Hospitalist Insights on COPD: Comprehensive Care for Admitted Patients

Podcast Transcript

Dr. Raed Dweik, MD (00:01):

Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease in the areas of lung health, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of your patients. I hope you enjoy today's episode.

Dr. Dan Culver, DO (00:34):

Hello and welcome to the Respiratory Exchange Podcast. I'm Dan Culver, Chair of Pulmonary Medicine. I'm hosting today's episode and I'm joined by Professor Moises Auron. Dr. Auron is professor of Medicine and Pediatrics at Cleveland Clinic Lerner College of Medicine, and he's a hospitalist who's worked with us over a large number of years. Besides that, he also is the immediate past president of the medical staff here at Cleveland Clinic Main Campus. I've known Moises for a number of years, and it's been a great relationship. Moises, welcome to the show.

Dr. Moises Auron, MD (01:12):

Thank you so much Dan. Thank you for the invitation.

Dr. Dan Culver, DO (01:15):

So, we're here today to talk about the hospitalist perspective on COPD and admitted patients and what every hospitalist and attending ought to know.

Dr. Moises Auron, MD (01:25):

This is a very important topic, Dan. it because a significant, not just financial constraint of patient as well as the healthcare, but it also impacts potentially on the patient's life, on the routine day to day.

Dr. Dan Culver, DO (01:41):

So, you've been dealing with hospitalized COPD patients, obviously throughout your whole career. This is still a major because of hospitalization, admissions and readmissions. And of course, most of the care for these patients is via hospitalists and internists, not through subspecialists like people in my team in pulmonary medicine. So, I'm curious from the standpoint of a hospitalist, when you hear that there is a COPD admission coming in, what's the first thing that goes through your mind? What are the boxes that you're ticking off as you think about how you're going to handle things?

Dr. Moises Auron, MD (02:18):

Well, that's a great question. The first thing is number one, if this is the first time this patient is having an exacerbation or not, number two, how often has that has been happening? It will be like how am I going to be presenting? Is the patient requiring oxygen, not requiring oxygen, the patient having some modifiable risk factors. In my mind, I am already going to start them on steroids, oral steroids. I want to put them on short acting, beta agonist as well as antimuscarinic agents every four hours or so. I want to give the vaccination that they need. I may decide to put them on an antibiotic like a macrolide, uh, for anti-inflammatory properties, more than antibacterial. I'm going to get a nutrition consult, evaluate are they having any cachexia related to the COPD? If this is the first time, they may be, okay, this is multiple admission, they may be already having those requirement.

(03:16):

Um, I will be addressing if they're still smoking or not, some modifiable risk factors that I can have a meaningful impact on them. And mostly that will be kind of my game plan. And I will also think ahead of the game, like who am I going to discharge them to? Not just the primary care physician who they should be, but also perhaps the COPD post-discharge clinic, exacerbation clinic that includes pulmonary rehabilitation. This is a very important thing that I personally take very seriously. People with COPD exacerbation, they should be considered to be evaluated for pulmonary rehabilitation and also because they will be addressing other components that can exacerbate their COPD.

Dr. Dan Culver, DO (04:01):

So, I like your approach. It's very comprehensive, it's holistic. You're thinking about the end game on the day the patient comes in to see you the first time you see the patient and also all of the comorbidities that might contribute to the short-term and the long-term outcome. And I want to get into all of those today with you. I wonder, just as a start, how has your process for thinking about the diagnosis itself, so many of the patients come from other settings like especially the emergency department on antibiotics and on some Lasix and on some treatment for COPD, and how do you conceptualize going through that diagnostic process, especially when patients don't have information in the system? For example, do you think that patients should have a spirometry in the hospital? Are you often finding yourself struggling with concomitant respiratory diseases? So how does that process go for you?

Dr. Moises Auron, MD (04:59):

Wow, that's just a phenomenal question, Dan. As a matter of fact, these patients have a lot of comorbidities. I mean patients have COPD, they often, I mean unless they have a genetic thing like cystic fibrosis or the alpha one antitrypsin deficiency, most of these patient will be having uh, nicotine used as a co-factor, often smoking, cigarette smoking, and they will be having other comorbidities that are associated like long-term hypertension that can let lead you to left and concomitant, right heart failure, right-sided failure. They could have diabetes, insulin resistance, obesity with OSA, or sleep apnea. So, you have to be looking at all of these things, not just rule them out. It is not that you have other COPD or heart failure or heart failure or COPD. This patient may come very in differentiative. They just come in with acute dyspnea or the worsening dyspnea.

