COPD in the Age of COVID: Ten Messages for Care

There has not been a more indelible health care crisis than COVID-19 in our generation.  Since the pandemic began, access to an international media that reports 24 hours a day has generated hundreds of thousands of medical reports, personal stories, and recommendations.  The pulse of data is fast and has overwhelmed the usual pace of life.

The ways we approach these significant events is as different as the number of individuals in our COPD community.  A fastidious few will stay engaged daily with facts and figures; these are the scientists (and most physicians) among us.  Another few will take the complete opposite approach with an emotional approach that has few underpinnings in any data. However, the great majority of the populace have periods of engagement with data, make an educated assessment of the next steps for personal health and live within this contextual world view for an extended period of time. This world view is then reassessed the next time that a significant data event impacts their personal lives.  And life goes on. 

Now, imagine you have the most common respiratory illness in the world, COPD.  Since COPD is a disease of the aging lung you are older. Excess mucus and cough, baseline shortness of breath that gets worse during exacerbations that occur in most years, and emphysema that limits gas exchange is your life.  Sure, you do most of the things you want to do on an average day.  However, you are older and have more co-morbidities than your neighbors.  And you know that if you get the SARS-CoV-2 virus, you might not fare so well.  With a preventive vaccine a few years away and no definitive cure in hand, what would you do?

The Isolationist Option
In February and March 2020 when there was an opportunity to apply case finding and isolation approaches that worked for SARS-CoV-1 and the MERS coronavirus strains, many felt it their civic duty to limit contact to their neighbors, family, and friends to prevent the surge. The surge would overwhelm healthcare and healthcare workers until such time as sufficient infrastructure could be put in place to provide sites of supportive care for those who became ill.  As the virus escaped into the community from failure of this strategy (in large part from inadequate testing), a new realism emerged. 

The new realism was that risk is personal.   Preservation of personal health falls completely on actions in the household.   In other words, if we never leave the house, then the chance of getting the virus diminishes greatly.  And if we spray the Amazon package with bleach, and wipe down each food item left on the porch from the grocer, then this option can last forever. 

The medication list can be reordered and mailed. The doctors can get a telemedicine platform to see the patients. But the mammograms and colonoscopies and emergency room evaluations for chest pain can wait a while. 

The “Whatever Will Happen Will Happen” Option
Some teenagers never grow up.  Our popular culture embodies an active lifestyle that necessarily involves being with others to enjoy sports, music, and dining. Although we don’t want exposure to SARS-CoV-2 or want to catch COVID pneumonia, if it happens then antibodies might form that would limit future infections or at least the severity of future infections.  And of all the people that catch COVID, 40% are asymptomatic, only 20% need the hospital, and only 2-5% die.  Those are pretty good odds. 

And there are plenty of stories of patients with COPD that had a hard time and eventually made it out of the hospital.  There was a similar decision we all had to make when the Surgeon General declared that cigarettes caused cancer in 1965.  Who knew it would be hard to stop smoking?  But it is also hard to practice social distancing and avoid all the things we love to do.  And what about the damage to the economy?  My option is to exercise my freedom to live the life of engagement.

The Pragmatic Option
In April and May the world watched New York City deal with a nightmare health care crisis.  However, much of the rest of the United States saw COVID-19 as a problem of the cities where access to public transportation, elevators and crowded shopping venues precipitated a rapid surge in COVID-19 cases.  Life on the farm and in small towns was very different.  Yes, this is a very contagious virus that our community needs to watch out for. But as long as we have testing and can identify the hotspots of contagion, then we can keep the economy of the United States running by keeping our small businesses running. 

We previously liked to travel a few times a year to the cities, but maybe those can wait.  We can’t yet decide what to do about high school football games and our small school classes in the fall, but know that online learning will leave a generation behind unless we can figure that out soon.  We view our nursing homes and hospitals and the other COPD patients in our community as special and share a sense of responsibility to keep them virus free.  We wear a mask when we are in a place where we must be less than 6 feet from a stranger, not knowing the extent that it helps them or us. We can wait this out until we have a cure or a vaccine.

