Posted on January 17, 2023 |
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.
Posted on December 16, 2022 |
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
Posted on November 30, 2022 |
This post was written by Michael W. Hess, MPH, RRT, RPFT with guest authors David Reynolds, RRT, EMT and Jean Rommes, PhD.
It is well-established that people new to long-term oxygen therapy face many barriers when first learning to use their equipment safely and effectively. Oxygen therapy outside the hospital is far different than using the seemingly endless flow at the bedside. A study published in 2018 found that 35% of new therapy users felt at least somewhat unprepared to operate their oxygen equipment. What is less commonly discussed is that health care professionals are also faced with confusion and misinformation that prevents them from helping their patients adapt. I enlisted two experts in the space to answer some of the most commonly asked questions we see about oxygen therapy. Dave Reynolds, RRT, is a respiratory therapist with over two decades of experience as a durable medical equipment (DME) supplier. Jean Rommes, Ph.D., is a longtime oxygen therapy user and COPD advocate. Together, we hope to help you learn more about optimal care for those who need supplemental oxygen outside the hospital.
TESTING THE RIGHT WAY
When a patient presents with potential hypoxemia, many HCPs know they need to test oxygen levels with a pulse oximeter at rest and during activity. Many describe this as a “six-minute walk test,” but that is something of a misunderstanding. The validated six-minute walk test measures exercise capacity in terms of distance over time. A good oxygen titration has no time limit and looks at saturation. In addition, people should be tested at different levels of activity. According to Jean, it is critical that the person doing the test replicates “the kinds of things you’ll do at home and in your daily routine,” including things like climbing stairs. Only then can a true picture of one’s oxygen demands be seen. Dave also reminds us that tests can also use arterial blood gas (ABG) results, which can be helpful for those prescribing oxygen after an inpatient admission. Either way, remember that the testing cannot be done by the DME supplier, only an HCP or independent testing center.
WORKING WITH YOUR LOCAL SUPPLIERS
It is critical to develop relationships with the DME companies in your area. Not only will they determine what equipment is accessible to your patients, but company policies can also affect how much they will pay. Dave says that many suppliers are approved by the Medicare program, but do not accept “assignment.” That means they are not obligated to accept Medicare reimbursement as payment in full and can charge up to 15%. Medicare will still only pay 80% of their approved fee, meaning your patient will be left responsible for the difference (plus the 20% copay). There are also some suppliers that do not participate with Medicare at all; in these cases, patients will have to sign a contract with payment details.
It is also important to remember that many DME companies have been under significant financial strain for many years. Changes in Medicare reimbursement policies have made it much more difficult to provide service at the same level as in previous decades. DME is a business like any other and the financial realities many suppliers face have many impacts, from reducing the kinds of equipment that may be available to the amount of training and education that can be provided. Patients therefore may need to rely heavily upon you (or resources like the COPD Foundation’s Oxygen Therapy Basics publication or the COPDF/American Thoracic Society collaboration website YouAndOxygenTherapy.com) when they have questions.
Posted on November 16, 2022 |
This article was written by Michael W. Hess, MPH, RRT, RPFT
For more than two decades, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Strategy Report has been one of the key resources in the COPD world. The annual report reviews the major research publications from the previous twelve months and provides recommendations for the diagnosis, management, and prevention of COPD. Periodically, the GOLD report undergoes a “major” revision, where significant changes in how we treat this condition are advised.
The 2023 report is an example of such an update. The past few years have seen the results of major longitudinal studies enter the conversation that have the potential to permanently change how we view COPD. I spoke with Dr. Antonio Anzueto, a member of both the GOLD Science Committee and the COPD Foundation Medical and Scientific Advisory Committee, about what he thought some of the most significant changes in the new document were and how those changes could impact COPD care.
Posted on September 12, 2022 |
This article was written by Michael W. Hess, MPH, RRT, RPFT
As clinicians, we are often called upon to make recommendations. We have access to peer-reviewed research, so we typically have an idea of the most appropriate therapy for a given situation. Wheezing? That calls for some bronchodilators. Hypercapnea? We may consider noninvasive ventilation. We tend to be confident that we know the best thing to do in most cases.
Despite our best efforts, sometimes there is a mismatch between what is in the textbook and what our patient truly needs. In our enthusiasm to provide optimal care, it can be easy to miss that those two things are not always the same. Unfortunately, when we lose sight of that, we can take our patients down a path where expectations do not match reality. That, in turn, leads to frustration and a lack of trust, which can have a devastating effect on therapy adherence and outcomes. That is why collaboration and the process of shared decision-making in goal setting and planning is essential to care.
