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Leah J. Witt, MD: Hello. I'm Dr Leah Witt. Welcome back to season 1 of the Medscape InDiscussion: Chronic Obstructive Pulmonary Disease (COPD) podcast series. Today we're talking about COPD exacerbations and hospitalizations with my guest, Dr Valerie Press. Dr Press is an associate professor of medicine and pediatrics and is the associate chief clinical transformation officer at the University of Chicago. Her research focuses on the use of behavioral randomized trials and implementation science research methods to develop, evaluate, and implement patient- and system-level interventions to improve the quality of care provided to patients with chronic diseases, with a focus on asthma and COPD. Welcome to the Medscape InDiscussion podcast, Val.
Valerie G. Press, MD, MPH: Thank you so much for having me.
Witt: I'm so glad you're here. We have worked together for many years, and I'm excited to share your expertise with a broader audience. I wanted to kick off the podcast by asking you, what's on your mind outside of medicine and healthcare — any hobbies or books?
Press: One of my newer hobbies is taking something that I didn't use to enjoy, which is running, and trying to turn it into something that I enjoy. I actually ran my first 5K race in October. I run slower than I walk, so keep that in mind, but I really do love it. I'm hoping to work toward a 10K, but I'm currently working through some hip issues and PT. So, hoping to get back to that soon.
Witt: That's nice. And then you rack up all the free T-shirts that you can display. What's on my mind is also fitness related. I also have been trying to exercise, but because I have two little kids, I can't find more than 10 minutes, so I have started doing Apple Fitness+ exercises. They have 10-minute increments of exercise, and I am swearing by it.
Let's start with our case. We've had the same case all season. We're talking about Mr Rivera. He's a 78-year-old man with COPD; we have staged him as group ECOPD (exacerbated COPD) because he's had frequent exacerbations and hospitalizations. During his last hospitalization — that's what we're going to talk about today; that's our focus — he came in after several days of increasing shortness of breath and coughing. His arterial blood gas showed that he had respiratory acidosis, and in the emergency room he was treated with bilevel positive airway pressure (BiPAP). So, I wanted to kick off our discussion by asking you, what is a COPD exacerbation, and does that sound like what he has?
Press: That's a great question. We often think we'll know it when we see it, but the guidelines in 2023 updated the specifics, so we really can focus in and try to be more precise. Nowadays, we're not only thinking of this as acute worsening of symptoms and an event, but we're also really making sure that it has increased dyspnea plus cough or sputum worsening over a short period of time, and particularly that it's sustained. We know that some patients can have very brief episodes of these symptoms, but we want sustainment. One thing to note is that if the dyspnea is just a little worse, that might not be a COPD exacerbation and you might want to think about other diagnoses.
In this case, he does sound like he's having multiple different systems with increased coughing along with shortness of breath, plus some of the other findings. I think that we would want to give our stamp of approval. This is probably a COPD exacerbation.
Witt: Would you be thinking about ruling out other causes? How would you think about that? Because sometimes these patients are sort of early closure. Maybe he's been hospitalized and we feel like it's the same old, same old. One of your areas of expertise is readmission. What do you think about that?
Press: I have a very low threshold for at least considering either co-diagnoses or alternative diagnoses. I'm really glad that the guidelines have updated that focus. We want to think about triggers. If it is a COPD exacerbation, why is it happening? Things that can affect the lungs can help trigger that, whether it's infection-related or other chronic conditions such as heart failure or end-stage renal disease. That would also be something to think about in these patients that gets missed frequently. Just because we put that COPD diagnosis on there without anything else, I would consider pulmonary embolism.
I do like to have a low threshold based on other symptoms, signs, and lab testing to really think about how we would go about making sure that it is or isn't a COPD exacerbation, or that it's a COPD exacerbation but possibly complicated by something else.
