This post was written by Mike Hess, MPH, RRT, RPFT.

Pulmonary rehabilitation (PR) has long been recognized as one of the most effective interventions for people living with chronic lung disease. It is also one of the most under-utilized and inconsistently applied interventions. One person's PR experience can be vastly different from another's, and much of the previous body of research was based exclusively on PR in the setting of chronic obstructive pulmonary disease (COPD). This has led to tremendous inequalities and access issues for many across the country.

The American Thoracic Society (ATS) sought to bring order to the PR universe by publishing updated clinical practice guidelines in 2023¹. Developed by a multidisciplinary team (including someone living with COPD) in accordance with the rigorous Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology, these guidelines provide formal guidance regarding who should receive PR and how it should be offered. It also provides a roadmap for future research and a clear call for policymakers to take actions that improve access.

A key component of the GRADE process is to establish specific questions that the guideline intends to address². These questions, known as PICO questions, serve to identify the relevant patient population (P), the desired intervention (I; in this case pulmonary rehab), a comparator (C; often the existing standard of care or a null hypothesis), and relevant outcomes (O; encompassing clinical outcomes, costs, risks, and other factors). Once the PICO questions are created, the review panel then carefully analyzes the results of literature reviews for each to answer the questions and evaluate the strength of the available data. These answers are then converted into recommendations, complete with context on how confident the panel is that the benefits of the recommendation outweigh the undesirable effects, as well as the quality of the data. This framework allows for objective analysis while including some room for expert opinion, especially in areas where evidence is less robust.

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This post was written by Arnelle Konde, MPH, CHES.

It is no secret that COPD rarely occurs alone. People living with COPD often face other comorbidities such as heart disease or diabetes, which can affect their symptoms and increase mortality risk.^1-2 Although comorbid conditions are common, many go undiagnosed or are identified too late.¹

Common Comorbidities Associated with COPD

Cardiovascular Disease

Cardiovascular disease (CVD) is highly prevalent in people living with COPD. Shared inflammatory pathways and overlapping symptoms, such as shortness of breath, fatigue, and chest tightness contribute to higher rates of heart failure, arrhythmias, and coronary heart disease in the COPD population.⁴ The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report identifies CVD as a leading cause of hospitalization and death among people with COPD.⁴ Because of this elevated risk, providers should conduct routine screenings to detect CVD earlier and begin treatment before complications develop.

Mental Health Conditions

Metal health conditions are also common in people with COPD. A cohort study showed that more than half of patients report symptoms of depression and anxiety.^2,5 Anxiety has been linked to lower treatment adherence, more frequent exacerbations, and reduced quality of life.^3,5 Depression and anxiety are also associated with hospital readmission for acute exacerbation of COPD.⁷ Routine mental health screenings can help reduce stigma and support timely intervention.

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This post was written by Jonnie Korinko, MSRC, RRT, RRT-ACCS.

Exposure to airborne irritants in the workplace can heighten the risk of developing COPD.^1-3 Approximately 15% of individuals with COPD link their symptoms to work-related pollutants.¹ These include dust from coal, silica, or wood; fumes from welding or asphalt; and smoke or other irritating chemicals. Consequently, occupations in fields like construction, agriculture, manufacturing, and public service, such as firefighting, pose a greater risk to lung health. Therefore, health care providers and employers need to take action to safeguard these workers.

COPD Can Raise Employer Costs

People living with COPD have medical costs about twice as high as people without COPD.⁴ Chronic lung disease can also lead to loss of productivity in the workforce:^4-5

• On average, people with chronic lung disease miss about five days of work annually.
• It is estimated that there is about a 10% productivity loss.
• On average, there are over 25 days of restricted activity.
• The estimated cost of disability due to COPD is $1,771.

What You Can Do to Make an Impact

If Your Job is High-Risk for Developing Lung Damage

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This post was written by Mike Hess, MPH, RRT, RPFT.

This year, as we recognize Black History Month, we can also recognize some long-overdue progress on the journey to better health equity. Biases and assumptions we have used for decades in two important diagnostic tools we use have recently been formally challenged, paving the way for more equitable care for all people living with lung problems.

Garbage In, Garbage Out

Spirometry data are obviously a key part of most long health journeys. As a refresher, numbers including the forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) are compared to "normal" numbers based on the subjects height, age, and biological sex. That comparison yields the "predicted" percentages on a spirometry report. But how did we get those normal numbers in the first place?