A Little More Conversation
So, what is shared decision-making? It's clear, open communication between the clinician and the patient that facilitates the development of a therapy plan that balances the patient's needs and values against potential risks and outcomes.1 Historically, many (if not most) clinical decisions were left to the people carrying the stethoscopes, and patients would dutifully carry out their instructions (or not). Studies have indicated that this model often led to decisions being made not by evidence but by the preferences of the ordering clinician, leading to massive inconsistencies in care.2 This, combined with the patient perceiving that he or she has no say in a treatment plan, can have a significant negative impact on the likelihood of adherence to that plan. However, when medical decisions are made collaboratively, people are often more likely to accept and stick with their prescriptions and therapies.3
Posted on August 08, 2022 |
This post was written by Christina Hunt, BS, RRT-NPS.
I consider myself an optimist. I try to think about the “best case scenario” in almost every situation that I encounter. In the medical world, we often talk about outcomes. We consider possible outcomes when we are deciding on treatment plans or starting any new course of therapy. As medical professionals, we are prepared to make decisions wherever the road might lead. Whether the outcome is good or poor, we have a plan. But I have a question for you… are your patients prepared?
Discussions centered around advanced directives should not only be directed at the chronically ill or elderly. The Covid-19 pandemic was eye-opening. We saw increased fatalities from the coronavirus, and often those individuals were not prepared with advance directives. Families were forced to make end-of-life decisions (often over the phone). We know as a society, that many of us leave instructions or wishes after our deaths. However, do your patients have instructions for their health care teams, families, and loved ones for the act of dying?
Here are some thoughts on how to have a courageous conversation with your patients about advance directives.
Posted on June 28, 2022 |
This post was written by Michael W. Hess, MPH, RRT, RPFT.
Early on in my primary care days, I had a patient come in for a one-month follow-up visit after starting a new medication. I asked them, "Are you taking your inhaler 2 puffs every day?" They nodded quickly and replied, "Oh, yes. Every day." I then handed them a demo version of the device and asked them to show me their technique. They turned the inhaler around in their hands once, twice, three times. They were unable to perform the task.
I am sure many of you have been in that position, where someone tells you something about their regimen that may not be accurate. Many of our discussions about assessment and adherence include discussing the use of objective measures or testing to overcome barriers. However, a better question might be, "Why does this happen?" Understanding the reasons for inaccuracy can help clinicians create environments where people feel empowered to overcome barriers to adherence, whether they are related to a lack of confidence, a lack of understanding, or another combination of factors.
Many of our modern chronic conditions can be closely tied to lifestyle-related factors like diet, exercise level, and, of course, tobacco exposure. That means many of the people living with these conditions have repeatedly heard things like, "Why don't you just quit smoking?" "Why don't you just eat less?" One I have heard myself is, "Can't you just go for a walk?" Of course, it is not that easy to "just" start doing those things regularly, so people are often made to feel guilty at every appointment for their lack of success. In these situations, to avoid that cycle of guilt, some people decide to just say, "yes, I'm doing that," and get that box checked off.
Posted on June 02, 2022 |
This post was written by Michael W. Hess, MPH, RRT, RPFT
In 2016, I underwent a sleeve gastrectomy. Since then, while my health has significantly improved, I still am obligated to take various vitamins, supplements, and a few prescription meds to counter the effects of decades of obesity (as well as the side effects of the procedure itself). I know what they all do. I know how they work. I know when and how to take them. I am ostensibly the most likely patient in the world to stick with my regimen.
I usually forget.
I have tried pill sorters, phone alarms, the whole gamut of reminder tools to keep me on track. Sometimes they even work for weeks or months at a time. But, more often than not, I eventually fall off the adherence wagon and forget a dose (or two). However, there IS one medication I do take very consistently. Every single day, I take my allergy medications. I started thinking about why that might be, and a very simple answer occurred to me: I take them because I can feel it when they work. Or, perhaps more accurately, I sure feel it when I DON’T take them.
This post was written by Michael W. Hess, MPH, RRT, RPFT
Imagine, if you will, one of the people in your care living with COPD. You have been following this person for many years, and you have watched their symptoms steadily worsen, gradually eroding their quality of life. You have advanced their therapy by the book, first adding bronchodilators, then corticosteroids, even phosphodiesterase inhibitors and ongoing antibiotic therapy. They have been through rounds of pulmonary rehabilitation. When you saw them last year, they had just started long-term oxygen therapy but still managed to get out and about regularly. But today they show up in your clinic and they tell you that they’re just tired. They’re tired of being short of breath all the time. They’re tired of having to watch the grandkids play instead of joining in. They’re tired of slowly giving up one hobby after another because they simply do not have the energy anymore. They don’t want to endure a major procedure like a lung transplant, but they’re not ready to just throw in the towel, either.
