COPD:

Why Test Your Lungs, Know Your Numbers

Is the New Battle Cry

Thomas L. Petty, M.D.

Louise M. Nett, R.N., RRT

University of Colorado

Dr. Petty is professor in the division of pulmonary sciences and critical care medicine at the University of Colorado Health Sciences Center and faculty consultant for HealthONE Columbia Center for Health Sciences Education in Denver. He is also chairman of the National Lung Health Education Program (NLHEP). Ms. Nett is an independent research consultant working with the NLHEP.

ABSTRACT: A major goal of the National Lung Health Education Program, which is aimed at early detection and treatment of chronic obstructive pulmonary disease, is to have all primary care practitioners perform spirometry on smokers and persons with respiratory symptoms to identify those with early disease. Smoking cessation is a key element in the program; options for nicotine replacement include gum, patches, spray, and a cigarette-like inhaler. Sustained-release bupropion can be used for nicotine withdrawal symptoms. Both intensive counseling and nicotine replacement therapy are required for the most heavily addicted smokers. Since spirometric abnormalities are surrogate markers for the four leading causes of death, widespread use could have a profound effect on health care. Consultant October 1998;38:2501-2508.The National Lung Health Education Program (NLHEP), created in 1995 following the completion of the Lung Health Study, is now entering the implementation stage. This program, the newest of the national health care initiatives, is directed toward primary care physicians and encourages widespread early detection and treatment of chronic obstructive pulmonary disease (COPD) and related disorders in high-risk patients. It is cosponsored by the National Heart, Lung, and Blood Institute; The National Cancer Institute (NCI); the American College of Physicians; the Society for General Internal Medicine; the American Osteopathic Association; and a number of pulmonary and respiratory therapy groups, including the American College of Chest Physicians (ACCP), the American Thoracic Society, the American College of Allergy, Asthma, and Immunology (ACAAI), the American Association for Respiratory Care, and the American Association for Cardiovascular and Pulmonary Rehabilitation. Other societies have been asked to join. It is hoped that each of the sponsoring organizations will develop educational programs for its own constituency.

As with other common chronic diseases, such as hypertension, asthma, diabetes, and arthritis, primary care physicians must be actively involved in the diagnosis and management of COPD. About 70% of tobacco users consult a physician at least once a year. Even if they do not present with a smoking-related problem, their physician is in an ideal position either to help prevent COPD or to diagnose and manage it in its early, reversible stages.

In this article, we will discuss the goals of the NLHEP and the important role of the primary care physician in implementing them.

BACKGROUND

The Lung Health Study provided researchers with a new scientific basis for early identification and management of COPD. It prospectively evaluated the effect of intensive smoking cessation efforts on the decline in lung function over 5 years in 5,877 patients. A major finding was that smokers who were relatively young B ie, older than 35 but not yet 60 B and who had only mild airflow obstruction, as measured by simple spirometry, faced progressive losses of lung function over 5 years if they continued to smoke.1 In contrast, those who quit smoking had a slight improvement in lung function and then only a very slight decline during the same period (Figure).

In the Lung Health Study, 5,877 middle-aged smokers were randomized to one of three groups: smoking intervention plus inhaled ipratropium, smoking intervention plus placebo, or no intervention. The results showed that rates of decline in post-bronchodilator forced expiratory volume in 1 second (FEV1) were higher for participants in the smoking intervention plus placebo group who were sustained quitters (o) than for continuing smokers(* ). The study confirmed that aggressive intervention can significantly reduce the age-related decline in FEV1 in middle-aged smokers with mild airflow obstruction.

The patients with only mild airflow obstruction were not even within the symptomatic range for COPD. Indeed, most patients who continued to smoke and who had the greatest rates of decline were not symptomatic even after the end of 5 years. None of the original 5,877 participants died of COPD during the 5-year follow-up. These patients= ventilatory function was well above the level at which morbidity and premature mortality begin to occur. (The disabling symptoms of COPD generally begin to occur at a forced expiratory volume in 1 second [FEV1] of 1.5 L or less.)

Another important finding of the Lung Health Study was the high death rate associated with lung cancer compared with that associated with cardiovascular disease and all other causes of death (Table). The association between smoking-related chronic airflow obstruction and an extremely high risk of lung cancer was also confirmed. More than 100 patients B approximately 2% of the original sample B have been given a diagnosis of lung cancer. More cases will emerge as this group continues to be followed.