Witt: That's such a good point. In our previous episode, we talked about how Occam's razor doesn't apply in older adult patients with COPD. People have multiple diagnoses, and even an exacerbation could have a co-occurring pulmonary embolism. Let's talk about initial treatment.
Mr Rivera came to the emergency room with these symptoms. He got put on BiPAP right away. You work in the inpatient setting quite a bit, as well as outpatient. How would you think about triaging — deciding who gets outpatient treatment, who gets inpatient treatment, and who gets treated in the ICU?
Press: In the case of this patient, given that he's an older patient and has frequent exacerbations, we're going to be a little bit heightened with this. But in general, taking a step back, there are patients with COPD exacerbations that can be treated, as you noted, in the outpatient setting.
You really want to think about those mild or moderate cases where they don't have any particular distress. They're not meeting any kind of moderate or severe symptoms that would be worrisome, such as acidosis or hypercapnia that would warrant ventilatory support or at least monitoring if there's new oxygen requirement or worsening. Those kinds of things would make you start worrying outside of that mild or moderate phase.
There are nice, precise cutoffs in the guidelines, where you think about a combination of vital signs, such as a rapid respiratory rate greater than 24, heart rates that are getting up there and are elevated at rest. These patients can go high with very minimal activity, and then we are keeping an eye on the oxygen saturation.
Anyone who you think needs, or might soon need, ventilatory support, those are the patients where you're really getting into some of the worst moderates or the severe cases that you would want to bring in for inpatient treatment.
And then just one note, referring to that earlier point: Is this an exacerbation or not? Some patients have resting severe symptoms, and so what's considered worsening is relative. That's good to remember. Sometimes clinicians who know a patient can see a patient who just is kind of breathing fast, kind of huffing and puffing, but that's usual for them. And if they don't have any of those additional cardinal signs, or they don't have any worrisome vital signs, they may not even have an exacerbation, or they actually may be okay to send home with the mild kind of treatment, outpatient therapies.
Witt: Yes, and our go-to therapy, prednisone, is obviously a mainstay, and in the past couple of decades our courses of prednisone have gotten shorter and shorter. What is your typical practice there?
Press: There is really good evidence published in the literature about this. There was a nice study that looked at low-dose, short-term (5-day) oral steroids vs IV steroids that were longer term. The researchers found pretty equivocal positive findings on the short-term, low-dose — 5 days of lower-dose prednisone that you just take by mouth. If you used IV, you didn't really get added benefit but you did get added side effects. We really can consider inpatient or outpatient treatment using that 5-day period with a lower-dose oral steroid.
Witt: I find this to be so interesting, IV vs oral having similar efficacy, and then the same for inhalers. We've talked about this before, nebulizers (nebs) and inhalers having similar efficacy if there's correct use, but there's a cognitive — I should just call it a placebo effect, right? People feel like IV and nebs are more powerful. I don't know if that's your experience.
Press: I think also we might have influenced that, in terms of the patient's perception of what works and getting some kind of response. If that's what they've gotten in the past and they felt relief, they may be nervous to do something different. I love that you pointed out this equal efficacy if you get those inhaled medicines from the devices into the lungs. Without a nebulizer, they work just the same.
One reason I do think that patients feel more from nebulizers in the healthcare setting is that they often come with oxygen and moisture that the inhalers don't use. If patients require oxygen, they can still get that. And then you can teach and train on the inhalers, side by side, and they still get the benefit of both.
Witt: There's a lot of education there. Inhaler teaching has been a big thrust of your career too. It's so important.
Press: Absolutely.
Witt: How about antibiotics? I think this is the area where there's so much more clinical uncertainty. When do we give antibiotics? How do we approach that?
Press: There was this great study published years ago that looked at the quality of inpatient care for COPD; they looked at what should be given and what shouldn't be given, and they called "ideal care" when you got everything you should and nothing you shouldn't.
It was hard to think about antibiotics in that because, really, those should be tailored. With antibiotics, you want to think about them more in patients that have some of the cardinal symptoms, particularly that sputum color change. Especially if they have two or three of the symptoms, that's when you want to consider the antibiotics more and then the antibiotics that have that anti-inflammatory effect as well.