The first efforts to tabulate these numbers actually started in the 1840s, not long after the spirometer was invented. Since these studies were done in Victorian-era London, they mostly included only White males. Things got a little more inclusive during the American Civil War, when researchers could include Black soldiers as part of their work. They found that Black soldiers often had lower spirometry values than their White counterparts. Today, we can recognize that those same Black soldiers often had lower-quality equipment, worse living conditions, and other factors that can influence overall health. Back then, it was generally believed that there was something genetic that caused lower lung function. Other studies using measurements like how much one's chest expanded during breathing showed no major difference between races, but the genetic difference theory managed to stick.

Fast forward to the early 2000s. Computerized spirometry tests now included automatic "corrections" based on race. However, different countries often used different tables of predicted values. That made it harder to do international comparisons, so a group of researchers tried to fix that. The Global Lung Initiative studied people from across the world to develop new standardized tables. It wasn't perfect, but since it was the largest set of data ever put together, it was a major improvement over previous tables. But the research didn't stop there. GLI research eventually suggested that there really were not major differences between race, especially since many countries had different definitions of different races. Finally, in 2023, the American Thoracic Society concluded that the downsides to using race-based measurements in pulmonary function testing (including spirometry) far outweighed any potential benefits and that clinicians should only use average reference equations to create tables of predicted values. Practice changes like this take time to become widespread, but we are finally seeing progress in making sure people are tested equally, regardless of how they look.

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This post was authored by Jonnie Korinko, MSRC, RRT, RRT-ACCS.

It is well-established that COPD is underdiagnosed.^1-3 When COPD is diagnosed early in its progression, it is linked to fewer exacerbations and lower healthcare costs.⁴ Increasing diagnosis in primary care can help people living with COPD manage their lung condition, allowing for early treatment and improved quality of life.

The Importance of Diagnosing COPD in Primary Care

Defining the prevalence of COPD can be difficult, as the diagnosis is dependent on the presence of post-bronchodilator spirometry. While less than six percent of the national population reports a COPD diagnosis, it is understood that this number misrepresents the burden of COPD, as spirometry is inaccessible or underutilized in many populations.⁵ Globally, it is estimated that 10.3% of the population live with COPD.5 COPD is listed as the sixth leading cause of death, accounting for approximately 4.5% of overall deaths in adults in the United States in 2022.⁶

Similarly, an estimated 90% of people with alpha-1 antitrypsin deficiency (AATD), a common form of genetic COPD, are not diagnosed.⁷ AATD classically results in panacinar emphysema, even when the person with the genetic condition does not have a tobacco smoking history. Other clinical manifestations of AATD include liver disease, panniculitis, bronchiectasis, and Wegner's granulomatosis.⁷ It is recommended that all people who have been diagnosed with COPD undergo AATD testing.⁷ Underdiagnosis of COPD contributes to the underdiagnosis of AATD.

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This post was written by Michael W. Hess, MPH, RRT, RPFT

When I was joining the COPD Foundation in 2020, my boss offered me a mission. It was a bit different role than the one I had applied for, but it seemed like an interesting challenge.

"How would you like to help fix supplemental oxygen?"

Now, I've never been a durable medical equipment (DME) person. I was coming from a position in primary care where I WORKED with a lot of DMEs, facilitating prescriptions and coordinating care. I had a vague understanding of how much the industry had struggled over the last decade, with payment cuts related to the Medicare competitive bidding process. I knew many people had been having a harder and harder time accessing equipment that fit their lifestyle and health goals. I knew that a lot of my respiratory therapist colleagues had been forced to move on because of budget cuts and consolidation. I figured getting to the root causes of the issues and developing strategies to overcome them would be an interesting challenge.

I call that time "the good old days," because I was caught completely off guard by the sheer magnitude of that challenge.

It turns out that here in the United States, we've actually been slowly chipping away at our ambulatory oxygen therapy infrastructure for decades. Some types of equipment, like liquid oxygen, have become essentially extinct because they're too expensive to provide. That, in turn, means that while we clinicians keep telling people that one of the keys to improving quality of life with chronic breathing problems is staying active, the system cannot provide them with the means to do so. Frustration abounds on both sides of the stethoscope, not to mention with the suppliers whose hands are tied.

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This post was written by: Jonnie Korinko, MSRC, RRT, RRT-ACCS.

