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

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

Smoking Cessation l l l l Change in approach recently Managed more as a Smoking Cessation l l l l 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 l Construction and contents vary and not standardized l Usually nicotine is dissolved E-Cigarettes l Construction and contents vary and not standardized l Usually nicotine is dissolved in liquid and vaporized l Question: what other chemicals involved? l Claim: entertainment tool, not for smoking cessation l Explosive rise in sales

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

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

Inhaled Medications: Technique All Important l Proper technique for inhaler use must be taught Inhaled Medications: Technique All Important l Proper technique for inhaler use must be taught well and constantly reinforced l 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 l l

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

Question l Answer: Probably from Heart, then Cancer, then COPD l We forget that Question l Answer: Probably from Heart, then Cancer, then COPD l We forget that smoking is a big risk factor for heart disease, strokes, leg artery obstruction, heart failure l 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: l Heart Disease: 33% Causes of Death in COPD Patients IF Continue to Smoke: l Heart Disease: 33% Lung Cancer: 33% l Other Cancer: 21% Respiratory: 10% l General Severe COPD (30% smokers) l Respiratory : 27% Heart: 26% l Cancer: 21% Pneumonia: 10% l Other: 17% l

Lung Cancer Screening by CT Scan of the Chest CT approved by Medicare and Lung Cancer Screening by CT Scan of the Chest CT approved by Medicare and required by Obamacare or the ACA l However Medicare has not outlined the procedure for implementation yet l 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 l

Vaccinations l l l Influenza, inactivated, injection, yearly Pneumococcal vaccines, protects against half of Vaccinations l l l Influenza, inactivated, injection, yearly Pneumococcal vaccines, protects against half of all pneumonias Two pneumococcal vaccines PPSV 23, Pneumo. Vax, the old one, given once before age 65 & once after PCV 13 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 l COPD & Heart Disease l COPD & Asthma l COPD & Overlap Syndromes l COPD & Heart Disease l COPD & Asthma l COPD & Bronchiectasis l COPD & Sinusitis l COPD & Sleep Apnea l COPD & Depression / Anxiety l COPD & Lung Cancer l COPD & Bone / Muscle Disease

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

Stem Cell Treatments l At best: a for profit experimental procedure l At worst: Stem Cell Treatments l At best: a for profit experimental procedure l At worst: fraud and abuse of patients that are desperate l 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 l The International Society for Stem Stem Cell Treatments: 6 False Hope Warning Signs l The International Society for Stem Cell Research lists these warning signs that a stem cell treatment is not legitimate l It makes claims based on patient testmonials l The same stem cells are used to treat many diseases l The source of the stem cells is not clearly documented

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

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

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

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

Websites & References l l l l American Thoracic Society: patients. thoracic. org Global Websites & References l l l l American Thoracic Society: patients. thoracic. org Global Initiative on COPD: goldcopd. com COPD Foundation: copdfoundation. org COPD Assessment Test (CAT); catestonline. org/english/index. EN. 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 l l l October 15 th, 2015: Medical News http: Stem Cell Clinics: Comments l l l October 15 th, 2015: Medical News http: //journals. lww. com/neurotodayonline/Fulltext/2015/10220/Unr egulated_Stem_Cell_Clinics_Proliferate_in_the. 1. aspx May 18 th, 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/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/NEJMp 1504560? query=TOC International Society for Stem Cell Research: Patient Handbook on Stem Cell Therapies, http: //www. isscr. org/home/publications/patient-handbook

References: Placebo l l l Dr Ted Kaptchuk, Director of the Program in Placebo References: Placebo l l l 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: You. Tube https: //www. youtube. com/watch? v=Hq. GSe. FOUs. LI Placebo Effect at Stanford Medical School: https: //www. youtube. com/watch? v=ud. J 31 KKXBKk