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COPD: Practical Aspects of Care Village Sleep Lab & Breathing Center Juan A. Albino, MD 751-4955 January , 2016 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 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 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 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 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 Medication Categories Short Acting bronchodilators: last 4 hours Albuterol (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”) 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 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 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. 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% 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 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 Overlap Syndromes COPD COPD COPD COPD COPD COPD COPD COPD & & & & & & & & Heart Disease Asthma Bronchiectasis Sinusitis Sleep Apnea Depression / Anxiety Lung Cancer Bone / Muscle Disease 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 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 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 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 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 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 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 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 Stem Cell Clinics: Comments October 15th, 2015: Medical News http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unre gulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx May 18th, 2015: San Jose Newspaper: http://www.mercurynews.com/business/ci_28139232/stem-cellclinics-run-amok-amid-lack-regulation Mayo Clinic: overview of stem cells: http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/indepth/stem-cells/ART-20048117?pg=1 September 10, 2015: Medical Journal: Medicine’s Wild WestUnlicensed 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 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/onescholars-take-on-the-power-of-the-placebo Article: http://harvardmagazine.com/2013/01/theplacebo-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