Living with COPD: 5 Things Your Patients Might Not Tell You

5 Things Your Patient With COPD May Not Tell You
1. I don’t feel like myself. I'm anxious and depressed and it's affecting my life.
2. I hate feeling like I’m out of breath all the time.
3. I don't think I'm using my inhaler correctly / I can't afford to use an inhaler.
4. I can't put weight on / I can't take any weight off.
5. I'm embarrased to use oxygen when I’m away from home/ I can't carry the oxygen tank.

The US Centers for Disease Control and Prevention estimate the number of Americans diagnosed with COPD at 12 million and that another 12 million are undiagnosed.¹ An estimated 5 Things Your Patient With COPD May Not Tell You
1. I don’t feel like myself. I'm anxious and depressed and it's affecting my life.
2. I hate feeling like I’m out of breath all the time.
3. I don't think I'm using my inhaler correctly / I can't afford to use an inhaler.
4. I can't put weight on / I can't take any weight off.
5. I'm embarrased to use oxygen when I’m away from home/ I can't carry the oxygen tank.

Patients with COPD are often reluctant to initiate conversations with health care providers on key aspects of the disease, its treatment, or its impact on their lives. To provide the best care for patients with COPD, be prepared to ask appropriate, and sometimes difficult questions—and to discuss what may be sensitive issues. Here are 5 important examples.

1. I don’t feel like myself. I'm anxious and depressed and its affecting my life.
Depression and anxiety are significant comorbidities among patients with COPD. Up to 50% of patients who have moderate-to-severe COPD³ or who were recently hospitalized for a COPD exacerbation may suffer from depression, although the exact prevalence is unknown. In a recent multicenter study, more than 2000 outpatients at different stages of COPD severity were screened for depression using the Center for Epidemiologic Studies-Depression Scale; 335 smokers without COPD and 234 nonsmokers without COPD were also screened. Among smokers with COPD, 26% were diagnosed with depression; by comparison, 12% of smokers without COPD were depressed, as were 7% of nonsmokers.³

A literature review also found that up to 96% of patients with COPD report anxiety symptoms. The prevalence of panic attacks and of generalized anxiety disorders among those with COPD ranges from 8% to 67% and 10% to 33%, respectively.⁴ The large variability in these studies is due to differences in screening tools used across studies, variations in sample size, and patient perception of symptoms, ie, that dyspnea is related to COPD rather than anxiety. Research also shows that depression and anxiety in patients with COPD are associated with poorer prognosis; thus, early detection of these mood disorders is important. Depression and anxiety are more common in patients with more severe COPD, and also in younger patients, female patients, patients who smoke, and in those with cardiovascular disease.

Given the burden of depression and anxiety in this population, make a point to inquire about both during routine health visits. Treatment can improve quality of life and may improve overall health status. The GOLD guidelines recommend following available treatment guidelines.^5,6 Where appropriate, referral for pulmonary rehabilitation is also recommended for its proven benefit in ameliorating depression.²

2. I hate feeling as though I’m out of breath all the time.
Clinicians are keenly aware of the characteristic symptoms of COPD: cough, phlegm production, and dyspnea. Patients, however, may not report these symptoms. Gender and cultural differences affect the frequency of reporting such symptoms as shortness of breath and sputum production. Women are more likely to report dyspnea than men, despite a higher FEV1.⁷ Smoking status can also affect how often people report dyspnea. It has been proposed that smoking-related abnormalities in sensory nerves might diminish the perception of bronchoconstriction in smokers.⁸ In addition, former smokers can have up to a 50% drop in symptoms such as cough, phlegm, and dyspnea compared to those who continue to smoke.8 People who resume smoking, however, are just as likely to suffer from respiratory symptoms as those who never quit.⁸
 
Patients with COPD often modify daily activities, without realizing it, to compensate for insufficient respiratory capacity and so may not be aware that such actions as mowing the lawn, carrying laundry, cooking, grocery shopping, or climbing stairs cause them shortness of breath. Because some patients may have limited awareness of dyspnea and others may choose not to "bother the doctor" about it, it is important, on a regular basis, to use objective tools to assess your patient’s symptoms.

The Modified British Medical Research Questionnaire (mMRC) and the COPD Assessment Tool (CAT) measure COPD-related health status and impairment, and are recommended in the GOLD guidelines. These are quick and easy assessments that can be performed in the office setting and both are available online: http://www.catestonline.org/ and http://www.goldcopd.org/.

3. I don't think I'm using my inhaler correctly / I can't afford to use my inhaler.
Many classes of medication for COPD are delivered by inhaler (eg, short- and long-acting β2-agonists, anticholinergics, corticosteroids.) There are also many different types of inhaling devices. Compliance with inhaler use, though, is poor. In a study of nearly 6000 patients with COPD, less than 50% were compliant with their inhalers 5 years after the initial prescription.¹¹ The 2 primary reasons for the problem are poor inhaler technique and the cost of the devices.^9,10 Improper technique can lead to decreased drug delivery and reduced efficacy.¹¹ A patient may become frustrated by a perceived lack of drug benefit and stop using the medication as prescribed.¹²

Patients may talk about their respiratory symptoms, but are less likely to be open about their medication-related concerns. This makes it essential that we specifically ask about inhaler technique, about when they use their inhalers, and about any potential financial burden that may limit access to an inhaler. Ask your patients to bring the inhaler to each office visit and to show you how they use it. This becomes a chance to correct technique and provide ongoing education. Try to ensure that the inhaler you initially prescribe corresponds to the patient’s skill and ability and his or her ability to pay for it. Over time the patient’s needs, skills, and resources may change so re-assessment and regular inquiry are important.
 
