Palliative Care: Increased Use for Hospitalized COPD Patients

Use of Palliative Care in COPD

Background: Palliative care focuses on providing people with relief from the symptoms, pain, physical stress, and mental stress of a serious illness.  It is provided by a team of doctors, nurses, occupational and physical therapists, and other health care professionals. It is appropriate at any age and at any stage in a serious illness.  It is not limited to only those as part of end-of-life care.  Palliative care can be provided at home, in the hospital, and in skilled nursing facilities.  

This care may be part of hospice services, but can be offered to any patient without restriction to the illness or outlook (prognosis).  For those with COPD, palliation typically focuses on relief of breathing difficulty and strategies for conserving energy.

Study: Dr. Barret Rush and colleagues at the University of British Columbia in Vanouver, Canada, recently published an analysis of the use of palliative care in the United States between 2006 to 2012. The findings were published in the January 2017 issue of the journal CHEST (volume 151; pages 41 – 46).

Results: From 2006 to 2012, the use of palliative care was 1.7% of the 181,689 patients with COPD hospitalized for a worsening of symptoms (called an exacerbation) and were also receiving oxygen at home. During this seven year period, there was a 4.5 times increase in referrals for palliative care.  In general, those referred for these services were older (75 years compared with 71 years) , had longer hospitalizations (5 days compared with 3 1/2 days), and were more likely to die in the hospital (32% compared with 2%).

Patient in the hospital receiving palliative care

Supportive care provided in the hospital

Conclusions: The use of palliative care increased dramatically during the seven year period. The barriers to receiving palliative care included race, low socioeconomic status, size of the hospital, and region of the country.

My Comments: Palliative care can provide important services for those with advanced COPD. The specialist will ask each person what are her or his major health concerns and goals. Usually, services focus on helping the individual breathe easier and on strategies for performing daily activities. In general, care referrals are greater in larger teaching hospitals. This reflects the presence of these services compared with smaller rural hospitals.

Can Depression Affect my Breathing and COPD?

Depression Occurs in 25% of those with COPD

Dear Dr. Mahler:

I wanted to know your thoughts on whether depression can affect my breathing. I am 57 years old and have had COPD for about 3 years. I seem to be tired all of the time and get short of breath with little activity. I was treated for depression when I was in my 20s, but have been fine until about 3 months ago. I work as a teacher’s aide in a grade school in my town, and am now off for the summer. I quit smoking soon after I was told that I had COPD. I have an appointment with a nurse practioner in a few weeks. What do you think?

Karen from Tupper Lake, NY 

Dear Karen:

I encourage you to discuss your concerns with your health care provider. Being tired and feeling short of breath may be due to various causes including a low red blood cell level (anemia), low thyroid function (hypothyroidism), another medical problem, and a psychological condition. I suspect that the nurse practioner will order tests to check for these possibilities.

Man with depression

Man with depression

Depression is considered a mood disorder caused by changes in chemicals within the brain. According to the World Health Organization, it is estimated that 21% of women and 12% of men in the U.S will experience an episode of depression at some point in their lifetime. Recent reports from the United Kingdom and from the U.S. found that about one in four (25%) of those diagnosed with COPD suffer from depression over a three year period.

The risk of an episode of depression is related more to how may episodes you have had in the past rather than life stresses. Your previous treatment in your 20s simply means an increase in risk for another episode. That is why is important that your health care provider do a complete evaluation of all possible causes of your symptoms.

Effects of depression

Effects of depression

This condition can affect your thoughts, emotions, behaviors, and overall physical health. Typical feelings are sadness, hopelessness, guilt, moodiness, and loss of interest in friends and family. You may find that it is hard to concentrate or make decisions. It is common to withdraw from others, use drugs or alcohol to “numb yourself” in order to temporarily feel better, and miss work or other commitments. Other symptoms are lack of energy and changes in appetite resulting in weight gain or weight loss.

