Chronic obstructive pulmonary disease (COPD) is a group of chronic, progressive conditions that result in irreversible airflow obstruction. In 2011, an estimated 12.7 million U.S. adults had COPD, and nearly 24 million had some evidence of impaired pulmonary function.1
COPD is characterized by periodic exacerbations, and the disease accounted for more than 700,000 hospital admissions in 2010.1
Chronic illness management is coming to the forefront of healthcare, along with a shift toward pay for performance. At the same time, a dramatic increase in healthcare technology applications has occurred. In 2013, 78% of office-based practices used electronic health records (EHRs) compared to 18% in 2001.2 Technologies used in COPD management fall into two categories: patient status monitoring and patient communication. By using technology effectively, providers can optimize COPD management, address exacerbations early, and empower patients to be active participants in their healthcare.
Oxygen saturations are commonly measured in healthcare settings and should be included with vital signs when assessing patients with pulmonary or cardiac diagnoses. This discussion focuses on patient use of pulse oximetry. Pulse oximeters are affordable ($20 to $50) and widely available. These devices usually are not covered by insurance.
For patients who require nocturnal oxygen only, home pulse oximetry is not useful. For patients requiring oxygen 24/7, the ability to self-monitor saturations is quite valuable. Ask the patient to check oxygen saturation during his or her usual activities. For example, if the patient routinely walks in the morning, ask him or her to check saturation during and following the walk several times to establish a baseline. If the saturation is adequate, the patient does not need oxygen during walks. The same method can be used to titrate oxygen flow needed for various activities.
In the event of acute shortness of breath, spirometry helps determine the best intervention. If the saturation is normal, the patient should rest and perhaps take a breathing treatment. If the saturation is low, the patient should use oxygen. Having a pulse oximeter empowers the patient to make decisions about oxygen management when a provider is not readily available.
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Toward Better COPD Management
Spirometry is easily accomplished in the office setting and can be performed by a medical assistant, respiratory therapist or nurse. For the test, the patient takes a deep breath and forcefully exhales as fast as possible through a tube. The volume of air is measured. This test is standard for a diagnosis of COPD. A ratio of FEV1 (forced expiratory volume in the first second of an exhale) over forced vital capacity (FVC) of less than 0.7 is diagnostic for COPD.
The GOLD Guidelines3 are the standard for staging COPD severity. Unfortunately, only 76% of patients with a diagnosis of COPD have completed a pulmonary function test.4
Spirometry is vital for both screening and monitoring. Any patient with a history of smoking should be screened with spirometry. Spirometry can detect COPD long before symptoms begin or complications develop. Additionally, serial spirometry performed at least annually alerts the provider to trends in lung function. Many EHRs can graph test result values, and such graphing highlights trends.
Spirometry can also be useful when symptoms worsen. It is neither practical nor advisable to have a patient who is clinically ill perform spirometry. However, when the etiology of increased shortness of breath is unclear (lungs are clear or diminished without adventitious sounds, absence of cough or purulent sputum), spirometry can help determine whether the underlying cause is pulmonary. A patient with spirometry close to baseline with increasing dyspnea may require cardiac work-up.
Patient portals allow patients to access their health information and communicate with providers from their computer or smartphone. My practice encourages patients to log on to our portal by sending clinical summary documents for each office visit to the patient via secure message. Patients have the opportunity to correct errors or outdated information. They can also review instructions from the provider if the printed summary has been misplaced.
COPD patients often take multiple long-acting inhalers in addition to short-acting rescue inhalers or breathing treatments. It is easy to confuse the directions for these drugs, and the portal can be source of clarification. If your practice has a workflow in place to address urgent patient messages from a patient portal, this can be a way for sick COPD patients to contact a provider without having to go through a phone tree.
Take full advantage of your practice’s website to provide general information about conditions common among your patients. Informative pages about COPD might include information about the condition and a list of symptoms for which patients should call their provider.
A 2013 meta-analysis found that telehome monitoring-based telenursing (THMTN) interventions resulted in fewer hospitalizations, emergency department visits and exacerbations, as well as shorter hospital stays, in patients with severe or very severe COPD.5 THMTN was developed in Japan, and it involves daily monitoring of physical and mental status, early identification of exacerbations, and patient education. A 2014 pilot study of a telerehabilitation program for COPD patients found improved adherence and higher activity levels compared to usual care.6 Telemedicine interventions are not widely available at this time. Preliminary findings show promise for the usefulness of these programs in the management of COPD.
By establishing clear communication, providing access to sources of patient information, and empowering each patient with COPD to self-monitor when appropriate, providers can partner with patients to achieve better outcomes.
1. American Lung Association. Chronic Obstructive Pulmonary Disease (COPD) Fact Sheet. http://www.lung.org/lung-disease/copd/resources/facts-figures/COPD-Fact-Sheet.html
2. Hsaio CJ, Hing E. Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001-2013. NCHS Data Brief. 2014;143:1-8. http://www.cdc.gov/nchs/data/databriefs/db143.pdf
3. Global Initiative for Chronic Obstructive Pulmonary Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD). http://www.goldcopd.org/Guidelines/guidelines-resources.html
4. Centers for Disease Control and Prevention. Chronic Obstructive Pulmonary Disease Among Adults – United States, 2011. MMWR. 2012;61(46):938-943.
5. Kamel T, et al. Systematic review and meta-analysis of studies involving telehome monitoring-based telenursing for patients with chronic obstructive pulmonary disease. Japan J Nurs Sci. 2013;10(2):180-192.
6. Tabak M, et al. A telerehabilitation intervention for patients with chronic obstructive pulmonary disease: a randomized controlled pilot trial. Clin Rehabil. 2014;28(6):582-591.
Melinda Darling specializes in pulmonology at Tucson Pulmonology Associates in Tucson, Ariz.