Three pharmaceutical companies have agreed to cap out-of-pocket costs to $35 in the U.S. The trend began on Thursday, March 7, 2024, when Boehringer Ingelheim, a pharmaceutical company that makes inhalers used for COPD and asthma, announced that it would begin limiting out-of-pocket costs for its inhalers for eligible patients to $35/month. This program will start on June 1, 2024, at retail pharmacies.¹ Click here for the full statement and a list of included inhalers. Patients using these inhalers from Boehringer Ingelheim who do not qualify for the $35/month inhaler cap, including those whose pharmacies do not participate and those without insurance, can visit www.InhalerOffer.com to sign up for a savings card. This card can be presented at pharmacies to receive the same discount.

On Monday, March 18, 2024, AstraZeneca followed suit, issuing a similar statement, with GlaxoSmithKline (GSK) issuing their statement on Wednesday, March 20, 2024. All three pharmaceutical companies are limiting out-of-pocket costs for their inhaler medications to $35. Click here for AstraZeneca's statement and list of included inhalers and here for GSK's statement and list of inhalers.

Because of government restrictions, people who use federal government insurance programs, like Medicare, may not get help with co-payments. However, the company will offer free products and assistance programs for people who need them. Insurance companies and pharmacy benefit managers (PBMs) will get discounts on inhalers.¹

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This post was written by: Amanda Atkinson, MSN, RN.

Have you ever pondered the fact that health is a fundamental human right? According to the World Health Organization's 1946 constitution, it is.¹ As practitioners we are uniquely positioned to help those around us fully exercise that right. The question that we must ask ourselves is, are we acting as a door or a barrier to that right? If we are not actively practicing cultural humility, we may be unknowingly hindering those around us from fully accessing quality healthcare.

You may be wondering: "what is cultural humility?" Cultural humility is not a quick answer, but rather a lifelong process. It involves self-reflection and the recognition that our lived experience and backgrounds impact how we learn, engage, connect, communicate, lead, and follow. Cultural humility allows us to recognize that we do not know everything about ourselves, others, or a culture, but are willing to learn from patients, peers, family, and those around us.² It mandates us to treat everyone as an individual and be receptive to learning about their diverse backgrounds and lived experiences. In a health care setting this practice helps informs care in all areas and allows us to truly keep the patient at the center of all we do.

Like many of you, in both my professional and personal life I have the privilege of connecting with many people of different ages, ethnicities, walks of life, faiths, and belief systems. One of the main things that I see as a universal theme across all of them is the desire for connection and authenticity. People want to be valued, seen, safe, empowered, and respected for who they are and what they bring to the table. When we feel these things, we are more likely to actively participate in relationships. In a health care setting, this translates to actions such as utilizing available resources, increased adherence to treatment regimens, and exploring new options for care.

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This post was written by: Michael W. Hess, MPH, RRT, RPFT.

In many ways, the current pharmacological landscape represents a Dickensian combination of the best of times and worst of times. We have never had as many options for inhaled medications to help manage COPD symptoms as we do now. We have more on the horizon, along with other therapeutics that promise to supplement our traditional bronchodilators and anti-inflammatories. Unfortunately, there is a downside to having such a vast array of options. The "paradox of choice" theory suggests that the more choices one has, the more difficult it is the select one with confidence. Couple that with often-confusing (and sometimes conflicting) clinical guidance and an ever-evolving evidence base and it is easy to become overwhelmed.

Fortunately, there are some strategies to guide your clinical decision-making. Keeping your patient's condition, abilities, and goals at the center of the process is essential and will allow you to then tailor a plan to address other concerns.

Where are they on their COPD journey?

According to the latest GOLD recommendations, virtually everyone new to COPD should start with, at minimum, dual bronchodilator therapy. COPD pathophysiology is often a mix of inflammation, mucus hypersecretion, alveolar damage, and bronchial hyperresponsiveness, and the degree to which each contributes to symptom burden can vary widely from person to person. However, the evidence points to the team of long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) medications providing some degree of benefit to a significant percentage of the population. That makes them great candidates for initial therapy. Sometimes, they're even available in the same inhaler, making things even easier for a patient getting used to a new medication regimen.

In some cases, it may also be appropriate to bring in an inhaled corticosteroid (ICS), the third common therapeutic class of COPD meds. If your patient can identify two or more symptom flare-ups in the last year, or just one that landed them in the hospital (where many with COPD first get diagnosed), take a look at their latest blood work. Eosinophil counts of over 300 cells/microliter are suggestive of the kind of inflammation that can respond to ICS therapy. There are even a few inhalers that provide this “triple therapy” all in one dose, again making it relatively easy to get started.

