Living with chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema, can be challenging, particularly as the disease progresses. Advanced stages of COPD require more aggressive therapies.
Fortunately, many new approaches are being developed for improving COPD symptoms and extending life expectancy and quality. We spoke with Dr. Frank Sciurba, associate professor of medicine and education at the University of Pittsburgh School of Medicine and director of the Emphysema/COPD Research Center at UPMC, about advanced COPD and new treatments now being tested.
What is considered advanced COPD?
I would define it as symptoms that become disabling to the extent that it interferes with the activities of daily living. A normal oxygen level is 96 percent saturation. Once you’re below 90 or 88 percent saturation, it stimulates receptors that detect low oxygen levels in the arteries, and the person gets very symptomatic. As severity gets worse, they are more likely to have exacerbations and deteriorations requiring more unexpected hospital visits. By lung function—if I had to create criteria--I would say it’s less than 50 percent FEV1 predicted, but there are a lot of other things we take into account and how that affects the individual.
What are the different kinds of advanced COPD treatment options?
People with severe emphysema might be a candidate for some of the surgical or bronchoscopic volume reduction procedures now emerging. Lung volume reduction surgery is possible in patients with an FEV1 of about less than 45 percent and hyperinflation, meaning they can’t get all their air out. If their CT scan shows they have emphysema, and it is worse in their upper lobes, then those folks may be candidates. In lung volume reduction surgery, we try to cut out the worst areas of emphysema, which allows the better quality lung to expand and function better. People who are candidates for this procedure could reduce their three-year mortality rate in half. This option can actually prolong life.
How does the healthy lung expand, and why do you want to cut bad areas?
In emphysema, you have areas that have holes, and they are big, giant air sacs. It’s as if I put a football in your lungs—your good lung now has much less room to expand. What we try to do is cut away or shrink down these giant air sacs so there is better quality lung that can expand into that space. The lungs in a patient with emphysema are overinflated because of obstruction of airflow. It’s easy to get the air in but hard to get the air out, so the lungs get overinflated. So, if you can cut away the worst parts of the lung, that leaves more space for the better part of the lung to expand and exhale within that chest.
Are there other surgical approaches?
More recently, some companies have been developing bronchoscopic approaches to try to mimic the effects of lung volume reduction surgery without going through major surgery. There has been some progress. Some companies make valves that go into the worst areas of emphysema and try to collapse those lobes, shrink them down and then allow the better quality of lung to expand. There was a trial done within the last 10 years that showed some patients to be good responders, while other patients don’t respond to these valves.
Another device that has been used with these bronchoscopic approaches is a coil. We just completed enrollment in a large international trial to assess the effect of these coils. They are little metal rods that are about 10 or 15 cm long that go into the lung, and then they coil up and roll in the emphysema; the bad lung. They spin thin little metal wires, and they go in, and they coil up, and they pull in the worst lung and collapse those bad areas with the goal to allow expansion of the better quality lung. We put about 10 to 14 coils in each lung over a four-month period. That trial should be completed by the end of this year, and we should know the results in early 2016 whether these are effective and whether the FDA is interested in approving them.
Who can be a candidate for these procedures?
Only people with an emphysema type of COPD are really going to benefit from these approaches. For the valves, the selection criteria are patients with a lot of variation in their disease. Some patients have connections between their two major lobes in each lung so the lobe won’t collapse when you put the valve in. So, we need to take patients whose lobes aren’t connected, so we can make sure the lobe will collapse. People who fit these two criteria tend to do really well with this procedure. But we’re looking at it again--there’s another ongoing clinical trial to evaluate these valves.
How about other therapies for the future?
Another approach in patients with advanced disease is noninvasive ventilation—kind of like what we use for sleep apnea with BiPAP. The patient wears a mask to help them breathe better—at least to let them rest overnight and intermittently during the day when they are very short of breath. There were some studies of lower level pressures of these devices over the last 20 years that really didn’t show a great effect. But in Europe, they have been using much higher pressures and having much better responses. In fact, there was a German study last year that showed that you can cut the mortality rate less than a third over a course of a year using this noninvasive ventilation technique in patients with really advanced disease and carbon dioxide retention. That will probably come back and be studied again in this country. Right now, it’s difficult to get that in the U.S. for patients with only COPD, unless they have underlying sleep apnea.
Can people with COPD get lung transplants?
In people under the age of 70 with very extreme disease, such as FEV1 under 30 percent, we would consider a lung transplant. Right now, the five-year survival rate for lung transplant patients is around 60 percent. After transplantation, people are almost symptom-free. Of course, they have to have commitment to take immunosuppressant drugs the rest of their life. There are consequences of potential increased risk of infection. Over time, most people reject those lungs. We do have some very long-term survivors that seem to do very well. In the additional years that people do get out of their transplanted lungs, even if they’re short-lived, they are quality years they get back. Hopefully we can make progress to prevent rejection and infection in these individuals and get them to live even longer. That’s sort of the last step in really advanced patients.
Is there a way to slow down the progression of COPD in advanced stages?
In general, it’s never too early to stop smoking. It’s never too early to begin to pay attention. And it’s never too late to think about therapies. At some point, when there is nothing left to do, and people are really suffering, we need to decide whether it’s really in their best interest to bring them in and out of the hospital and treat with therapy. Or, do you want to stay in your own home where we will still treat you with all the right medications. However, if you are so short of breath that you can’t breathe, we are going to give you medications to make you comfortable and allow you, in the comfort of your home with your family, to pass on. I think that is something that we don’t think about enough. That’s in the very final stages. But before that, we have approaches at almost every stage, and we don’t give up. Except for stopping smoking, which prevents the decline of lung function, there is no therapy that we have available yet that slows the progression of the disease effectively, except in the alpha-1 genetic abnormality. So what we try to do is improve symptoms, try to increase quality of life, and make them the best they can be.
Why is it important for someone with advanced COPD to continue their treatment?
Just to feel optimal. Depression and anxiety are also a big overlap in patients with more advanced disease. Sometimes getting them counseling, or just a good social worker can help, and sometimes just participating in pulmonary rehab can help with the depression. But in those patients where none of these help, antidepressant medication can be very beneficial to give them a better outlook and a desire to participate in their care. It can be very frustrating, because in patients with advanced disease you are almost never able to get rid of symptoms. It’s all helping them cope and having a little bit of edge for a better quality of life. I would encourage all patients until that final end-stage disease to participate in all these things and go to a pulmonologist and internist that can help them find the best options to feel better.