This post was written by Michael W. Hess, MPH, RRT, RPFT

When I was joining the COPD Foundation in 2020, my boss offered me a mission. It was a bit different role than the one I had applied for, but it seemed like an interesting challenge.

"How would you like to help fix supplemental oxygen?"

Now, I've never been a durable medical equipment (DME) person. I was coming from a position in primary care where I WORKED with a lot of DMEs, facilitating prescriptions and coordinating care. I had a vague understanding of how much the industry had struggled over the last decade, with payment cuts related to the Medicare competitive bidding process. I knew many people had been having a harder and harder time accessing equipment that fit their lifestyle and health goals. I knew that a lot of my respiratory therapist colleagues had been forced to move on because of budget cuts and consolidation. I figured getting to the root causes of the issues and developing strategies to overcome them would be an interesting challenge.

I call that time "the good old days," because I was caught completely off guard by the sheer magnitude of that challenge.

It turns out that here in the United States, we've actually been slowly chipping away at our ambulatory oxygen therapy infrastructure for decades. Some types of equipment, like liquid oxygen, have become essentially extinct because they're too expensive to provide. That, in turn, means that while we clinicians keep telling people that one of the keys to improving quality of life with chronic breathing problems is staying active, the system cannot provide them with the means to do so. Frustration abounds on both sides of the stethoscope, not to mention with the suppliers whose hands are tied.

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This post was written by: Jonnie Korinko, MSRC, RRT, RRT-ACCS.

Three pharmaceutical companies have agreed to cap out-of-pocket costs to $35 in the U.S. The trend began on Thursday, March 7, 2024, when Boehringer Ingelheim, a pharmaceutical company that makes inhalers used for COPD and asthma, announced that it would begin limiting out-of-pocket costs for its inhalers for eligible patients to $35/month. This program will start on June 1, 2024, at retail pharmacies.¹ Click here for the full statement and a list of included inhalers. Patients using these inhalers from Boehringer Ingelheim who do not qualify for the $35/month inhaler cap, including those whose pharmacies do not participate and those without insurance, can visit www.InhalerOffer.com to sign up for a savings card. This card can be presented at pharmacies to receive the same discount.

On Monday, March 18, 2024, AstraZeneca followed suit, issuing a similar statement, with GlaxoSmithKline (GSK) issuing their statement on Wednesday, March 20, 2024. All three pharmaceutical companies are limiting out-of-pocket costs for their inhaler medications to $35. Click here for AstraZeneca's statement and list of included inhalers and here for GSK's statement and list of inhalers.

Because of government restrictions, people who use federal government insurance programs, like Medicare, may not get help with co-payments. However, the company will offer free products and assistance programs for people who need them. Insurance companies and pharmacy benefit managers (PBMs) will get discounts on inhalers.¹

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This post was written by: Amanda Atkinson, MSN, RN.

Have you ever pondered the fact that health is a fundamental human right? According to the World Health Organization's 1946 constitution, it is.¹ As practitioners we are uniquely positioned to help those around us fully exercise that right. The question that we must ask ourselves is, are we acting as a door or a barrier to that right? If we are not actively practicing cultural humility, we may be unknowingly hindering those around us from fully accessing quality healthcare.

You may be wondering: "what is cultural humility?" Cultural humility is not a quick answer, but rather a lifelong process. It involves self-reflection and the recognition that our lived experience and backgrounds impact how we learn, engage, connect, communicate, lead, and follow. Cultural humility allows us to recognize that we do not know everything about ourselves, others, or a culture, but are willing to learn from patients, peers, family, and those around us.² It mandates us to treat everyone as an individual and be receptive to learning about their diverse backgrounds and lived experiences. In a health care setting this practice helps informs care in all areas and allows us to truly keep the patient at the center of all we do.

Like many of you, in both my professional and personal life I have the privilege of connecting with many people of different ages, ethnicities, walks of life, faiths, and belief systems. One of the main things that I see as a universal theme across all of them is the desire for connection and authenticity. People want to be valued, seen, safe, empowered, and respected for who they are and what they bring to the table. When we feel these things, we are more likely to actively participate in relationships. In a health care setting, this translates to actions such as utilizing available resources, increased adherence to treatment regimens, and exploring new options for care.

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This post was written by: Michael W. Hess, MPH, RRT, RPFT.