(05:54):

They have always dyspnea at home. You are having mostly, mostly respiratory symptoms, uh, dyspnea more than the edema, although they could have some right-side failure from chronic COPD and pulmonary hypertension and core pulmonary. But it's mostly respiratory symptoms that we are seeing the increase of sputum production, the change of the color of the sputum, the evidence of infection, the active smoking. So that's how I conceptualize there. This is mostly a COPD exacerbation and the question about the [inaudible] is fundamental. I particularly, I'm possible that in the system healthcare-wise, people label COPD without spirometric diagnosis, and this is not adequate. Even the goal guideline, they tell you the step number one, you have to have a spirometry to make a diagnosis

Dr. Dan Culver, DO (06:46):

Because once it's in the EHR one time you can't get it out there.

Dr. Moises Auron, MD (06:51):

It's COPD, COPD, COPD, COPD. And wait a second, does the patient have COPD? And here's the deal - sometimes for this patient, when I have confusion, I look at the chest x-ray. I think chest x-ray is a phenomenal imaging, but I don't trust chest x-ray completely. And you may argue that it may not be an entirely high value here, but if I am having question, I get a simple CT of the chest. Especially if they have smoked, it becomes also screening test for lung cancer. But a simple CT tells me is there really emphysema if there is evidence of bronchiectasis, if I don't have that, then I could be leaning toward something else. But I often find those things and it's an opportunity to showcase the patient the consequences that could be potentially avoided or stop the progression.

Dr. Dan Culver, DO (07:40):

I think you bring up a good point which is really thinking broadly about the patients and I think your, your process really outlined that. One of the things that comes to mind, as you mentioned CT that is always in the back of everyone's mind is thromboembolic disease. So, what would trigger you to think about excluding thromboembolic disease in a patient with a label of COPD or with deteriorated chest symptoms?

Dr. Moises Auron, MD (08:08):

No, no. This is actually interesting. There are some studies have shown that about 30% of some patients with COPD, they're actually having a PE at the time. But we cannot be just doing CAT scan with contrast. But when you have this patient that have like, like for instance, not just progressively worsen in dyspnea but sudden onset of dyspnea, that is the red flag. Patients have like pleuritic pain, hemoptysis normally COPD is not going to be coming with bad hemoptysis. Even if they have terrible bronchiectasis when they have like on explain hemodynamic changes like bad tachycardia, sinus tachy, uh, the patient has hypotension. Those things should make you think that you're having a hemodynamic impact from PE worsening needs of oxygen from the baseline that you cannot explain just by the COPD. The symptoms are really not that that severe.

(08:59):

When chest x-ray is normal, you have no sputum, no increased worsening in the sputum, the classic chronic bronchitis exacerbation, you don't have that. When instead of having respiratory acidosis, you have respiratory alkalosis. That should make think, okay this patient tachypneic, having hypokalemia respiratory alkalosis. Think about... when the patient have evidence of right, right-sided heart strain in the EKG or echo, when you have the classic S one, Q3 three or when the patient have the classic risk factors being hospitalized, having cancer, using estrogen, active smokers, uh, they have unilateral lower extremity edema or they are not improving. You have two, three days with a very comprehensive COPD care with steroid, LABA, LAMA plus the short acting medication and they're not getting better. You give the antibiotic not getting better, let's just rule out the PE because then, then there's something, something on behind. Those will be kind of the criteria we'll be doing.

Dr. Dan Culver, DO (10:00):

So, I didn't hear any comment in there about using D-dimer or ultrasound as a way to help your decision making. Do you use those?