But I am going to see my doctor for my necessary health maintenance tests.  My small lung nodule that is being radiographically followed needs that CT scan.  If I have chest pain, I will go to the emergency department because medical care makes a difference in quality of life. And in the case of chest pain, a visit to the emergency department might allow for an intervention for heart attack.  Yes, COVID-19 has changed the way I approach life.  But I can have it both ways with attention to detail, knowledge of my community virus density, and continued emphasis on the proven ways to prevent spread of SARS-CoV-2. 

Ten Messages for the COPD community

1. Don’t let fear take over your life.  If you choose to be isolationist, know that it is easy to have added burdens of anxiety and depression without the social interactions of life.  At least get out in the yard and reach out with the telephone or internet to keep life ongoing. Practical strategies for maintaining emotional wellbeing are available here.
2.  Keep the medications we know work for COPD ongoing.  We have good evidence that long acting beta agonists (LABA), long acting muscarinic antagonists (LAMA) and inhaled corticosteroids (ICS) alone or in combination are effective at prevention of exacerbations. 
3. Use this opportunity to stop smoking if this is still part of your life. There is good data that current cigarette smoking increases the risk of respiratory infections.  This infection is one you do not want to have.
4. Help with education for the those who believe that life should be back to normal now.  There will always be individuals who cannot be reached through pragmatic education.  Try and not make this education political since we all recognize that political divides are among the most difficult to overcome.  A personal story goes a long way toward reaching your friends and family.
5. Exercise, exercise, exercise.  One of the most underutilized aspects of COPD care is pulmonary rehabilitation.  Almost all of the pulmonary rehab centers in the US were closed during the pandemic and some are beginning to reopen.  However, a center is not the most important aspect of your care. Your exercise itself is the most important.  What better to do with time on your hands?  Walking or performing easy exercises in your home can make a tremendous difference in how you feel and prevent deconditioning of your muscles. Without exercise, deconditioning of muscles will make them inefficient at using oxygen and as a result produce more carbon dioxide (CO2), thus increasing the amount of ventilation required to keep blood CO2 levels stable. Learn how you can continue your own pulmonary rehabilitation even if your center is not open at by clicking here.
6. Knowledge is power, don’t be afraid to ask for testing if you think you might have this virus.  Viral testing options are available in most communities, often with drive through testing. Many tests return the same day that allow you to contact any recent contacts and allow a two week quarantine to begin.
7. Knowledge is power, use reputable websites such as the online community COPD360 social, COPD Foundation COVID-19 web page or the ATS COVID pages.
8. Your medical team can sometimes help if you need letters for your employers.  As a vulnerable population there may be a future time to take leave or return to home in the event of a local surge in virus cases.  Be pragmatic, take charge of your health.
9. Since there is increased risk of ICU care, make sure your family knows your end of life wishes. Back this up with some documents. There are three documents that should come to mind and state specific template for all states are available on the internet. 1) A Living Will defines the extent of procedures that you would choose if there is no hope for a meaningful recovery from illness.  This document is often not as important as talking with your partner about your wishes. 2) Designating a healthcare power of attorney is important so a person that you trust is deciding care with the healthcare team. This document is legally binding and needs to be notarized.  3) Lastly, if the decision is that you do not want to have cardiopulmonary resuscitation as part of your living will, remember that a call to 911 will bring a crew who will perform CPR unless you have an emergency medical services (EMS) Do not resuscitate form.  These are state specific documents and need to be accessible if 911 is activated for a healthcare issue.
10. Live a thoughtful and careful life. The stories of patients with COPD who did well despite having COVID are common. Stay engaged, stay connected and be informed as we move through this pandemic together.

Sources:

Charlie Strange, MD, University of South Carolina
Sara Latham, COO, COPD Foundation