Posted on April 28, 2022 |
Written by Michael W. Hess, MPH, RRT, RPFT.
One of the first things our respiratory instructors taught us way back in the day was that we were to treat the patient, not the number. Focusing on what the numbers say can prevent you from seeing the bigger picture, whether it’s the oximeter that is reading the saturation of a bedsheet or the person who has been in an exacerbation so long their respirations have come back down to normal despite their tripod breathing and cyanosis. Actually looking at the person in your care can give you a much clearer picture of what’s going on.
I have taken that advice to heart throughout my career and passed it along to many a new therapist starting out. It has helped me, for example, understand why we cannot just focus on any singular metric when we talk about COPD severity. As I’ve gotten further along in my career, I’ve discovered that it still comes up short in one very important way. Just as numbers should not define the entirety of the patient, the word “patient” alone cannot be allowed to define the person in your care.
It can be easy to forget that in this era of unimaginable stress in health care, where visits are compressed and hurried, and where efficiency is often prioritized over empathy. However, it is still the key to truly effective patient care. I learned that firsthand a few years back when I had the chance to develop a COPD-focused chronic lung disease program in a primary care clinic. One of the first things I did was to ask my friends in the COPD community what an ideal clinic space might look like to them. I knew I would not have the leeway to do any major redesign or remodeling of the clinic space, but I wanted to know how to get people comfortable with the place from the jump.
Posted on March 07, 2022 |
This PRAXIS Nexus post was authored by Ken W., an active member of our COPD360social community who was diagnosed with COPD in 2010. He is married, has two grown children and nine grandchildren, and is an enthusiastic traveler and exerciser. Ken lists nature photography and bird watching – including eagle nest monitoring! – as well as complex cross stitching among his many hobbies. Thanks to Ken for sharing his experience with pulmonary rehabilitation (PR) with our community!
10. Forced me out of the house and into a small group of people with similar challenges.
In 2010, I spent 13 days in the hospital and was then released with O2 24/7. I knew nothing about COPD or O2 options. I also didn’t know if I would ever work again or if I could leave the house for more than an hour or so with a small tank. Being encouraged to travel to PR and the chance to see I was not alone on this journey were extremely helpful to me.
9. Exposed me to the various options for stationary and portable oxygen.
The only thing I knew before PR about supplemental O2 was that I had a concentrator for home use and small tanks for outside the home. PR taught me about options including LOX (liquid oxygen) and POCs (portable oxygen concentrators) as well as the difference between pulse and continuous flow.
8. Helped me to understand the various medications I am on, the dosage and how to properly use an inhaler.
I was sent home on lots of medications but didn’t understand what they were, what each was for or even how to use an inhaler or a nebulizer, all of which was cleared up at PR.
Posted on January 27, 2022 |
This post was written by Michael W. Hess, MPH, RRT, RPFT, COPD Foundation.
Inhaled medications tend to get the lion’s share of attention when it comes to COPD therapies, and for good reason. They’re familiar, they’re accessible, and they have long been some of the most effective tools we have for reducing symptom burden and managing other aspects of COPD, especially as we’ve focused on overall symptom control and reducing exacerbations. As COPD management evolves in the 21st century, the idea of “treatable traits” that can be directly addressed in order to manage symptoms and reduce exacerbation risk has risen to the fore, allowing for a more individualized approach to someone’s care.1
One of those traits is mucus hypersecretion, common in those people whose COPD leans more toward the chronic bronchitis side of things. Frequent, productive coughing is a way of life for this population, as their airways struggle to stay clear. For these folks, aerosol medications may not be enough to keep their COPD in check. That’s where basic airway clearance techniques come in. From breathing exercises like huff coughing to oscillatory positive expiratory pressure (OPEP) devices, these therapies assist the body’s own mechanisms clear out excess mucus, reducing cough and improving comfort. They come in several form factors, but the general idea of providing expiratory resistance coupled with airway vibration to both recruit alveoli and loosen secretions is consistent across all these devices. They are generally easy to use and have a track record of improving outcomes, at least in the short term.2 There are certain subsets of people living with COPD who need a still more aggressive option. Historically, this role has been filled by mechanical insufflation-exsufflation equipment. These devices use positive inspiratory pressure with a shift to negative expiratory pressure, simulating a forceful natural cough and assisting mucus clearance.3 However, there is limited clinical information to actually support the use of these devices in any disease state, and rates of adherence to therapy.4 Fortunately, there is another potentially valuable option for people who need higher-level airway clearance but who may not tolerate insufflation-exsufflation: high-frequency chest wall oscillation (HFCWO). HFCWO has long been used in other lung conditions, notably cystic fibrosis and bronchiectasis. Research into its application for COPD is still relatively young, but there are some promising signs.
