Petty Memorial Lecture: Past, present, and future of pulmonary rehab and self-management in COPD

Over the last several decades, pulmonary rehabilitation has been supported by strong evidence demonstrating its effectiveness in patients with chronic obstructive pulmonary disease (COPD) over a large spectrum of acuity and severity. A fundamental and now well-recognized component of patient care for those with COPD is self-management behavior modification (SMBM) intervention.

Despite this progress, challenges remain, said Jean Bourbeau, MD, MSc, Professor of Medicine in the Respiratory Division at McGill University and Director of the Centre of Innovation Medicine at the McGill University Health Research Institute in Montreal.

Dr. Bourbeau discussed some of the challenges and opportunities in the continued expansion and evolution of pulmonary rehabilitation and SMBM when he delivered the Thomas L. Petty, MD, Master FCCP Endowed Memorial Lecture: Pulmonary Rehabilitation and Self-Management in COPD: Understanding the Past to Build the Future at CHEST 2021.

“We have come a long way, but we still have many challenges, such as underdiagnosed COPD, which is still a worldwide problem,” Dr. Bourbeau said. “And while there are treatments nowadays, the diagnosis is often made late in the disease process. This is important to change, and there is a huge gap in this area.”

Once a diagnosis is made, he said, the challenge becomes how to best assess the severity of disease, which is key to determining treatment, pulmonary rehabilitation strategies, and self-management interventions.

“We have filled some gaps in the last decade addressing the heterogeneity of the disease, where the disease was primarily defined in terms of severity based on the FEV₁/FVC ratio,” Dr. Bourbeau said. “In the last few years, however, there has been increased interest in doing an evaluation, like in many other chronic diseases, based on symptom burden and risk of exacerbation.”

Additionally, he said that recommendations for pharmacologic treatment of COPD from many societies, including the Global Initiative for Chronic Obstructive Lung Disease (GOLD), have been updated to account for new therapies and new understanding of the stages of disease severity and levels of risk.

“In lower-risk patients where the treatable trait is dyspnea with a low risk of exacerbation, long-acting bronchodilator [LABD] and monitoring is recommended,” Dr. Bourbeau said.

For treatable traits of exacerbation in higher-risk patients, dual therapy of LABD combined with a long-acting muscarinic antagonist (LAMA) has been shown to be effective, he said, noting that the results of recent clinical trials have suggested that triple therapy, with the addition of inhaled corticosteroids (ICS) to LABD/LAMA, may be effective in patients at high risk for acute exacerbations of COPD.

Another evolving area of ongoing research involves the identification of therapeutic targets using predictive biomarkers.

“We have seen in different studies that blood eosinophil level in COPD, particularly in patients who have a risk of exacerbation, predicts the response to an ICS-containing regimen,” Dr. Bourbeau said. “In the real world, evidence has been shown that when patients, especially those who have a blood eosinophil level of 300 or more, are not on ICS, there is an increased probability of moderate to severe exacerbation, and while when they are on ICS, they are less probable to have an exacerbation. This is very promising.”

Evidence also continues to grow, he said, on the benefits of self-management interventions and the components that comprise an actionable and effective self-management program.

“It’s been shown that self-management interventions that include written action plans and coaching with a health care professional for prompt treatment of worsening symptoms lead to lower probability of both respiratory-related and all-cause hospitalizations and improved health status,” Dr. Bourbeau said. “As part of any self-management intervention, two components—self-recognition and self-treatment of exacerbations—have to be present.”

Self-management intervention, he emphasized, is not an alternative to pulmonary rehabilitation.

“The precise content of self-management intervention would be an approach aimed at behavioral change and will depend on the severity and complications—such as the patient having exacerbations—the presence of comorbidity, and the patient’s capacity to manage their disease,” Dr. Bourbeau said. “While we still have many gaps to fill, we have to be able to recognize and make sure we implement what we know can improve patient functional capacity and related quality of life.”