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This post was written by Michael W. Hess, MPH, RRT, RPFT

This may come as a surprise to many, but when I first started as a respiratory therapist, I didn't really think about COPD very much. Sure, I saw the "frequent flyers" coming in through the ER for their tune-ups, and I would dutifully show up every four hours out on the floors with my trusty albuterol and ipratropium. Being a child of the 80s, I usually used its brand name so I could them "the A-Team." I even took care of the really rough cases up in the ICU, where debates about matching intrinsic PEEP and other ventilation strategies seemed to be the most interesting aspect of treating this condition. This attitude was no outlier either; COPD was not on very many people's radars at all. The very first Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report was a mere five years old; the COPD Foundation itself was even younger. We had no endobronchial valves, far fewer pharmaceuticals, relatively little noninvasive ventilation in the home. Limited options led to therapeutic nihilism which led to viewing COPD as just not a priority. In other words, there's nothing we can really do, so why spend much time thinking about it?

Obviously, my views have changed over the last couple of decades. Fortunately, the prevailing views of health care have largely changed along with me. These days, we know there is a great deal we can do for members of the COPD community to help them live healthier, more active lives. We are seeing the growth of "care navigator" roles that focus specifically on getting people through the complexities of managing therapy plans. We here at the Foundation are celebrating our twentieth anniversary in 2024 and as a part of that, we are proud to have launched a new educational resource highlighting the new horizons of the COPD world.

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This post was written by Michael W. Hess, MPH, RRT, RPFT

“Is it a bad day? Or is it an exacerbation?”

That question may not have the same ring as a Shakespearean soliloquy, but it is certainly closer to the front of most clinician’s minds when dealing with COPD. It has also largely been a question with no very definitive answers. Treatment recommendations have long held that early intervention in exacerbations is the key to minimizing further tissue injury (not to mention a hospital admission). At the same time, those recommendations also tell us that symptoms can vary widely from person to person and from day to day. How can clinicians tell the difference between an early intervention and an unnecessary one?

The answer may finally be on the horizon. Along with the other major paradigm shifts in the COPD world, 2023 brought the beginnings of a new framework to define and manage exacerbations. Known as the “Rome Proposal,” this new algorithm was technically published in late 2021 but really began to take hold after inclusion in the 2022 GOLD Report.

WHEN (NOT) IN ROME

The Rome Proposal is the product of a year of discussions, literature reviews, and analysis from some of the world’s leading COPD minds.1 They were originally intended to meet in Rome, Italy in January 2020, but that meeting was one of the earliest cancellations of the COVID pandemic. The group’s primary goal was to standardize the definition and evaluation of COPD exacerbations using objective measures. Previous attempts to grade the severity of an exacerbation were based almost exclusively on subjective measures like a person’s perception of their symptom burden. Symptoms are also not always tied to the physiological mechanisms at play during an exacerbation, potentially leading clinicians down incorrect pathways and possibly preventing them from detecting more serious issues during the course of treatment.

The result was a consensus document proposing a new “conceptual model” of a COPD exacerbation, a consensus definition, and a proposed severity classification scale. It is important to note that the algorithm does NOT make specific recommendations based on severity (unlike other aspects of the GOLD strategy). Instead, it is up to clinicians themselves to initiate the best therapies available to treat the underlying cause of the exacerbation (and hopefully relieve symptoms at the same time).

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This post was written by Kristen Szymonik, BS, RRT, AE-C.

When we think of pulmonary rehabilitation, we usually think of a clinic-based, in-person program. But the COVID-19 pandemic has changed the landscape of medicine and has paved the way for comprehensive virtual medical programs. These include telehealth visits, online support groups, and even virtual pulmonary rehab.

In the past few years, traditional pulmonary rehab programs across the United States have been forced to reduce their capacity or consolidate locations. Some have permanently closed their doors. These changes in service negatively impact patients, particularly those in rural areas. Patients who once showed progress in their COPD management with the help of in-person pulmonary rehab were suddenly left without those services. Many lost the progress they had made and found themselves with worsening symptoms and reduced quality of life.

While COVID-19 may have increased the need for virtual pulmonary rehab, the interest in these programs has always been present. Virtual pulmonary rehab has been a helpful resource for patients who either didn’t have access to a pulmonary rehab program in their community or were unable to travel to a local in-person program due to severe COPD symptoms or transportation and logistical factors. One study showed that just under 3% of eligible patients actually accessed a pulmonary rehab program within a year of their discharge from the hospital.¹ In this study, distance was a major indicator of program utilization.¹ Virtual pulmonary rehab addresses these barriers to participation, offering patients an important service that is not dependent upon transportation to a clinic or similar facility.