You do not, as you're pointing out, have to give antibiotics for COPD exacerbation. It's really good to tailor to those patient needs.
Witt: That's another one where it can be hard having that conversation with patients if they have something in mind that they really want. But I guess talking about the pros and cons of antibiotics is useful. And I like that framework of considering things like, is the sputum very purulent? I seem to be seeing a lot of people with COPD and bronchiectasis.
Sometimes I'm even getting sputum cultures, though that's not guideline based for just COPD on its own.
Press: It can be helpful testing. I think that's another one where we like things to just be cookie-cutter: We do this or we don't do this. It is appropriate at times to get that sputum testing. You sometimes need that to help direct your therapy, especially with that comorbid diagnosis. I think it's a good point.
Witt: Let's talk about discharge planning. This is so important. We're going to talk about readmissions in the next section, but discharge planning is key to reducing readmissions. How would you approach his discharge from the hospital?
Press: I like to think about patients coming in to the hospital as an area of focus. I think, How can we keep them from coming back? And so, yes, at discharge planning, there are the usual things that we think about, like, let's make a follow-up appointment.
A key aspect is that we are finding more and more that very short-term — 1- to 2-week — follow-ups for patients to check in could be very helpful to avoid those frequent early readmissions.
There are a lot of reasons; patients may not have gotten their medication, such as that important prednisone. Maybe they need a few more days at home and you can't always go straight from the hospital to the pharmacy. Maybe you don't have a ride. So sometimes they go a couple days without their medication. Now their exacerbation is getting worse. There are other triggers, and they also often have other conditions that may be worsening. Early check-in allows you to help with that.
We already talked about inhaler teaching. I really like using inhalers during the hospitalization to do teaching. It also helps you assess whether the patient can use them. There are times where, due to dexterity or cognitive issues, or just difficulty understanding how to use inhalers, nebulized therapies are better, and you have time to set that up.
That can be part of your discharge planning; what should that home regimen be? This is part and parcel of medication reconciliation, right? Sometimes we have to change what they take in the hospital, based on our formularies. So we are making sure we get them back on the medicines they know how to use, they're familiar with, and that their insurance will cover.
There are a few other things I like to think about at discharge. We can talk about this more if we're going to talk about readmissions, but sometimes there are things you want to do for patients that you can't do in the hospital, like lung function testing. Maybe they haven't had that ever or not recently.
It's possible that they don't even have COPD, right? Sometimes that's a clinical diagnosis that isn't correct. We often don't do that in the hospital. You can if you have that set up. And then there's also this really great treatment that I just wish everyone could get more of, which is pulmonary rehab. A lot of our hospitalized patients in this age group often go home with home health.
You often can't prescribe outpatient pulmonary therapy and home health at the same time. That just reinforces why that quick follow-up appointment after discharge can help you with some planning that started inpatient but can help finish it up and wrap it up outpatient.
Witt: That is such a good framework. One of our previous guests, Dr Stephanie Christenson, talked about a COPD exacerbation as a lung attack because it's so dangerous: Next-year mortality is up, lung function on average goes down, and it takes a surprisingly long amount of time for people to recover back to baseline. I really feel like COPD does not get the respect it deserves. We don't think of a lung attack; we think of a heart attack.
Press: Correct. Yes. It is very similar to that. It's not just, "Oh, we get you totally better in the hospital and you don't have to think about it." It's a longer thread there. One thing to think about with inhaler teaching is that how you teach matters. We often think of the hospital setting as this great opportunity where patients are there and have all the time. And it can be a really good place to start. We like to go with the guideline-recommended "teach back" model at our hospital. Recently the guidelines added how to teach, not just to teach. You can use "teach back" to assess whether patients are learning appropriately. But another good reason for that follow-up appointment is that inhaler use is a skill, just like driving a car. You don't just do one practice session and you're done. Using "teach back" and doing repeated sessions is another part of discharge planning, when are they going to get checked in on their self-management skills and not just their symptoms or medications.
