COPD can be a devastating disease, but when caught in the early stages, the prognosis is encouraging for patients who follow their treatment regimen and make the lifestyle changes necessary to slow the progress.
The problem is, most patients aren’t diagnosed until the condition has done significant damage to the lungs and quality of life has already deteriorated.
Respiratory therapists across the country are working to ensure more patients at risk for COPD are diagnosed soon enough to do something about it.
Going on the offensive
Schneck Medical Center in Seymour, IN, is taking an aggressive stance when it comes to early diagnosis, says Susan Wynn, MSM, BSBA, RRT, the hospital’s director of respiratory care and sleep services. In addition to working with providers and staff in local physicians’ offices to implement the GOLD Guidelines and sharing the DRIVE FOR GOLD screening tool, they make sure office-based spirometers meet quality control standards and staff are competent to use them.
“We are also formalizing phase 1 pulmonary rehab in our inpatient population and teach all RTs to contribute to the COPD education as outlined by the GOLD guidelines,” she said. BODE scores are performed on all their outpatients, and they acquire orders for spirometry testing post-discharge for patients who have yet to have the test.
She and her RTs assess patients for home NIV as well and share the COPD Foundation website for continuing COPD education and support. They use COPD Assessment Test scores in the inpatient setting so that PCPs can compare outcomes at follow-up and regular visits.
Wynn says every patient has the STOP-Bang assessment performed by nursing as well, and this too opens doors for respiratory therapists to get involved when COPD symptoms are noted.
“We focus on OSA first and progress to a respiratory assessment to see if the patient has any respiratory issues,” Wynn said. “This is not a fool-proof system, of course, but it increases the likelihood of patients with lung issues getting educated and/or tested. It definitely increases awareness.”
She and her RTs are getting ready to start their Better Breathers Club back up to support interested patients as well.
In-office spirometry and more
As the chronic lung disease coordinator at Western Michigan University Homer Stryker MD School of Medicine in Kalamazoo, Mike Hess, MPH, RRT, RPFT, supports the primary care office team in their efforts to identify COPD early by performing in-office spirometry on patients considered at risk.
“We can do preliminary spirometry incidental to a primary care visit, and then follow it up with more formal pre- and post-bronchodilator testing on a follow-up visit,” he said.
He has also been working with his team to integrate screening tools like CAPTURE into the general workflow, such as during the rooming process.
“That way, we may better detect people at risk for the development of COPD, or those who have not yet recognized the early symptoms,” Hess said.
He’s trying to build some community screening events into the mix as well to ensure more people are reached.
According to Hess, these initiatives are crucial because annual surveys conducted by the National Institutes of Health have made it clear that failure to report and/or recognize symptoms and poor access to spirometry are two of the most significant barriers to diagnosis. At the same time, studies have shown that early intervention with long-acting bronchodilators has the potential to slow down the generally progressive loss of lung function that is a hallmark of COPD.
“We know that we often miss people with early symptoms until their FEV1 is down below 50% of the predicted value, which has tremendous impact on quality of life and activity tolerance,” Hess said. “This puts people at much higher risk for a variety of bad things, including leaving the workforce due to disability, social isolation, and depression.”
He sees these factors play out in his practice every day.
“I can’t tell you how many people have come back for their 30-day follow-up telling me, ‘I had no idea how bad my breathing had gotten, until it got better!’” Hess said.
Hess believes patient education must be a big part of the process for anyone diagnosed with COPD, early or not.
“I like to say that simply handing over an inhaler without initial training or a follow-up plan is like asking someone to pound in a nail using a screwdriver,” he said. “You may make a little progress, but it’s going to be inefficient, it’s probably going to cause more damage, and nobody’s going to be happy with the results.”
In his mind, RTs are the right clinicians to take the lead in this area of care.
“If RTs can help get people the right diagnosis and the right symptom management plan, we can make a powerful difference in those patients’ lives, and the lives of their families,” Hess said.
It can all start in the home
At Lourdes at Home in Port Crane, NY, Judy Kochmanski, RRT, works with patients in rehabilitation and their homes to ensure an early diagnosis.
“All staff who have clients with wheezing, dyspnea on exertion, or respiratory meds are encouraged to have a respiratory referral placed,” she said. “Most are homebound at the initial visit, so they may have, or need, respiratory meds to start to get mobile.”
Patients who show signs of COPD or asthma but have had no testing for these diseases are educated on ways to decrease dyspnea, and she helps to choose the best medication device based on the client’s abilities and insurance coverage.
She also asks the patient’s PCP to order pulmonary function testing to identify the underlying respiratory condition that may be causing the symptoms.
Kochmanski spends time educating the patient on the value of early detection as well, explaining that treatment can decrease the rate of respiratory decline. In order to ensure adequate follow-up, she also requests an additional respiratory visit after the diagnosis has been obtained to deliver specific respiratory education aimed at preventing exacerbations.
More great progress
Other hospitals are getting into the act too.
RTs at Hillsdale Hospital in Hillsdale, MI, perform a COPD screening on symptomatic patients admitted to their hospital and ask a physician to order pulmonary function testing for those who come back at risk, says Valerie Boyd, RRT, manager of cardiopulmonary and the sleep center.
“When performing their PFT, if they meet certain criteria, we may test them for Alpha 1,” she said, noting this is a free test in her facility. “If they qualify for pulmonary rehab by PFT results, we will provide education to the patient about our program and ask their physician for a referral.”
At Norton Healthcare in Louisville, KY, therapists have started a project this year targeting medical group offices to improve early diagnosis of COPD.
“We have a care algorithm that uses spirometry at the medical group office if they meet certain points on that algorithm,” explained Shelby Blankenship-Cutler, RRT, director of pulmonary services at Norton Audubon Hospital. “The theory is to ‘Know your Numbers’ in regard to spirometry so the patient can make certain lifestyle and health choices.”
The program is also aimed at facilitating an early intervention by a pulmonary physician if needed and encouraging the patient to attend educational classes regarding their disease, smoking cessation, pulmonary rehab.
Toni Caldwell, RRT, is the COPD care coordinator at Abington Jefferson Health in Abington, PA. Early diagnosis of the disease is considered critical at her facility as well.
“Early diagnosis is very important to us because the earlier it is diagnosed, the sooner they can get treatment,” she said. “Also, if they are still smoking, they can get smoking cessation and NRT.”
Her RT department screens all patients receiving treatments who are age 40 or over, have a 20-pack year smoking history, and are symptomatic. They use the COPD Screener from the COPD Foundation for the assessment.
“Patients who score five or higher are recommended to take a copy of their screener to their PCP and have PFTs done,” Caldwell said. “We also put a note in their discharge instructions recommending they have PFTs done, and I send a note to their PCP recommending PFTs, along with a copy of the COPD Screener that they filled out.”
A goal worth striving for
Catching COPD while there is still time for medications, lifestyle changes, and other treatments to do the most good is increasingly becoming a goal in hospitals across the country. Clearly, respiratory therapists are the best clinicians to ensure early diagnosis is not just the exception, but the rule.
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