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.

Improving COPD Care in a Medically Underserved Primary Care Clinic: A Qualitative Study of Patient Perspectives.

We conducted a focus group study in an urban hospital-based primary care teaching clinic serving an indigent and Hispanic (predominantly Puerto Rican) population in New England in order to learn how patients with Chronic Obstructive Lung Disease (COPD) perceive their disease, how they experience their medical care, and the barriers they face managing their disease and following medical recommendations. The research team included medical doctors, nurses, a medical anthropologist, a clinical pharmacist, a hospital interpreter, and a systems analyst. Four focus groups were conducted in Spanish and English in April and May 2014. The demographic characteristics of the 25 focus group participants closely reflected the demographics of the total COPD clinic patients. The participants were predominantly female (72%) and Hispanic (72%) and had a median age of 63. The major themes expressed in the focus groups included: problems living with COPD; coping with complexities of comorbid illnesses; challenges of quitting smoking and maintaining cessation; dealing with second-hand smoke; beliefs and myths about quitting smoking; difficulty paying for and obtaining medications; positive experiences obtaining and managing medications; difficulties in using sleep machines at home; expressions of disappointment with the departure of their doctors; and overall satisfaction with the clinic health care providers. The study led to the creation of an action plan that addresses the concerns expressed by the focus study participants. The action plan is spearheaded by a designated bilingual and bicultural nurse and is now in operation.

Improving exercise tolerance and quality of life in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of mortality in the United States. Its symptoms, comorbidities, and sequelae also result in high morbidity and healthcare costs. The impact of progressive dyspnea, fatigue, exercise intolerance, and recurrent exacerbations in patients with COPD can be devastating to their quality of life. Un-addressed, these symptoms often result in depression and social isolation, causing further decline in exercise tolerance and functional performance. Assessing the physiologic, pharmacologic, and psychosocial factors that influence these elements can be challenging in the primary care setting. The present article describes a practical approach to assess functional performance and outlines pharmacologic and nonpharmacologic strategies-particularly self-management education and pulmonary rehabilitation-to improve quality of life indicators.

Targeting the COPD exacerbation.

Exacerbations of COPD have a profound detrimental effect on the patient and impose a significant burden on healthcare resource utilization. Prevention and treatment of exacerbations are major objectives of the clinical management of COPD. For this approach to be successful, clinicians must combine both pharmacologic approaches and non-pharmacologic strategies aimed at improving the patient's disease management. Non-pharmacologic approaches include those that can be incorporated into the office setting as well as intervention strategies that are integrated into the lifelong management of COPD. These strategies include developing a partnership with the patient and their social supports, encouraging and facilitating smoking cessation, immunizations, proper use of supplemental oxygen, and most importantly, giving the patient the tools to manage their illness appropriately. Moreover there is clear evidence of an irrevocable decline in pulmonary function after each exacerbation, usually resulting in reduced physical activity and impaired skeletal muscle function. Not surprisingly, pulmonary rehabilitation after such events has been shown to prevent relapse, improve survival and enhance patients' overall function after acute exacerbations.

Environmental tobacco smoke: respiratory and other health effects.

Involuntary exposure to environmental tobacco smoke (ETS) is a serious and entirely preventable public health hazard. It has become clear that ETS adversely affects the health of all who breathe its toxins. Independent of active smoking, ETS exposure is a modifiable risk factor for chronic obstructive pulmonary disease. The expanding body of research presented in this article provides evidence that the damaging consequences of ETS reach far beyond the lungs. Having been determined the third leading cause of preventable death in this country, this is a problem that must be addressed aggressively.

COPD and exercise: what's really important? A nursing perspective.

