Transcript COPD Practical Aspects of Care, 2016

COPD: Practical
Aspects of Care
Village Sleep Lab &
Breathing Center
Juan A. Albino, MD
751-4955
January , 2016
COPD: National Priority
 3rd
leading cause of death
 24 Million people have COPD
 Smoking is main cause
 Early diagnosis requires testing with
spirometry
 Cough, phlegm, shortness of breath,
wheezing are the common symptoms
 Slowly progressive, with accelerations
Smoking Cessation
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Change in approach recently
Managed more as a chronic disease
Patient understanding & motivation all important
as well as overall plan & Quit Date
Combine Counseling and Medications
Approach: Long acting drugs & short acting
rescue drugs: e.g. antidepressants with nicotine
replacement lozenges
Varenicline (Chantix) can be effective but side
effects including depression
E-Cigarettes controversial
E-Cigarettes
Construction and contents vary and not
standardized
 Usually nicotine is dissolved in liquid and
vaporized
 Question: what other chemicals involved?
 Claim: entertainment tool, not for smoking
cessation
 Explosive rise in sales
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Exercise or Activity
As little as 5 min /day makes a difference
 Maintenance of fitness: walk 3 days/wk for
30 minutes, for increasing fitness: walk
30-60 minutes 5 days / wk
 Exercise: best predictor of mortality in
both heart & lung disease
 Modern evidence confirms no medication
better for heart & lung disease
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Pulmonary Rehabilitation
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Inactivity most powerful predictor of mortality
Pulmonary Rehabilitation: reduces dyspnea,
depression, hospitalizations & exacerbations
Increases activity, oxygen saturation, sense of
well being
Exercise: endurance involving legs, heart, lungs,
and resistance or weights involving arms
Dancing, Tai Chi, Singing, Yoga also promote
balance
But only 25% of COPD patients sent for Rehab
Medication Categories
Short Acting bronchodilators: last 4 hours
Albuterol (Pro-Air, Ventolin, Proventil), Atrovent
rescue / back up: sick, exercise, allergy
 Long Acting bronchodilators: 12 hours or 24
hours, convenient, easier to use, probably the
best drugs for COPD
 Nebulizer: short & long acting bronchodilators
are available and paid by Medicare Part B
 Steroids over used in COPD maintenance
therapy (“Triple Therapy”)
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Inhaled Medications:
Technique All Important
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Proper technique for inhaler use must be
taught well and constantly reinforced
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Over 70% of patients use inhalers improperly
Spacers / chambers helpful, glass best for HFAs
Nebulized drugs cheaper & easier to use
Dry powdered inhalers also easier to use
A host of recent inhalers assure better delivery
of mists but need to be learned
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Question
A 70 year old patient has severe COPD
and some heart disease, and he has been
a heavy smoker and continues to smoke
 He will probably die from: COPD, or Heart
Disease, or Lung Cancer?
 See next slide
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Question
Answer: Probably from Heart, then Cancer,
then COPD
 We forget that smoking is a big risk factor
for heart disease, strokes, leg artery
obstruction, heart failure
 Smoking causes over 80% of all lung
cancers, & major factor for throat, liver,
bladder, kidney, liver, stomach, colon, etc.
