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A better understanding of the molecular and cellular pathogenic mechanisms of COPD should lead to many new directions for both basic and clinical investigations. Improved methods of early detection, new approaches for interventions through targeted pharmacotherapy, possible means to identify the “susceptible” smoker, and more effective means of managing exacerbations are needed.
Some research recommendations and future program goals are provided to stimulate the efforts of investigators around the world. There are many additional avenues to explore.
· Until there is a better understanding of the causal mechanisms of COPD, an absolutely rigid definition of COPD, and its relationship to other obstructive airway diseases, will remain controversial. The defining characteristics of COPD should be better identified.
· The stages and natural history of COPD vary from one patient to another. The clinical utility of the four-stage classification of severity used in the GOLD Report needs to be evaluated.
· Surrogate markers of inflammation, possibly derived from the analysis of sputum (cells, mediators, enzymes) or exhaled condensates (lipid mediators, reactive oxygen species, cytokines), that may predict the clinical usefulness of new management and prevention strategies for COPD need to be developed.
· Information is needed about the cellular and molecular mechanisms involved in inflammation in stable COPD and exacerbations. Inflammatory responses in nonsmokers, ex-smokers, and smokers with and without COPD should be compared. The mechanisms responsible for the persistence of the inflammatory response in COPD should be investigated. Why inflammation in COPD is poorly responsive to glucocorticosteroids and what treatments other than glucocorticosteroids are effective in suppressing inflammation in COPD are research topics that could lead to new treatment modalities.
· Standardized methods for tracking trends in COPD prevalence, morbidity, and mortality over time need to be developed so that countries can plan for future increases in the need for healthcare services in view of predicted increases in COPD. This need is especially urgent in developing countries with limited healthcare resources.
· Longitudinal studies demonstrating the course of COPD are needed in a variety of populations exposed to various risk factors. Such studies would provide insight into the pathogenesis of COPD, identify additional genetic bases for COPD, and identify how genetic risk factors interact with environmental risk factors in specific patient populations. Factors that determine why some, but not all, smokers develop COPD need to be identified.
· Data are needed on the use, cost, and relative distribution of medical and non-medical resources for COPD, especially in countries where smoking and other risk factors are prevalent. These data are likely to have some impact on health policy and resource allocation decisions. As options for treating COPD grow, more research will be needed to help guide healthcare workers and health budget managers regarding the most efficient and effective ways of managing this disease. Methods and strategies for implementation of COPD management programs in developing countries will require special attention.
· While spirometry is recommended to assess and monitor COPD, other measures need to be developed and evaluated in clinical practice. Reproducible and inexpensive exercise-testing methodologies (e.g., stair-climbing tests) suitable for use in developing countries need to be evaluated and their use encouraged. Spirometers need to be developed that can ensure economical and accurate performance when a relatively untrained operator administers the test.
· Since COPD is not fully reversible (with current therapies) and slowly progressive, it will become ever more important to identify early cases as more effective therapies emerge. Consensus on standard methods for detection and definition of early disease need to be developed. Data to show whether or not screening is effective in directing management decisions in COPD outcomes are required.
· Primary prevention of COPD is one of the major objectives of GOLD. Investigations into the most cost-effective ways to reduce the prevalence of tobacco smoking in the general population and more specifically in young people are very much needed. Strategies to prevent people from starting to smoke and methods for smoking cessation require constant evaluation and improvement. Research is required to gauge the impact and reduce the risk from increasing air pollution, urbanization, recurrent childhood infections, occupational exposures, and use of local cigarette equivalents. Programs designed to reduce exposure to biomass fuel in countries where this is used for cooking and domestic heating should be explored in an effort to reduce exposure and improve ventilation in homes.
· The specific components of effective education for COPD patients need to be determined. It is not known, for example, whether COPD patients should be given an individual management plan, or whether these plans are effective in reducing healthcare costs or improving the outcomes of exacerbations. Developing and evaluating effective tools for physician education concerning prevention, diagnosis, and management of COPD will be important in view of the increasing public health problem presented by COPD.
