Chronic Obstructive Pulmonary Disease (COPD) The Basics

Transcription

1 LAN Event COPD 101 Chronic Obstructive Pulmonary Disease (COPD) The Basics Learning and Action Network (LAN) Event, November 1, 2017 Welcome and Introduction Welcome to the atom Alliance Learning and Action Network event entitled, COPD 101. My name is Lynn. As you may know, atom Alliance is a five year-five state initiative to ignite powerful and sustainable change in healthcare quality focusing on Alabama, Indiana, Kentucky, Mississippi, and Tennessee. Thank you for taking the time to join us today. We appreciate all you do to improve quality and achieve better outcomes in health and healthcare and at lower costs for the states and communities we serve. It is my pleasure to introduce our speaker for today, Stephanie Williams. Stephanie is a recognized leader and educator in respiratory therapy. Over the course of her career, she has designed and implemented pulmonary rehabilitation and respiratory programs in a variety of patient care settings. During her tenure as a director in cardiopulmonary, in an acute care setting. She has started up a group for COPD patients in the community, as well as a smoking cessation program. Stephanie's intellectual curiosity, commitment to patient engagement and hard work has allowed her to play an essential role in numerous areas respiratory innovation. She is a Registered Respiratory Therapist and holds a Bachelor s Degree in education from Tennessee Technological University. Stephanie, the floor is yours. Thank you very much. When I was first asked to join the COPD Foundation a couple of years ago, one of the questions that came up was, why do you want to devote your time and energy toward COPD? And as a respiratory therapist, my answer was over the course of my career I have worked with many patients and family members to try and improve quality of life for those living with COPD. What I would like to do further is to educate people so that we have less incidence of COPD in the future and hopefully are able to diagnose and treat COPD more effectively than we are now. Using that information, I thought we would just go over some of the basics of COPD to try and inform the public and let people know what COPD is and how it impacts people's lives. You see on the screen I have no real or perceived conflicts of interest in this presentation, so any names that I use are brand names are just to illustrate points. Impact of COPD in the U.S. Going back to COPD and impacting quality of life, one of the things I like to point out at the very beginning is that we have 25% of the patients that are diagnosed with COPD have never smoked. Often times, when I think of COPD, we think of it as purely a smoker disease. I think we can safely move away from that now and say 25% of the COPD population has never smoked. We can't truly attribute all of that to smoking or to the environment. We will go into

2 some of the other causes of that later. We can look at how people say the COPD has affected their quality of life and we see that 64% of people who have COPD say has is to say it has really impacted their quality of life. We see that 17, almost 18% of the population has been hospitalized in the past, and 50% of them take at least one daily medication. Digging a little deeper, we can look at how COPD impacts people in the United States. It does impact people all over the world, but primarily in the United States what we see is a population of about 15 million people who have been diagnosed with COPD, and what we estimate to be another 15 million who have the symptoms of COPD, but are not yet being treated for that disease. Looking here on this slide, we see that race versus COPD, in the top right-hand corner, we see that it affects whites more than any other ethnic group. We see that it is more predominantly found in households that make less than $25,000 a year. We see that it affects more women than men, and we also can see that it really starts to impact people when they are in their 50s and 60s and 70s. I did want to mention that first grouping that says incidence ages 18 to 44. There is another subset of COPD that we will discuss in a moment that has to do with genetics, which will impact that age group that you see, that young age group. What Is COPD? As a COPD 101 course, we need to define what COPD is. It stands for chronic obstructive pulmonary disease, and we will break that down a bit and discuss what that title actually includes. As I say the word chronic, I mean something that is going on and on. It is not a shortlived illness. It would not be something like an infection that just clears up with the course of antibiotics and goes away. This is something that people when diagnosed with a chronic illness, they are going to deal with it ongoing in the future. When I say the word obstructive, it means something is in the way. Something is keeping the air from being able to move in and out of the lungs freely. It is obstructing the path. Pulmonary has to do with lungs and then the word disease. COPD is the acronym. It is a serious lung disease that over time it makes it difficult to breathe, and if you think of COPD as an umbrella term, underneath that umbrella you will find these types of illnesses. You would see emphysema, chronic bronchitis, some forms of asthma, and so those first two, emphysema and chronic bronchitis, generally, we see those two occurring together. We will see some slides here in a few moments that illustrate those diseases. Here in the 21st century, what we see are these overlapping illnesses. You see the chronic bronchitis, emphysema and asthma, and you see how many of them overlap with each other. Bronchiectasis, obstructive sleep apnea, alpha-1 deficiencies, all of these illnesses come together and create the COPD population. What we know is that COPD is completely preventable. If we can improve air quality, if we can help people with smoking cessation and encourage people not to start smoking in the first place, we know that we can eliminate or significantly reduce the number of people who would be impacted by COPD in the future. We know that it is a progressive disease. We know that it is created by an abnormal inflammatory response in the