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Causes of Death
in COPD Patients
IF Continue to Smoke:
 Heart Disease: 33%
Lung Cancer: 33%
 Other Cancer: 21%
Respiratory: 10%
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General Severe COPD (30% smokers)
 Respiratory : 27%
Heart:
26%
 Cancer:
21%
Pneumonia: 10%
 Other:
17%
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Lung Cancer Screening
by CT Scan of the Chest
CT approved by Medicare and required by
Obamacare or the ACA
 However Medicare has not outlined the
procedure for implementation yet
 In general screening is for: ages 55 to 75, no
symptoms, 30 Pack Years of smoking, current
smoker or quit within the last 15 years, able to
withstand lung cancer treatment if found, shared
decision making session, no recent chest CT
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Vaccinations
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Influenza, inactivated, injection, yearly
Pneumococcal vaccines, protects against half of
all pneumonias
Two pneumococcal vaccines
PPSV23, PneumoVax, the old one, given once
before age 65 & once after
PCV13 or Prevnar 13, should be given once
after age 65
In general the pneumococcal vaccines should be
given about a year apart and not together
Overlap Syndromes
COPD
 COPD
 COPD
 COPD
 COPD
 COPD
 COPD
 COPD
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Heart Disease
Asthma
Bronchiectasis
Sinusitis
Sleep Apnea
Depression / Anxiety
Lung Cancer
Bone / Muscle Disease
Community Care of COPD
Self care, family care, community care
 Probably the best form of care
 Immensely important in treating:
anxiety/depression, especially 2ary to
isolation, lack of interaction, spiritual
poverty, lack of exercise
 Advocacy at the government, insurance,
hospital level
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Stem Cell Treatments
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best: a for profit experimental
procedure
 At worst: fraud and abuse of
patients that are desperate
 History of experimental procedures:
about one third help, one third
have no effect, and one third
hurt
Stem Cell Treatments:
6 False Hope Warning Signs
The International Society for Stem Cell
Research lists these warning signs that a
stem cell treatment is not legitimate
 It makes claims based on patient
testmonials
 The same stem cells are used to treat
many diseases
 The source of the stem cells is not clearly
documented
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Stem Cell Treatments:
6 False Hope Warning Signs
There is no clear protocol or detailed
guide to treatment
 Claims that there is no risk; all medical
procedures carry risk
 High cost or hidden costs; legitimate
clinical trials do not charge patients, and
may even pay them
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Placebo Effect
During WWII a medic, Henry Beecher ran
out of morphine
 So he gave just plain saline to wounded
soldiers hoping to calm them
 To his surprise almost half experienced
significant pain relief and thanked him
 In general from one third to two thirds of
people can have a placebo response
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Placebo Effect
Medicine with inactive ingredients is given
to a patient
 However the patients responds favorably:
subjectively and sometimes objectively
 Placebo response documented for pain,
depression, anxiety, Parkinsonism, Asthma
 FDA standard: new medicines must be
compared to placebo and be superior
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Use of the Placebos
In past used by physicians and nurses
when drugs ran out
 Used for problematic patients
 Used for poor patients
 But in USA placebo use, outside of a
study, considered unprofessional,
unethical, and illegal
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Websites & References
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American Thoracic Society: patients.thoracic.org
Global Initiative on COPD: goldcopd.com
COPD Foundation: copdfoundation.org
COPD Assessment Test (CAT);
catestonline.org/english/indexEN.htm
American Lung Association: lungusa.org
Smoking Cessation: smokefree.gov
National Heart, Lung, and Blood Institute:
nhlbi.nih.gov/health/public/lung/copd/index.htm
Centers for Disease Control and Prevention:
cdc.gov/copd
Stem Cell Clinics: Comments
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October 15th, 2015: Medical News
http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unre
gulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx
May 18th, 2015: San Jose Newspaper:
http://www.mercurynews.com/business/ci_28139232/stem-cellclinics-run-amok-amid-lack-regulation
Mayo Clinic: overview of stem cells:
http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/indepth/stem-cells/ART-20048117?pg=1
September 10, 2015: Medical Journal: Medicine’s Wild WestUnlicensed Stem Cell Clinics
http://www.nejm.org/doi/full/10.1056/NEJMp1504560?query=TOC
International Society for Stem Cell Research: Patient Handbook on
Stem Cell Therapies,
http://www.isscr.org/home/publications/patient-handbook
References: Placebo
Dr Ted Kaptchuk, Director of the Program in Placebo
Studies at Harvard Medical School:
 Interview:
http://www.npr.org/2012/01/06/144794035/onescholars-take-on-the-power-of-the-placebo
 Article: http://harvardmagazine.com/2013/01/theplacebo-phenomenon
 Placebo Effect in Knee Surgery: YouTube
https://www.youtube.com/watch?v=HqGSeFOUsLI
 Placebo Effect at Stanford Medical School:
https://www.youtube.com/watch?v=udJ31KKXBKk
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