Numerous studies demonstrate the importance of exercise training to improve endurance in patients with chronic obstructive pulmonary disease (COPD) and its positive effect on activities of daily living and quality of life. However, successful care of the individual with COPD also relies on recognizing that this person requires individualized care and non-pharmacologic modalities specific to their needs in order to cope with the various aspects of their disease. It is also important to note that improvement in quality of life is not necessarily related to improvement in exercise endurance alone. Comprehensive and effective pulmonary rehabilitation for the COPD patient needs to encompass several components to provide benefit for the spectrum of symptoms of COPD beyond exercise tolerance and dyspnea to ultimately improve quality of life.

Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals: American Association of Cardiovascular and Pulmonary Rehabilitation Position Statement.

The article provides an outline of clinical competencies recommended for personnel providing comprehensive services in pulmonary rehabilitation (PR), complementing the American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for Pulmonary Rehabilitation Programs. Individuals wishing to provide PR services should possess a common core of professional and clinical competencies regardless of their academic discipline.

Functional status and quality of life in chronic obstructive pulmonary disease.

Exertional dyspnea often causes patients with chronic obstructive pulmonary disease (COPD) to unconsciously reduce their activities of daily living (ADLs) to reduce the intensity of their distress. The reduction in ADLs leads to deconditioning which, in turn, further increases dyspnea. Both dyspnea and fatigue are important factors affecting health-related quality of life (HRQOL). The functional status of patients relates to how well they perform ADLs. Activities, however, may not be severely limited until the disease becomes advanced. The elimination of an ADL depends on the necessity or desirability of that activity and the intensity of the associated symptoms. HRQOL is measured using symptoms, functional status, and a rating of their impact on the individual. The Pulmonary Functional Status Scale (PFSS) and the Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) are 2 COPD-specific functional status questionnaires. Pedometers or accelerometers can quantify the levels of activity of patients with COPD. HRQOL is measured with validated multidimensional questionnaires that cover symptoms, physical, psychological, and social domains. Ideally, these instruments are discriminative (i.e., separate degrees of impairment) and evaluative (i.e., detect small changes after therapy). HRQOL questionnaires may be generic (e.g., Medical Outcomes Study Short Form-36 [SF-36]) and can measure favorable changes after intervention, such as pulmonary rehabilitation, or they can be disease specific with disease-related domains, e.g., Chronic Respiratory Disease Questionnaire (CRQ) with domains of dyspnea, fatigue, emotion, and mastery; and St. George's Respiratory Questionnaire (SGRQ) with domains of symptoms, activity, and psychosocial impact. A case is presented that depicts how these tools may be used to evaluate improvement with intervention in a patient with COPD.

The effect of pulmonary rehabilitation on healthcare utilization in chronic obstructive pulmonary disease: The Northeast Pulmonary Rehabilitation Consortium.

Although pulmonary rehabilitation results in improvement in multiple outcome areas, relatively few studies in the United States have evaluated its effect on healthcare utilization. This study compared aspects of healthcare utilization during the year before to the year after outpatient pulmonary rehabilitation in patients with chronic obstructive pulmonary disease referred to 11 hospital-based centers in Connecticut and New York. Utilization data from 128 of 132 patients who originally gave informed consent were evaluated; their mean age was 69 years and their forced expiratory volume in 1 second was 44% of predicted. Forty-five percent had 1 or more hospitalizations in the year before beginning pulmonary rehabilitation. In the year after pulmonary rehabilitation, there were 0.25 fewer total hospitalizations (P = .017) and 2.18 fewer hospital days (P = .015) per patient and 271 fewer hospital days for the group. Hospitalizations for respiratory reasons also decreased significantly. Most of the reduction in hospital utilization was due to a decrease in intensive care unit days. The number of physician visits decreased by 2.4 in the year after pulmonary rehabilitation (P < .0001); most of this reduction was due to decreased visits to primary care providers. The estimated costs/charges for the aspects of healthcare utilization that we studied decreased by a mean of 4,694 dollars and a median of 390 dollars (P = .0002). This study suggests that pulmonary rehabilitation leads to a reduction in healthcare utilization.

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.