· Studies are needed to determine whether education is an essential component of pulmonary rehabilitation. The cost effectiveness of rehabilitation programs has not been assessed and there is a need to assess the feasibility, resource utilization, and health outcomes of rehabilitation programs that are delivered outside the major teaching hospital setting. Criteria for selecting individuals for rehabilitation should be evaluated, along with methods to modify programs to suit the needs of individual patients.
· Collecting and evaluating data to classify COPD exacerbations by severity would stimulate standardization of this outcome measure that is so frequently used in clinical trials. Further exploration of the ethical principles of life support and greater insight into the behavioral influences that inhibit discussion of such intangible issues are needed, along with studies to define the needs of end-stage COPD patients.
· There is a pressing need to develop drugs that control symptoms and prevent the progression of COPD. Some progress has been made and there are several classes of drugs that are now in preclinical and clinical development for use in COPD patients.
Bronchodilators: Bronchodilators are the mainstay of symptomatic therapy and new short-acting and long-acting bronchodilators are anticipated. With the recognition that there are different subtypes of muscarinic receptors, there has been a search for more selective antagonists. Tiotropium bromide, a new drug in advanced clinical trials, is a quaternary ammonium compound like ipratropium bromide, but with the unique property of kinetic selectivity and very long duration of action. Selective phosphodiesterase type IV inhibitors might combine bronchodilator and anti-inflammatory activity.
Mediator
antagonists: Attention
has largely focused on mediators involved in recruitment and activation of
neutrophils, and reactive oxygen species. In this category are the LTB4
antagonists, lipoxygenase inhibitors, chemokine inhibitors, and TNF-
inhibitors.
Antioxidants: Oxidative stress is increased in patients with COPD, particularly during exacerbations. Oxidants are present in cigarette smoke and are produced endogenously by activated inflammatory cells, including neutrophils and alveolar macrophages, suggesting that antioxidants may be of use in therapy for COPD.
Anti-inflammatory drugs: The limited value of glucocorticosteroids in reducing inflammation in COPD suggests that novel types of nonsteroidal anti-inflammatory treatment may be needed. There are several new approaches to anti-inflammatory treatment in COPD including, for example, phosphodiesterase inhibitors, transcription factor NF-kB inhibitors, and adhesion molecule blockers.
Proteinase inhibitors: There is compelling evidence that an imbalance between proteinases that digest elastin (and other structural proteins) and antiproteinases that protect against this digestion exists in COPD. Considerable progress has been made in identifying the enzymes involved in elastolytic activity in emphysema and in characterizing the endogenous antiproteinases that counteract this activity, including neutrophil elastase inhibitors, cathepsin G and proteinase 3 inhibitors, and matrix metalloproteinase inhibitors. Other serine proteinase inhibitors (serpins), such as elafin, may also be important in counteracting elastolytic activity in the lung.
Mucoregulators: It may be important to develop drugs that inhibit the hypersecretion of mucus, without suppressing the normal secretion of mucus or impairing mucociliary clearance. There are several types of mucoregulatory drugs in development including tachykinin antagonists, sensory neuropeptide inhibitors, mediator and enzyme inhibitors, mucin gene suppressors, mucolytic agents, macrolide antibiotics, and purinoceptor blockers.
Alveolar repair: A major mechanism of airway obstruction in COPD is loss of elastic recoil due to proteolytic destruction of the lung parenchyma. Thus, it seems unlikely that this obstruction can be reversed by drug therapy, although it might be possible to reduce the rate of progression by preventing the inflammatory and enzymatic disease processes. It is even possible that drugs might be developed to stimulate regrowth of alveoli. Retinoic acid increases the number of alveoli in rats and, remarkably, reverses the histological and physiological changes induced by elastase treatment. The molecular mechanisms involved and whether this can be extrapolated to humans are not yet known. Several retinoic acid receptor subtype agonists have now been developed that may have a greater selectivity for this effect. Hepatocyte growth factor (HGF) has a major effect on the growth of alveoli in the fetal lung, and it is possible that in the future drugs might be developed that switch on responsiveness to HGF in adult lung or mimic the action of HGF.
Route of delivery: Many inhalers that deliver bronchodilators have been optimized to deliver drugs to the respiratory tract in asthma. Methods to quickly and safely deliver medications to target sites of inflammation and tissue destruction in COPD need to be evaluated.