In many ways, the current pharmacological landscape represents a Dickensian combination of the best of times and worst of times. We have never had as many options for inhaled medications to help manage COPD symptoms as we do now. We have more on the horizon, along with other therapeutics that promise to supplement our traditional bronchodilators and anti-inflammatories. Unfortunately, there is a downside to having such a vast array of options. The "paradox of choice" theory suggests that the more choices one has, the more difficult it is the select one with confidence. Couple that with often-confusing (and sometimes conflicting) clinical guidance and an ever-evolving evidence base and it is easy to become overwhelmed.

Fortunately, there are some strategies to guide your clinical decision-making. Keeping your patient's condition, abilities, and goals at the center of the process is essential and will allow you to then tailor a plan to address other concerns.

Where are they on their COPD journey?

According to the latest GOLD recommendations, virtually everyone new to COPD should start with, at minimum, dual bronchodilator therapy. COPD pathophysiology is often a mix of inflammation, mucus hypersecretion, alveolar damage, and bronchial hyperresponsiveness, and the degree to which each contributes to symptom burden can vary widely from person to person. However, the evidence points to the team of long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) medications providing some degree of benefit to a significant percentage of the population. That makes them great candidates for initial therapy. Sometimes, they're even available in the same inhaler, making things even easier for a patient getting used to a new medication regimen.

In some cases, it may also be appropriate to bring in an inhaled corticosteroid (ICS), the third common therapeutic class of COPD meds. If your patient can identify two or more symptom flare-ups in the last year, or just one that landed them in the hospital (where many with COPD first get diagnosed), take a look at their latest blood work. Eosinophil counts of over 300 cells/microliter are suggestive of the kind of inflammation that can respond to ICS therapy. There are even a few inhalers that provide this “triple therapy” all in one dose, again making it relatively easy to get started.

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This post was written by Michael W. Hess, MPH, RRT, RPFT

This may come as a surprise to many, but when I first started as a respiratory therapist, I didn't really think about COPD very much. Sure, I saw the "frequent flyers" coming in through the ER for their tune-ups, and I would dutifully show up every four hours out on the floors with my trusty albuterol and ipratropium. Being a child of the 80s, I usually used its brand name so I could them "the A-Team." I even took care of the really rough cases up in the ICU, where debates about matching intrinsic PEEP and other ventilation strategies seemed to be the most interesting aspect of treating this condition. This attitude was no outlier either; COPD was not on very many people's radars at all. The very first Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report was a mere five years old; the COPD Foundation itself was even younger. We had no endobronchial valves, far fewer pharmaceuticals, relatively little noninvasive ventilation in the home. Limited options led to therapeutic nihilism which led to viewing COPD as just not a priority. In other words, there's nothing we can really do, so why spend much time thinking about it?

Obviously, my views have changed over the last couple of decades. Fortunately, the prevailing views of health care have largely changed along with me. These days, we know there is a great deal we can do for members of the COPD community to help them live healthier, more active lives. We are seeing the growth of "care navigator" roles that focus specifically on getting people through the complexities of managing therapy plans. We here at the Foundation are celebrating our twentieth anniversary in 2024 and as a part of that, we are proud to have launched a new educational resource highlighting the new horizons of the COPD world.

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This post was written by Michael W. Hess, MPH, RRT, RPFT

“Is it a bad day? Or is it an exacerbation?”

That question may not have the same ring as a Shakespearean soliloquy, but it is certainly closer to the front of most clinician’s minds when dealing with COPD. It has also largely been a question with no very definitive answers. Treatment recommendations have long held that early intervention in exacerbations is the key to minimizing further tissue injury (not to mention a hospital admission). At the same time, those recommendations also tell us that symptoms can vary widely from person to person and from day to day. How can clinicians tell the difference between an early intervention and an unnecessary one?

The answer may finally be on the horizon. Along with the other major paradigm shifts in the COPD world, 2023 brought the beginnings of a new framework to define and manage exacerbations. Known as the “Rome Proposal,” this new algorithm was technically published in late 2021 but really began to take hold after inclusion in the 2022 GOLD Report.

WHEN (NOT) IN ROME

The Rome Proposal is the product of a year of discussions, literature reviews, and analysis from some of the world’s leading COPD minds.1 They were originally intended to meet in Rome, Italy in January 2020, but that meeting was one of the earliest cancellations of the COVID pandemic. The group’s primary goal was to standardize the definition and evaluation of COPD exacerbations using objective measures. Previous attempts to grade the severity of an exacerbation were based almost exclusively on subjective measures like a person’s perception of their symptom burden. Symptoms are also not always tied to the physiological mechanisms at play during an exacerbation, potentially leading clinicians down incorrect pathways and possibly preventing them from detecting more serious issues during the course of treatment.

