COPD: Practical Aspects of Care Village Sleep Lab & Breathing Center

1. COPD: Practical Aspects of CareVillage Sleep Lab & Breathing Center Juan A. Albino, MD 751-4955 January , 2016

2. COPD: National Priority • 3rd leading cause of death • 24 Million people have COPD • Smoking is main cause • Early diagnosis requires testing with spirometry • Cough, phlegm, shortness of breath, wheezing are the common symptoms • Slowly progressive, with accelerations

3. Smoking Cessation • Change in approach recently • Managed more as a chronic disease • Patient understanding & motivation all important as well as overall plan & Quit Date • Combine Counseling and Medications • Approach: Long acting drugs & short acting rescue drugs: e.g. antidepressants with nicotine replacement lozenges • Varenicline (Chantix) can be effective but side effects including depression • E-Cigarettes controversial

4. E-Cigarettes • Construction and contents vary and not standardized • Usually nicotine is dissolved in liquid and vaporized • Question: what other chemicals involved? • Claim: entertainment tool, not for smoking cessation • Explosive rise in sales

5. Exercise or Activity • As little as 5 min /day makes a difference • Maintenance of fitness: walk 3 days/wk for 30 minutes, for increasing fitness: walk 30-60 minutes 5 days / wk • Exercise: best predictor of mortality in both heart & lung disease • Modern evidence confirms no medication better for heart & lung disease

6. Pulmonary Rehabilitation • Inactivity most powerful predictor of mortality • Pulmonary Rehabilitation: reduces dyspnea, depression, hospitalizations & exacerbations • Increases activity, oxygen saturation, sense of well being • Exercise: endurance involving legs, heart, lungs, and resistance or weights involving arms • Dancing, Tai Chi, Singing, Yoga also promote balance • But only 25% of COPD patients sent for Rehab

7. Medication Categories • Short Acting bronchodilators: last 4 hoursAlbuterol (Pro-Air, Ventolin, Proventil), Atrovent rescue / back up: sick, exercise, allergy • Long Acting bronchodilators: 12 hours or 24 hours, convenient, easier to use, probably the best drugs for COPD • Nebulizer: short & long acting bronchodilators are available and paid by Medicare Part B • Steroids over used in COPD maintenance therapy (“Triple Therapy”)

8. Inhaled Medications: Technique All Important • Proper technique for inhaler use must be taught well and constantly reinforced • Over 70% of patients use inhalers improperly • Spacers / chambers helpful, glass best for HFAs • Nebulized drugs cheaper & easier to use • Dry powdered inhalers also easier to use • A host of recent inhalers assure better delivery of mists but need to be learned

9. Question • A 70 year old patient has severe COPD and some heart disease, and he has been a heavy smoker and continues to smoke • He will probably die from: COPD, or Heart Disease, or Lung Cancer? • See next slide

10. Question • Answer: Probably from Heart, then Cancer, then COPD • We forget that smoking is a big risk factor for heart disease, strokes, leg artery obstruction, heart failure • Smoking causes over 80% of all lung cancers, & major factor for throat, liver, bladder, kidney, liver, stomach, colon, etc.

11. Causes of Death in COPD Patients • IF Continue to Smoke: • Heart Disease: 33% Lung Cancer: 33% • Other Cancer: 21% Respiratory: 10% • General Severe COPD (30% smokers) • Respiratory : 27% Heart: 26% • Cancer: 21% Pneumonia: 10% • Other: 17%

12. Lung Cancer Screening by CT Scan of the Chest • CT approved by Medicare and required by Obamacare or the ACA • However Medicare has not outlined the procedure for implementation yet • In general screening is for: ages 55 to 75, no symptoms, 30 Pack Years of smoking, current smoker or quit within the last 15 years, able to withstand lung cancer treatment if found, shared decision making session, no recent chest CT

