COPD: Providing the right treatment for the right patient at the right time.

Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Receipt of Tobacco Treatment and One-Year Smoking Cessation Rates Following Lung Cancer Screening in the Veterans Health Administration.

BACKGROUND: Implementation of effective smoking cessation interventions in lung cancer screening has been identified as a high-priority research gap, but knowledge of current practices to guide process improvement is limited due to the slow uptake of screening and dearth of data to assess cessation-related practices and outcomes under real-world conditions. OBJECTIVE: To evaluate cessation treatment receipt and 1-year post-screening cessation outcomes within the largest integrated healthcare system in the USA-the Veterans Health Administration (VHA). Design Observational study using administrative data from electronic medical records (EMR). Patients Currently smoking Veterans who received a first lung cancer screening test using low-dose CT (LDCT) between January 2014 and June 2018. Main Outcomes Tobacco treatment received within the window of 30 days before and 30 days after LDCT; 1-year quit rates based on EMR Smoking Health Factors data 6-18 months after LDCT. Key Results Of the 47,609 current smokers screened (95.3% male), 8702 (18.3%) received pharmacotherapy and/or behavioral treatment for smoking cessation; 531 (1.1%) received both. Of those receiving pharmacotherapy, only one in four received one of the most effective medications: varenicline (12.1%) or combination nicotine replacement therapy (14.3%). Overall, 5400 Veterans quit smoking-a rate of 11.3% (missing=smoking) or 13.5% (complete case analysis). Treatment receipt and cessation were associated with numerous sociodemographic, clinical, and screening-related factors. CONCLUSIONS: One-year quit rates for Veterans receiving lung cancer screening in VHA are similar to those reported in LDCT clinical trials and cohort studies (i.e., 10-17%). Only 1% of Veterans received the recommended combination of pharmacotherapy and counseling, and the most effective pharmacotherapies were not the most commonly received ones. The value of screening within VHA could be improved by addressing these treatment gaps, as well as the observed disparities in treatment receipt or cessation by race, rurality, and psychiatric conditions.

The Role of Telemedicine in Extending and Enhancing Medical Management of the Patient with Chronic Obstructive Pulmonary Disease.

Medical management of a chronic obstructive pulmonary disease (COPD) patient must incorporate a broadened and holistic approach to achieve optimal outcomes. This is best achieved with integrated care, which is based on the chronic care model of disease management, proactively addressing the patient's unique medical, social, psychological, and cognitive needs along the trajectory of the disease. While conceptually appealing, integrated care requires not only a different approach to disease management, but considerably more health care resources. One potential way to reduce this burden of care is telemedicine: technology that allows for the bidirectional transfer of important clinical information between the patient and health care providers across distances. This not only makes medical services more accessible; it may also enhance the efficiency of delivery and quality of care. Telemedicine includes distinct, often overlapping interventions, including telecommunication (enhancing lines of communication), telemonitoring (symptom reporting or the transfer of physiological data to health care providers), physical activity monitoring and feedback to the patient and provider, remote decision support systems (identifying "red flags," such as the onset of an exacerbation), tele-consultation (directing assessment and care from a distance), tele-education (through web-based educational or self-management platforms), tele-coaching, and tele-rehabilitation (providing educational material, exercise training, or even total pulmonary rehabilitation at a distance when standard, center-based rehabilitation is not feasible). While the above components of telemedicine are conceptually appealing, many have had inconsistent results in scientific trials. Interventions with more consistently favorable results include those potentially modifying physical activity, non-invasive ventilator management, and tele-rehabilitation. More inconsistent results in other telemedicine interventions do not necessarily mean they are ineffective; rather, more data on refining the techniques may be necessary. Until more outcome data are available clinicians should resist being caught up in novel technologies simply because they are new.

Dual LABA/LAMA Therapy versus LABA or LAMA Monotherapy for Chronic Obstructive Pulmonary Disease. A Systematic Review and Meta-analysis in Support of the American Thoracic Society Clinical Practice Guideline.