Dr. Moises Auron, MD (10:10):

Oh yes, yes. No, no, no. You're absolutely right. I mean we will do like the PERC, for instance, we have an algorithm, you have a PERC score, but the thing with the PERC score is like you need to have very, very low suspicion. You still use it. If you have one single factor, then that's it. Then you go to your WELLS and Geneva and if you have like a WELLS that is more than four, then you get your D-dimer. Either you image or you, you want to be very conservative getting your D-dimer. And if it's more than a thousand you just get your image. Yeah, you could do like a patient have really bad renal kidney function. You could just do the lower extremity ultrasound and the D-dimer or a VQ scan. VQ scan can be very useful for acute but also for chronic embolic pulmonary hypertension.

Dr. Dan Culver, DO (10:55):

So, you would use the D-dimer in the setting where there's some risk factor and use it as an exclusionary tool.

Dr. Moises Auron, MD (11:02):

Yeah, when it's not categorically, if I feel that this categorical I chest pain, I you go for the CT scan. But if I am like eh, I, I am like this, this really AC, PE? Get the PERC. PERC has one factor, okay, go WELLS and Geneva and then you can support your D-dimer that way you avoid over scanning patient. We want to avoid scanning excessively because it's very easy to scan. But these are not my kidneys, this is my patient kidney.

Dr. Dan Culver, DO (11:28):

Just a few keystrokes, right?

Dr. Moises Auron, MD (11:30):

Exactly.

Dr. Dan Culver, DO (11:30):

Oh, you can get a scan anytime of the day

Dr. Moises Auron, MD (11:32):

<laugh>. That is absolutely right. You want to have high value care approach. Very conscientious. But we do have great tools, and I love that you ask about the stratification. We have to risk stratify the patient because it's very easy to just shoot the gun and target getting studies that well they, they're negative. I mean well that is great, but then now the patient already had radiation already has contrast. So, you want to avoid those things

Dr. Dan Culver, DO (12:01):

And this is so frequent because for admission COPD, that if it's your routine practice scan, eventually you will because some problems with it. So, I like your, I like your strategy. I want to just pivot to the idea that now we have a reasonably confirmed diagnosis of COPD with an exacerbation and you mentioned a few fundamental therapies that you like to use, which I think are pretty standard and one of the most standard of course is inhaled therapy either by an inhaler or a nebulizer. And I wondered, uh, if there are patient populations that you recommend using a nebulizer versus those where you could simply use an inhaler. Obviously, the nebulizer is a safer bet for many patients, but it's also labor intensive and there are other issues with it, of course.

Dr. Moises Auron, MD (12:52):

No, that's a fantastic question and we always ask our trainees, is the nebulizer more effective than the inhaler? And this is the trap question. And it is not. If you have good technique with your meter dose inhaler or the dry powder inhaler, it should work perfectly well. The thing is that this is not an issue of potency or efficacy. It's about an issue of delivery and when patients are having hard time taking deep breaths, patients who are very deep condition, that they have very weak respiratory muscles, the nebulizer works very well for them because they don't have to do that much effort. You're micronizing the particles and it just goes inside. But if they can take a good deep breath with a spacer that is just not in a one-on-one that is no superiority of the nebulizer over the metered dose inhalers,

Dr. Dan Culver, DO (13:46):

Do you look at the degree of COPD or the degree of airflow obstruction as a way to help judge that?

Dr. Moises Auron, MD (13:54):

Actually, it's more about the clinical. If the patient is able to make the effort, then we just use, use the metered dose inhalers. Our respiratory therapist at the Cleveland Clinic, they're phenomenal in assessing this. They're very, very good and because they also understand that if the patient is able to have good technique with inhalers in the hospital, which will impact tremendously in the adhering to treatment and the longitudinal care. So, if they're able to do it well here, it can even become the way that we teach them how to use it. You know, like in the Dr. House that they, they use the inhaler as a perfume. This is of course as a tongue in cheek, but the point is it's an opportunity for the patient to approach the use of the technique in a good way. Most of the time we just put the nebulizer across the board. But it is not a good practice because as you said, it is labor intensive. When we have the respiratory season, our respiratory therapists, they have a lot of patients that being admitted and we have to prioritize the care of those higher risk patients rather than the one that can just be managed with a metered dose inhalers.

