Managing COPD During the COVID-19 Pandemic

In this podcast, David Hill, MD, answers our questions about managing chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic, including whether patients with COPD are at an increased risk for severe illness because of the virus that causes COVID-19, and optimal medical treatment for a patient with COPD and COVID-19.

Additional Resources:

• Maintaining control of COPD during the COVID-19 Pandemic. American Lung Association. Published August 11, 2020. Updated December 14, 2020. Accessed April 12, 2021. https://www.lung.org/blog/control-copd-during-covid-19-pandemic
• Kaye L, Theye B, Smeenk I, Gondalia R, Barrett MA, Stempel DA. Changes in medical adherence among patients with asthma and COPD during the COVID-19 pandemic. J Allergy Clin Immunol Pract. 2020;8(7):2384-2385. https://doi.org/10.1016/j.jaip.2020.04.053 
• Tan JY, Conceicao EP, Wee LE, Sim XYJ, Venkatachalam I. COVID-19 public health measures: a reduction in hospital admissions for COPD exacerbations. Thorax. Published online December 3, 2020. 10.1136/thoraxjnl-2020-216083

David Hill, MD, is a pulmonary critical care physician and director of the clinical research program at Waterbury Pulmonary Associates in Waterbury, CT. He’s a faculty member at Yale University, Quinnipiac University, and the University of Connecticut medical schools. Dr Hill is a national spokesperson for the American Lung Association.

TRANSCRIPTION: 

Jessica Bard: Hello, everyone. Welcome to another installment of "Podcasts360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

According to the American Lung Association, COPD affects millions of Americans, and it’s the third leading cause of disease‑related death in the United States. Dr David Hill is here to speak with us about managing COPD during the COVID‑19 pandemic.

Dr Hill is a pulmonary critical care physician and director of the clinical research program at Waterbury Pulmonary Associates in Waterbury, Connecticut. He's a faculty member at Yale University, Quinnipiac University, and the University of Connecticut medical schools, and also a national spokesperson for the American Lung Association.

Thank you for joining us today, Dr Hill. To start, are patients with COPD at an increased risk for severe illness from the virus that causes COVID‑19?

Dr David Hill: That's an interesting question with an almost yes and no answer. In terms of increased risk of severe disease, the evidence seems to state that patients with COPD are at increased risk to develop severe disease if they get infected with COVID‑19.

The interesting thing is that the prevalence rate of COVID‑19 in the COPD population seems to be lower than the prevalence rate that would be expected based on the amount of COPD that is out there.

What we're seeing in patients who get sick and hospitalized with COVID‑19 is about five percent of them have COPD. Whereas the diagnosed rate of COPD in the population is in the 9 to 10 percent range.

A couple reasons that may be occurring are COPD patients may be really smart. Because they know they have chronic lung disease, they have been hunkering down at home, wearing masks when they go out, and avoiding infection.

There may also be some protective effects of inhaled steroids. About 60 percent of the COPD population are taking inhaled corticosteroid‑containing medications. There's some suggestion that inhaled steroids may down‑regulate the ACE receptor that COVID‑19 uses to cause infection and may be protective.

When patients of COPD get sick, the evidence we have is that they are more likely to become severely ill and more likely to die from COVID‑19. Certainly, our patients want to avoid this infection if they can. They're probably at higher risk because of their underlying lung disease.

The COPD population in general, also is older and has more comorbidities. Things like diabetes, hypertension, obesity may be playing a role, along with the fact that we know that the older patients are, the higher their risk from COVID in general.

Jessica: That's really interesting. Maybe the first part of that is counter what people might actually expect. That's an interesting point. How has the pandemic affected COPD diagnosis, treatment, and exacerbations?

Dr Hill: In general, COPD is under‑diagnosed. The feeling is, across the population, about half of the patients who have COPD have been officially diagnosed by a physician with COPD. There's a couple of reasons for that, lack of testing, physicians not testing people who are symptomatic with spirometry, people downplaying their symptoms.

Frequently, in my practice, someone will say they're not short of breath. Then I'll ask them what happens if they climb a flight of stairs, and they'll say they get short of breath. Patients will say they don't have a cough but tell me they bring up sputum every morning. It's under‑reporting of symptoms leading to under‑diagnosis.

What the pandemic has done is decrease people's interaction with medical care in general. Less primary care visits lead to less diagnosis and less referrals to pulmonologists like me. Pulmonary function testing, which is a mainstay of diagnosing COPD, has been significantly decreased due to the pandemic.