Table - Deaths of participants in the Lung Health Study during the 5-year follow-up period
____________________________________________________________________________________
Cause of death                   Special care          Usual care         Total
____________________________________________________________________________________
Lung cancer                                    38                                    19                                57

Cardiovascular disease                 25                                    12                                37
(heart attack/stroke)

Other (including other                  35                                     20                                55
smoking-related cancers)
 
            Total                                    98                                     51                              149

The 5,877 participants in the study were middle-aged smokers with spirometric signs of early chronic obstructive pulmonary disease. They were randomly assigned to special care and usual care in a ratio of 2:1. Special care consisted of either smoking intervention and ipratropium or smoking intervention and placebo. The usual care group had no intervention.

Adapted from Anthonisen NR et al. JAMA. 1994.1

THE ROLE OF THE PRIMARY CARE PHYSICIAN

The resource document that defines the NLHEP guidelines for identifying and treating all stages of COPD was written for primary care physicians and has been published in two medical journals2,3 that reach more than 62,000 health care workers. It is available from the ACCP at 3300 Dundee Road, Northbrook, IL 60062-2348.

Respiratory care professionals will be important colleagues in teaching the fundamentals and practical aspects of spirometry. Most hospital pulmonary function laboratories and some pulmonary practice offices are staffed by expert respiratory care and pulmonary function technicians, who can instruct frontline practitioners in the proper techniques of simple spirometry. These laboratories will remain available for referrals when more complex pulmonary function tests are deemed necessary by either primary care physicians or consulting specialists.

One of the goals of the NLHEP is to ensure that primary care physicians are armed with the knowledge and technology to provide state-of-the-art care for their patients. A powerful therapeutic armamentarium exists for patients who have symptomatic COPD, but many are not receiving optimum treatment. The appropriate therapies and their applications have been summarized in the resource document.

The Lung Health Study demonstrated that most patient with COPD show improved airflow in response to the inhaled anticholinergic agent ipratropium.1 Another study showed an improvement in baseline lung function with long-term use of this agent.4 Certainly, patients who are symptomatic should be treated with both an anticholinergic agent and a ?-agonist, if needed, to control symptoms and to maximize improvement in airflow. The available of a combination product containing ipratropium and albuterol makes dosing these two agents practical and convenient.5

The empiric use of antibiotics for episodes of purulent bronchitis is helpful in at least shortening the course of exacerbations in many patients.6 Corticosteroids are also useful in acute exacerbations.7 A small subset of patients who have COPD may actually experience significant objective improvement when treated with corticosteroids.7 A meta-analysis of corticosteroid use showed that in approximately 10% of patients, FEV1 improved by more than 20%.

Pulmonary rehabilitation programs that teach exercise, breathing training, good nutrition, and general body conditioning are an essential component of a treatment program for patients with advanced stages of COPD.8 Supplemental oxygen can be lifesaving for those patients with chronic stable hypoxemia.9 Of course, all patients with COPD should receive an influenza vaccination each fall and a pneumococcal vaccination at least once in their lifetime.

New therapies directed at inflammatory processes in the airways and surrounding alveoli are being studied. If proved effective, such agents would promote the goals of the NLHEP in halting the progress of COPD.

Primary care physicians will play a crucial role in the success of the NLHEP, but the program should be of interest to pulmonologists and other specialists as well. There are approximately 15 million persons with undiagnosed COPD in the United States. Patients with few or no symptoms are unlikely to be referred to specialists unless an occult abnormality is identified by a primary care physician. This can be done through simple spirometric testing. When early intervention is unsuccessful or if there are complex complications B such as rapidly progressive disease, unexplained pulmonary nodules or infiltrates, or cardiovascular complications B referral to a specialist is appropriate.

THE ROLE OF SPIROMETRY

Since patients at risk for premature morbidity and mortality from COPD and related disorders can be accurately detected only by spirometry, the NLHEP will promote the widespread use of spirometers in all primary care physicians= offices. The program=s motto is ATest Your Lungs, Know Your Numbers.@

The NLHEP believes that all smokers and any patient with cough, dyspnea, or wheeze should have spirometric measurements done as a baseline and serially, depending on whether smoking cessation can be achieved and whether symptoms persist. It recommends that all health care practitioners B including family practitioners, internists, obstetricians, gynecologists, and specialists B perform spirometry as part of the database for their patients who smoke or who have pulmonary symptoms.