This concludes the GOLD report!! We will now present other important information regarding the complex disorder known as COPD.
Chronic obstructive pulmonary disease (COPD) refers to the combination of chronic bronchitis and emphysema resulting in obstruction of airways. Although chronic bronchitis and emphysema are distinct conditions, smokers and former smokers often have aspects of both. In chronic bronchitis, the linings of the bronchial tubes are inflamed and thickened, leading to a chronic, mucus-producing cough and shortness of breath. In emphysema, the alveoli (tiny air sacs in the lungs) are damaged, also leading to shortness of breath. COPD is generally irreversible and can be fatal.
Lifestyle changes that may be helpful: Smoking is the underlying cause of the majority of cases of emphysema and chronic bronchitis. Anyone who smokes should stop, and although quitting smoking will not reverse the symptoms of COPD, it can help preserve the remaining lung function. Exposure to other respiratory irritants, such as air pollution, dust, toxic gases, or fumes, can aggravate COPD and should be avoided when possible.
The common cold or other respiratory infections can aggravate COPD. Avoiding exposure to infections or bolstering resistance with immune-enhancing nutrients and herbs can be valuable.
Dietary and other natural therapies that may be helpful: Although clues about the relationship between COPD and diet have surfaced, as yet, they have not formed a coherent picture. Malnutrition is common in individuals with COPD and can further compromise lung function and overall health of people with this disease.1 However, evidence of malnutrition may occur despite adequate dietary intake.2 Researchers have found that increasing dietary carbohydrate increases carbon dioxide production, which leads to reduced exercise tolerance and increased breathlessness in people with COPD.3 Despite this evidence, a study comparing the diets of men over a twenty-five-year period found that those with a higher intake of fruit (high in carbohydrate) were at lower risk of developing lung diseases.4 People with COPD should talk with a nutritionally oriented doctor before making significant dietary changes.
Chronic bronchitis has been linked to allergies in many reports.5 6 7 In a preliminary trial, long-term reduction of some COPD symptoms occurred when people with COPD avoided allergenic foods and (in some cases) were also desensitized to pollen.8 People with COPD interested in testing the effects of a food allergy elimination program should talk with a nutritionally oriented doctor.
Negative ions may counteract the allergenic effects of positively charged ions on respiratory tissues and potentially ease symptoms of allergic bronchitis, according to preliminary research.9 10
Nutritional supplements that may be helpful: N-acetyl cysteine (NAC) helps break down mucus. For that reason, inhaled NAC is used in hospitals to treat bronchitis. NAC may also protect lung tissue through its antioxidant activity.11 Oral NAC (200 mg taken twice per day) is also effective, improving symptoms in people with bronchitis in double blind research.12 13 Results may take six months.
Vitamin C has mucus-thinning properties and may be helpful to respiratory conditions. A review of nutrition and lung health reported that people with a higher dietary intake of vitamin C were less likely to be diagnosed with bronchitis.14 Vitamin C was also shown to be related to greater volume of air expired from the lungs—a sign of healthy lung function. As yet, the effects of supplementing with vitamin C in people with COPD have not been studied.
Antioxidants in general are hypothesized to be important for neutralizing the large amounts of free radicals associated with COPD. However, use of antioxidant supplements (synthetic beta-carotene and vitamin E) did help people with COPD in a double blind trial despite the fact that people who ate higher amounts of these nutrients in their diets appeared to have lower risk.15
A greater intake of the omega-3 fatty acids found in fish oils has been linked to reduced risk of COPD,16 though research has yet to investigate whether fish oil supplements would help people with COPD.
Many prescription drugs commonly taken by people with COPD have been linked to magnesium deficiency, a potential problem because magnesium is needed for normal lung functioning.17 One group of researchers reported that a magnesium deficiency was found in 47% of people with COPD (as determined by muscle biopsy) but was not reflected in blood levels of magnesium.18 In this study, magnesium deficiency was also linked with increased hospital stays. Thus it appears that many people with COPD may be magnesium deficient, a problem that could worsen their condition; moreover, the deficiency is not easily diagnosed.
