Considerations for tracking patients’ responses to treatment and achieving treatment goals.
Neil B. Minkoff, MD: We’ve been discussing the goals of therapy and escalation strategies, but I know it’s important to you: Tell us the importance of lifestyle modifications and self-management strategies and why you find that important. And then how lung function impacts people’s ability to go through their daily lives.
Byron Thomashow, MD: The lower the FEV1 [forced expiratory volume during the first second], the worse the lung function, the more symptomatic someone will be, and oftentimes the more limitations there are. The problem is that there’s a tremendous amount of variability. You can have 2 people with the exact same FEV1, and some people function better than other people do. Some of that has to do with their other comorbid conditions. If you have someone with the same FEV1, but 1 person has arthritic limitations in their legs, they’re going to be able to do less than someone else. No one cares. I don’t have a single patient who cares what their FEV1 is. They care about how they breathe and how they function. And our job is to maximize what they’re doing with their lives. Part of that is improving the FEV1 if we can. Much of that is improving their level of function, which can be partly medicines and partly exercise programs and other things.
Frank C. Sciurba, MD, FCCP: You can actually objectively measure FEV1, which is important but isn’t everything. And you can objectively measure the air trapped in their lungs at the end of a breath. And while FEV1 often reflects, when that improves, less hyperinflation and less air trapping, there are many circumstances and well-done studies that show that you can get deflation in the absence of improvement in FEV1.
That winds up that degree of hyperinflation. The barrel chest overinflated, and not being able to exhale completely, correlates with shortness of breath more closely than FEV1. So FEV1 is relevant, but it is not everything. If we get improvement in quality-of-life parameters independent of FEV1 or disproportionate to FEV1, it’s probably meaningful.
Byron Thomashow, MD: I agree with that.
Neil B. Minkoff, MD: Are you able to get access to any of this data, in terms of trying to make formulary management decisions—whether it’s in the whole or it’s patient by patient—in terms of whether they can escalate therapy?
Maria Lopes, MD, MS: I think now with the apps and the newer tools, it will be interesting to see in heart failure, we’ve been tracking patients. With telehealth, we can track their weights and symptoms, and that comes together into an algorithm that is more timely, meaningful, and actionable in terms of a protocol. It will be interesting, as we start gathering data from apps, to see how this can integrate with care managers, for example, and respiratory therapists, so that between office visits maybe there’s a better assessment. But if this can tie to a protocol or even a referral process, as needed, to a pulmonologist, I think that’s the exciting part.
I have to believe that in the end, as we look at new therapies that are coming forward, pharmacotherapies, it is more than FEV1. FEV1 is objective. But how patients are feeling, and shortness of breath that ultimately leads to… It’s the tip of the iceberg with everything underneath—shortness of breath, how they’re functioning—so it’s going to escalate to resource utilization, ER [emergency department] visits, and ultimately total costs of care.