The result was a consensus document proposing a new “conceptual model” of a COPD exacerbation, a consensus definition, and a proposed severity classification scale. It is important to note that the algorithm does NOT make specific recommendations based on severity (unlike other aspects of the GOLD strategy). Instead, it is up to clinicians themselves to initiate the best therapies available to treat the underlying cause of the exacerbation (and hopefully relieve symptoms at the same time).

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This post was written by Kristen Szymonik, BS, RRT, AE-C.

When we think of pulmonary rehabilitation, we usually think of a clinic-based, in-person program. But the COVID-19 pandemic has changed the landscape of medicine and has paved the way for comprehensive virtual medical programs. These include telehealth visits, online support groups, and even virtual pulmonary rehab.

In the past few years, traditional pulmonary rehab programs across the United States have been forced to reduce their capacity or consolidate locations. Some have permanently closed their doors. These changes in service negatively impact patients, particularly those in rural areas. Patients who once showed progress in their COPD management with the help of in-person pulmonary rehab were suddenly left without those services. Many lost the progress they had made and found themselves with worsening symptoms and reduced quality of life.

While COVID-19 may have increased the need for virtual pulmonary rehab, the interest in these programs has always been present. Virtual pulmonary rehab has been a helpful resource for patients who either didn’t have access to a pulmonary rehab program in their community or were unable to travel to a local in-person program due to severe COPD symptoms or transportation and logistical factors. One study showed that just under 3% of eligible patients actually accessed a pulmonary rehab program within a year of their discharge from the hospital.¹ In this study, distance was a major indicator of program utilization.¹ Virtual pulmonary rehab addresses these barriers to participation, offering patients an important service that is not dependent upon transportation to a clinic or similar facility.

Pulmonary rehab is one of the most effective treatments for managing COPD symptoms. While many patients benefit from the camaraderie and interaction with other patients that in-person pulmonary rehab provides, they can still participate in and benefit from the other components of pulmonary rehab that are still present in a virtual program. In fact, recent studies indicate that virtual pulmonary rehab is not inferior to in-person programs.² Instead, it was determined to be a safe and beneficial alternative to traditional pulmonary rehab programs.²The benefits of pulmonary rehab can extend for several months beyond the completion of a program. These improvements in symptoms, stamina, and overall health can be long-lasting.

Unfortunately, despite the value pulmonary rehab brings to the COPD community and the demonstrated benefit of virtual pulmonary rehab, these programs are threatened with the potential loss of Medicare coverage on May 11, 2023. On this date, the federal extension of Medicare coverage for pulmonary rehab is set to expire, potentially leaving many patients without this vital service.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

Inhaled medications have been with us for a very long time; longer, perhaps, than we usually recognize. The first known description of a medicinal inhaler device (outside of pipes and such used for smoking and similar activities) was actually created in 1654 by an English physician by the name of Christopher Bennet.​¹​ Just over three hundred years later, an American scientist named George Maison invented a dose-metering valve at the behest of his daughter, who sought a more convenient way to take her asthma medication. That invention, and the subsequent development of the metered-dose inhaler (MDI), set the stage for decades of convenient, portable, and effective inhaled therapy for a variety of respiratory conditions.^​2​

At least, it was supposed to.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

Much has been written about the new GOLD Strategy Report since it launched this past November. Considered one of the most significant revisions to the GOLD strategy in years, this latest iteration has many in the field rethinking how we look at the very definition of COPD. But the report also contains some major changes to initial therapy recommendations, not to mention refinements of ongoing therapeutic pathways. These changes have the potential to affect your clinical decision-making as your patients travel on their COPD journey, so it is important to not allow them to get overlooked.

A NEW GOLD BOX

Perhaps the most notable change is another revision to the “GOLD Box.” First seen over a decade ago, the Box was created to make more practical initial therapy recommendations based on exacerbation risk and symptom burden, rather than simply airflow obstruction. It has traditionally grouped people with COPD into four groups based on that risk and that burden, with suggested therapies based on the best evidence for their subcategory. However, newer evidence compiled in this year’s report suggests that for those people who have at least two exacerbations over the course of 12 months (or one that lands them in the hospital), symptom burden is far less clinically significant in terms of clinical relevance. Thus, the previous two high exacerbation risk groups (C and D) have been combined into a single group, E.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

It is once again that magical time of year when everyone gets ready to engage in healthier lifestyles in the new year.  We’ve all heard (and likely made) the resolutions, then felt guilty after a week or two when, despite our best efforts, we came up a bit short. As health care professionals, one of the more common goals we can help the people in our care with is quitting smoking. Of course, it is also one of the trickiest goals to accomplish, for a variety of reasons. However, by resolving to look at tobacco treatment a little differently this new year, we may be able to improve the odds of success.