3 lungs, and so the next slide will show some of these responses. If you look at the healthy lung picture, look at all those little tiny clusters, it looks like grapes that are growing in a bunch. Each one of those, those are called alveoli and each one is a pretty significant surface area to helps transport oxygen into the bloodstream and pick up carbon dioxide that is raised for the body and help remove it, so that when you breathe out carbon dioxide is exhaled. Those normal, healthy little pink alveoli, every individual grouping, that is healthy lungs. Those are able to expand and contract. If you think of it as a balloon that you would blow up and then you could let the air out of the balloon, it squeezes the air back out of each of those alveoli that helps you exhale. Looking below that, you see lung tissue that is affected by COPD. You can see that you have some pink and normal-looking alveoli. Some of those are stretched out. Some of them look like perhaps the walls of the alveoli have been eroded away, and when that happens, you actually lose surface area. You lose a lot of the ability to exchange oxygen and carbon dioxide as you would in a healthy lung. Also, looking at some of those larger more oddly shaped alveoli, they have lost their elasticity. If you think that top picture being a balloon that you can expand and let the air out and it contracts out to its normal size, the alveoli at the bottom as rescinded no longer has that elastic ability, so it cannot contract and force the air out of the lungs as a normal lung would do. What we find are people that have difficulty releasing all of the air, and they feel as though their breaths are becoming more and more shallow, and that is, in fact, what is happening because older air is being trapped in the spaces of the long, so they are actually reducing the amount of space they have to be able to take in the next breath that they want. About COPD What are some symptoms of COPD? The first one that usually comes up is coughing, and many people are familiar with the term smokers cough. I do want to point out that not everyone, as it says in the last bullet, and not everyone has a chronic cough that has COPD. Not everyone with a cough or will develop it in the future, but coughing does seem to be one of the indicators that physicians look for when they are screening for COPD. Also, shortness of breath. Shortness of breath is maybe one of the sneakiest symptoms of COPD because it is one that folks are experiencing. They start eliminating activities that cause the shortness of breath, so that they don't have shortness of breath any longer. I will give you a couple of examples. Many times, my patients would say it's difficult for me to bend over and tie my shoes, so what they start doing is buying shoes that they don't have to tie. Buying shoes that they can slide the feet in and go, or sometimes they will say it is hard for me to carry things upstairs or carry things and walk and talk at the same time. They will find other ways around those chores. They will have people carry things up the stairs for them, or they will have people help them carry things as they walk and talk, so that they don't experience that shortness of breath. Excessive sputum or phlegm, this is something that we ask in our five-question screener. We ask do you have a cough, is it productive? And if the answer is yes, then it is something that we would want to follow up on with a spirometry test. Another symptom would be feeling like you

4 can't breathe or can't take a deep breath. Those were symptoms that we discussed a moment ago when we looked at the slide, the lungs that the alveoli that were misshapen and wheezing. Often times, the person that is doing the wheezing doesn't even know that they are wheezing. It is called to their attention by someone else, a spouse, a friend, coworker. Someone will say to them are you wheezing? Are you having difficulty? Those are just some of the symptoms that people will experience when they are being impacted by COPD. Here is kind of a graphic for how the COPD affects airways in different manners. To the left, you see the normal lungs, and you can see represented there, the little alveoli and you can see that it is wide open and the airway and you can see that the alveoli are individually formed. If you move over to the middle graphic, you see the bronchitis affected airways. You see the gray ink there that indicates that maybe there is something blocking the airway, and with bronchitis, we think of that is being mucus that builds up, and also it can be inflammation. When someone has bronchitis, not only do they have the cough because of the mucus but because they are coughing, they can irritate the airways themselves and cause swelling and other irritation. Which just makes the airways smaller and increases the chance the person will feel short of breath or experience wheezing. To the right you see the lungs that are affected by emphysema and you see how they are not clearly defined alveoli any longer. They are just distended and misshapen. So, again, loss of surface area which will decrease the ability to move oxygen and carbon dioxide. COPD Risk Factors What are some of the risk factors for COPD? The first one that people come up with is smoking, and it does increase your chances of developing COPD. However, as many as one out of four people with COPD have never smoked. They have not lived in a house with someone that smokes. They have never been around secondhand smoke. We know that there must be other causes, other things that trigger the onset of COPD. They may be things like environmental or occupational exposures, chemicals, fumes, other exposures to elements that don't involve smoking. We also know that there is a genetic component of COPD for many people. It is called an alpha one antitrypsin deficiency. What that is a protein that the body normally develops that protects the lungs and is not being produced by the body, and so the lungs are missing the potential layer of protection from the alpha-1 antitrypsin. They are more likely to be impacted by cigarette smoke or other environmental exposures. These people that are alpha-1 patients usually have an early onset of COPD. Usually they are younger than 45 years old. Often, we see them in their 20s that are being diagnosed with COPD, and that would be something that is abnormal. If you have someone that you know that has been diagnosed at an early age with COPD, it is really important for them to be tested for alpha-1. There's actually an alpha-1 foundation that will provide free test kits to people that suspect maybe they have an alpha-1 antitrypsin deficiency. How Your Lung Function Changes As you age I think it is important for us to know how our lung function changes as we age because many times what we hear are people that say I am sort of breath or I have difficulty

