5 Ways PCPs Can Manage Chronic Respiratory Conditions

Medscape

5 hours ago

Breathing is something you normally do without thinking. Adults do it some 12-18 times per minute.
For your patients with chronic respiratory illness, every breath is not always so easy and automatic.
Around 27 million Americans have asthma, which accounts for millions of emergency room visits each year. Another 12 million have chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema.
These common conditions, plus seasonal allergies, can be successfully managed by primary care physicians (PCPs), said Jonathan Jennings, MD, an internist with Medical Offices of Manhattan in New York City.
'The role of the primary care physician is to recognize the condition and assist with facilitating definitive diagnosis and treatment plans,' Jennings said. 'We also assist with educating patients and their families about the condition and treatment strategies.'
Jonathan Jennings, MD
Getting the Right Diagnosis
'Patients with chronic lung disease often live in a state of 'diagnosis limbo' for years, so it's important to provide them with a clear diagnosis and a structured treatment plan,' said Sanjay Ramakrishnan, a board-certified respiratory physician and specialist in asthma and COPD care at Sir Charles Gairdner Hospital and The Institute for Respiratory Health at The University of Western Australia in Nedlands, Australia.
For example, Ramakrishnan said, 'COPD diagnosis is often delayed. In the United States, it can take a patient many events over a number of years before they go to their PCPs for a diagnosis.
Patients may initially present with milder symptoms, such as cough or chest infection, which could get misdiagnosed. Sometimes, these symptoms could take years before progressing to something worse that prompts testing and further investigation.'
Sanjay Ramakrishnan
Ramakrishnan recommends doing a spirometry test to test lung function if a patient presents with chronic cough and has known risk factors, such as a history of smoking, childhood respiratory infections, and long-term exposure to indoor or outdoor pollutants.
'This offers a safe and affordable method to glean valuable insights for their care,' he said.
Ramakrishnan is also a proponent of pulmonary rehabilitation. 'It's an essential part of the management plan for individuals living with a chronic lung disease, such as asthma or COPD,' he said.
Educating Patients About Red Flags
'Red-flag symptoms are not only condition-specific but patient-specific, and a clear understanding of the condition and their symptoms is the best method to keep respiratory conditions well controlled,' Jennings said.
Some common signs of worsening disease include cough, fever, and a need for rescue medications more frequently.
Repeated COPD exacerbations are a warning sign that more needs to be done to control the disease.
Check blood eosinophil levels on a complete blood count test, even if that was already done as part of a routine exam and not during the time of exacerbation, Ramakrishnan advised.
For patients having exacerbations and a raised blood eosinophil count (≥ 300 cells/μL), treatment guidelines recommend inhaled corticosteroids. However, despite this, about half of the patients with COPD continue to experience exacerbations. For some of those patients, Dupixent (dupilumab) can be included as an add-on maintenance treatment with unstable COPD and an eosinophilic phenotype.
In a phase 3 clinical trial, Dupixent resulted in an up to 34% reduction in COPD exacerbations over a year and more than two times greater improvement in lung function at 12 weeks.
If your patients are on prednisone, it is important to make sure they are not overusing it. There can be serious consequences if prednisone is not managed properly. Continued refills might be a sign that the disease is not well controlled and further investigation is needed, according to Ramakrishnan.
Kick the Habit
'Smoking cigarettes and vaping pose significant risks, and we should help patients prioritize clean air in their lungs,' Ramakrishnan said. 'On average, in the US, quitting smoking takes up to eight attempts. As healthcare professionals, if we haven't helped our patients reach their eighth attempt, then I would say we haven't tried hard enough.'
Talk to your patients on every visit and remind them that quitting smoking is one of the best things they can do to improve their health. Counseling and FDA-approved smoking cessation medications used together can double your patients' chances of success.
Some current or former smokers older than 50 years may be eligible for lung cancer screening. Discuss the pros and cons of this special low-dose CT scan with your high-risk patients.
Encourage Vaccination
Respiratory conditions are often worsened by common viruses like the flu. Baseline damage to the respiratory tissues in those with chronic lung conditions make complications more common and can lead to a slow recovery, Jennings said.
Preventative vaccinations for flu, pneumonia, COVID, and respiratory syncytial virus are critical for these patients.
When to Call a Specialist
There are a number of chronic respiratory conditions, and various specialists are charged with managing different components of the respiratory system. One of the roles of the primary care provider is to figure out which specialist is most appropriate for the respiratory condition of concern, Jennings said.
Complicated conditions that need focused attention and advanced treatment are usually managed by a specialist. These include:
Chronic sinusitis
Sarcoidosis
Interstitial lung diseases
There is often an overlap in conditions, and some patients require multiple specialists. Sometimes asthma, COPD, and allergies need specialist care if they aren't responding to first-line treatment or if there's a question about the diagnosis, Jennings said.
Final Thoughts
Chronic lung disease disproportionately affects working class people — especially those living in cities, Ramakrishnan said. These patients sometimes downplay their problems and, therefore, don't get a timely diagnosis.
'They may dismiss their symptoms as 'just a cough' when it could be much more than that,' Ramakrishnan said. 'So it is important to help them understand the significance of their symptoms and help them prioritize their health.'
'These conversations can sometimes be challenging, but if we don't have them, we run the risk of allowing them to tolerate their symptoms for a long time until they significantly worsen,' he said.
Jennings encourages patients to trust their bodies and find doctors they are comfortable working with in order to develop the best individualized treatment plans.