In many ways, NLHEP is patterned after the National Hypertension and National Cholesterol Education programs. The identification of abnormalities in systolic and diastolic blood pressure and in lipid profiles was the first step toward therapeutic interventions for atherosclerotic heart disease and stroke. When these initiatives were launched, both blood pressure cuffs and blood tests for cholesterol were already widely available to all practitioners. This is not so with spirometry, since only approximately 25% of primary care practitioners use this test in their day-to-day practices. It is unfortunate that spirometry is most commonly done in traditional pulmonary function laboratories, at considerable cost and inconvenience to the patient. The NLHEP believes it is now time to put the spirometer in the primary care physician=s office or clinic. Home spirometry is also a possibility.

The NLHEP has encouraged the development of a new generation of simple, accurate, and reliable spirometers. One such device has received FDA approval; it will cost less than $500. This spirometer uses sophisticated software and a disposable flow transducer to record FEV1, expiratory air volume (forced vital capacity), and the ratio between the two. These measurements are all that are needed to identify COPD and to plot its course and responses to therapy.

In a related development, the ACAAI is promoting screening pulmonary function tests to identify patients with unidentified asthma. These free tests are being conducted in shopping malls and other public places. The NLHEP is not yet promoting widespread screening for COPD but, rather, is encouraging the identification of early disease in high-risk patients (ie, those who smoke or who have symptoms) by the patients= personal physicians.

According to Joesph Dizon, MD, the Los Angeles coordinator for the ACAAI, AThe tragedy of deaths underscores the need for people to know the symptoms of asthma and see a specialist for an evaluation. Screening programs are part of the answer for asthma because they inform and educate people about the importance of early treatment. With proper treatment, asthma conditions can be controlled.@ One could make the same plea for early detection of COPD, since treatment can be initiated early. This is a major goal of the NLHEP.

SMOKING CESSATION

The NLHEP strongly promotes smoking cessation, since this measure has been shown to retard the course of COPD, to lessen the risk of death from heart attack and stroke, and even B after many years of abstinence B to reduce the risk of lung cancer. Advances in smoking cessation methods are noteworthy. There are many options for nicotine replacement, including gum, patches, spray, and a new cigarette-like inhaler. A possible treatment for nicotine withdrawal symptoms is sustained-release bupropion, which achieved a biologically proven success rate of approximately 23% at 1 year compared with placebo.10 Using several nicotine replacement strategies, or nicotine in conjunction with bupropion, may achieve a quit rate as high as 50%, some experts say.11

Compared with other preventive interventions, smoking cessation is extremely cost-effective.12 The more intensive the program, the greater the likelihood of permanent cessation. Both an intensive level of counseling and nicotine replacement therapy are required for the most heavily addicted smokers. Most physicians need to do more to meet the standards initiative by the NCI or the Agency for Health Care Policy and Research (AHCPR).13

The AHCPR pamphlet Smoking Cessation: Information for Specialists contains key points for intervention and specific new information, including ideas for effective counseling techniques. The panel suggests targeting the smoker=s motivation to quit and advocates use of the A4 Rs@:

$ Relevance. Make the motivation relevant to the person=s disease status; family or social situation; health concerns; age; gender; and other characteristics, such as previous attempts at quitting.

$ Risks. Review with the patient the potential risks associated with smoking. Have him or her identify the risks and highlight the ones that are most personally relevant. Emphasize that smoking low-tar/nicotine cigarettes or using other forms of tobacco such as smokeless tobacco, pipes, or cigars, will not eliminate the risks. In fact, the growing use of cigars in this country is cause for alarm, since cigar smoking is a cause of tobacco-related diseases. The risks of cigar smoking are described in a new NIH monograph.14

Examples of risks include:Acute risks: Shortness of breath, worsening of asthma, impotence, infertility, increased serum carbon monoxide.

Long-term risks: Heart attack, stroke, cancer (lung, larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix and colon; leukemia), COPD (chronic bronchitis, emphysema), premature blindness, hearing deficits.

Environmental risks: Increased risk of lung cancer in spouse and children; higher rates of smoking by children of smokers; increased risk of sudden infant death syndrome, asthma, middle ear disease, and respiratory infections in children of smokers.

$ Rewards. Ask the patient to identify the potential benefits of quitting, and highlight those that seem most relevant. Examples include improved health, improved sense of taste and smell, freedom from addiction, increased self-esteem, improved performance

in sports, and feeling better physically. Patients will be free of the worry about quitting and about exposing others to smoke; they will set a good example for their children; may have healthier babies and children; and their breath, home, and car will smell better.

$ Repetition. Repeat the motivational intervention, as needed during subsequent office visits.