Intravenous magnesium has improved breathing capacity in people experiencing an acute exacerbation of COPD.19 In this double blind study, the need for hospitalization was also reduced in the magnesium group (28% versus 42% with placebo) but this difference was not statistically significant. Intravenous magnesium is known to be a powerful bronchodilator.20 The effect of oral magnesium supplementation in people with COPD has yet to be investigated.
Carnitine has been given to people with chronic lung disease in trials investigating how the body responds to exercise.21 22 In these double blind reports, 2 grams of carnitine taken twice per day for two to four weeks led to positive changes in breathing response to exercise.
Researchers have also given coenzyme Q10 (CoQ10) to people with COPD after discovering their blood levels of CoQ10 are lower than those found in healthy people.23 In that trial, 90 mg of CoQ10 given for eight weeks led to no change in lung function, though oxygenation of blood improved, as did exercise performance and heart rate. Until more research is done, the importance of supplementing with CoQ10 for people with COPD remains unclear.
Herbs that may be helpful:
(For more information on herbs, see course number 201127: Complementary and Alternative Medicine: Expanding Medical Horizons.)
Mullein is classified in the herbal literature as an expectorant (to promote the discharge of mucus) and demulcent (to soothe and protect mucous membranes) herb. Historically, mullein has been used as a remedy for the respiratory tract, particularly in cases of irritating coughs with bronchial congestion.24 Other herbs commonly used as expectorants in traditional medicine include elecampane, lobelia, yerba santa (Eriodictyon californica), wild cherry bark, horehound (Marrubium vulgare), gum weed, anise, and eucalyptus. Animal studies have suggested that some of these increase discharge of mucus.25 However, none of these herbs have been studied for efficacy in humans.
Ephedra sinica (Ma huang) has been used by the Chinese for medicinal purposes for over 5,000 years, including for lung and bronchial constriction, coughing, and shortness of breath. However, this herb has the potential for serious side effects and is best used only with the guidance of a nutritionally oriented physician.
Checklist for Chronic Obstructive Pulmonary Disease
|
Ranking |
Nutritional Supplements |
Herbs |
|
Primary |
N-acetyl cysteine (for bronchitis) |
|
|
Secondary |
|
|
|
Other |
Anise Elecampane Eucalyptus Gum weed Horehound Lobelia Yerba santa |
Within Healthnotes Online, information about the effects of a particular supplement or herb on a particular condition has been qualified in terms of the methodology or source of supporting data (for example: clinical, double blind, meta-analysis, or traditional use). For the convenience of the reader, the information in the table listing the supplements for particular conditions is also categorized. The criteria for the categorizations are:
1. “Primary” indicates there are reliable and relatively consistent scientific data showing a health benefit.
2. “Secondary” indicates there are conflicting, insufficient, or only preliminary studies suggesting a health benefit or that the health benefit is minimal.
3. “Other” indicates that an herb is primarily supported by traditional use or that the herb or supplement has little scientific support and/or minimal proven health benefit.
1. Pingleton SK, Harmon GS. Nutritional management in acute respiratory failure. JAMA 1987;257(22):3094–99.
2. Fiaccadori E, Del Canale S, Coffrini E, et al. Hypercapnic-hypoxemic chronic obstructive pulmonary disease (COPD): influence of severity of COPD on nutritional status. Am J Clin Nutr 1988;48:680–85.
3. Efthimiou J, Mounsey PJ, Bensen DN, et al. Effect of carbohydrate rich versus fat rich loads on gas exchange and walking performance in patients with chronic obstructive lung disease. Thorax 1992;47:451–56.
4. Miedema I, Feskens EJM, Heederik D, et al. Dietary determinants of long-term incidence of chronic nonspecific lung diseases. Am J Epidemiol 1993;138:37–45.
5. Bsucinco L, Businco E. Allergic pathogenesis in chronic bronchitis. Allergol Immunopathol (Madr) 1975;3:1–8.
6. Krawczyk Z. Role of allergy of the immediate type in the pathogenesis of chronic bronchitis in adults. Penumonol Pol 1976;44:829–36 [in Polish].