Dr. Dan Culver, DO (15:05):

Yeah, respiratory therapists aren't just growing on trees. And so, I like that you're uh, very much thinking about how do we manage the efficiency and the productivity of the team instead of doing everything to everybody. One of the other things that we sometimes ask the respiratory therapists to do, and that often comes up in the assessment and management of COPD patients in the hospital is to get a blood gas. And I'm curious about your perspective on when do you ask for a blood gas? Are there some clinical signs that trigger it and how do you use other signs to decide how to, how to titrate that?

Dr. Moises Auron, MD (15:43):

No, no, this is a fantastic question. First of all, we can use nowadays venous blood gases, venous blood gases are very effective. They tell you about the hypoventilation very well. In my concern it's about unexplained hypoxemia and there is no way, I don't understand that there're no mismatch. There is no shown diffusion problem. I mean of course there's no high altitudes here and it's just mostly hypoventilation and, and I, I look at this, this, this, uh, physiologic because for hypoxemia, I don't have a clear explanation and patient not improving. I mean that will be the only indication for an arterial blood gap.

(16:24):

To be honest with you. I haven't done an arterial blood gas in many years. Um, the venous blood gas has helped me. It can be done by the nurse doesn't need a respiratory therapist to do that in the COPD setting. I mean, to be honest, to getting an arterial blood gas will be in the setting where the oxygen requirements are really prominent are you're unable to wind them down and you have, you just say, well, the CAT scan does not explain why the patient needs so much oxygen. Then you would get it because then you can have further assessment of, of uh, of risk factors and refine the workup. But then that is not just pure COPD. For a pure COPD, a venous blood gas could be fine because you want to look at the ventilation part and the pH. That's what you really want to focus upon. But if your workup is for hypoxemia percent, that will be the only reason I would do ABG. And in, in COPD hypoventilation explains it, the pathophysiology.

Dr. Dan Culver, DO (17:23):

So, getting a VBG, which sounds like that's now where you've almost entirely moved to, is that a decision you can make from the foot of the bed? This is really all about the feel of the patient and how they look or do you have some other things that lead you to think about that?

Dr. Moises Auron, MD (17:40):

Yes, indeed. Because first of all, an ABG, which we used to do a lot of time before and now I regret, I mean that was part of my medical student. I was the guy doing the blood gas medical school and then, uh, during residency you're poking the artery. Every time you poke the artery you could just sacrifice the distal blood flow. And, and a lot of people don't even do the Allen test <laugh>. So, I, kind of like, oh my goodness, how unsafe this was. So, poking an artery, which is painful, is that really going to impact on my care? Probably not. I think if my patient is headed toward the ICU and I need to escalate to now non-invasive positive pressure ventilation and I am going to likely going to potentially intubate that will change my and that I am at the bedside. I'm seeing the patient is having significant strain use of accessory muscles, tachypneic not responding to conventional therapy. That is probably an appropriate thing because you want to really have no doubt about what is the physiology that is happening and then ABG would be indicated. For the common blood and border patient, you don't really need the, the ABG the VBG would be more than plenty and it's very...

Dr. Dan Culver, DO (18:53):

And not even necessary for everybody.

Dr. Moises Auron, MD (18:56):

We don't really get the VBGs on, I would say 80, 80% of patients are those that are like heading toward the ICU. Why? Because you need to speak a language that the ICU attending is going to understand. I mean why the patient needs the ICU. Well, because you have worsening respiratory acidosis, you have worsening lactic acidosis. That is, I cannot just explain that by the beta agonist. This is worsening patients who are having increased stress, but I am supporting a physiologic rationale. And of course that helps them to, okay, well these warrant, they need to triage patient. Because the ICU staff gets called for 10 patients every hour. So not all can go to the ICU, but it helps you to have better communication that is much more nuance.

Dr. Dan Culver, DO (19:44):

I think that's very useful information for people who are thinking of how to care for the patients. One of the other things you mentioned besides thinking about the lungs is all the comorbidities. And you mentioned sleep apnea. You mentioned sarcopenia or, or nutritional issues. You mentioned the possibility of secondary pulmonary hypertension, smoking, which is I think present in 30 or 40% of our admitted COPD patients here in our system. How do you as a hospitalist who's really got the goal of stabilizing the patient and getting them back to their outpatient primary care doctor, how do you think about which tests ought to be done in the hospital and which ought to be deferred until after the hospitalization, especially when you're thinking of hospital throughput and the costs to the system in a value-based era of doing more tests?