Rationale: There is uncertainty on the optimal first-line therapy for symptomatic chronic obstructive pulmonary disease (COPD). Long-acting ß2-receptor agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) have long been mainstays of treatment, though it is still not clear if dual therapy with LABA/LAMA is superior to monotherapy for symptomatic COPD.Objectives: To clarify the evidence landscape, we conducted a systematic review to answer the following question: in patients with COPD who complain of dyspnea and/or exercise intolerance, is LABA/LAMA combination therapy more effective and equally safe compared with LABA or LAMA monotherapy?Methods: A search of Medline, EMBASE, and the Cochrane Library databases was conducted by a medical librarian for randomized controlled trials enrolling patients with COPD who complain of dyspnea and/or exercise intolerance that compare LABA/LAMA combination therapy to LABA or LAMA monotherapy. A systematic approach was used to screen, abstract, and critically appraise the emerging study evidence. The Grading of Recommendations Assessment, Development, and Evaluation method was applied to rate the certainty and quality of the evidence.Results: A total of 24 studies were eligible for inclusion (n = 45,441). Pairwise random-effects meta-analysis revealed reductions in hospital admissions (11% reduction; P < 0.01) and acute exacerbations of COPD (20% reduction; P < 0.002), all in favor of LABA/LAMA dual therapy. Although there is reduced dyspnea (0.10 standardized mean difference; P < 0.001) and improved health-related quality of life (-0.13 standardized mean difference; P < 0.001), both values did not meet a clinical meaningful difference threshold. LABA/LAMA combination therapy showed no difference in treatment-emergent adverse effects (risk ratio, 0.99; P = 0.34) when compared with either LAMA or LABA monotherapy.Conclusions: Based on the reviewed evidence, in patients with symptomatic COPD who complain of dyspnea and/or exercise intolerance, dual LABA/LAMA therapy is superior to either LABA or LAMA monotherapy based on the reduced risk of exacerbations and hospitalizations.

Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017.

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Integrated Care in Chronic Obstructive Pulmonary Disease and Rehabilitation.

Individuals with advanced chronic obstructive pulmonary disease (COPD) often have complex medical problems that require more than simple pharmacological therapy to optimize outcomes. Comprehensive care is necessary to meet the substantial burdens, not just from the primary respiratory disease process itself, but also those imposed by its systemic manifestations and comorbidities. These problems are intensified in the peri-exacerbation period, especially for newly discharged patients. Pulmonary rehabilitation, with its interdisciplinary, patient-centered and holistic approach to management, and integrated care, adding coordination or transition of care to the chronic care model, are useful approaches to meeting these complex issues.

There's no place like home: Integrating pulmonary rehabilitation into the home setting.

Traditional, outpatient pulmonary rehabilitation provided to stable COPD patients leads to significant improvements in dyspnea, exercise capacity and health related quality of life.  Also, when started during or shortly after a hospitalization for a COPD exacerbation, pulmonary rehabilitation improves these patient-centered outcomes and arguably reduces subsequent health care utilization and mortality.  Despite these benefits, the uptake of traditional pulmonary rehabilitation remains disappointingly poor.  Home-based pulmonary rehabilitation, a safe and effective alternative to traditional, center-based programs, can broaden access. While proven improvements in dyspnea, exercise capacity and health status justify implementation of home-based pulmonary rehabilitation, it would be helpful to know whether it can also decrease health care utilization and be cost-effective.

Self-management in chronic obstructive pulmonary disease. Time for a paradigm shift?

Self-management in chronic obstructive pulmonary disease, centering on an action plan for the exacerbation and enhanced communication between the patient and health care providers, makes good clinical sense. However, five relatively large trials of self-management in chronic obstructive pulmonary disease have had inconsistent results: only two demonstrated reductions in health care utilization and one had to be discontinued prematurely because of increased mortality. Do these discordant findings require a paradigm shift in our concept of self-management? Probably not-but an analysis of the negative studies can give us valuable insights. There are data to support the idea that patients in the trial that showed increased mortality did not self-manage appropriately. Only 4.5% of these patients called in before starting treatment for their exacerbation, the time to initiation of antibiotics or steroids was unsatisfactorily long, and the intervention arm used minimally more prednisone and antibiotics than the control arm. The reasons for a higher mortality will likely never be known, but it is possible that these high-risk patients may have needed earlier assessment by a trained professional, or that self-management led to overconfidence and treatment delays. We clearly need more effective ways to implement self-management and better define which groups of patients stand to benefit (or be harmed) by this intervention. This will require an investment in well-thought-out clinical trials.