For a number of months, the American Thoracic Society recommended that pulmonary function testing only be pursued for emergent situations, when it was absolutely necessary somebody being evaluated for lung resection or for a disease that was completely out of control. Otherwise, they had to shut down our labs for fear of spreading the virus.

Now that we have opened up medical care more, we are still not doing as much spirometry and lung function testing as prior to the pandemic.

We have to COVID test everyone prior to PFTs. We have to have good cleaning protocols in place in order to keep our labs clean and prevent spread. We need more PPE for our pulmonary function staff. All of that has slowed down testing. Less testing equals less diagnosis.

In terms of treatment, same sort of situation has occurred. There are less follow‑up visits. Patients aren't getting as closely followed, more of a chance of disease being out of control.

Again, less pulmonary function testing to follow disease course. Pulmonary rehabilitation in a lot of settings was shut down. Our mainstay for care of patients with more moderate to severe disease, most of our pulmonary rehab programs ‑‑ because they were in person, and exercising like gyms ‑‑ were shut down for a period of time.

Those have reopened with a lower population of patients and good protocols in place, but that has affected treatment. There's been a decrease in lung cancer screening because patients don't want to go in and have low‑dose CT scans done in order to find lung cancer, that has the potential to miss some cancers at a time where we could control them and cure them.

On the other side of things, there's been some evidence that patients with COPD are more adherent to their medication during the pandemic. It goes back to that fear of getting sick that I talked about earlier.

There are some studies published showing that patients are using their controller medicines with more regularity during the pandemic than they were prior to the pandemic. There has been an overall decrease in COPD exacerbation rates, which is fascinating.

One of the take‑homes from the pandemic is that wearing masks and social distancing work. They work incredibly well for things like influenza and the common cold. Influenza is almost non‑existent throughout the world.

Rates of viruses that cause the common cold and other viruses that cause severe respiratory illness like RSV, or human melanoma virus are also way down. There have been over a 50 percent reduction in COPD exacerbations across the board than compared to pre‑pandemic.

Some of that may be because patients don't want to seek medical care. Most of it is because they're staying healthier. I saw one study that showed that the prevalence of non‑COVID viruses had dropped from 50 percent of COPD exacerbations to about 10 percent.

That was even in the setting of us doing a lot more viral testing. The RNA testing we have available to check for viral infections is relatively new. If we go back a few years ago, a lot of centers didn't have it.

Some centers still don't have it. We're testing more and seeing less virus because social distancing and masking stops people from getting sick. It will be one of the take‑homes from this pandemic probably change the way some of us lead our lives.

Jessica: What is the optimal medical treatment for a patient with COPD and COVID‑19?

Dr Hill: This goes down to optimal therapy for both disease states. If I talk specifically about COPD, the patients have been more adherent to their usual medications. That's great, because one of the big take‑home messages is stick to your usual medicines.

You don't want to stop therapies and potentially get sick. When patients do become ill or before they become ill, smoking cessation is key. Smoking makes COPD worse. There is some evidence suggesting that active smoking makes people more susceptible to COVID‑19. As always, getting your patient to stop smoking is a key to health.

There isn't a change in other management. For COPD exacerbations prior to the pandemic, very frequently we would treat for bacterial infections empirically. In this setting, if somebody has COVID‑19 and COPD, don't treat for bacterial infections unless there's other evidence pointing to co‑infection.

Antibiotics for bacterial infections don't help COVID‑19 and may make patients sick. In terms of the COVID therapies our mainstays when patients get sick enough to be hospitalized are Decadron, which may treat both the COPD exacerbation and treat COVID‑19.

Remdesivir, which is anti‑viral, should still be used in the hospitalized COPD population if they meet other measures that suggest it's going to be effective such as worsening hypoxemia. For patients that are sick with COVID‑19, but not sick enough to be hospitalized, consideration for monoclonal antibody therapy, which is available to prevent severe COVID‑19 infection is something that should be pursued. This depends on the health care center. Some of them have strict restrictions, because there's limited availability of monoclonal antibody therapy and it's expensive. The preliminary data is promising. Certainly, knowing what we know about COPD patients being at higher risk to become severely ill, they would be good candidates to receive that treatment.

Oxygenation should be monitored closely in a COPD patient. In a COPD patient who's not sick enough to be hospitalized, making sure they have access to a pulse oximeter to monitor their oxygen levels at home probably make sense if they have anything more than very mild COVID illness.