7. No author listed. Preliminary study on the relation between allergy and chronic bronchitis. Chin Med J 1976;2:63–68.
8. Rowe AH, Rowe A Jr, Sinclair C. Food allergy: its role in the symptoms of obstructive emphysema and chronic bronchitis. J Asthma Res 1967;5:11–20.
9. Gualtierotti R, Solimene U, Tonoli D. Ionized air respiratory rehabilitation technics. Minerva Medica 1977;68:3383–9.
10. Jones DP, O’Connor SA, Collins JV, et al. Effect of long-term ionized air treatment on patients with bronchial asthma. Thorax 1976;31(4):428–32.
11. Van Schayck CP, Dekhuijzen PNR, Gorgels WJMJ, et al. Are anti-oxidant and anti-inflammatory treatments effective in different subgroups of COPD? A hypothesis. Respir Med 1998;92:1259–64.
12. Boman G, Bäcker U, Larsson S, et al. Oral acetylcysteine reduces exacerbation rate in chronic bronchitis: a report of a trial organized by the Swedish Society for Pulmonary Diseases. Eur J Respir Dis 1983;64:405–15.
13. Multicenter Study Group. Long-term oral acetylcysteine in chronic bronchitis. A double-blind controlled study. Eur J Respir Dis 1980;61:111:93–108.
14. Sridhar MK. Nutrition and lung health. BMJ 1995;310:75–76.
15. Rautalahti M, Virtamo J, Haukka J, et al. The effect of alpha-tocopherol and beta-carotene supplementation on COPD symptoms. Am J Rispir Crit Care Med 1997;156:1447–52.
16. Shahar E, Folsom AR, Melnick SL, et al. Dietary n-3 polyunsaturated fatty acids and smoking-related chronic obstructive pulmonary disease. Atherosclerosis Risk in Communities Study Investigators. N Engl J Med 1994;331:228–33.
17. Rolla G, Bucca C, Bugiani M, et al. Hypomagnesiumia in chronic obstructive lung disease: effect of therapy. Magnesium Trace Elem 1990;9:132–36.
18. Fiaccadori E, Del Canale S, Coffrini E, et al. Muscle and serum magnesium in pulmonary intensive care unit patients. Crit Care Med 1988;16:751–60.
19. Skorodin MS, Tenholder MF, Yetter B, et al. Magnesium sulfate in exacerbations of chronic obstructive pulmonary disease. Arch Intern Med 1995;155:496–500.
20. Okayama H, Aikawa T, Okayama M, et al. Bronchodilating effect of intravenous magnesium sulfate in bronchial asthma. JAMA 1987;257:1076–78.
21. Dal Negro R, Pomari G, et al. L-carnitine and rehabilitative respiratory Physio kinesitherapy: metabolic and ventilatory response in chronic respiratory insufficiency. Int J Clin Pharmacol Ther Toxicol 1986;24:453–56.
22. Dal Negro R, Turco P, Pomari C, De Conti F. Effects of L-carnitine on physical performance in chronic respiratory insufficiency. Int J Clin Pharmacol Ther Toxicol 1988;26:269–72.
23. Fujimoto S, Kurihara N, Hirata K, Takeda T. Effects of coenzyme Q10 administration on pulmonary function and exercise performance in patients with chronic lung diseases. Clin Investig 1993;71(8 Suppl):S162–66.
24. Hoffman D. The Herbal Handbook: A User’s Guide to Medical Herbalism. Rochester VT: Healing Arts Press, 1988, 67.
25. Boyd EM. Expectorants and respiratory tract fluid. Pharmacol Rev 1954;6:521–42 [review].
One issue we have not discussed involves the training of healthcare professionals to be able to deal with COPD. One hospital system (which shall for important reasons remain un-named here) published a list of problems they saw with how their medical staff, from physicians to nurses to RCPs were empowered to deal with COPD:
Rationale
The chronic obstructive pulmonary
diseases (chronic bronchitis/ emphysema) are important causes of morbidity and
mortality and are a major cause of total disability, second only to coronary
artery disease. Cigarette smoking plays a major role in the progression of the
disease, with survival rates lower among patients who continue to smoke
cigarettes. The severity and debilitation of these particular disorders make
them an important training problem for healthcare professionals.
