COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 2
Factors that influence the quality of life for patients with chronic obstructive pulmonary disease, including a timely diagnosis, and the role of measuring peak inspiratory flow.
Neil Minkoff, MD: We’ve touched on the clinical [burden]. We’re touching on the economic drivers. We’re going to delve a lot deeper into both of those. But that’s leaving out one group: the patients. What’s the patient experience? Because my understanding as a former internist and ED [emergency department] doctor is that the patient experience is a big driver of behavior and other changes in COPD [chronic obstructive pulmonary disease]. Could you talk more about the patient experience and what your work on that is like?
Michael Hess, MPH, RRT, RPFT: Absolutely. Interestingly enough, the patient experience and quality of life can be highly variable, particularly in early phases of COPD. And that leads to a lot of issues with diagnosis because, in those early phases, we may see a lot of accommodation, basically where you modify different aspects of your life to accommodate your shortness of breath. For example, you might take the elevator instead of taking the stairs when you’re going to your office. That leads to a lot of delayed diagnosis. As we get into later phases of COPD, we see much higher impacts throughout your daily life. Obviously, we breathe, essentially every minute of every day. So when you have a disorder that affects your breathing, you’re going to see impacts from that every day of your life as well.
Most people are familiar with the idea of shortness of breath while we’re doing major exertion like exercise or things like that. But imagine having that at rest. Imagine being so short of breath all the time and doing simple things like using the restroom. It obviously has a major impact on your life. In addition, a lot of people with COPD have problems with producing too much mucus and too much phlegm, and so you have these sudden coughing fits, which can be very embarrassing. Imagine being at the store, particularly in this era of COVID-19 [coronavirus disease 2019], or in church or something like that, and you start coughing uncontrollably and everybody is suddenly looking at you. Those issues then lead to a cycle of anxiety and isolation, which then leads to depression. And so there’s a wide variety of impacts throughout the entire course of your life.
Donald A. Mahler, MD: Neil, can I add a brief comment?
Neil Minkoff, MD: Yes, please.
Donald A. Mahler, MD:To illustrate even further what Michael described, the American Lung Association previously had a tagline that states, “If you can’t breathe, nothing else matters.” I think when you see and talk to patients with lung disease, especially COPD, that says it all.
Neil Minkoff, MD: That’s an unplanned but perfect segue to the question I was going to ask you, which is—you know if you can’t breathe, nothing else matters. What are the factors that influence patient outcomes in COPD, ie, getting them to breathe? And what’s the patient’s role vs the clinician’s role?
Donald A. Mahler, MD: To expand on the outcomes, that’s part of the question, certainly, Brad mentioned symptoms—shortness of breath is the key one—and exacerbations, which we discussed briefly. I would add 2 more outcomes, and one is disease progression. Can we somehow impact things from getting worse, particularly as measured by lung function? And then the fourth outcome that is reasonable to consider is mortality. We do have some interventions that can impact mortality in patients with COPD. Maybe we can talk about them later.
As far as factors that can alter these outcomes, No. 1 is obviously smoking cessation. That leads the list in treatment options for all the guidelines including the GOLD [Global Initiative for Chronic Obstructive Lung Disease] document. We have evidence that smoking cessation delays progression of disease, improves symptoms, reduces the risk of exacerbations, and after a decade, can even improve mortality.
Other factors include lifestyle. Are people active? Do they exercise? Do they have an appropriate diet? Do they maintain a normal body weight? These are important, simple things that apply to all of us, including those with COPD. Then my last comment would be about medications. I know we’ll talk more about inhaler medications later, but over the past 10 or 15 years, we have had better and more effective medications. The challenge is to make sure people are using them correctly.
Neil Minkoff, MD: Do you use peak inspiratory flow with your patients?
Donald A. Mahler, MD: I do. Peak inspiratory flow is the maximal flow generated during inspiration and is applicable to patients who are using dry powder inhalers. To get the powder out of the device and into the lungs, the patient has to generate turbulent energy within the dry powder inhaler. Turbulent energy is dependent on 2 main factors: the resistance of the dry powder inhaler and the inspiratory flow that the person generates. We can measure peak inspiratory flow with commercially available flowmeters, and that is one parameter that can affect the efficacy of dry powder inhaler medications.
This activity is supported by an educational grant from Boehringer Ingelheim.