Depression is usually diagnosed by excluding other medical conditions and by your answers to a questionnaire. Once again, tell you health care provider how you are feeling and that you were treated for depression in the past.

Best wishes,

Donald A. Mahler, M.D.

 

Highlights from European Respiratory Society Congress

September 26 – 30, 2015, in Amsterdam

One of the highlights of the International Congress was a session on improving outcomes in those with COPD. A major emphasis was on the current goals of treatment:

  1. Reduce shortness of breath – which can generally be measured in a few weeks of starting a new inhaled bronchodilator medication
  2. Reducing the risk of an exacerbation (worsening of symptoms usually due to a chest infection) – this requires at least six months to assess.
David Singh, M.D., from University of Manchester in UK

David Singh, M.D., from University of Manchester in UK

Dr. David Singh of Manchester, United Kingdom, spoke about optimizing bronchodilation (opening the airways). He quoted one study that showed that most patients with COPD were still short of breath with activities after being started on a single long-acting  bronchodilator (Primary Care Respiratory Journal, year 2011, volume 20, page 46). He then discussed the role of using two different bronchodilators in a single inhaler to get the greatest benefit. In the US, there are two approved dual bronchodilators in a single inhaler – Anoro Ellipta and Stiolto Respimat. The evidence suggests that two bronchodilator medications that work in different ways can provide better stability in keeping the breathing tubes open longer. This means that it should be easier to breathe for those with COPD and should have a better quality of life.

 

Dr. Marc Miravitlies of the University Hospital in Barcelona, Spain, discussed both daytime and nighttime shortness of breath (medical word is dyspnea) in those with COPD. Studies show that many

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

Marc Miravitlles, M.D., of University Hospital in Barcelona, Spain

individuals who have COPD wake up due to breathing difficulty. Also, poor sleep is considered a risk factor for having an exacerbation (worsening of shortness of breath and/or coughing up yellow-green mucus). Bronchodilators that work throughout the night should help if the sleep problem is due to COPD, but will not help if there is another cause like sleep apnea.

Dr. Neil Barnes, Medical Head of GlaxoSmithKline pharmaceutical company, spoke about the benefits and side effects of using inhaled corticosteroids (prednisone like medication). He emphasized that inhaled corticosteroids combined with long-acting beta-agonist bronchodilator (in US: brand names are Advair, Symbicort, and Breo) are widely prescribed, but should primarily be used in those who have had two or more exacerbations (worsening of symptoms) in the past year OR one exacerbation in the past year that required treatment in the hospital. A major concern about the use of

Neil Barnes, M.D., Medical Head of GalxoSmithKline pharmaceutical company

Neil Barnes, M.D., Medical Head of GlaxoSmithKline pharmaceutical company

inhaled corticosteroids is the risk of developing pneumonia.

 

 

My Comment: Each year at medical conferences there is growing research interest in helping those with COPD. Novel therapies are being evaluated in addition to improving inhaled bronchodilators. All of us need to promote greater public awareness of COPD and encourage the National Institute of Health, various professional organizations, and pharmaceutical companies to increase research funding.

Wild Fires Affect Lung Health

Dear Dr. Mahler:

I have moderate COPD and worry that the wild fires here in northern California are making it harder for me to breathe. The drought in the west has enabled wild fires to start, and the local papers report air pollution. I try to stay inside as much as possible, but I notice that my breathing has been more difficult the past week or so. What do you think? 

Will  from Sacramento, CA

Dear Sam:

Sorry to hear of your problem with the wile fires. As you know, the blazes are  a direct result of the prolonged dry heat, and increase particulate matter (particles) in the air. The byproducts of smoke can drift for hundreds of miles as shown in the photos.

Wild fire in California.

Wild fire in California.