Dr. Moises Auron, MD (20:44):

No, well, that's a great question. First of all, pulmonary function tests, you often do not do them during an exacerbation. That can be done as an outpatient after six weeks, six to eight weeks after an exacerbation will be best, the patient gets stabilized an echocardiogram. You can get an echocardiogram in the hospital. It will give you good information that you can also use for the language that you will be sharing with a primary care physician. You have LVAs, you have pulmonary hypertension, you have the plethora of your IVC. So why you need to do pretty low reduction and things like that, like a sleep apnea test. We have now the luxury in the Cleveland Clinic that we can go do have inpatient sleep consult, and we have the home sleep test. But it's not an ideal test. That test you can be done, can be done in an outpatient lab to get a formal polysomnogram with titration study.

(21:41):

I think the sleep apnea is a very prevalent disease that carries significant morbidity and it causes you on control, hypertension, it causes you increasing intracranial hypertension, worse glaucoma, it causes ventricular dysfunction, catecholamine release that can actually shorten people's lifespan. People with sleep apnea that not treated, they're more, they're hungrier and they're already having large BMIs. So, when you treat that, they start losing weight, they're feeling more energetic and a lot of things actually improve. I think these comorbidities, people don't think about them often, but also the systemic process for addressing sleep apnea doesn't help because you have to make the appointment for the sleep test. They're very saturated. It takes a long time for them to get there. Then after the test, they need another one, a titration and, and there's people that do not tolerate the masks and the positive pressure, but there's a way that we can make them tolerate like a pap nap, for example.

(22:46):

But not everybody knows that. And a pap nap is patient comes during the day for one hour, two hours, take a nap in the, in the sleep test, sleep lap, and they try like nasal pillow, different devices and they tolerate. Then they become more, a more friendly approach to it. But that takes time and patient and resources. So anyway, I, I think that sleep apnea is something I would really defer to the outpatient. I would encourage the audience to think about sleep apnea, often do the stop band questionnaires and even with people with BMI more than 35 to think about it and not just asking about Epworth Sleep Scale and, and the, the, the screening with... But think about it and encourage the patient to have the workup that is appropriate.

Dr. Dan Culver, DO (23:36):

You're watching the patient in the hospital over a whole shift, a whole bunch of shifts in a row. You watch the trajectory and you learn a lot about the patient in a way that I think the outpatient doctor doesn't always get the chance to do, especially if they see the patient in stable times for 20 minutes or 15 minutes at a time. So, I, I wonder if you have thoughts about how you communicate what you've learned about the patient to the longitudinal physician. I think the discharge summary doesn't do it justice. And I wonder if you, you can just imagine for us how it would look better to get the information about your observations and your thoughts, uh, along with the next person who's going to be caring for the patient.

Dr. Moises Auron, MD (24:21):

No, this is phenomenal. I don't think that we do a good job communicating back to the primary care physicians. One of the beauties that we have here is that we have the post discharge COPD clinic. We also have a post discharge team that may actually go to the patient’s home. It's called origin dispatch. I think for the primary care physician is number one, teaching them about the patient's comorbidities that have to be addressed and optimized. Uh, teach them, speak with them about the changes we did with the treatment. Like, okay, you know what, I started your patient on a LABA LAMA and you know what they, the patient has four 50 eosinophils. So, I started on inhaled corticosteroids now. Oh, okay. So just be careful with the chronic inhaled corticosteroids things. I mean, do you appropriate to osteoporosis management, vitamin D check, I mean, just, I'm not going to tell you how to practice medicine, just be aware that did this change.

(25:17):

Regarding the nutritional part, the sarcopenia, this is a very important thing because we have even a lot of patients with obesity and sarcopenia. Actually, BMI is, it's just a good, it's a good index because it helps you to stratify patients. But the BMI by itself is, doesn't tell you all the story what matters. Your muscle mass and the percentage of body fat, we don't really do that that often. The thing is, is sarcopenia, when you get the nutrition consult and, and you get the patient with sarcopenic obesity, you let the primary care physician be aware about a, I am just worried about sarcopenic obesity may not be a bad idea to do a body composition assessment on this patient so that they can look into those things, but also understand that primary care physician are very limited in the time they have.

