By Stephen Spotswood
WASHINGTON – Chronic obstructive pulmonary disease (COPD) is sometimes referred to as the “quiet” or “silent” killer by clinicians trying to treat it. It presents few symptoms in its earliest stages and so is often not diagnosed until the patient arrives at the doctor’s office suffering from severe breathing problems —pain, wheezing, barely able to function.
Veterans are three times more likely than their civilian counterparts to be those patients.
While the full prevalence of COPD among veterans is not fully known, it’s generally recognized that they are at a particularly high risk for the disease, with as many as 15% of the VA patient population currently affected. Because it goes undiagnosed in its earliest stages, this percentage could be quite higher, but, even if underestimated, COPD still ranks as the fifth leading cause of death among veterans.
This is partly due to the aging veteran population. VA’s patient population skews older than the general populace, and COPD disproportionately affects older individuals, with 65% of hospitalizations for COPD occurring in patients 65 and older.
Historically, men have had higher rates of COPD than women, making VA’s overwhelmingly male patient population especially susceptible. That number is changing, however, and women in recent years have been catching up with men for risk of death from COPD.
During the past 50 years, the two biggest factors that put veterans at a higher risk for COPD than the general populace have been cultural and environmental.
Cigarette smoking is the biggest known risk factor for COPD, more than three times that of nonsmokers, and smoking has traditionally been a staple of military culture. While smoking is no longer nearly as accepted in the military as it once was, the cumulative effects of decades of tobacco use among servicemembers continues to make its way through the VA healthcare system.
According to the CDC, approximately 18% of adults in the U.S. are current or former smokers. The estimated number of veterans who smoke is nearly double.
Veterans also are at higher risk of exposure to environmental factors known to contribute to COPD and other lung problems. In theater, servicemembers often are exposed to toxic chemicals, airborne debris, dust, fumes and a host of other risk factors.
Research in Its Infancy
It’s important to understand how young the science around lung disease actually is, explained Marta Render, MD, VA’s national program director for pulmonary care.
The use of bronchodilators and an emphasis on smoking cessation only came into play in the 1990s. Prior to that, the primary treatment had been oxygen therapy, although even that only has been in use since the mid-1960s. As late as the early 1960s, oxygen therapy was contraindicated for COPD, and exercise was prohibited because of a fear it might put too much strain on the heart.
“From a lung biology point of view, we’re where cardiology was 20 years ago — the tip of the iceberg,” Render declared. “I think we don’t understand the ways we can protect patients. Our interventions are also still pretty limited in management of exacerbations. The physiology is poorly known. Much work remains to be done in terms of lung biology.”
For example, patients with COPD can experience unwanted weight loss. How does nutrition come into play in preventing that? Also, how can clinicians help patients maintain respiratory muscle strength? These questions are just a few that need to be answered by future research.
“There are a lot of research gaps, I regret to announce,” Render said. “It’s not a sexy disease. It comes from a heritage of [being considered] a disease people inflict on themselves. It wasn’t recognized that cigarettes were addictive.”
Diagnosing the problem and treating it effectively as early as possible is critically important in limiting progression and maintaining quality of life. This is why VA is working to ensure that, wherever the first point of contact is for a veteran in the VA system, there will be someone there who can accurately test for and diagnose COPD.
“There are a thousand things that can cause shortness of breath,” Render noted. “Most mortality from shortness of breath is from artery disease. So when a patient comes in, you have to explore other contributors.”
When a patient comes in complaining of shortness of breath, there are five common diagnoses: ischemia, heart failure, arrhythmia, reflux and pulmonary embolism. All of these can be screened for by taking a patient history and through simple lab testing, Render explained. The obstruction test determines whether a patient will be treated for COPD.
The spirometer is increasingly being used because it is the most accurate method of measuring airflow obstruction. While it seems like a simple test to administer, it can be surprisingly difficult to get accurate results, she pointed out.
“The test involves taking a deep breath and blowing into a mouthpiece for 12 seconds. Some people with COPD have difficulty blowing at all,” Render said. “The test is quite simple. The training has to do with getting the maximal effort from the patient consistently.”
Patients are asked to repeat the test several times, which can lead to frustration and lack of effort.