13. Vaccinations • Influenza, inactivated, injection, yearly • Pneumococcal vaccines, protects against half of all pneumonias • Two pneumococcal vaccines • PPSV23, PneumoVax, the old one, given once before age 65 & once after • PCV13 or Prevnar 13, should be given once after age 65 • In general the pneumococcal vaccines should be given about a year apart and not together

14. Overlap Syndromes • COPD & Heart Disease • COPD & Asthma • COPD & Bronchiectasis • COPD & Sinusitis • COPD & Sleep Apnea • COPD & Depression / Anxiety • COPD & Lung Cancer • COPD & Bone / Muscle Disease

15. Community Care of COPD • Self care, family care, community care • Probably the best form of care • Immensely important in treating: anxiety/depression, especially 2ary to isolation, lack of interaction, spiritual poverty, lack of exercise • Advocacy at the government, insurance, hospital level

16. Stem Cell Treatments • At best: a for profit experimental procedure • At worst: fraud and abuse of patients that are desperate • History of experimental procedures: about one third help, one third have no effect, and one third hurt

17. Stem Cell Treatments: 6 False Hope Warning Signs • The International Society for Stem Cell Research lists these warning signs that a stem cell treatment is not legitimate • It makes claims based on patient testmonials • The same stem cells are used to treat many diseases • The source of the stem cells is not clearly documented

18. Stem Cell Treatments: 6 False Hope Warning Signs • There is no clear protocol or detailed guide to treatment • Claims that there is no risk; all medical procedures carry risk • High cost or hidden costs; legitimate clinical trials do not charge patients, and may even pay them

19. Placebo Effect • During WWII a medic, Henry Beecher ran out of morphine • So he gave just plain saline to wounded soldiers hoping to calm them • To his surprise almost half experienced significant pain relief and thanked him • In general from one third to two thirds of people can have a placebo response

20. Placebo Effect • Medicine with inactive ingredients is given to a patient • However the patients responds favorably: subjectively and sometimes objectively • Placebo response documented for pain, depression, anxiety, Parkinsonism, Asthma • FDA standard: new medicines must be compared to placebo and be superior

21. Use of the Placebos • In past used by physicians and nurses when drugs ran out • Used for problematic patients • Used for poor patients • But in USA placebo use, outside of a study, considered unprofessional, unethical, and illegal

22. Websites & References • American Thoracic Society: patients.thoracic.org • Global Initiative on COPD: goldcopd.com • COPD Foundation: copdfoundation.org • COPD Assessment Test (CAT); catestonline.org/english/indexEN.htm • American Lung Association: lungusa.org • Smoking Cessation: smokefree.gov • National Heart, Lung, and Blood Institute: nhlbi.nih.gov/health/public/lung/copd/index.htm • Centers for Disease Control and Prevention: cdc.gov/copd

23. Stem Cell Clinics: Comments • October 15th, 2015: Medical News http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unregulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx • May 18th, 2015: San Jose Newspaper: http://www.mercurynews.com/business/ci_28139232/stem-cell-clinics-run-amok-amid-lack-regulation • Mayo Clinic: overview of stem cells: http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/in-depth/stem-cells/ART-20048117?pg=1 • September 10, 2015: Medical Journal: Medicine’s Wild West- Unlicensed Stem Cell Clinics http://www.nejm.org/doi/full/10.1056/NEJMp1504560?query=TOC • International Society for Stem Cell Research: Patient Handbook on Stem Cell Therapies, http://www.isscr.org/home/publications/patient-handbook

24. References: Placebo • Dr Ted Kaptchuk, Director of the Program in Placebo Studies at Harvard Medical School: • Interview: http://www.npr.org/2012/01/06/144794035/one-scholars-take-on-the-power-of-the-placebo • Article: http://harvardmagazine.com/2013/01/the-placebo-phenomenon • Placebo Effect in Knee Surgery: YouTube https://www.youtube.com/watch?v=HqGSeFOUsLI • Placebo Effect at Stanford Medical School: https://www.youtube.com/watch?v=udJ31KKXBKk