Jessica: Are there ways to reduce readmissions for patients with COPD to prevent possible exposure to COVID‑19 in a healthcare setting?

Dr Hill: That's always a challenging question. Medicare has focused on COPD readmissions and focused primarily on readmissions within 30 days of hospital discharge. It's somewhat fascinating that they've done that, because there isn't a lot of medical evidence about what we can do as clinicians to stop patients from getting readmitted.

Jokingly, I'll say there's a few things that are proven to prevent readmission. Death prevents readmission. We don't want to promote that. Not discharging the patient from the hospital prevents readmission. That is half‑jokingly but sometimes in the modern era, we push patients out of the hospital before they're strong enough to function well at home.

Sometimes an extra day of hospitalized care, close attention, physical therapy may keep them from getting readmitted, or getting discharged to inpatient rehabilitation, as opposed to home may prevent a readmission. Smoking cessation again has been shown to stop readmission.

Patients who resume smoking when they're discharged from the hospital are much more likely to get readmitted than those who refrain from smoking after a hospital stay. Most of our patients are forced to quit smoking while they're hospitalized, so they've already gotten past the initial withdrawal phase. Hopefully, that's an opportunity to keep them from smoking again.

I talked about rehabilitation, so the patient is able to walk more. One mile is the magic number, which is a lot of walking. That patient is much less likely to get readmitted. Anytime somebody is hospitalized with a COPD exacerbation, talking to the patient about rehab, whether it's inpatient rehabilitation or post‑discharge, outpatient rehabilitation is important.

One of the important things to mention when we talk about keeping patients safe in the healthcare setting is that the healthcare setting is an incredibly safe environment now. You're very unlikely to get exposed to COVID‑19 if you go to a health care center or a hospital.

We are screening patients when they hit the door. We have adequate amounts of PPE, more isolation rooms than we ever had. If you need acute medical care, the hospital is a safe place. It's probably safer than the grocery store.

Jessica: You mentioned some lessons and some take‑home nuggets. What lessons have you learned about treating patients with COPD throughout the COVID‑19 pandemic?

Dr Hill: One, patients are smart. As I looked at the data that's out there about COPD and COVID. Those numbers I talked about before about the decreased amount of COVID infection in the COPD population is fascinating.

When I see my patients in my practice, the vast majority of my COPD patients have been fully hunkered down and avoiding people to the degree that public health experts are recommending for everyone else. They've proven if you do that, you stay safe and healthy, masks and distancing work.

As I mentioned, I don't envision myself going to work and seeing patients in the hospital or in my office without a mask on. I don't know if I'll ever do that again. I've enjoyed not having a common cold in my household for a year. Keeping my patients from getting sick by wearing a mask myself and keeping myself in my family healthy by wearing a mask just makes sense to me.

In general, as a society, we have learned that we are really bad at preventative care. It's a take‑home. It's something for us to work on through the government, through education. We did not handle the pandemic well. We haven't handled the flu or the common cold well over my entire career.

Every year, we push trying to get people to get flu shots. What we've proven this year is that if people just mask up and distance we can stop the flu. As a society, we focus on short‑term gains over long‑term gains that can be much more cost‑effective, particularly for patients at risk.

Those patients with COPD or having frequent exacerbations or getting hospitalized, wearing masks and distancing may become more of a way of life. It doesn't mean they can't see their family or have meaningful social interactions.

It just may mean they need to limit certain interactions that are high‑risk and weigh the benefits of dining out in a crowded restaurant versus staying out of the hospital and staying alive.

Jessica: What would you say are the biggest take‑home messages for our audience listening to this today?

Dr Hill: Right now in March of 2021, if I don't mention as a take‑home message, get the COVID vaccine when you can and make sure your patients get them, and that all three currently available vaccines are safe and effective, I'm not doing my duty. That's a huge take‑home message for society across the board. These are incredibly safe and incredibly effective vaccines.

They're our key to getting to the other side. Again, COPD is a risk for severe COVID‑19, but patients who do the right things are unlikely to get COVID‑19. Keep taking your usual medications. If you do get sick, get in touch with your doctor so that we can get therapy started appropriately and early.

Jessica: Thank you so much, Dr Hill. Is there anything else that you'd like to add today?

Dr Hill: No. I think we covered it. I'm glad I could participate.

Published in partnership with the American Lung Association in New Jersey