Susan Jacobs, RN, MN has been a busy lady. She prepared a 5 page guide for the California Thoracic Society Pulmonary Nursing Committee called "Living And Caring For Persons With Chronic Lung Disease". And, she also prepared a new brochure called "Choosing Medical Insurance When You Have Chronic Lung Disease" Susan did her usual great job on both of these valuable sources of information. Call 1-800-LUNG-USA or e-mail ctslung@aol.com for further information.
Peter Marshall asked for more information about the upcoming Long Term Oxygen Consensus Conference (LTOT). Past issues of the 2nd Wind , including June-July, have some explanation of the Consensus Conference. But, in a nutshell, one of its major efforts is to save portable oxygen, liquid specifically, which we feel is in great danger. It may not be generally known that in the past there have also been times when the reimbursement of liquid was in danger. Previous Consensus Conferences, led by Dr. Petty, saved liquid oxygen.
This will be an interactive conference with all members being active participants. There are a limited number of representatives from various segments of the community taking part. In this way, a particular industry or company can not dominate the proceedings by inundating it with representatives.
The purpose of the first day will be to present problems, giving specific examples. The second day will be devoted to recommending solutions. These recommendations will be published on the Internet as well as various journals.
Participants at the Conference will include members in manufacturing, oxygen supply companies, the medical community, HCFA, NIH, insurance companies and HMOs. Patients will also be represented by 3 speakers. One will discuss the general problems of being on oxygen, another the problems of being the spouse of an oxygen user, and the third, the problems of travel with oxygen. Five other patients have been invited to actively participate and comment.
Mary Burns will also represent patients in general by presenting problems that have been sent to PERF and the 2nd Wind over the past year. This probably will be done by separating a thick folder of responses into categories, giving specific examples with names, dates and places. Frequency of the problem along with the seriousness of its impact should also play a role.
You still have a little time to submit your problems with obtaining portable oxygen, so that Mary can better represent you.
21st Century Therapies for COPD
Richard Casaburi, Ph.D.,M.D.
President, PERF
- Better Bronchodilators
In the second article of this series, I will discuss potential advances in inhaled bronchodilator therapy. As I said I would, I’m starting with therapeutic advances that are unromantic, but relatively sure, before getting to more exciting, but speculative, topics. Bronchodilators have been available for many years, and only incremental improvements are expected.
Pity the poor pulmonary doctor. Every day he sees a parade of patients suffering from COPD, all looking for help. In his (or her) bag of tricks are only two therapies universally accepted to be of help: bronchodilators and supplemental oxygen. As we will see in next month’s installment, supplemental oxygen is of use in only a minority of COPD patients, so a prescription for a bronchodilator is what the patient is likely to have in his hand when he leaves the doctor’s office.
In a way, this is a strange situation. COPD is supposed to be a disease of irreversible airways obstruction, to contrast it with asthma in which the airways obstruction is reversible. By definition, this means that bronchodilators should not be of much help. However, it is now clear that if a good bronchodilator drug is given for a period of time an appreciable effect is usually seen. In several studies of large numbers of patients with severe COPD, average increases in FEV1 (a measure of the severity of airflow obstruction) on the order of 20% have been seen. In a typical patient, this might represent an improvement from 40% of the normal value to 48% of the normal value — hardly a startling increase. Yet this increase can often be the difference between being severely short of breath and being only mildly short of breath while performing an activity.
Inhaled bronchodilators have been around for about 35 years. The earlier ones were effective, but had troublesome side effects (often producing heart rate increases and a feeling of nervousness). The only over-the-counter inhaled bronchodilator currently available is of this class. Later versions have virtually no side effects in most people — currently the most popular of these is albuterol (also called Proventil or Ventolin). The original drugs were all of one class, called beta agonists. More recently, a second class of drugs, called anticholinergics, has been introduced. The anticholinergic drug, atropine, has been around for hundreds of years. But atropine causes severe side effects, including dry mouth. Introduction of ipratropium (or Atrovent) about 15 years ago was welcomed since it produced no side effects in most patients (and mild dry mouth in a minority). More recently, a combination inhaler that delivers both albuterol and ipratropium has been introduced that has been shown to be somewhat more effective than either drug alone.
I would guess (but might be wrong) that dramatically more effective bronchodilators are not likely to be introduced soon. Progress is more likely in two other areas, however. The first improvement is in duration of action. The first generation of bronchodilators had to be taken every couple of hours. Current drugs like albuterol and atrovent need to be taken every 4-6 hours. A few years ago, a long acting beta agonist was introduced. Salmeterol (or Serevent) only needs to be taken every 12 hours and relieves symptoms and improves exercise tolerance for at least that long. On the launching pad is an anticholinergic drug, called tiotropium (or Spiriva), that appears to be effective when taken every 24 hours. I participated in a research trial of this drug. In a trial that lasted one year, COPD patients took the drug every morning. A clear sign of the 24 hour duration of action was that the FEV1 measured just before the morning dose remained high, a result of the dose taken the previous morning. Such drugs seem sure to be more convenient for patients to use.
The other improvement is likely to occur in the area of delivery systems for inhaled bronchodilators. Pressurized inhalers utilizing fluorocarbon propellants will not be with us for very much longer. Fluorocarbons have been declared harmful to the ozone layer and are slated to be phased out over the next few years. New technologies are being perfected to take the place of the metered-dose inhaler. One approach being studied is to inhale a dry powder containing the drug. Another is to manually pressurize the drug before each inhalation and to use an array of nozzles to generate a fine mist. It seems possible that these new devices may make one of the problems with metered-dose inhalers a thing of the past. Initiating the inhalation at precisely the right time after the dose has been released is necessary to get the drug delivered to the airways. This requires a degree of coordination many find difficult to achieve. Because most of the new devices are breath actuated, timing the inhalation may not be necessary. You may be able to throw your spacer away!
As I said, these are small but worthwhile advances. Future installments will cover the more radical departures in treatment. Till next month.. :) :) :) Stay well!