Maggie McKay (Host): Welcome to the Live Greater podcast series, information for a Healthier You from the University of Maryland Medical System. I'm your host, Maggie McKay. Today, we'll learn how COPD treatment is changing, including newer medications, ways to prevent flare-ups, affordability tips, and questions to ask your pulmonologist. Our guest today is Dr. Kathryn Robinett, a pulmonary critical care physician at UMMC Midtown Center for Pulmonary Health. Thank you so much for being here today.

Kathryn S. Robinett, MD: Thank you, Maggie, so much for having me

Host: Let's get right into it, because I know I have a lot to learn about this. When people hear COPD, they may think it only gets worse over time. What do you want patients to know about how COPD can be managed today?

Kathryn S. Robinett, MD: We have a lot of terrific options today. COPD is a chronic disease and something that's very serious. It can get worse over time, but how much worse is very unpredictable. So, we have plenty of interventions we can make in order to slow that process down and to keep people feeling well for as long as possible.

Host: And what has changed in COPD treatment over the past few years?

Kathryn S. Robinett, MD: So for many years, we've had excellent inhalers to help patients and other interventions like pulmonary rehab. More recently, we have some exciting new treatments that can be really tailored to the patient. People have probably seen ads on TV, but there are a lot of new biologic therapies out there for COPD.

We also have procedures that can be done that kind of help block off the bad parts of the lungs and optimize the good parts of the lungs. And then, our center also engages in, if necessary, transplants. So, there are a variety of different things that people can do if their COPD is getting worse.

Host: And are treatments becoming more personalized based on a patient's symptoms, flare-ups, or test results?

Kathryn S. Robinett, MD: Yes, absolutely. So, COPD is this huge disease that affects people in a variety of different ways. Some people have mostly coughs, some people have shortness of breath, some people have lots of flares. And we know that these probably need to be treated in different ways. So, we have different therapies based on people's imaging, so their CAT scan of their lungs, based on their lab work that help us understand what type of inflammation is driving their COPD. And we can pick out just the right treatment for them.

Host: How do you decide which COPD treatment is right for a patient?

Kathryn S. Robinett, MD: Basically, there are some foundational treatments that help people with COPD. So, everyone who's short of breath should be on an inhaler. Everyone who's short of breath and has flares that ends them up needing antibiotics or steroid bursts, we add extra inhalers to help them.

If they're not better, there are some more specialized treatments for people with different types of inflammation. So, we do lab work to help figure out what the best treatment will be. That CAT scan can help us figure out, if there's a procedure that we can do to help block off those bad parts of the lung. So, it really depends on the CAT scan and the lab work.

Host: That's encouraging. It sounds like a lot of options. What should patients tell their doctor if they feel their current treatment is not working well enough?

Kathryn S. Robinett, MD: I find that that is a very important question. But even taking a step back, talking to your doctor as soon as you feel like your life is being limited by shortness of breath. One really difficult cycle we see patients get into is they just get short of breath. They, you know, might say something like, "Oh, I'm a smoker. I'm just getting older. So of course, I'm short of breath," and they do less and less. And that is not good for their lungs, and they get more deconditioned. So, it makes it harder to treat their overall disease. So, I'd really encourage people to reach out for help as soon as they find they're getting short of breath doing normal activities that they weren't short of breath doing a year before.

I should have stepped back too, like even if smoking is still something patients struggle with, we recognize that it is a trillion-dollar industry and that people have become addicted because cigarettes are really difficult and tobacco is really difficult to give up. So, we have ways to help people quit smoking too.

So even if you're still smoking, if you're getting short of breath or noticing a cough that's really limiting whether you go to church, limiting what you can do in the grocery store, talk to your doctor sooner rather than later, even if you're not on therapies yet.

Host: If somebody lived with a smoker but they didn't smoke, could you get COPD from secondhand smoke?

Kathryn S. Robinett, MD: it depends. So, that certainly is a possibility. What we know is that not everyone who smokes gets COPD, and some people who never smoke but have other exposures do. There's probably some sort of genetic predisposition, so you're more likely to get COPD if you're exposed. So, there are some people, even with relatively low cigarette smoke exposure or other exposures that can get COPD even if they haven't smoked.

Host: So, there are newer medications available for some people with COPD, and you touched on this a little bit, but including newer inhaled treatments and biologics, what should patients know about these options?

Kathryn S. Robinett, MD: Yeah. So, I think that there are a lot of great inhalers out there. There's a new nebulizer treatment that can help patients. There are some pills that have been around for a while that go beyond kind of the standard treatment that most primary care physicians are comfortable prescribing that can help. And there are injectable medicines that people can even do at home just once a month that can help with their COPD. A lot of these treatments are targeted towards preventing flares or exacerbations from COPD, but some of them can also just make you feel better on a day-to-day basis and give you more stamina.