Prerequisite
Prior knowledge, skills and attitudes during the pre-clinical (basic science) years should include:
1. normal structure and function of the heart and lungs and how these are altered in respiratory system diseases
2. pathogenesis and pathophysiology of pulmonary diseases
3. pharmacology of drugs used for pulmonary diseases
4. epidemiology and risk factors of lung disease
5. ability to take a medical history and perform a physical exam
6. ability to communicate with patients of diverse backgrounds
7. ability to perform a respiratory risk assessment
A. Knowledge: Professionals should be able to define and describe:
1. disease entities and pathophysiologic processes of common, serious, or prototypical respiratory diseases that can result in COPD
· asthma
· chronic bronchitis
· emphysema
· genetic predisposition -- alpha 1 antitrypsin deficiency
2. other disease entities that may cause symptoms or signs similar to those caused by COPD
3. allergic and non-allergic factors that may precipitate bronchospasm and asthma
4. the risks for developing COPD in various patients and correlate risk factors associated with each respiratory tract diseases with occupational and environmental hazards
5. basic principles of O2, antibiotic, bronchodilator and corticosteroid therapy
6. the scientific evidence supporting use of influenza vaccine/Pneumovax in COPD patients
B. Skills: Healthcare professionals should demonstrate specific skills including:
1. history-taking skills: Healthcare professionals should be able to obtain, document and present an age-appropriate medical history, that differentiates among etiologies of disease including:
· existence, duration, and severity of the following symptoms:
· shortness of breath
· sputum production
· cough
· wheezing
· hemoptysis
· fever
· abnormal nocturnal/diurnal sleep patterns
· patient’s occupational history, including current and past exposures, environmental, smoking (active and passive), travel, and family respiratory tract history, including:
· a history of allergies, previous respiratory tract diseases, and previous PPD, TB, and BCG status
· the risk for alpha 1 antitrypsin deficiency
2. physical exam skills: Healthcare professionals should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
· assessing the use of accessory muscles for breathing
· inspection, palpation, percussion and auscultation of the chest discriminating the following:
· recognizing and differentiating abnormal lung sounds, such as wheezing, rales, and rhonchi from normal breath sounds.
· differentiating between a normal, dull and hyperresonant chest by percussion.
· differentiating between areas of consolidation and pleural fluid by assessing the quality of the breath sounds and ancillary findings such as egophony and whispered pectoriloquy
· assessing the presence of pleural friction rub.
3. differential diagnosis: Healthcare professionals should be able to generate a prioritized differential diagnosis, recognizing specific history and physical exam findings that confirm or refute a diagnosis of asthma, chronic bronchitis, or emphysema
4. laboratory interpretation: Healthcare professionals should be able to recommend when to order diagnostic and laboratory tests and interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
Laboratory and diagnostic tests, when appropriate, should include:
· chest x-ray to recognize x-ray patterns that suggest asthma, bronchitis, and emphysema
· basic pulmonary function tests (such as ABG, pulmonary function tests, and spirometry) used to evaluate respiratory tract diseases
· interpretation of a gram stain of sputum
· pulse oximetry
5. communication skills: Healthcare professionals should be able to:
· communicate the diagnosis, prognosis and treatment plan of the disease to patients and their families, taking into consideration their knowledge of the disease and their treatment preferences
6. basic procedural skills: Healthcare professionals should be able to perform:
· gram stain of sputum
· arterial blood gases
7. management skills: Healthcare professionals should be able to develop an appropriate evaluation and treatment plan for patients including:
· the basic principles of oxygen, antibiotic, bronchodilator, and corticosteroid therapy
· the basic bronchodilator and corticosteroid management when appropriate
· the steps in a critical pathway for patients hospitalized with COPD exacerbations
· smoking cessation strategies
· accessing and utilizing appropriate information systems and resources to help delineate issues related to COPD
C. Attitudes and Professional Behaviors: Healthcare professionals should be able to:
1. recognize that poor working, living, and environmental conditions can contribute to respiratory tract disease
On a closing note to this informative module, you should be aware that COPD has become so ubiquitous that there is even an “online” magazine directed at persons with COPD. The URL is: http://www.healthyresources.com/copd/copd-today/
Sample table of contents for first issue:
A diagnosis of Chronic Obstructive Pulmonary Disease doesn’t spell the end of an active life, but it must be dealt with effectively. In “COPD: A life challenge,” Mary Grauerholz introduces us to the experiences of people living with COPD and of people who love and care for them. In related articles and resources we explain and expand on the ideas in the story.
