Innovations to Achieve Excellence in COPD Diagnosis and Treatment in Primary Care

Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
Postgraduate Medicine (Impact Factor: 1.7). 09/2010; 122(5):150-64. DOI: 10.3810/pgm.2010.09.2212
Source: PubMed


Recognition of chronic obstructive pulmonary disease (COPD) is often missed or delayed in primary care. Once recognized, COPD is often undertreated or episodically treated, focusing on acute exacerbations without establishing maintenance treatment to control ongoing disease. Diagnostic and therapeutic pessimism result in missed opportunities to reduce exacerbations, maintain physical functioning, and reduce emergent health care requirements. Proactive diagnosis and evidence-based management can alleviate the impact of COPD on patients' lives. Smoking cessation has been proven to slow the rate of lung function decline. Maintenance pharmacotherapy and immunizations reduce exacerbations. Pulmonary rehabilitation improves respiratory symptoms and physical functioning and reduces rehospitalizations after exacerbations. Self-management education improves health-related quality of life and reduces inpatient and emergency care usage. Maintenance treatment with long-acting inhaled bronchodilators is appropriate beginning in moderate COPD to maintain airway patency and reduce exacerbations. Tiotropium is US Food and Drug Administration (FDA) approved to treat bronchospasm and reduce exacerbations in patients with COPD; salmeterol/fluticasone is FDA approved to treat airflow obstruction in COPD and reduce exacerbations in patients with a history of exacerbations. Other maintenance long-acting bronchodilators-salmeterol, formoterol, and budesonide/formoterol-are FDA approved to treat airway obstruction in COPD but lack an approved indication against exacerbations. FDA warnings on the use of long-acting beta-adrenergic agents (LABAs) in asthma specifically exempt COPD and do not apply to LABA/inhaled corticosteroid combinations used in COPD. The actual effectiveness achieved in practice with any COPD therapies depends on patients' inhaler technique, adherence, and persistence. Medication usage rates and inhaler proficiency may be improved by concordance, in which the health care provider and patient collaborate to make treatment plans sustainable in the patient's daily life. Practice redesign for whole-patient primary care provides additional tools for comprehensive COPD management. Innovations such as group visits and the patient-centered medical home provide newer ways to interact with COPD patients and their families. Patient-focused and evidence-based options enable primary care practices to manage COPD longitudinally and improve patient outcomes through the course of the disease.

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    • "The actual effectiveness achieved in clinical practice with any COPD therapies depends on patients’ inhaler technique, adherence, and persistence.59 Low adherence to maintenance inhaled therapy is common in COPD and is associated with worst prognosis,60 whereas improved adherence to regular treatment is associated with reduced rate of all-cause hospitalization.61 "
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    ABSTRACT: Currently, there is no cure for chronic obstructive pulmonary disease (COPD). The limited efficacy of current therapies for COPD indicates a pressing need to develop new treatments to prevent the progression of the disease, which consumes a significant amount of health care resources and is an important cause of mortality worldwide. Current national and international guidelines for the management of stable COPD patients recommend the use of inhaled long-acting bronchodilators, inhaled corticosteroids, and their combination for maintenance treatment of moderate to severe stable COPD. Once-daily fluticasone furoate/vilanterol dry powder inhaler combination therapy has recently been approved by the US Food and Drug Administration and the European Medicines Agency as a new regular treatment for patients with stable COPD. Fluticasone furoate/vilanterol dry powder inhaler combination therapy has been shown to be effective in many controlled clinical trials involving thousands of patients in the regular treatment of stable COPD. This is the first once-daily combination of ultra-long-acting inhaled β2-agonists and inhaled glucocorticoids that is available for the treatment of stable COPD and has great potential to improve compliance to long-term regular inhaled therapy and hence to improve the natural history and prognosis of COPD patients.
    International Journal of COPD 02/2014; 9:249-256. DOI:10.2147/COPD.S32604 · 3.14 Impact Factor
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    • "Initially, pulmonary rehabilitation can be implemented at an outpatient setting, usually followed by a home-based intervention that relies mostly on the compliance of the patient. Efficacy was established after systematic review of both outpatient pulmonary rehabilitation [12-14] and home-based pulmonary rehabilitation [15-17]. "
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    ABSTRACT: Background Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterised by dyspnoea, excessive sputum production, chronic cough, bronchitis and emphysema. Functionally, exercise tolerance is poor for people with COPD and is linked to difficulty in performing daily tasks. More specifically, exercise difficulties are due partly to dyspnoea and lower limb skeletal muscle dysfunction. The benefit of exercise that does not exacerbate the disease while improving exercise tolerance is salient. Whole-body vibration (WBV) is a mode of physical activity known to improve muscular function of the lower limbs, yet efficacy has not been investigated for a WBV intervention conducted in a home-based setting for people with COPD. Methods/design This clinically registered trial is a non-randomised placebo cross-over intervention based in the home of each participant (ACTRN12612000508875). Participants diagnosed with COPD will complete a six-week WBV intervention and then after a two-week washout period, will complete a six-week placebo training intervention. Participants will complete sessions twice a week. The duration of the trial is 14 weeks. Community-dwelling older adults with COPD will provide informed voluntary consent to participate. Outcome measures will include immediate, acute, and long-term responses to exercise. Discussion Quantifying responses to WBV among people with COPD will allow discussion of efficacy of WBV as a mode of physical activity. The skill required by the participant to perform physical activity with WBV is not demanding and may enhance habitual sustainability. The results of this trial could be used to support further research in both clinical and community settings. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR12612000508875)
    BMC Pulmonary Medicine 11/2012; 12(1):71. DOI:10.1186/1471-2466-12-71 · 2.40 Impact Factor
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    Respirology 10/2010; 16(2):187-9. DOI:10.1111/j.1440-1843.2010.01887.x · 3.35 Impact Factor
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