Pulmonary rehab is one of the most effective treatments for managing COPD symptoms. While many patients benefit from the camaraderie and interaction with other patients that in-person pulmonary rehab provides, they can still participate in and benefit from the other components of pulmonary rehab that are still present in a virtual program. In fact, recent studies indicate that virtual pulmonary rehab is not inferior to in-person programs.² Instead, it was determined to be a safe and beneficial alternative to traditional pulmonary rehab programs.²The benefits of pulmonary rehab can extend for several months beyond the completion of a program. These improvements in symptoms, stamina, and overall health can be long-lasting.

Unfortunately, despite the value pulmonary rehab brings to the COPD community and the demonstrated benefit of virtual pulmonary rehab, these programs are threatened with the potential loss of Medicare coverage on May 11, 2023. On this date, the federal extension of Medicare coverage for pulmonary rehab is set to expire, potentially leaving many patients without this vital service.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

Inhaled medications have been with us for a very long time; longer, perhaps, than we usually recognize. The first known description of a medicinal inhaler device (outside of pipes and such used for smoking and similar activities) was actually created in 1654 by an English physician by the name of Christopher Bennet.​¹​ Just over three hundred years later, an American scientist named George Maison invented a dose-metering valve at the behest of his daughter, who sought a more convenient way to take her asthma medication. That invention, and the subsequent development of the metered-dose inhaler (MDI), set the stage for decades of convenient, portable, and effective inhaled therapy for a variety of respiratory conditions.^​2​

At least, it was supposed to.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

Much has been written about the new GOLD Strategy Report since it launched this past November. Considered one of the most significant revisions to the GOLD strategy in years, this latest iteration has many in the field rethinking how we look at the very definition of COPD. But the report also contains some major changes to initial therapy recommendations, not to mention refinements of ongoing therapeutic pathways. These changes have the potential to affect your clinical decision-making as your patients travel on their COPD journey, so it is important to not allow them to get overlooked.

A NEW GOLD BOX

Perhaps the most notable change is another revision to the “GOLD Box.” First seen over a decade ago, the Box was created to make more practical initial therapy recommendations based on exacerbation risk and symptom burden, rather than simply airflow obstruction. It has traditionally grouped people with COPD into four groups based on that risk and that burden, with suggested therapies based on the best evidence for their subcategory. However, newer evidence compiled in this year’s report suggests that for those people who have at least two exacerbations over the course of 12 months (or one that lands them in the hospital), symptom burden is far less clinically significant in terms of clinical relevance. Thus, the previous two high exacerbation risk groups (C and D) have been combined into a single group, E.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

It is once again that magical time of year when everyone gets ready to engage in healthier lifestyles in the new year.  We’ve all heard (and likely made) the resolutions, then felt guilty after a week or two when, despite our best efforts, we came up a bit short. As health care professionals, one of the more common goals we can help the people in our care with is quitting smoking. Of course, it is also one of the trickiest goals to accomplish, for a variety of reasons. However, by resolving to look at tobacco treatment a little differently this new year, we may be able to improve the odds of success.

NOT JUST A HABIT

Historically, as HCPs, we have looked at tobacco smoking as simply a “bad thing” that our patients should stop doing. Even today, many of our strategies focus on establishing distinct quit dates and similar ideas which make it seem like making a major lifestyle change is the equivalent of flipping a light switch. However, experts from places like the Mayo Clinic reinforce that only around five percent of those who attempt a cold turkey quit are successful for more than six months.¹ The Centers for Disease Control and Prevention put the annual success rate of quit attempts of any kind at a dismal 10%.² Clearly, the cold turkey method needs some reassessment.

I would argue that one of the biggest barriers here is the separation of the behavior from the person. People smoke for many reasons, with nicotine dependence surprisingly often being a lesser one. For example, in the mid-1990s, tobacco companies employed a strategy known as Project SCUM (SubCulture Urban Marketing) to specifically target certain demographics, including sexual minority groups and the unhoused, to create new customers. Project SCUM preyed upon the isolation of many LGTBQ+ community members who wanted to become part of a larger community and establish new connections. In an interview with News Center Maine, anti-smoking advocate Shane Diamond (who describes themselves as queer and trans) stated, “They used our daily experiences of homophobia and transphobia and otherness, and they built us a community and culture that drew us in.” Project SCUM continued the legacy of decades of targeted marketing toward minority groups, with the

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