5 catching my breath, but it is just because I am older, or maybe I am out of shape or overweight. I think it is important for you to see the difference between someone who is a non-smoker and how their lung function declines as they age versus someone who has COPD and how their lung function changes as they age. This particular graphic does show the impact of smoking on someone's lung function. If you look at the green line, you see that the line peaks somewhere around age 27 or 28, and then begins to decline a bit as the person ages crossing the 75% lung function at around age 75. A person who has not ever exposed, never had any exposures to increase their risk of COPD, will have about 75% of their lung function at 75 years of age, and that is really incredible. At 75%, most people don't notice a difference in their lung function. They feel like they are breathing just fine. They are able to catch a breath and do exactly all the things they would want to do. Looking at the black line on that graph, again you see that a person who maybe started smoking or had an exposure at around age 18 or 19, they never reset full peak. They don't ever get to 100% of their lung function and they start to decline at around age 26 or 27. They cross the 75% lung function portion at around age 40 to 45. Again, most people at 75% don't really notice a difference in their ability to be active or maintain normal quality of life, but notice that that line keeps its downward trend pretty steeply, and they cross the 50% mark at around age 55. That is that 50% mark when people really start to notice I am having trouble. I am having a lot more difficulty doing the things that I want to do and 50%. If they can stop smoking at any point along that line, notice that those blue dotted lines start to follow the green line in a more parallel fashion. It does not necessarily mean we are going to stop the progression of decreasing lung function as we age. It just means that wherever you stop along that line, you will now start only deteriorating at a rate normal to humans. Criteria for Testing How do we define COPD in our patients? Testing is usually done on people that are smokers, over 40 years old with the symptoms. Anybody with a chronic cough or sputum production, anybody that is experiencing shortness of breath with exertion or wheezing, and that testing, again, is done for people over 40, but should be done to anyone that has a chronic cough, sputum production, wheezing, or shortness of breath. There is a screening tool that is available on the COPD Foundation website so that if you are concerned about your risk factors for developing COPD, you can go online to the COPD foundation.org and take this five-question screener and it asks a very simple question. It gives you a score and based on your answers and anyone that scores five or more will see that they are at an increased risk of developing COPD. Anyone scoring four or less would have a minimal risk of developing COPD. This is kind of an easy way to determine what kind of conversation you need to have with your doctor going forward. COPD Breathing Test After that, when your doctor says, I think we need to do a breathing test, what he is talking about is doing a test called spirometry. You can see the lady in the graphic who is doing a spirometry test, it is easy and quick. It is not painful. It is noninvasive, but it can very quickly help your

