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By Angela C.C. Wang, MD, CTS President
In retrospect, the comment was not unexpected, and meant to be funny given the informal setting of the critical care case conference I was attending. "But that's what outpatient docs do...look at the FEV1 and give an inhaler." As with most humor, the comment was more revealing of the speaker's unspoken prejudices rather than providing any insight into the outpatient management of COPD. It's easy to underestimate the clinical complexities involved in treating COPD. The advent of treatment guidelines has lent clarity to how we approach COPD therapy but also resulted in an unintentional oversimplification that reduces the art of medicine to a "paint-by-numbers" approach that is a disservice to patients and providers alike. The stigma of being smoking-related also contributes to dismissive attitudes toward this disease. November is COPD Awareness Month. The four opinion pieces in this issue strongly argue against the therapeutic nihilism towards COPD that many healthcare providers possess. They are humbling and inspiring, reminding us of notable treatment advances (anyone remember "subQ epi or terbutaline"?) and the complexities of a "bread and butter" disease that is finally getting the research and attention it deserves.
CTS is also excited to announce a new multidisciplinary symposium aimed at advanced practice providers entitled "COPD TODAY: A TEAM APPROACH" on Friday, Jan. 29 that will be held in conjunction with our annual Carmel Conference Jan. 29-30. This full day event features a mix of didactic, state-of-the art talks by COPD experts, small group interactive sessions, and a panel discussion on building multidisciplinary care teams in different clinical settings. More information is included in this newsletter and can be found on our website.
Medical Director, Smoke-Free Life, St. Helena Lifestyle Medicine Institute, St. Helena, California
Chronic obstructive pulmonary disease (COPD) was, for much of the 20th century, referred to, by many, as an irreversible disease for which little could be done. In 1973, I helped start one of the early pulmonary rehabilitation programs in California and witnessed the impressive gratitude of patients (and their families) who attended the programs. However, most physicians at that time had either never heard of pulmonary rehabilitation or never referred their patients with COPD to such programs. Even in 1981, when the American Thoracic Society approved their first statement supporting pulmonary rehabilitation (Hodgkin JE, et al. pulmonary rehabilitation: official position statement. Amer Rev Respir Dis 1981; 124:663-666), I would commonly find myself supporting the pro position of pulmonary rehabilitation, with an esteemed pulmonary colleague arguing the con position (i.e. that such programs were not worth the time, effort and cost). It has been gratifying to see the transition, over the decades, to the current position that pulmonary rehabilitation represents the "standard of care" for patients with COPD.
Crucial strategies for dealing with the epidemic of COPD confronting us include: 1) Teaching primary care providers how to identify their patients with COPD, since it is estimated that as many as half of all the patients with COPD in the U.S. remain undiagnosed, 2) Educating healthcare professionals about the many therapeutic interventions for patients with COPD that are available, and encouraging them to refer these patients for pulmonary rehabilitation, 3) Disseminating the latest strategies for how to stop smoking to cigarette smokers and their healthcare providers. Since smoking is the major cause of COPD and lung cancer, quitting even after 20 or more years of smoking, can significantly improve the individual's quality and length of life.
Professor of Medicine
Division of Pulmonary & Critical Care Medicine
Director, Fellowship Program in Pulmonary & Critical Care Medicine
Senior Investigator, Cardiovascular Research Institute
When I started my training in pulmonary and critical care medicine in the mid-'70s, COPD was a pretty hopeless disease. The only things known to have a significant impact on disease progression or survival were smoking cessation and oxygen for patients with hypoxemia. Funding for COPD research was very limited. Now we have a number of interventions that improve symptoms, prevent exacerbations, slow loss of lung function and improve quality of life. Perhaps most important, the NIH and others have now made the commitment to fund research on COPD. The NHLBI's COPD Clinical Research Network, COPDGene and SPIROMICS networks have identified new approaches to treatment, and have begun to unravel the complex mechanisms that lead to the development and progression of COPD. In addition, the American Lung Association is expanding its Airway Clinical Research Center Network beyond asthma, to include COPD. Mortality from COPD continues to increase throughout the world, there is lots to be done, and the need for ever more work, but I think the tide has turned and we can now be cautiously optimistic!
Director, Preventative Pulmonary and Rehabilitative Services, UC San Diego Health System
Most pressing issues in COPD today:
The need for earlier detection and referral to pulmonary rehabilitation. Just yesterday I sat with a group of patients who were unhappy that they were not referred to pulmonary rehab sooner. Some felt that they had needlessly suffered and avoided doing important activities and hobbies because they were not using inhaled medications correctly, or had not been prescribed oxygen when needed. They wondered if improved knowledge and skills might have staved off ED visits and hospitalizations. Pulmonary rehabilitation also enhanced their ability to cope with chronic breathlessness and losses in personal freedom.
Hopes for the future:
I'm hoping that COPD readmission reduction penalties will act as a catalyst to improve coordination and collaboration between providers in all healthcare settings. Eventually we should be performing the same patient centered care for all of our chronic lung disease patients from hospital to home. I would like to see respiratory therapists trained in chronic care, working in tandem with pulmonologists in office settings to support patients over the course of their life, performing assessments (changes in exercise/oxygen), monitoring progress, guiding recommended therapies and adapting home regimens as disease progresses.