Host: And who might benefit from these newer treatments?

Kathryn S. Robinett, MD: It really depends on what your blood work shows, which one might help. There are a variety of different injectable medicines right now. The one that is on the market now is for people who have high eosinophils. Again, not a word we heard very often, but now I feel like during football games I'll see this on TV. So, there is lab work that can help us figure out if you're a good candidate for an injectable treatment. But there are also new ones coming out hopefully in the next couple of months that anyone who has COPD and has flares and aren't doing well could benefit from these injectable medicines. It's just a matter of which one is right for them based on their lab work.

Host: And speaking of flare-ups, some newer treatments are aimed at reducing COPD flare-ups, also called exacerbations. Hopefully, I'm saying that right. Why are flare-ups so serious and how can treatment help prevent them?

Kathryn S. Robinett, MD: So, flare-ups are specifically hard on patients with COPD. What we know is when we follow patients over time, and they've followed thousands and thousands of patients, that often after a flare-up when the patient loses some lung function, they're never actually able to get back to the lung function where they were before that flare.

So, that flare-up, even though people might feel better with a burst of steroids or some antibiotics or both, that flare-up can do permanent harm to patients' lungs. So, any time we can prevent a flare-up from happening, that's a win, and hopefully preserves people's lung function over time so they can live a much longer kind of healthier life with COPD.

Host: Let's talk about the cost. A lot of COPD medications are very expensive. What should a patient do if they're having trouble affording theirs?

Kathryn S. Robinett, MD: So, it's hard. And I'm not going to say this is easy. And, you know, we spend a lot of time as physicians kind of putting in different medicines and seeing what works best for patients' insurance. But just let us know immediately, because one of the big things I find is that I'll prescribe a medication hypothetically in my computer, it says that that medication is covered.

But then, when the patient gets to the pharmacy, it's covered. But instead of $600, it's $200, and no one can afford that. So unfortunately, what will sometimes happen is when I see them back in six months, they tell me that, you know, "Dr. Robinett, I couldn't afford my medication, so I haven't been on anything." And usually, we can find something else or a program through a pharmaceutical company that can help them, or some way to help them afford their medication. So, please just let us know as soon as you can.

Interestingly, some of the newer medications even have better plans to help patients who can't afford them, because those are very expensive. But there are a lot of options out there.

Host: Beyond medications, what treatments or habits make the biggest difference for people living with COPD?

Kathryn S. Robinett, MD: Absolutely. So, one of the things I said in the beginning, as soon as you know you're getting short of breath, don't blame it on aging, don't blame it on the fact you've been a smoker or just your COPD getting worse, because the more active you stay, the better you do with your COPD. So, the more physically active you can be, and this can be just, you know, I tell people walk around the whole Walmart or the Costco before you start shopping. Just day-to-day life, staying physically active makes a huge difference in how patients do over time.

One of the official ways we had to do this is through pulmonary rehab, which is a great option. They actually help patients by educating them about nutrition, breathing techniques that can help, and helping them exercise and stay confident that they're staying safe. I think that there can be a lot of fear if you feel short of breath, that you're hurting your lungs or hurting your heart. And really, what we know based on the science is the more active you can stay, the stronger your heart and lungs stay.

Host: Do people need to quit smoking once they find out they have COPD? That's got to be hard to do.

Kathryn S. Robinett, MD: Yes. So, quitting smoking is incredibly difficult, and it's the most important thing you can do. And this is smoking everything, like cigarettes, marijuana. There's, I feel, like some language out there or advertising that vaping is better, which it is not better than cigarette smoking. COPD is too much inflammation in your lungs, and any time you're breathing in any of those irritants, you're just driving that inflammation, continuing to irritate your lungs and causing destruction of the airways.

We have a whole clinic at University of Maryland to help people quit smoking. There are a lot of different techniques, and there's actually a lot of science recently that's gone into how to help patients quit smoking. What happens is when people smoke, they lose a lot of lung function over time, and if we can help you quit smoking, then that levels out so you're not continuing to lose that lung function. So, quitting smoking is actually the number one most important, but also shouldn't be a barrier to getting other treatments. So while you're quitting smoking or while you're working on that, it's important to treat your shortness of breath and your COPD.

Host: How do vaccines fit into the picture for people living with COPD?

Kathryn S. Robinett, MD: Absolutely. Vaccines are a great topic, and it's something that I'm very passionate about. It is truly an ounce of prevention is worth a pound of cure. Things like viruses can cause those COPD flares. And a lot of times, it can end patients up in intensive care units. Once a patient ends up in an intensive care unit, their next six months is as risky as someone who had a heart attack.