NOT JUST A HABIT

Historically, as HCPs, we have looked at tobacco smoking as simply a “bad thing” that our patients should stop doing. Even today, many of our strategies focus on establishing distinct quit dates and similar ideas which make it seem like making a major lifestyle change is the equivalent of flipping a light switch. However, experts from places like the Mayo Clinic reinforce that only around five percent of those who attempt a cold turkey quit are successful for more than six months.¹ The Centers for Disease Control and Prevention put the annual success rate of quit attempts of any kind at a dismal 10%.² Clearly, the cold turkey method needs some reassessment.

I would argue that one of the biggest barriers here is the separation of the behavior from the person. People smoke for many reasons, with nicotine dependence surprisingly often being a lesser one. For example, in the mid-1990s, tobacco companies employed a strategy known as Project SCUM (SubCulture Urban Marketing) to specifically target certain demographics, including sexual minority groups and the unhoused, to create new customers. Project SCUM preyed upon the isolation of many LGTBQ+ community members who wanted to become part of a larger community and establish new connections. In an interview with News Center Maine, anti-smoking advocate Shane Diamond (who describes themselves as queer and trans) stated, “They used our daily experiences of homophobia and transphobia and otherness, and they built us a community and culture that drew us in.” Project SCUM continued the legacy of decades of targeted marketing toward minority groups, with the

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This post was written by Michael W. Hess, MPH, RRT, RPFT with guest authors David Reynolds, RRT, EMT and Jean Rommes, PhD.

It is well-established that people new to long-term oxygen therapy face many barriers when first learning to use their equipment safely and effectively. Oxygen therapy outside the hospital is far different than using the seemingly endless flow at the bedside. A study published in 2018 found that 35% of new therapy users felt at least somewhat unprepared to operate their oxygen equipment. What is less commonly discussed is that health care professionals are also faced with confusion and misinformation that prevents them from helping their patients adapt. I enlisted two experts in the space to answer some of the most commonly asked questions we see about oxygen therapy. Dave Reynolds, RRT, is a respiratory therapist with over two decades of experience as a durable medical equipment (DME) supplier. Jean Rommes, Ph.D., is a longtime oxygen therapy user and COPD advocate. Together, we hope to help you learn more about optimal care for those who need supplemental oxygen outside the hospital.

TESTING THE RIGHT WAY

When a patient presents with potential hypoxemia, many HCPs know they need to test oxygen levels with a pulse oximeter at rest and during activity. Many describe this as a “six-minute walk test,” but that is something of a misunderstanding. The validated six-minute walk test measures exercise capacity in terms of distance over time. A good oxygen titration has no time limit and looks at saturation. In addition, people should be tested at different levels of activity. According to Jean, it is critical that the person doing the test replicates “the kinds of things you’ll do at home and in your daily routine,” including things like climbing stairs. Only then can a true picture of one’s oxygen demands be seen. Dave also reminds us that tests can also use arterial blood gas (ABG) results, which can be helpful for those prescribing oxygen after an inpatient admission. Either way, remember that the testing cannot be done by the DME supplier, only an HCP or independent testing center.

WORKING WITH YOUR LOCAL SUPPLIERS

It is critical to develop relationships with the DME companies in your area. Not only will they determine what equipment is accessible to your patients, but company policies can also affect how much they will pay. Dave says that many suppliers are approved by the Medicare program, but do not accept “assignment.” That means they are not obligated to accept Medicare reimbursement as payment in full and can charge up to 15%. Medicare will still only pay 80% of their approved fee, meaning your patient will be left responsible for the difference (plus the 20% copay). There are also some suppliers that do not participate with Medicare at all; in these cases, patients will have to sign a contract with payment details.

It is also important to remember that many DME companies have been under significant financial strain for many years. Changes in Medicare reimbursement policies have made it much more difficult to provide service at the same level as in previous decades. DME is a business like any other and the financial realities many suppliers face have many impacts, from reducing the kinds of equipment that may be available to the amount of training and education that can be provided. Patients therefore may need to rely heavily upon you (or resources like the COPD Foundation’s Oxygen Therapy Basics publication or the COPDF/American Thoracic Society collaboration website YouAndOxygenTherapy.com) when they have questions.