6 doctor to determine if you have COPD, and it can also determine how severe it is. We also do, in clinical office spaces, a pre-and post-spirometry. What that would mean is you would come in without having taken any breathing medicine that morning. You would do the test. We would then administer your breathing medication, wait for several minutes and then re-administer the test to see if there was any change in your pulmonary function test based on the medication that you had taken. That is how the doctors understand the type of COPD that you have, whether it is more chronic bronchitis, asthma, or emphysema, and determine the right treatment plan for you. Care for COPD Optimal care for COPD would include these five things. We would ask that if someone is currently smoking, we find that it is best practice to have them stop. That is based on the graphic that I showed moments ago, that no matter where you stop along the curve when you stop smoking your lungs will only deteriorate at a normal rate. We also think that pulmonary rehab is best practice, and pulmonary rehab is really the best tool that we can put in the toolbox for someone living with COPD. It helps to educate the person on exercise and nutrition. It helps them to recognize when they may be experiencing a flare up, and often what we find is the earlier we can capture someone that has that early flareup and get them on a right treatment plan, it will decrease the rate of deterioration in the lungs. It is really important to recognize these infections early. Breathing Techniques We also teach breathing techniques for patients that are living with COPD, and ways that they can -- it says coping skills and what I mean by that is energy management. When someone is living with COPD, what they will find is that they are a little more tired than he used to be. It is really important to work smarter not harder, and so we teach energy conservation techniques and energy management skills. We also want to always include end-of-life care. I will touch on this briefly because I think at least in the area where I live, I think palliative care and hospice care is greatly underused. I think that many people have been misinformed about what it is, and honestly, hospice care is something that can really improve quality of life for people living with chronic illness, and it can also increase and extend lifespan. End-of-life care is always touched upon within a pulmonary rehabilitation setting. We always ask for patients to get annual checkups and spirometry's to help us keep an eye on how their lung function is progressing. Also, best practices anyone that is diagnosed with COPD should be tested for alpha-1 and [ antitrypsin deficiency because it can change the treatment plan for each individual patient, and then medication adherence. This is important and that I can much the same way that you are in desperate prescribed an antibiotic, it is important to finish that course of antibiotic no matter how good you are feeling. Medication adherence is important to those living with COPD because many of the medications that are prescribed are maintenance medications. You would not want to stop taking maintenance medication that are keeping you healthy, that are keeping you feeling good, because when you stop taking them and they worked their way out of

7 your system, you will start to experience a flare up. Medication adherence is very, very important. Some of the breathing techniques that are important for those living with COPD are called pursed lip breathing and the other is diaphragmatic breathing. This is important for COPD patients to know these techniques, because when they are exerting themselves or when they are experiencing a flare up, these types of breathing techniques can really help to focus a person under breathing and reduce some of the anxiety that they feel during one of the flare-ups. Just really quickly, pursed-lip breathing is fairly simple to do. Sometimes it can be hard to remember to do when you're having a flare up, but we ask you to practice these so that when they need to do pursed-lip breathing it is a more natural event for them. The way you would do this is inhale through the nose for the count of two and then cover your lips like you're going to blow out a birthday cake, and you exhale slowly to the count of four. I would tell my patients to breathe out for as long as you can past four, because you're making room for the next breath and that is the one that we all want is the next one. Diaphragmatic breathing is something that is really helpful to encourage patients to relax. Sometimes the stress can bring on some of these flareups and, so we asked patients to practice diaphragmatic breathing where they would either rest by leaning back in a chair or lying down on the couch and putting one hand on their chest and one hand on their abdomen. What you want to do is for the hand on the chest is to remain still while your hand on the abdomen would want to rise and fall with each breath. And by having your hand placed one of the chest and abdomen, you can really concentrate on where the breath is happening in the body, and it does help to relax the patient and take their mind off of the flareup that they might be experiencing. Summary The summary for today is that we want to really emphasize optimal care and things that are best practices for those living with COPD. We want people to always be educating themselves and informing themselves about COPD and treatments that are coming out. There are medications that are happening and being developed all the time. There are new therapies that are being implemented. We are encouraging people to participate, and research programs that are being sponsored through the COPD foundation that pharma is trying to really promote good health for COPD patients. We also talked a little bit about pulmonary rehab and the importance that it places for those living with COPD. We talked about seeing your doctor and having a spirometry done every year just to make sure that you're keeping up with what your lung function is and how your diseases is progressing. Our end result is that we decrease hospitalization and improve quality of life for those living with COPD. Just as a point of reference, there is an 800 line that is sponsored by the COPD foundation. It is a peer information line, so when you call this number, you can receive education and information from someone that also is experiencing COPD. All of our information lines, employees are also

8 experiencing COPD, and so I think it really creates that relationship that someone is out there, and they understand what you're living with. Closing The slide here shows website information, COPD information on our website, There are online support groups and programs you can find to maximize your quality of life as you are encountering COPD, either with yourself or family members. I thank you very much for your time and for your interest in COPD. Thank you, Stephanie, and to all of our participants for joining the call today. Please contact us if you have any questions about what you just heard or need technical assistance with your improvement initiative. Have a wonderful day.