The AHCPR practice guidelines and published materials are available on the Internet at http://www.ahcpr.gov. They are also available by calling 800-358-9295, or by writing to AHCPR Publications Clearinghouse, PO Box 8547, Silver Springs, MD 2090715.

The NLHEP will also stress the high risk of COPD in women who smoke. Women may be even more susceptible than men to the harmful effects of tobacco smoke and more vulnerable to lung cancer at a given level of smoking. The American Cancer Society has acknowledged that women have a higher risk of lung cancer than men. The Society for the Advancement of Women=s Health Research, recognizing that smoking will kill 23,000 more women than breast cancer in 1998, has recently called for a ban on tobacco advertising targeted at women. Women=s magazines are a popular source of health information, but magazines that carry cigarette advertising rarely publish articles that present complete information on the risks of smoking.

COPD is a smoker=s disease that clusters in families and worsens with age. As the population ages, we will have more patients with COPD, particularly if 25% of the population continues to smoke. It is hoped that the NLHEP will succeed in mounting an effective national campaign to keep children and teenagers from starting to smoke and to encourage all smokers B particularly those who are identified as being at highest risk because of airflow obstruction B to quit.

Dietary factors. Since oxidants are believed to be central to the pathogenesis of COPD, many experts recommend a diet high in fruits and vegetables as well as antioxidant vitamins and minerals for smokers with COPD, whether or not they are able to quit smoking.

NLHEP: ITS POTENTIAL IMPACT

The NLHEP may have perhaps the greatest impact of all the national health care initiatives because it could affect the incidence not only of COPD, the fourth most common cause of death, but also of the three more common causes of death: heart disease, cancer, and stroke. Spirometric abnormalities are surrogate markers of these conditions; indeed, spirometric abnormalities are predictive of total mortality.16

The program=s goal now is to develop educational programs for primary care physicians. One such program, Frontline Treatment of COPD B a pilot project to provide hands-on instruction in COPD B has been organized and widely promoted through Medical Education Resources of Englewood, Colorado, a provider of continuing education programs. In 1997, 13 such programs attracted more than 2,500 physicians, nurses, therapists, pharmacists, and other health care workers to a 3-hour morning symposium designed to change practice patterns and to encourage interventions in early stages of COPD. There will be 12 programs in 1998, beginning in September.

Feedback from these pilot programs indicated a high level of acceptance and increased use of spirometry, both immediately following the sessions and over the longer term. A Train the Trainer program was provided for the governors of the ACCP recently in hopes that they would provide regional programs for primary care physicians aimed at emphasizing the early diagnosis and treatment of COPD.

We need to take the NLHEP message to the front lines and make it a massive grassroots effort that will result in a change in practice patterns. The new, more user-friendly spirometers are essential to this effort. Their use may ultimately help identify large numbers of patients who have early COPD and who are at increased risk for death from other disorders at a stage when interventions can have a profound impact. The end result could be a massive improvement in the quality of health care and a decrease in the socioeconomic impact of COPD and related disorders.
 
CLINICAL HIGHLIGHTS
o  The Lung Health Study confirmed the association between smoking-related chronic airflow obstruction -- as measured by simple spirometry -- and a high risk of lung cancer.

o  Sophisticated new spirometric devices are simple to use and allow for early identification and high-risk patients.

o  Optimum treatment of symptomatic chronic obstructive pulmonary disease includes the use of both an anticholinergic agent and a beta agonist, if necessary.  Antibiotics are recommended for episodes of purulent bronchitis; corticosteroids may also help some patients with acute exacerbations.

o  Smoking cessation techniques including making motivation relevant to each patient, reviewing risks, identifying rewards, and repeating the intervention as needed.

References:

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  5. Petty TL, chairman. Combivent7 Inhalation Aerosol Study Group. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. An 85-day multicenter trial. Chest. 1994;105:1411-1419.
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  10. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337:1195-1202.
  11. Fiore MC. Personal communication, May, 1998.
  12. Cromwell J, Bartosch WJ, Fiore MC, et al. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA. 1997;278:1759-1766.
  13. Goldstein MG, Niaura R, Willey-Lessne C, et al. Physicians counseling smokers: a population-based survey of patients= perceptions of healthcare provider-delivered smoking cessation interventions. Arch Intern Med. 1997;157:1313-1319.
  14. National Institutes of Health. Cigars, Health Effects, and Trends. Washington, DC: National Institutes of Health; February 1998. NIH publication 98-4302.
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