Respiratory therapist Michael Hess, MPH, RRT, RPFT, discusses the main therapies used for chronic management of chronic obstructive pulmonary disorder (COPD), as well as the decision to escalate to triple therapy.
Diagnosing chronic obstructive pulmonary disease (COPD) can be challenging because of the nonspecific nature of the early symptoms of COPD, noted Michael Hess, MPH, RRT, RPFT, respiratory therapist, and senior director of public outreach and education for the COPD Foundation.
One someone is diagnosed with COPD and put on treatment, there are also supportive programs to consider that help treat the whole patient and not just their condition, he added.
In this interview with The American Journal of Managed Care® (AJMC®), Hess also discusses the current treatments available for chronic management of COPD, evaluating when a patient needs to be escalated to triple therapy, and assessing patients to evaluate the effectiveness of a treatment regimen.
AJMC®: What factors influence patient outcomes in COPD?
Hess: There is a whole gamut of things that can affect outcomes from the pharmacological therapies that we usually start with—medications, inhalers, that sort of thing, which we also have to be very careful that we've taught people how to use the tools that they've been given, make sure that they're using proper technique, make sure that they can have, for example, proper inspiratory flow for dry powder inhalers, or proper coordination with metered-dose inhalers. We also see that nonpharmacological interventions also have a lot of impact. These are things like tobacco treatment, getting people to quit tobacco products, as well as staying active and going through programs like pulmonary rehabilitation and other healthy and safe ways to move about.
AJMC®:Could you provide a brief overview of the main drug classes used for the chronic management of COPD, including key efficacy and safety considerations for each?
Hess: The first main class we use would be the long-acting beta-agonists or LABAs. These are long-acting bronchodilators that are typically taken once or twice a day that do basically exactly what they say. They reduce some of the bronchoconstriction that is involved with COPD, and they help people breathe a little bit better with those wider airways. There's another class of long-acting bronchodilators called the long-acting muscarinic antagonists or LAMAs. These do basically the same thing just on a slightly different chemical path inside the body. Both of these are generally considered quite safe. You do see some side effects from time to time with the LABAs since they're kind of related to that fight or flight instinct receptors in the body. You might see some jitteriness or that sort of thing. That's more common with the shorter-acting bronchodilators, but you do see it on occasion with the longer-acting ones. With the LAMAs you might see things like dry eye, dry throat, that sort of thing.
The final main class that we use are called inhaled corticosteroids, and those work slightly differently. They don't really do anything with bronchodilation, but they reduce inflammation in the airways. We see a lot of folks with COPD, especially who may have had preexisting asthma, have a lot of that inflammation in there, which leads to a lot of mucus over secretion and that sort of thing, and those inhaled corticosteroids do tend to bring that down a bit. We're a little bit more judicious with the use of this class, because there is an association with some increased risk of pneumonia and some other systemic effects with long-term use. Again, generally considered safe but there are some things to consider there.
There are a couple of other drug classes that we use on occasion like phosphodiesterase 4 inhibitors for more difficult to manage cases, but those are the 3 main classes.
AJMC®:What is the starting point for most patients? When did they get to the point where it's decided that therapy needs to be escalated to a triple therapy regimen?
Hess: Most people start with at least one bronchodilator. There's an increasing body of evidence to support the use of both bronchodilators at the same time: the LAMA-LABA combination. That usually does a pretty good job in managing most people, but if you see somebody who still has a lot of issue with ongoing cough, especially productive cough, or you see that they're ending up in the hospital a lot, or even maybe they have exacerbations that are above their baseline but maybe not enough to land them in the hospital, that's when you would want to consider escalating and adding some of those inhaled corticosteroids on there, as well.
AJMC®:Could you discuss the strengths and limitations of the various inhaled devices such as meter dose inhalers, dry powder inhalers, soft mist inhalers, and nebulizers?
Hess: We'll start with the metered-dose inhaler—or pressurized metered-dose inhaler as it's often called—arguably one of the most well-known devices in all of pulmonary medicine. This is a device that's very portable. It's very lightweight. You take it with you all the time. It's relatively easy to use, in concept, but it can be a little bit difficult to use in practice. When you actuate it, the medication mist comes out in a very quick stream so there's a lot of hand-eye coordination, basically, or hand-lung coordination as it were in order to get medication down into the lungs where it's going to work rather than impacting on the back of the throat or in the mouth.
Then we have dry powder inhalers, which similarly are very compact. They don't require any kind of external power source or anything like that. These can be a little bit easier to use in some cases because they don't require that kind of coordination. Some of them do require a little bit of assembly. They need to put a little capsule into a device, but many of them come in these multi-dose formats now where essentially all you have to do is open it up and then breathe in on it. The catch with these devices is that they do require a certain amount of peak inspiratory flow. A lot of folks with more advanced airway obstruction or more severe airway obstruction have some trouble generating that kind of flow, and so they're not able to get the proper dose out of the device and, again, into the lungs where it's going to work. If you're prescribing that kind of inhaler device, you're going to want to be very careful to make sure that you're measuring the peak inspiratory flow so that you know your patient is getting their medication.
One of the newer devices on the market is the soft mist inhaler, which combines a lot of the good parts and a few of the bad parts of both of the previous inhalers. It can be a little bit tricky to assemble sometimes, especially before the first use. Once you do assemble it, it is a lot easier to use. It does require some coordination, but not nearly as much as a metered-dose inhaler. You just have to make sure that the person using it can inhale for a certain amount of time. Because it is a slower mist, it comes out in a slower stream, and we focused a lot on peak inspiratory flow and speed and all that sort of thing, but we wanna make sure that people are actually able to take that deep breath when they're using the soft mist inhaler.