4. No matter what I do I cannot gain / lose weight.
Weight loss, fatigue, anorexia, and malnutrition are common among people with severe COPD. Nutritional status is also known to correlate with COPD symptoms, disability, and prognosis.² Low body mass index (BMI [≤21]) in patietns with COPD is also an independent risk factor for mortality. Increasing calories alone has not shown to be of significant benefit in these patients. Current evidence, however, supports a combination of exercise and increased caloric intake to support muscle growth.¹³

Patients with COPD who have markedly elevated BMI may also have many of the known complications associated with obesity. Obesity itself can cause dyspnea and may lead to over treatment with inhalers. The cause of dyspnea can be confusing in these patients, and the extra weight may limit activity and exercise independently of COPD. Comorbidities seen commonly with obesity, such as obstructive sleep apnea and diabetes, also can complicate COPD management. Monitoring a patient’s weight is an important aspect of COPD management. Consider referral to a dietician and to pulmonary rehabilitation to improve BMI in patients who are underweight or overweight.

5. I’m embarrassed to use oxygen when I’m away from home / I can’t maneuver the oxygen tank.
Supplemental oxygen at more than 15 hours per day in persons with chronic respiratory failure has been shown to increase survival in those with severe resting hypoxemia.¹⁴ Current criteria for  supplemental oxygen in stable COPD is O₂ ≤ 88% or a PaO₂  ≤55 mm Hg on 2 occasions over 3 weeks.²  A patient who qualifies for oxygen, however, may have concerns and limitations that affect adherence to the prescribed therapy. Patients frequently find the oxygen tank bulky and embarrassing and for those with severe COPD the cylinder of compressed oxygen can be too heavy to transport.

It is important to address a patient’s concern(s) about oxygen supplementation before starting therapy. It is equally important routinely to ask if they are wearing oxygen as prescribed. Some patients will use it only when they feel they need it, only at night, or only at home and not when attending public events. Patients may need ongoing reassurance of the benefits of using supplmental oxygen for >15 hours a day and to be reminded that they are not alone in their need for the treatment. Referral to a local or hospital-affiliated COPD support group may be valuable. Educational handouts also may be helpful in addressing concerns. For example, “Traveling with Portable Oxygen” from the American College of Chest Physicians is availabel at: http://www.accpstorage.org/newOrganization/patients/TravelingwithOxygen.pdf.

References
1. Institute NHLBI. U.S. Department of Health and Human Services National Institiutes of Health. Available at : http://www.cdc.gov/copd/pdfs/fact_sheet-4_reasons_to_learn_more_about_copd.pdf. Accessed March 1, 2012.
2. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) 2011. Available at: http://www.goldcopd.org/. Accessed March 1, 2012.
3. Hanania NA, Mullerova H, Locantore NW, et al. Determinants of depression in the ECLIPSE chronic obstructive pulmonary disease cohort. Am J Respir Crit Care Med. 2011;183(5):604-611.
4. Hill K, Geist R, Goldstein RS, et al. Anxiety and depression in end-stage COPD. Eur Respir J. 2008;31:667-677.
5. Qaseem A, Snow V, Denberg TD, et al. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008;149:725-733.
6. Kavan MG, Elsasser G, Barone EJ. Generalized anxiety disorder: practical assessment and management. Am Fam Physician. 2009;79:785-791.
7. Kanner RE, Connett JE, Altose MD, et al. Gender difference in airway hyperresponsiveness in smokers with mild COPD. The Lung Health Study. Am J Respir Crit Care Med. 1994;150:956-961.
8. Rosi E, Scano G. Cigarette smoking and dyspnea perception. Tob Induc Dis. 2004;2:35-42.
9. Castaldi PJ, Rogers WH, Safran DG, et al. Inhaler costs and medication nonadherence among seniors with chronic pulmonary disease. Chest. 2010;138:614-620.
10. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127:335-371.
11. Dolovich M, Ruffin RE, Roberts R, Newhouse MT. Optimal delivery of aerosols from metered dose inhalers. Chest. 1981;80(6 Suppl):911-915.
12. Hanania NA, Wittman R, Kesten S, Chapman KR. Medical personnel's knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105:111-116.
13. Steiner MC, Barton RL, Singh SJ, Morgan MD. Nutritional enhancement of exercise performance in chronic obstructive pulmonary disease: a randomised controlled trial. Thorax. 2003;58:745-751.
14. Stoller JK, Panos RJ, Krachman S, et al. Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial. Chest. 2010;138:179-187.