 

 

Wild fire in Lower Lake, California

Wild fire in Lower Lake, California

 

 

 

 

 

The particles in the air can be  quite small at 1/30 the size of the diameter of hair. Their tiny size means that they can  bypass the nose and mouth and reach the lower parts of the lungs. This can cause the breathing tubes to narrow or constrict making it harder to breathe and cause coughing. Dr. James  Brown, a pulmonary physician who works at the VA in San Francisco, has reported an increase in the respiratory complaints brought on by the drought and wild fires.

I encourage you to pay close attention to reports of air quality where you live. If the pollutants are high in the air, take precautions like staying inside, rolling up car windows, make sure to take your inhalers regularly, and don’t hesitate to use albuterol as needed.

Hopefully it will rain soon in these drought areas. Best wishes,

Donald A. Mahler, M.D.

Decline in Physical Activity

Over Time, Physical Activity Decreases in COPD

Little is know about the role of physical activity over time in those with COPD. In the August 1, 2015, issue of the American Journal of Respiratory and Critical Care Medicine (commonly called the Blue journal), Dr. Waschki and others from Grosshansdorf, Germany, described the changes in physical activity (measured by an armband sensor), results of breathing tests, 6 minute walking distance, muscle mass, and  blood tests to assess inflammation in the body.

Results

At the start there were 170 patients with COPD tested; 3 years later, 137 were retested. The average age was 64 years and 74% were men. Changes were observed in all stages of COPD. The following numbers are the mean changes:

______________________________________________________

  1. total daily energy expenditure:  – 200 kcal
  2. steps per day: – 957
  3. amount of air exhaled in one second (FEV1): – 168 milliliters
  4. distance walked in 6 minutes:  – 60 meters

______________________________________________________

However, not everyone got worse over the 3 years. Physical activity level went down in 71% and went up in 29%.

My Comment

Most healthy people are less active when they reach their 60s and 70s than when they were younger. However, the authors of the study stated that the decline in activity level observed in those with COPD averaged about 5 -6 % for the group. This decline is about 2 – 4 times what typically occurs in healthy individuals.

An important question is WHY? One possibility is that breathing difficulty has worsened. This

Downward Cycle of Breathing Difficulty Leading to Reduced Physical Activity and Deconditioning ("out of shape"). Taken from page 70 of COPD: Answers to Your Questions (with permission).

Downward Cycle of Breathing Difficulty Leading to Reduced Physical Activity and Deconditioning (“out of shape”). Taken from page 70 of COPD: Answers to Your Questions (with permission).

problem, breathlessness with activities,  is unpleasant and usually causes those with COPD to reduce or limit their physical activities as shown in this figure.

Another important question is WHETHER the declines observed in the study can be slowed down or even reversed. Although there is no clear answer to this at the present time, daily physical activities provide one approach. If you aren’t a daily walker or aren’t doing daily gardening or whatever, you should ask you doctor about a referral to nearby pulmonary rehabilitation program. These supervised exercise programs offer the opportunity to exercise in a safe place with appropriate monitoring. Everyone whom I see in my practice who goes to pulmonary rehabilitation has told me that, “it has changed my life.”

Individuals at Pulmonary Rehabilitation  performing resistance training

Individuals at Pulmonary Rehabilitation performing resistance training

Man pedaling stationary cycle being supervised by rehabilitation specialist.

Man pedaling stationary cycle being supervised by rehabilitation specialist.

What Shortness of Breath feels like for Those with COPD

Work and Effort of Breathing  in COPD 

An on-line publication this week by Chang and colleagues in the journal Chest describes the experience of breathing difficulty as reported by those who have COPD.

The first author is Andrew Chang, a medical student at the Geisel School of Medicine at Dartmouth. He worked on this research study between his 1st and 2nd years of medical school with three Pulmonary doctors on the staff of Dartmouth-Hitchcock Medical Center. In the study, patients with different respiratory conditions answered “Yes” or “No” for each of 15 different statements that described  experiences of breathing discomfort. Then, each person was asked to select the “Best Three” that most closely matched how they felt when short of breath doing daily activities.