Witt: Who is doing the teaching? Is it the nurse, the pharmacist, or the physician in your practice?
Press: At our hospital, we're very lucky. We work with our pharmacy team. We have pharmacy students and residents who can be taught and trained how to teach the patients, and that's a great value-added role for those learners. But honestly, we can have anyone. Respiratory therapists, pharmacists, nurses, physicians, and community health workers are all great partners. They're working more and more in hospitals and with patients in their homes. As long as the trainer knows what to do, they can be trained to then teach the patient. Not everyone has all the same resources, but I like to remind folks that really anyone can be taught to teach.
Witt: We talked with pharmacist Amber Lanae Martirosov about how most physicians have no idea how to use inhalers. I'll disclose that I once was asked in fellowship how to use a dry powder inhaler, and I was like, "I think I'll go look that up online." I don't think we do a great job of teaching the device technique in medical training so that we can be the teachers in clinic. I invite everybody to watch the videos, even if you don't have your own personal experience with inhalers, to become experts.
Press: It's a great point and I do reinforce that. We have to know a lot as physicians but we can't know everything, and pharmacists are out there for a reason. It's a good tip for outpatient, where you often don't have anyone in clinic to do it. And if you know that you might not have time to do a whole educational session, you can prescribe education to the outpatient pharmacy, where they often are trained to do this kind of teaching. When patients pick up their medicines, they often sign for them. They're signing that they don't have any questions, but if you tell the pharmacist on your prescription, "Please teach the patient," that might be a way to get some of that education if you don't know how, or you don't have anyone who knows how, or you do know how but you don't have time.
Witt: I'm going to start adding that to my prescription instructions. That's a great tip.
Well, let's move to the next part of the case. Two weeks later, you see Mr Rivera in your outpatient clinic. He does get an outpatient follow-up. He is dyspneic and even seems a bit confused. You decide to send him back to the emergency room for evaluation and admission. I want to talk about hospital readmission and how common COPD exacerbations are.
Press: They're actually very common. Many years ago, Medicare as well as a research study published data that about 1 in 5 patients with Medicare get readmitted within 30 days in general. When you look at different metrics, COPD is either second or third on that list.
Policies recently have been put into place and hospitals are trying to improve that. That's a whole other conversation. There's not always an easy fix. What's interesting to note is that only about a third of patients with COPD come back in those 30 days for COPD. About half are for respiratory, including those with COPD, but the other half are for something else. A lot of our patients in this population have lots of things going on, and so we do like to think in that discharge planning about the whole patient and what else we should be keeping our eye on that could go awry after having a hospitalization and being away from home.
Witt: We've talked about how dangerous hospital admission and readmission are for exacerbations. We talked a little bit about increased mortality. Anything else that is on the list for what patients might expect in the year following a COPD exacerbation or a hospitalization?
Press: The increased mortality is one that's picked up on. It's very important. I think that's related to what you were talking about earlier with a lung attack, but there are other things. There is often more need to use healthcare resources in general. That can be a cost burden on patients, a time burden on them and their caregivers, and decreased quality of life.
One thing that can happen when patients get hospitalized for COPD or something else is that they often are just lying around in a hospital. There's not a lot of activity. They may not feel well enough, and so they can get weaker and frail. When they go home, it's important to encourage them, as they can tolerate it, to become active and not get isolated.
Patients who go home on oxygen for the first time may not be adapted or have the resources to use oxygen outside the home, so they can kind of get stuck there and have decreased activity, which then can spiral into other things. There's also an increased risk for future hospitalization, which leads back to that conversation about why rehospitalizations are so frequent.
Witt: What do we know about how to prevent hospital readmission? I know this has been the thrust of a lot of the work that you've done.