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This article was written by Michael W. Hess, MPH, RRT, RPFT

For more than two decades, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Strategy Report has been one of the key resources in the COPD world. The annual report reviews the major research publications from the previous twelve months and provides recommendations for the diagnosis, management, and prevention of COPD. Periodically, the GOLD report undergoes a “major” revision, where significant changes in how we treat this condition are advised.

The 2023 report is an example of such an update. The past few years have seen the results of major longitudinal studies enter the conversation that have the potential to permanently change how we view COPD. I spoke with Dr. Antonio Anzueto, a member of both the GOLD Science Committee and the COPD Foundation Medical and Scientific Advisory Committee, about what he thought some of the most significant changes in the new document were and how those changes could impact COPD care.

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This article was written by Michael W. Hess, MPH, RRT, RPFT

As clinicians, we are often called upon to make recommendations. We have access to peer-reviewed research, so we typically have an idea of the most appropriate therapy for a given situation. Wheezing? That calls for some bronchodilators. Hypercapnea? We may consider noninvasive ventilation. We tend to be confident that we know the best thing to do in most cases.

Despite our best efforts, sometimes there is a mismatch between what is in the textbook and what our patient truly needs. In our enthusiasm to provide optimal care, it can be easy to miss that those two things are not always the same. Unfortunately, when we lose sight of that, we can take our patients down a path where expectations do not match reality. That, in turn, leads to frustration and a lack of trust, which can have a devastating effect on therapy adherence and outcomes. That is why collaboration and the process of shared decision-making in goal setting and planning is essential to care.

A Little More Conversation

So, what is shared decision-making? It's clear, open communication between the clinician and the patient that facilitates the development of a therapy plan that balances the patient's needs and values against potential risks and outcomes.¹ Historically, many (if not most) clinical decisions were left to the people carrying the stethoscopes, and patients would dutifully carry out their instructions (or not). Studies have indicated that this model often led to decisions being made not by evidence but by the preferences of the ordering clinician, leading to massive inconsistencies in care.² This, combined with the patient perceiving that he or she has no say in a treatment plan, can have a significant negative impact on the likelihood of adherence to that plan. However, when medical decisions are made collaboratively, people are often more likely to accept and stick with their prescriptions and therapies.³

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This post was written by Christina Hunt, BS, RRT-NPS.

I consider myself an optimist. I try to think about the “best case scenario” in almost every situation that I encounter. In the medical world, we often talk about outcomes. We consider possible outcomes when we are deciding on treatment plans or starting any new course of therapy. As medical professionals, we are prepared to make decisions wherever the road might lead. Whether the outcome is good or poor, we have a plan. But I have a question for you… are your patients prepared?

Discussions centered around advanced directives should not only be directed at the chronically ill or elderly. The Covid-19 pandemic was eye-opening. We saw increased fatalities from the coronavirus, and often those individuals were not prepared with advance directives. Families were forced to make end-of-life decisions (often over the phone). We know as a society, that many of us leave instructions or wishes after our deaths. However, do your patients have instructions for their health care teams, families, and loved ones for the act of dying?

Here are some thoughts on how to have a courageous conversation with your patients about advance directives.

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This post was written by Michael W. Hess, MPH, RRT, RPFT.

Early on in my primary care days, I had a patient come in for a one-month follow-up visit after starting a new medication. I asked them, "Are you taking your inhaler 2 puffs every day?" They nodded quickly and replied, "Oh, yes. Every day." I then handed them a demo version of the device and asked them to show me their technique. They turned the inhaler around in their hands once, twice, three times. They were unable to perform the task.

I am sure many of you have been in that position, where someone tells you something about their regimen that may not be accurate. Many of our discussions about assessment and adherence include discussing the use of objective measures or testing to overcome barriers. However, a better question might be, "Why does this happen?" Understanding the reasons for inaccuracy can help clinicians create environments where people feel empowered to overcome barriers to adherence, whether they are related to a lack of confidence, a lack of understanding, or another combination of factors.

Building Trust

Many of our modern chronic conditions can be closely tied to lifestyle-related factors like diet, exercise level, and, of course, tobacco exposure. That means many of the people living with these conditions have repeatedly heard things like, "Why don't you just quit smoking?" "Why don't you just eat less?" One I have heard myself is, "Can't you just go for a walk?" Of course, it is not that easy to "just" start doing those things regularly, so people are often made to feel guilty at every appointment for their lack of success. In these situations, to avoid that cycle of guilt, some people decide to just say, "yes, I'm doing that," and get that box checked off.

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