A Physician’s Role in Guiding Severe COPD Patients Toward Advanced Treatments

Photo Credit: iStock.com/Nadzeya Haroshka

Severe emphysema is a progressive, debilitating disease that quietly erodes patients’ quality of life, but emerging treatments like bronchoscopic lung volume reduction offer hope for restoring function and independence in carefully selected individuals.

Emphysema is a slow killer. It ages the lungs faster than the body. Patients routinely modify their lives around the loss of pulmonary function even without realizing it. Some patients are forced to use motorized wheelchairs to get around grocery stores while others must choose slip-in shoes over shoelaces as the steady, unrelenting depreciation of their bodily autonomy is dictated by the disease.

Severe emphysema even alienates family members as the patients relegate themselves to the length of their oxygen tubing and suffer through an acquired mutism from conversational dyspnea. Patients and families slowly realize the limitations caused by the irreversible loss of pulmonary reserve. Daily tasks become cumbersome. Maintaining any quality of life becomes insurmountable. Sometimes the realization is slow even on the part of their healthcare professionals.

While patients modify their lives around emphysema, professionals, too, fall within a certain lassitude in the management of it. Emphysema, which is a common form of COPD, causes breathlessness due to hyperinflation, among other pathophysiology. Despite the hours spent counseling tobacco cessation, encouraging the use of inhalers with proper technique, ensuring compliance with durable medical equipment, and enrolling in pulmonary rehabilitation, more than once have we observed these methods fall short of the expected outcome.

As an internal medicine resident, the limitations of the treatment options were enumerated through my training. Several years later as a pulmonary fellow, the limitations had not changed. As healthcare professionals, we have watched as patients progressed from one to three inhaler combinations, to requiring oxygen, to getting on lung transplant lists.

One of my earliest patients as an interventional pulmonologist shared that she could not visit her grandchildren because of her pulmonary limitations. She remained on 5 L of oxygen provided over a low-flow nasal cannula at rest. She could not perform many activities but on one of my very first visits stated that she was motivated to get better.

Patients who are sufficiently debilitated by the disease despite the available management options are sent to the few transplant centers scattered throughout the country. According to the registry of transplant recipients, of those patients who qualify for lung transplants, approximately 13% die or are removed within the first year of being listed. My patient was unable to make it onto a transplant list at all.

Thankfully, a lung transplant is not the only option for patients with severe emphysema. Another modality for the effective management of hyperinflation is ‘literally’ lung volume reduction. In appropriate patients, both surgical and bronchoscopic lung volume reduction (BLVR) can have significant morbidity benefits. BLVR is an excellent minimally invasive option for patients who fit within specific criteria, and physicians play a critical role in recognizing potential candidates and facilitating timely evaluation. Patients who experience severe airflow limitation (FEV1≤50%) and hyperinflation (TLC ≥ 100; RV ≥ 150) meet initial screening criteria to be seen by an experienced interventional pulmonologist who can discuss BLVR. After initial screening, they are enrolled in pulmonary rehabilitation (if not previously completed), optimized on their cardiac health, and the perfusion within the lungs are mapped. These patients then undergo a specialized CT scan of the chest to map the completion of fissures and to evaluate the degree of destruction of the individual lobes in the lungs.

Most BLVR procedures in the USA are performed using endobronchial valves (EBVs), which are placed in the airways of the selected lobes to block airflow to the most diseased areas, allowing healthier lung tissue to function more efficiently. My patient underwent the evaluation and successfully received EBVs.

Several months after the successful placement of EBV in the RUL, she progressed from slip-on shoes to shoelaces, from walking to the bathroom with a portable concentrator to dancing on the weekends, from celebrating events over Facetime to hosting Christmas at her house. While her change is truly dramatic, other patients have had varying outcomes. For most patients, it feels like their lungs have aged backwards. They can walk a little further, speak a little more, and live a little easier.

As healthcare professionals, it’s important to understand the broader impact of severe COPD on our patients’ everyday lives. Asking questions about their lifestyle and how the disease affects their daily activities, personal goals, etc. can provide valuable insights into their quality of life. For instance, questions like, “Are your symptoms preventing you from enjoying hobbies or activities you used to love?” and “Have you had to miss out on family gatherings or social events due to shortness of breath?” can help identify areas where interventions like BLVR might make a significant difference. By exploring these aspects, we can better tailor our treatment approaches.

While the rate of development and implementation of new medical technology is always slower than the progression of the disease, it is imperative to know that there is now something more we can do for patients who suffer from severe emphysema or COPD.

Results may vary.

Important Safety information: https://pulmonx.com/prescriptive-information/

Dr. Guda is a paid consultant of Pulmonx Corporation.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Physician’s Weekly, their employees, and affiliates.