(26:09):

It's just these are 15 minutes, 20 minutes and they have to look to too many things in this case will be for COPD post visit. So have them be aware of the change in medication, but then the comorbidities that you think that they should address, like, you know what I do, for example, if patient have, like the heart rate was always in the seventies and they have this bad hypoxemia recording, a lot of oxygen, breathing heavily. That is not a normal heart rate. That heart rate should be in the nineties, a hundred. So address hypothyroidism, and we find, but you don't want to check the stage in the acute setting because it's not a good what you, you get 3, 4, 3 and you now you find something, you tell the, the, the primary care I, I'm worried about some chronotropic incompetency. Monitor the thyroid function as an outpatient. Maybe a stress test may not be a bad idea because something is not fitting here. So that type of observations become very helpful because the primary care physician, they say, oh, vitals are fine, heart rate is 70. It's 70, but patient was breathing like almost 30 per minute.

Dr. Dan Culver, DO (27:17):

So, it's really about conveying information in the transitions of care. And of course we are blessed here at the Clinic. We have research going on in sarcopenia and the effect of intermittent hypoxia on sarcopenia and we have a sarcopenia clinic for our COPD patients as well as pulmonary rehab as you talked about. And so, I think that's a really helpful framing. You're really thinking of this as a holistic internist rather than somebody who is just adding inhalers, adding some steroids and walking away. You know, we're coming to the end here, but it occurs to me, Moises, that you've been doing this for more than five minutes. Uh, you've seen a lot of patients over the years with COPD exacerbations in the hospital. And I think it would be interesting to just hear what is, what is the biggest thing we're missing? Where do you see the mistake most common, the single most common mistake or omission that you see? And then maybe if you want to just reflect for a minute or so on, where do you see care of the hospitalized COPD patient moving next? I'll ask you those two questions to wrap up here.

Dr. Moises Auron, MD (28:26):

No, this is a great question. I think that every time a patient is hospitalized for COPD or other reason, the hospitalization is an opportunity to reflect on the overall patient's healthcare and status addressing comorbidities and be deliberate and have a nuance approach. But in regard with COPD and the patient with chronic lung disease, I think immunization, especially adult immunization, we have a huge opportunity to close the gap. This is, uh, for instance, I have my patient right now that I'm giving RSV vaccine and Prevnar 20 closing that gap. So now they are vaccinated for life. Of course, the flu season is coming to an end. Well, not yet. I really, I'm having wishful thinking still in January, but I want it to end <laugh>.

Dr. Dan Culver, DO (29:14):

It's certainly looking better now than it was a couple weeks ago.

Dr. Moises Auron, MD (29:16):

It's looking better, especially with the subclavian, I mean with all the new, the new flu, uh, new flu strain. Uh, no, but, uh, I, I think that the flu shot, complete flu shot, of course the new COVID shot. So, I think the opportunity about completing immunizations is a good opportunity and we leverage it very well. We're fortunate we have all these immunization resources here and we provide, and the patient have been very receptive and very grateful to get them. Like right now, I just gave RSV vaccine today and Prevnar 20 patient was very happy about that. So, because they understand that these are going to prevent life threatening, uh, manifestation. I think that is one big opportunity in the care of our COPD patient.

Dr. Dan Culver, DO (30:05):

So, there you heard it. Blocking and tackling and doing the basics really well is the key to the best outcomes. I want to really thank you for joining us here today. It was great to hear the hospitalist perspective. Get us all up to speed about how we can work together as a team, and I hope that everybody in the audience found this informative and also educational.

Dr. Moises Auron, MD (30:27):

Dan, thank you so much for the opportunity and the privilege, and I want to also express my gratitude to all the audience who take care of patients out there. And thank you for what you do and continue to remain fascinated and inspired by medicine. Thank you for serving.

Dr. Dan Culver, DO (30:42):

Thank you, Moises. And thank you to everybody for joining today. Until next time.

Dr. Raed Dweik, MD (30:48):

Thank you for listening to this episode of the Respiratory Exchange podcast. You can find additional podcast episodes on our website, cleveland.org/podcasts or wherever you get your podcasts.