An official American Thoracic Society workshop report: the Integrated Care of The COPD Patient.

The optimal care of the patient with chronic obstructive pulmonary disease (COPD) requires an individualized, patient-centered approach that recognizes and treats all aspects of the disease, addresses the systemic effects and comorbidities, and integrates medical care among healthcare professionals and across healthcare sectors. In many ways the integration of medical care for COPD is still in its infancy, and its implementation will undoubtedly represent a paradigm shift in our thinking. This article summarizes the proceedings of a workshop, The Integrated Care of the COPD Patient, which was funded by the American Thoracic Society. This workshop included participants who were chosen because of their expertise in the area as well as their firsthand experience with disease management models. Our summary describes the concepts of integrated care and chronic disease management, details specific components of disease management as they may apply to the patient with COPD, and provides several innovative examples of COPD disease management programs originating from different healthcare systems. It became clear from the discussions and review of the literature that more high-quality research in this area is vital. It is our hope that the information presented here provides a "call to arms" in this regard.

Pulmonary rehabilitation: WHAT WE KNOW AND WHAT WE NEED TO KNOW.

The multidisciplinary treatment of pulmonary rehabilitation (PR), which includes exercise training, self-management education, and psychosocial and nutritional intervention, is now a standard of care for chronic obstructive pulmonary disease (COPD) and has been incorporated into major guidelines. We must now focus efforts on improving its impact and widening its applicability. What is the direction of PR; where does it fit in the comprehensive care of the COPD patient; and how can clinicians best apply this important intervention? This was the charge of the roundtable discussion, Pulmonary Rehabilitation: Moving Forward, involving 20 experts from North America and Europe, which was convened in Fort Lauderdale, Florida, in early 2008. It is not meant to be an exhaustive review; rather, this report summarizes the roundtable proceedings, while providing direction to best position PR into the continuum of COPD care. By consensus, it was agreed upon that although PR is effective for other chronic respiratory diseases, the discussion focus was COPD since most of the evidence base and patient referral are for this disease. These proceedings provide insight into 3 broad areas appropriate for investigation or implementation: positioning PR in an integrated care model for COPD patients; improving the effectiveness of this intervention; and expanding the recognition, application, and accessibility to PR. It is the hope that this document will provide a catalyst for clinicians, investigators, and healthcare policy makers to help realize these goals as well as serve to suggest important areas for future research and development in PR.

Pulmonary rehabilitation for COPD.

Pulmonary rehabilitation is a therapeutic process, which entails taking a holistic approach to the welfare of the patient with chronic respiratory illness--most commonly chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation is considered essential throughout the lifetime management of patients with symptomatic chronic respiratory disease. It requires the coordinated action of a multidisciplinary healthcare team in order to deliver an individualised rehabilitation programme to best effect--incorporating multiple modalities, such as advice on smoking cessation, exercise training and patient self-management education, among others. As core components of pulmonary rehabilitation, exercise training and self-management education have been shown to be beneficial in improving health-related quality of life (HRQoL) in patients with chronic respiratory disease. Physical training can help to reduce the muscle de-conditioning that occurs when the activity of patients is restricted by their breathlessness and fatigue, and is often associated with an increase in patient HRQoL. HRQoL can also be improved by the use of self-management education, which is designed to provide the patient with the skills to manage the health consequences of their disease. In doing so, patients are better able to cope with disease symptoms, potentially leading to reduced healthcare costs. A great deal of research has been conducted to try and fully define which patients will benefit most from pulmonary rehabilitation. Although progress has been made, many questions remain as to the best means of delivering rehabilitation, particularly with respect to the optimum programme of physical training and patient self-management education.