Here are the “Best Three” statements chosen by 68 individuals with COPD:

  1. I feel out of breath.
  2. My breathing requires effort.
  3. I cannot get enough air in.

Does your breathing difficulty match up with these statements?

These experiences are considered to be due to the work and effort required by the breathing muscles to breathe in (inspire). Because those with COPD have narrowed breathing tubes (airways), it is often difficult to get all of the air out when exhaling. As a result, air is trapped in the lung leading to hyperinflation of the lungs as shown in the figure.

On left: Normal size of lungs. On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.

On left: Normal size of lungs.
On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.

 

As a result of the hyperinflation of the lungs, the diaphragm (the main muscle of breathing) has to work harder when it contracts to breathe air in.  This added work and effort of the diaphragm is sensed by those who have COPD. This is the major reason why someone with COPD finds that it is hard to breathe or have shortness of breath.

Bronchodilator medications are the cornerstone for treatment of COPD because they open the breathing tubes (airways). This allows more air to be exhaled and thereby reduces hyperinflation – making it easier to breathe. Long-acting bronchodilators that last 12 – 24 hours provide more sustained benefit than the short-acting inhalers (typically last 4 hours).

Hopefully, this information will help you understand why taking your bronchodilator medications regularly is important for your breathing.

 

Stem Cell Therapy

Dear Dr. Mahler:

I have been reading that stem cell treatment can repair the damage in my lungs caused by emphysema. What are your thoughts on this? I am 69 year old, and have been told that my COPD is stage 4. I use three different inhalers and oxygen at a setting of 2 when I do things, but not at rest.  I am starting to feel desperate about my breathing. Thanks. 

Catherine from Reno, NV

Dear Catherine:

Your question is quite interesting, and a few patients in my practice have asked me the same thing. I will try to explain what are stem cells without being too technical.

Stem cells are unique because they can develop into any type of tissue in the human body.

 

Stem cells can develop into other types of cells such as blood vessels or nerves shown in this figure or lung tissue.

Stem cells can develop into other types of cells such as blood vessels or nerves shown in this figure or lung tissue.

As they have regenerative properties, stem cells offer hope for curing a variety of diseases including emphysema and scarring in the lung (fibrosis). There are two types of stem cells – one is called embryonic because they are found in embryos and the other is called adult because they are found in the umbilical cord, placenta, blood, bone marrow, skin, and other tissues. Large numbers of stem cells are needed to repair damaged tissue.

Several human embryonic stem cell colonies

Several human embryonic stem cell colonies

Embryonic stem cells are grown in a culture medium where they divide and multiply (see figure). However, adult stem cells have difficulty dividing once they are removed from the human body.  Currently, scientists are trying to find better ways to grow adult stem cells in cell culture and to manipulate them into specific types of cells that have the ability to treat injury and disease.

 

For stem cell therapy to be useful to treat COPD, millions of stem cells are needed to be implanted into a specific part of the body, such as the lungs. To make millions of cells, a process called manipulation is required. However, the Food and Drug Administration considers that manipulation of these cells is equivalent to a prescription medication, and therefore the process must be carefully regulated.

Without going into detail, there are potential risks of stem cell therapy that need further study.

In summary, the use of stem cells for treating COPD has great appeal. However, there is very little known about short and long term effects. At the present, there are a few approved clinical trials (studies) in the United States and Canada evaluating stem cell therapy. They can be found on the website of the National Institutes of Health at www.clinicaltrials.gov.

Because of potential for harm, the lack of any proven benefits so far, and the high fees that are typically charged, I advise caution before further consideration of stem cell therapy for your COPD. Hopefully, the medical profession will learn more about this unique treatment.

Regarding your breathing, are you under the care of a pulmonary specialist? If not, I encourage to ask your doctor to refer you a pulmonologist to make sure that you are receiving optimal medical care for your COPD.

Sincerely,

Donald A. Mahler, M.D.