“It can be annoying for the patient,” she explained. “But if you don’t have obstruction, you don’t have COPD, and it’s important to have a correct diagnosis.”
This year, VA is sending experts to its community-based outpatient clinics (CBOCS) to train staff to reliably do that testing. There is also the potential for virtual testing.
“You can see the patient do it on a two-way video and coach them and get the same results as if you were in the room,” Render explained. “One of the fun things about VA is the ability to use telehealth to reduce travel for patients and still provide a standard of care.”
However the testing is done, VA’s goal is that a patient presenting with shortness of breath will be diagnosed as quickly and accurately as possible.
“We make the diagnosis of COPD relatively late in symptomatic patients,” Render said. “If we don’t pick it up until they have advanced COPD our treatment options are much more limited.”
Treatment and Prevention
Patients with COPD tend to fall into two different groups, Render explained. There are those who present with exercise intolerance, and they are often prescribed an inhaler and never have another incident. The other group includes those VA characterizes as at risk for exacerbation. These are patients who have previously had breathing problems, who have been admitted to the hospital, had visits to the ER or have been prescribed antibiotics and steroids.
For these higher-risk patients, treatment is a long-acting bronchodilator partnered with long-acting beta-agonists with the possible addition of an inhaled glucocorticoid.
Because COPD is a progressive condition, preventive care is critically important post diagnosis. Lifestyle changes are often necessary to prevent the disease from getting worse.
“Effective smoking cessation cannot be underestimated as a research and implementation area. Smoking is enormously common in the military. And it’s accepted that patients develop lung disease after smoking,” Render said. “If we get them to quit smoking, it’s the one thing shown to change course in lung progression in COPD.”
The DoD now has an intense focus on smoking cessation, but that is a more recent development. Cigarettes were included in C-rations until 1975, and advertisements for smoking in the 20th century often featured servicemembers in uniform.
The use of vaccines to help prevent influenza and complications such as pneumonia also is key. “Smoking and prevention pneumonia — these are the really big hitters that keep patients with COPD functional and healthy into their 80s and 90s,” Render said.
Exercising also has shown to slow the progression of the disease, as well as improve quality of life in myriad ways.
“Pulmonary rehab programs across the country, both in VA and the private sector, have fallen out of favor because they’re hard to show cost benefits. But there’s a subset [of patients] that show benefit and less likelihood for readmittance,” Render explained. “One thing we’d like to see is increased efforts in participation and rehabilitation. One area being investigated right now is virtual rehab where a nurse might check in with a patient and watch them do their exercises and see how far they’ve walked that day. The problem is that the benefits of exercise decrease after you stop exercising, and most folks are not great at continuing exercising. That’s a continuous challenge, especially as you get older. To keep moving your body is integral for health prevention.”
While knowledge is growing, it will take time for the gaps in research to be filled in, she cautioned.
“There are simple things,” Render said about the information gaps. “Not everyone wears their oxygen 18 hours a day. People don’t all take their long-acting inhalers. Sometimes they don’t like their case. Some of the [drugs] give them tremors. There’s information we need to know about how to improve adherence.”
One area of study that has come into sharp relief in recent years is self-management. A study conducted through the Puget Sound VA looked at whether taking part in an intensive self-management and self-monitoring program would reduce hospitalization in patients with COPD.
There was no difference seen in hospitalization, and the mortality rate among those in the intervention group was more than twice the level in the control group, prompting VA to shut down the study early.
“We don’t understand why those results were shown,” Render said. “Self-management is a big byword in primary care right now. We have to engage the patient in making better choices for themselves, but in COPD there’s a big research gap where self-management comes in.”
Part of the problem might be that it can be difficult for patients to realize when their symptoms are worsening.
“A lot of patients with COPD are so short of breath at baseline [that] it’s hard for them to recognize when they’re worse,” Render said.
The good news is that VA is at the forefront of filling in those knowledge gaps. With a unified care system where an increasing percentage of patients are presenting with COPD, the department has the resources to make a difference in answering those questions.
“I think VA is a good place to conduct health service research on patient preferences, adherence, models of care,” Render said. “To some extent we’re already doing that. And we could always do more.”