· The story “COPD: A life challenge” How Herb Cowles and his wife met the challenge of COPD
· Diagnosis and treatment of COPD Information and links about the diagnosis and treatment of COPD
· Finding support Gaining a new perspective on COPD through support of your peers: readings online, organizations, support groups, online meeting places
· Locating authoritative information sources Governmental, medical, and other national institutions providing information
· Newsletters, web sites, and other information sources including associations and offerings by people with COPD. Helpful information and support from people with credentials earned by experience, as well as professional and institutional offerings.
· Editorial: Medicare Should Support Rehabilitation
Rehabilitation support by Medicare needed
4 October, 2000
The Honorable Barney
Frank
2210 Rayburn
Washington, D.C. 20515
Dear Mr. Frank:
I am writing to urge your support for the inclusion of outpatient pulmonary rehabilitation under the Medicare program. There are about 16 million people with chronic obstructive pulmonary disease (COPD) and it is reasonable to estimate that over 200,000 new cases are diagnosed annually. I am genuinely concerned about patient access to pulmonary rehabilitation programs. As it is there are not enough rehab programs to serve the population with COPD. I strongly support congressional efforts to add this service to the Medicare program.
The precipitous implementation of the hospital outpatient prospective payment system taken on August 1, 2000, has eliminated the payment mechanisms for pulmonary rehabilitation. Without Congressional action to specifically cover pulmonary rehabilitation under Medicare, by amending the Social Security Act, many Medicare beneficiaries will no longer have access to this care. Your action to do this will not result in new Medicare costs; only restoration of payments that were available under a cost-based system. It is imperative that people with Chronic Lung Diseases have access to rehabilitation programs. It extends their lives by reducing complicating conditions, improves their overall outlook on life, and improves their general well being. People with COPD need to remain active under skilled medical supervision that will provide the correct interventions to reduce hospital readmissions and improve daily living.
If people with COPD learn how to manage their condition (ideally, in a professional rehab program), they can avoid exacerbations and hospitalization. Many can live a normal span of life with a much-improved quality of life. But untreated they are condemned to a form of house arrest and likely early death.
My knowledge of this field is based on the fact that I am the publisher of a handbook for people with COPD; the authors (medical experts and a person with COPD) present information based on modern rehab philosophy. I would be pleased to provide a free copy of our book to aid in your consideration of this issue. You may also wish to visit our web site at www.HealthyResources.com which includes information drawn from our book and reports prepared specially for the internet.
Thank you for your support in this matter.
Sincerely,
(Signed)
Jerry Halberstadt
Congress of the United States
House of Representatives
Washington DC
October 25, 2000
Dear Mr. Halberstadt:
Thank you for your letter. I share your view that we should extend Medicare coverage for pulmonary rehabilitation programs. In fact, I believe we ought to extend Medicare as well to cover other services currently not available under it, e.g., prescription drugs, routine physicals, etc., and my preference for doing that would be to extend the program into a universal healthcare program for all. But achieving that goal will be difficult, and so in the very least, I think that services, such as pulmonary rehabilitation programs, which currently are not covered by Medicare, but are important health wise for beneficiaries to have access to, should be included in it. Obviously, with adjournment about to happen, it is too late to do anything useful this year, but I promise you that I will be doing what I can next year for a broadening of Medicare along the lines that you advocate.
(Signed)
Barney Frank
For an excellent guide to advocacy on COPD issues, written by Bill Horden, see his Newsletter “Grassroots Organizations,” which is in the Archive listed on The COPD Advocate Home Page
We hope you have enjoyed and been “enlightened” by the contents of this CEU. At very least, you are now in possession of an enormous bibliographical resource. It is now time to take your Examination!
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