Press: It's a multipronged approach. We need to treat the whole person, and not just think about Are they admitted for this and We'll just focus on that at that current hospitalization. We are learning more and more as a profession and as a society about how lots of things affect not just health but social determinants of health.
There are approaches you can use to screen for issues. Is transportation going to be an issue? Is getting medications going to be an issue? And do we have ways to solve that? A lot of hospitals, including ours, are using a "meds to beds" program to try to get medicines in patients' hands before they leave the hospital.
That can help particularly, and often, with those early re-exacerbations if it's COPD specific or just some of the chronic diseases in general. Maybe they've been in the hospital and missed some other chronic-care outpatient appointments, and then they lose track of their medications. Thinking about the whole person for COPD-specific readmissions to avoid that reoccurrence for COPD, there are great publications coming out with a lot of evidence for pulmonary rehabilitation. As I already mentioned, it's good in general. It has been shown to reduce all-cause and COPD-specific readmissions in the early phase, the 1- to 3-month phase. And we talked about inhaler technique teaching, using that "teach back" approach. We actually looked at that, and we can reduce that 30-day acute care visit at an ED or hospitalization within a month if you use "teach back" compared with just telling the patient and not using check-ins and demonstration. How you teach matters, and that's why we're so happy that it's in the guidelines.
Those quick follow-up appointments that I told you about also can really help. And then also just monitoring the sequelae or consequences of the COPD treatments or therapies that you've done. A great example is patients who also have diabetes and you're starting them on prednisone. Make sure you're titrating those medications as well. It's really a multipronged approach, considering the whole patient's medical issues and other social factors, and addressing what you can.
Witt: Your approach echoes a lot of what we've talked about this season with Chris Garvey and pulmonary rehab: a pretty amazing dose-dependent effect of pulmonary rehab, reducing hospitalizations and even mortality in the first year after an exacerbation. And then with Adrian Austin, we talked a lot about managing comorbidities. So, you're right. It really is the long, comprehensive, whole-person approach that takes an interprofessional team, which you alluded to. One profession — just physicians or just pharmacists or just nurses — can't do it on their own. We have to work together.
Press: Absolutely.
Witt: Before we wrap up, do you have any resources that you want to share with our listeners?
Press: One great resource I like to point to is the COPD Foundation. They have a ton of resources for patients, where patients can access educational materials, information, and groups where they can talk and meet with each other and get support. There's also provider-facing information and videos — how to use inhalers, how to use nebulizer machines. There are also great videos in general. One caution is that sometimes the people making the videos don't always get it exactly right. If you happen to see something and maybe it goes against what you've seen before, it's okay. Every once in a while, it's wrong. But I think the COPD Foundation is a great resource to start with, and like you said, it's interprofessional. You can also always phone a friend if you're not sure. New devices are coming out every day for inhaled medications. This might be new to you and you might not have seen it before. Call a pharmacist or look on the website to see if they have a video on how to use that particular device.
Witt: I love the COPD Foundation app because it's hard for me, even as a pulmonologist, to keep updated on all of the different types of medications and devices. In the past year, there's been a lot of devices, or inhalers, removed from the market. Sometimes I'll just scan through their medication list by class. It's really helpful.
Press: I actually use the app myself all the time.
Witt: And the website is so good too, especially for patients. Thank you so much for joining us. We have learned so much from you and really appreciate that you shared your expertise.
Today we've talked to Dr Valerie Press about COPD exacerbations — treatment, triage, and discharge planning and hospital readmissions.
Thank you so much for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series. This is Dr Leah Witt for the Medscape InDiscussion COPD podcast.
Resources
Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary
Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review
COPD Case Study: Pearls for Diagnosis and Initial Management
COPD: Finding the Right Inhaled Medication at the Right Price
Is Pulmonary Rehab Right for Your Patient With COPD?
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Heart Attack of the Lung: COPD Exacerbations - Medscape - Jun 26, 2024.
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