Primary Care Providers’ Knowledge and Beliefs about COPD

Survey of 426 Primary Care Providers about COPD

Background: Primary care physicians, nurse practitioners, and physician assistants provide the majority of care for those who have COPD. Thus, it is important to ask these primary care providers about their overall knowledge and beliefs about diagnosis and treatment of COPD.

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Study: Barbara Yawn, MD, MSc, and colleagues at the Olmstead Medical Center in Rochester, MN, surveyed 426 primary care providers at 3 different medical meetings in 2013 and 2014. The survey asked questions about perceived barriers to diagnosis of COPD and beliefs concerning the value of available COPD medications. The findings were published in the August 2016 issue of the Journal of the COPD Foundation (volume 3; pages 628-635).

Results: Of the 426 people who answered the questions on the survey, there were 278 medical doctors (MDs) and doctors of osteopathic medicine (DOs) and 148 nurse practioners (NPs) and physician assistants (PAs). 

The two most common barriers to making a diagnosis of COPD were: ♦ patients had many chronic medical conditions, not just COPD; and ♦ patients often failed to recognize and report breathing difficulty. These barriers were similar between MDs/DOs and NPs/PAs.

Woman performing breathing test.

Woman performing breathing test (spirometry).

About one-half of the clinicians said that they had equipment (spirometry) in their office, but less than 2/3 reported using testing to diagnose COPD.

Only 10% of those answering the survey reported ordering blood tests (screening) for alpha-1 antitrypsin deficieny, a hereditary form of emphysema.

About 75% said that there were available treatments to reduce shortness of breath, and 85% answered that medications for COPD could reduce exacerbations (flare-ups) of COPD. Some of these medications are shown below.

Examples of dry-powder inhalers

Examples of dry-powder inhalers

Conclusions: Primary care providers continue to report multiple barriers to diagnose COPD including easy access to testing equipment. However, most respondents noted that effective medications were available to improve breathing difficulty and to reduce the risk of a flare-up.

My Comments: In the past, many primary care providers felt that diagnosing those with COPD was not important because: COPD was self-inflicted by smoking; and treatments for COPD were not generally effective.

This survey shows that knowledge and attitudes among primary care providers have changed. Primary care providers do not need to have testing equipment (spirometers) in their offices, but instead can refer patients for testing at the local hospital.

If you have told that you have COPD and have not had breathing tests, ask your health care provider to order testing. Ask about what treatments are available to “make it easier to breathe.” BE PROACTIVE. 

Home Testing of Lung Function with a Smartphone

Home Testing System Approved by FDA

Background: It would be helpful to those with asthma or COPD to monitor their lung function by doing breathing tests in their home. Then, the results could be sent electronically to a health coach or to the office of their health care provider. This information could be used along with the person’s symptoms, such as shortness of breath, to evaluate any changes.

New Home Testing System: The US Food and Drug Administration recently approved Wing, an app-connected spirometer from St. Louis, Missouri-based Sparo Labs (see image below). Wing is a “pocket-sized device that will help individuals know how well their lungs are functioning” at home. It connects to a smartphone and is smaller, easier to use, and less expensive than other testing systems typically used in a medical office or hospital.

Sparo testing system using iPhone

Sparo testing system using iPhone

 

The FDA has cleared the device so it can purchased over-the-counter without a prescription. This means that the company can market it directly to consumers. The press release did not state how much the Wing system will cost.

Woman performing breathing test.

Woman performing breathing test.

My Comments: This device will measure how much air that you can exhale [called forced vital capacity (FVC)] and how much air you can exhale in one second [called forced expiratory volume in one second (FEV1)].  These results provide more useful information than simply measuring peak expiratory flow. Peak flow meters for use at home have been available for decades.

I have no financial interest in Sparo Labs.

 

Could I have COPD?

Hello Dr. Mahler – Could I have COPD?

I have been thinking about COPD, but not sure all of the symptoms. I am a 41 year old woman and I suffered a PE in September of this year. There were four blood clots present in my lungs. The doctors wanted to go in and perform the clot busting surgery but decided against it. Since then I have had to be on a constant flow of oxygen. I cannot do more than 3 minutes of exercise. I sleep a lot and I am tired all the time. The doctors are perplexed and are trying to regroup until February 2016 and then bring me back in. I have never been a smoker but was born with underdeveloped lungs. I am overweight and there is a history of Pulmonary Embolisms in my family. With the oxygen my O2 is at 96 and without the oxygen it is at 73%.

Thank you for any information that you can provide me.

Chakula in Charlotte, NC

Dear Chakula:

Sorry to hear of your ongoing problems.

The two main symptoms of COPD are shortness of breath and cough. At your age of 41 years, it is unusual for you to have COPD, especially since you have not smoked. Do you have any history of inhaling irritants (like dust, fumes, smoke, & fibers) in the air at work or at home? COPD is diagnosed by a simple breathing test called spirometry (see figure below).

Diagram of spirometry to diagnose COPD.

Diagram of person breathing out hard and fast into a machine. This test is used to diagnose COPD.

If you doctors have not ordered this breathing test, I suggest that you ask about such testing.

As you probably know, pulmonary embolism develops from “blood clots” in the legs, mainly in the thighs (see figure below). The blood clot breaks away from the vein and travels to the blood vessels of the lungs (called pulmonary arteries). This can cause shortness of breath, chest pain, and possibly coughing up blood.

Blood clot in leg can break off and travel to the blood vessels in the lungs

Blood clot in leg can break off and travel to the blood vessels in the lungs

Are you taking anticoagulant medication to prevent more “clots” from forming? With your family history of pulmonary embolism, and as you had a a blood clot at an early age, it is likely that you have a genetic factor contributing to blood clots forming. I suggest that you ask your doctors about being tested for various genetic causes for “blood clots,” including Factor V Leiden, a genetic disorder.

In some individuals who have pulmonary embolism, the inner lining of the blood vessels of the lungs can develop thickening and “webs” that reduce or block blood flow. If severe enough, this may also cause an increase in the pressure in the blood vessels of the lungs (called pulmonary hypertension). Both changes in the inner lining of the blood vessels and pulmonary hypertension can lead to a low oxygen level as you are experiencing.

If I saw you in my practice , I would order breathing tests including diffusing capacity to help explain the low oxygen saturation with walking and an echocardiogram (ultrasound of the heart) to test for pulmonary hypertension. Also, I would order blood tests or refer you to a hematologist (a specialist in blood clotting) to evaluate for a possible genetic problem in blood clotting.

I hope that this information is helpful. Try to stay as active as possible. Walk, then stop to catch your breath, and then resume walking again. I realize that this may be hard for you, but it is important for your overall health. Keep this up with a goal of 15 – 20 minutes of actual walking.

Best wishes,

Donald A. Mahler, M.D.