Then finally we have our very old friends, the nebulizer. These require no special technique or anything like that. You can just use normal tidal breathing with these. However, they are generally less portable. They require some kind of external power source, whether it's something battery-operated or plugged into a wall. They're a little bit more cumbersome to use. They're a little bit trickier to clean. Sometimes we forget to encourage people to clean those or people forget to clean them on their own. They're a little bit higher maintenance than the inhaler devices, but they can be a very good option for people who can't generate that inspiratory flow, can't do the coordination, or have other issues that prevent them from using an inhaler.
AJMC®:Can you discuss the diagnostic approach to patients with suspected COPD?
Hess: It can be tough. This is one of the biggest issues in COPD right now—we have a lot of folks who experience what we call diagnostic delay because some of the early symptoms of COPD are very nonspecific: coughing more than they used to or they get tired faster than they used to. Things like that. Things that a lot of people can just kind of chalk up too. Well, I must be getting older or I'm outta shape or that sort of thing. I would caution any clinician who has somebody come to you and say, well, I'm just not doing as much as I used to or things like that, that's where we would really want to consider doing some spirometry.
Spirometry is a very basic pulmonary function test where you basically have somebody blow into a device a few times and get an idea of how well they're moving air in and out of their lungs. Based on certain diagnostic criteria with spirometry, then we can get a clearer picture of whether they have a chronic airway obstruction as in COPD or maybe they have something going on in their vocal cords or upper airway, things like that or maybe they need a little bit more investigation. We are starting to see some tools come online now. There is a tool called CAPTURE [COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk]. It's a 5-question screening tool where you basically ask a person 5 questions and maybe do a little bit of a peak flow meter, which is very common in most clinical offices. It has a pretty good track record now these days. It's been validated in several countries, and it can be a good tool for population screening if you want something that's going to cast a little bit broader net.
AJMC®:How do you evaluate the effectiveness of treatment regimen, and how often are patients assessed?
Hess: We've got a couple of effective tools for that, as well. In my previous practice, we used a tool called the COPD Assessment Test, which is an 8-question questionnaire that looks at different domains of symptom burden. It looks at breathlessness at rest, breathlessness on exertion, cough, mucus production, sleep quality, those sorts of things. What I would do is I would have somebody do that on their very first visit to kind of establish a baseline. Then, I was lucky enough to be able to see people about once a month. More commonly it's going to be every 3 months, every 6 months, something along those lines. But we can use that COPD Assessment Test to, again, track where people are in their various symptom burdens, whether it's overall or in the individual domains. We have electronic tools now where you can access the COPD Assessment Test online, and people can do the tracking on their own and get a better sense of where they are.
We also have various tools like the COPD Foundation's My COPD Action Plan where people can kind of get a sense of where they are day to day and do a little bit better job of understanding when they have these changes, when these changes are consistent, and when they maybe need to call in for a checkup.
AJMC®:What are some considerations for a personalized COPD treatment regimen, and how is the peak inspiratory flow assessment for a device selection done? Do you consider patient preferences when choosing a therapy for them?
Hess: When we're discussing a personalized COPD action plan, absolutely, we're going to want to take personal preferences into account. Because people are generally not going to use tools they don't like. Often one of the questions I ask somebody is not just, “are you taking your meds?” but finding out why they're not taking their meds, if they aren't. You'd be surprised how many people that came to me and said, “I just don't like the way it tastes. It makes my mouth feel funny.” Or things like that. We're fortunate enough these days to have a couple of different options in each medication class so that we can find a tool that's going to work within those preferences and that lifestyle.
One thing we do want to be very careful of is—again, I mentioned, peak inspiratory flow earlier—we want to avoid the issue of what I call accidental nonadherence where somebody may think they're taking their medication and they're actually not. I use a device called an In-Check Dial, which was basically a peak inspiratory flow meter that had adjustments to change the resistance based on the different inhalers that are on the market. I would have somebody inhale through that to make sure that they're able to generate enough flow for that particular device, and then we'd be able to make any adjustments as necessary. Those are definitely important components.
Again, asking somebody: Can they afford their medications? Do they understand when to take their medications? Do they understand how to take their medications? It's really important to have that 2-way communication and shared decision-making so that you can develop these optimized regimens.
AJMC®:What additional supportive programs may be beneficial such as pulmonary rehab or smoking cessation?
Hess: Well, pulmonary rehab is probably our most criminally underused tool in any kind of respiratory disease. It's been a little bit difficult over the course of the COVID-19 pandemic, but we're overcoming a lot of those challenges these days, and we need to see a lot more people be referred to these programs. The last time I saw data, we were looking at about 1 in 10 people who were eligible and could likely benefit actually getting referred to these programs and following through with them. For those who may not be familiar, pulmonary rehab is a program of monitored exercise and education so that people can not only learn exercises that can get them into better shape and help their lungs breathe a little bit easier but also understand their condition a little bit more and what might affect that.
Usually, good programs will cover even things like nutrition, breathing exercises, relaxation exercises, all of those things that kind of go into treating the entire patient and not just the condition itself. Again, tobacco cessation, tobacco treatment is another key component of that. Using tools like motivational interviewing instead of just shaming and guilting people into trying to quit. Again, trying to do that shared decision-making and get somebody on a program that works for them.
We also see peer support is incredibly invaluable whether it's a local support group or an online support group or discussion board, things like that, people wanna know that they are not alone. They're not strange. They're not unusual. They want to talk to other people who are going through similar experiences. Again, we have the tools these days to make that happen. Those are very important interventions to encourage with your panel.