Director of Pulmonary Rehabilitation, City of Hope National Medical Center
It is never a good time to have COPD. However, if you have to have it — perhaps this era has its advantages. COPD is beginning to achieve the attention it deserves as a cause of disability and worse. Research into understanding it as a heterogeneous disorder, its relationship with and without smoking, understanding its impact on the patient and society, and recognizing the central benefits of pulmonary rehabilitation after 50 years is at an upward trajectory. Medication opens airways, improves breathing and prevents exacerbations. Outcomes from our lifetime pulmonary rehabilitation program indicate that most hospitalizations for exacerbations are avoidable either by prevention or rapid action plans that are quickly responsive, intense and appropriately monitored. Collective experience of physicians, therapists, scientists and patient experts tells us that how the patient lives at home with active lifestyles, regular exercise and self-efficacy makes the greatest difference on disease impact. Life can have quality with COPD.
Mark your calendars for a full two-day program in Carmel!
Saturday, Jan. 30
Acute Respiratory Distress Syndrome (ARDS) & Extracorporeal Membrane Oxygenation (ECMO) (morning) AND Changing Paradigms in the Diagnosis and Management of Mycobacterial Disease and non-CF Bronchiectasis (afternoon)
Charles Daley, MD, National Jewish Health; Atul Malhotra, MD, UCSD & ATS President; Brian Morrissey, MD, UC Davis; Bob Owens, MD, UCSD; Douglas Conrad, MD, UCSD, Kevin Thornton MD, UCSD
NEW in 2016 — TWO Additional Courses on Friday, Jan. 29
COPD A Team Approach Course
Advanced Multidisciplinary Practice in COPD Course is the center-piece of CTS's core curriculum for advanced clinical practice training for as well as part of the CTS COPD Initiative. The course goal is to advance the science and practice of clinical care in chronic lung disease including COPD. Target audience includes advance practice nurses, RTs, RNs, pulmonary fellows and residents and other clinicians.
Richard Casaburi Phd, MD, Harbor-UCLA; Atul Malhotra, MD,UCSD, ATS President;
Ni Cheng Liang, UCSD: George Su MD, SFGH / UCSF; Stephanie Tsao NP, SFHG; Sam Louie MD, UC Davis; Jessica Goggin MSN, UCSD; and Vipul Jain, MD, MS, UCSF Fresno.
Fluoroscopy Safety for the Medical Provider
The purpose of this program will be to provide the standard instruction in radiation and fluoroscopy safety required to pass the initial test for certification to perform fluoroscopy. This course* will provide up to date education, interaction, clinical problem solving and resources for physicians, nurses and respiratory therapists to meet their radiation educational and safety requirements.
Sean Jones, MS, UC Davis; Lorri Leard, MD, UC San Francisco; Jia Wang, PhD, Stanford University
*8-hour CME course meets CA State Radiation Safety certification requirements.
Click here for more information
Children with asthma who are treated by an allergist are less likely to end up in the emergency department with an asthma attack, according to research presented at the American College of Allergy, Asthma, and Immunology (ACAAI) Annual Scientific Meeting. The study indicated that the probability of future acute care visits increased from 30 percent with one acute care visit to 87 percent with more than five acute care visits.
States hit hardest by the ravages of tobacco are often the least aggressive at hitting back, a USA Today analysis found. So a deadly culture of smoking lingers, which officials say is fueled relentlessly by tobacco companies targeting minorities and the poor.
Surgery to remove part of the lung can be a safe and effective treatment option for people with early stage lung cancer, even those traditionally considered "high-risk," a new study finds. Previous research had suggested that high-risk patients are more likely to have complications or to die after lung surgery. People aged 60 and older, long-term smokers and people who have other health problems are considered high-risk for partial lung removal surgery, the researchers said.
Lung Disease News
Findings from a recent study published in the Journal of Inflammation showed that knockdown of the CFTR gene of two intestinal epithelial cell lines triggers an inflammatory response, which may have clinical implications for patients with cystic fibrosis.
Los Angeles Times
Rare summer rainstorms fueled by a strengthening El Niño helped Southern Californians breathe easier this year by sweeping away smog, air quality officials say. The region had nine fewer bad air days during this year's summer smog season than in 2014, according to the South Coast Air Quality Management District.
A noninvasive and quick lung-function test frequently used to evaluate whether or not a smoker is at risk for developing pulmonary disease is likely mislabeling a significant percentage of smokers as healthy, a research team suggests. A more specialized but still noninvasive test can more accurately represent this risk, the researchers found in a new study, published in the European Respiratory Journal.
The Washington Post
Sleep apnea may increase the risk of developing gout and experiencing flare-ups, according to a new study. Gout's intense pain and swelling of a joint, often a big toe, results from the deposit of uric acid crystals in joints and tissues. The study team found that sleep apnea, a condition that prompts people to stop breathing during the night, causes periods of oxygen deprivation, triggering overproduction of uric acid in the bloodstream.
Children who are raised in households with dogs or farm animals during their first year of life may have a lower risk of asthma a few years later, a new study suggests. In the study, the researchers looked at early exposure to dogs and farm animals and the rate of asthma among about 377,000 preschool-age and 276,000 school-age children in Sweden. The study was published in the journal JAMA Pediatrics.
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