problem is, and is it only patients with severe COVID-19 infection, hospitalized, or [in] an intensive care unit? Or even in people with milder forms of infection who never were hospitalized? What is the nature of their problem in the long term?