So even one hospitalization ICU with COPD puts patients at huge risk over time. So if we can prevent that by getting a flu vaccine or a COVID, RSV or pneumonia vaccine, all of those are big triggers for patients with COPD. So if we can prevent that infection and then prevent that exacerbation, that can really help a patient kind of do well and thrive over time, rather than continuing to lose that lung function and putting them at risk.

Host: Can nutrition help? Good nutrition?

Kathryn S. Robinett, MD: Yes. So, I feel like protein is like the word of the moment, but certainly eating well. I really advise my patients to just try to eat as few processed and ultraprocessed foods. I think it's difficult to define these things, and the definition is moving over time. But eating well, just healthy whole foods as much as possible makes a huge difference. In part because if you lose weight with COPD, because it takes your body a lot more effort to breathe, you're using more calories, that actually has a worse outcome. So if you're losing weight because your body's working so hard to breathe, that can predict that you're going to do poorly over time. So, make those calories count. Eat good quality food with good vitamins, and that makes the biggest, biggest difference over time.

Host: And oxygen therapy or inhaler technique, tell us about those.

Kathryn S. Robinett, MD: Well, inhaler technique is so tricky. I spend an entire day at our national conference teaching doctors how to use inhalers, because there are so many different types. Just because you're good at one type doesn't mean you know how to use another type. So, being able to use that medicine to get it deep down into your lungs where it's doing all of the benefit is of critical importance.

So, talk to your doctor, talk to your pharmacist. There are lots of great videos and probably podcasts too, but videos on YouTube that are put out to help people use their inhalers properly. If you're on the right medicine—I shouldn't put that in air quotes—if you're on the right medicine but you're not taking it properly, it's not getting to the place where it can help you most. That's a little bit of a different topic than oxygen therapy.

So, oxygen therapy is mission critical for people whose oxygen level drops below a certain number. And the number is 88%. That's not something you need to remember. That's something your doctors will know. But, you know, if you find that your oxygen level's dropping, I feel like some people have those what we call pulse oximeters or things at home that can measure oxygen, if that's dropping down into the low 90s, definitely talk to your doctor. What we know about oxygen is if you really need it and you use it, again, it can really affect how long you live and how well you live. So, that's a very important thing to be aware of, talk to your doctor about. And if it is prescribed, try to use it

Host: What are three questions someone with COPD should ask their pulmonologist at their next visit?

Kathryn S. Robinett, MD: I think more than questions to ask the doctor—and I will get back to that—is just being very honest about how you're limited by COPD. I think this is my third time saying it, but I have just seen so many patients struggle. And then, when I ask them, "How are you limited by your COPD?" or, "What are you not doing now that you were doing six months ago?" People will be like, "Oh, I'm fine. I feel great." And, you know, "No problems. I just have my smoker's cough." But then, you talk to them, and they're not doing things that they were doing six months ago. So, keeping that in mind. And the moment—I guess on the flip side—the moment you notice that you can't do something that you were doing six months ago, make sure you ask your doctor if there are better options for treatment of your COPD.

If you ever need a burst of steroids, and steroids and antibiotics can make you feel better, make sure that you're asking about whether or not you're on the best treatment or if you should be seeing a specialist for your COPD. Because those flares, even if it goes away with some antibiotics and prednisone, really are causing further destruction of your lungs rapidly every time you have one. So, those flares or exacerbations, as soon as you have one, make sure you're asking your doctor about next steps.

And then, the last thing is what you asked me about exercise. I think sometimes, you know, we get wrapped up in the medicines and the prescriptions we can prescribe, but asking your doctor about what exercise might be right for you, if you might qualify for rehab in any way to kind of help keep you active and keep you strong.

Host: In closing, is there anything else you'd like to add?

Kathryn S. Robinett, MD: I would just say I think that there's a lot of patients that blame themselves when they have COPD, which can be different than other diseases like asthma or other things. And that is just a complicated topic. We have things that can help you. Don't feel ashamed of your disease. Don't be afraid to ask for more.

If you're feeling short of breath, if you're having symptoms, if you're noticing you're making your life smaller because of your cough, because you can't breathe like you used to, make sure to ask for help. There are specialists that can help you with some of these more advanced medicines we touched on today.

And also, just really the vaccines are one of the things that can make the biggest impact. Because if you get one of those viruses and have a flare, it can cause a lot of long-term damage to your lungs that we can't reverse

Host: Good to know. Thank you so much for sharing your expertise. This has been so informative and helpful.

Kathryn S. Robinett, MD: Of course, Maggie. I really appreciate the opportunity.

Host: Again, that's Dr. Kathryn Robinett. Listen to more at umms.org/podcast, YouTube, or your favorite podcast platform. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media.