As a quick review, HFCWO is delivered through the use of a percussive vest that uses either rapid air pressure cycling or small electric motors to induce percussion and vibration all around the thoracic cage. These impacts work to loosen mucus and move it from peripheral airways to more central ones with larger caliber, facilitating a more effective cough.5 Clearing the mucus out not only reduces cough frequency, but also reduces the risk that stagnant, pooled mucus will become infected, leading to what is often described as a vicious cycle of infection, inflammation, dysfunction, and structural damage in the airways.6
Posted on January 23, 2022 |
This post was authored by Michael W. Hess, MPH, RRT, RPFT, Senior Director of Public Outreach & Education, COPD Foundation
“When all you have is a hammer, every problem looks like a nail.”
It can be amazingly easy to get tunnel vision as a health care specialist. One can get so used to treating certain conditions that the care of every person in your care gets viewed through the lens of that particular pathology. It is a lesson I myself have learned the hard way as a respiratory therapist, especially as one working in chronic disease management. I remember one specific patient who first presented with spirometry, symptoms, and imaging entirely consistent with emphysema. We started them on a particular medication regimen and soon got their symptoms under control, for which they were quite grateful. Then one day they came back, complaining of new-onset cough. The rest of his primary care team and I worked diligently over the course of the next few months, following right along with best practices and strategy recommendations, adding this medication or that, calling in airway consults, and various other tricks to address this ‘progression’ of COPD. Unfortunately, not a single thing worked for this person, and while their shortness of breath and activity tolerance were still great, the cough was more bothersome every day. We were stumped.
Posted on July 13, 2021 |
This post was reviewed by Xavier Soler, MD.
The following resource provides respiratory therapists and other allied health professionals key clinical information regarding a new minimally invasive treatment option, Bronchoscopic Lung Volume Reduction (BLVR), for patients suffering from severe emphysema.
The respiratory therapy community is committed to providing optimal patient care to those with cardiopulmonary health issues. These dedicated healthcare professionals provide critical respiratory services and often follow the patient throughout their entire treatment plan. Chronic obstructive pulmonary disease (COPD) is a common diagnosis among a respiratory therapist’s patient base; COPD is one of the leading causes of death worldwide and in the United States, with nearly 16 million people diagnosed.1 Of those 16 million, at least 5 million people suffer from emphysema, one of COPD’s main presentations, involving progressive damage of lung tissue and distal airway (alveoli). This condition often results in hyperinflation of the lung, causing significant breathing challenges for patients.1
Until recently, treatment options for emphysema were limited to pharmacological treatment, or for patients that qualified, invasive procedures, such as lung volume reduction surgery (LVRS) or lung transplant. Bronchoscopic lung volume reduction (BLVR) with endobronchial valves is a relatively new, minimally invasive treatment option available for a subgroup of patients suffering from the debilitating symptoms of severe emphysema. This procedure has shown significant clinical benefits including improvements in lung function, shortness of breath, and quality of life. Specifically, for some patients with emphysema with hyperinflation, these benefits were achieved by ultimately improving gas exchange and allowing healthier parts of the lung to re-expand.
Posted on March 19, 2021 |
This article was written by Jane M. Martin, BA, CRT
We all know that comprehensive group pulmonary rehabilitation is one of the most effective treatments for COPD with documented improvements in exercise capacity, health-related quality of life, reduced hospitalizations, and possibly improved survival. Thus, it is considered the standard of care for most patients with COPD who have activity limitation.
Despite this, it is estimated that only 2-3% of patients with COPD who are candidates for pulmonary rehabilitation in the United States undertake this treatment program. This is due, in part, to a number of barriers including lack of access, high cost, lack of transportation, poor reimbursement, and physical incapacitation.
While the COVID-19 pandemic has led to many in-person pulmonary rehabilitation programs being temporarily closed, virtual, or remote, methods through telehealth platforms has allowed continued contact with patients and delivery of pulmonary rehab to individuals in their homes.
The outcomes of these programs have been mixed. In general, patients who adhere to a remote program show improved exercise capacity and well-being, but there is a poor record of continued participation in an exercise program. The absence of a sense of community and peer interactions contribute to this poor program adherence and suboptimal outcomes. In addition, many virtual programs have not included the full range of rehab elements.