In a hospital setting, COPD can be treated in a variety of ways. But problems can arise when patients get back home. One way to mitigate COPD hospital readmissions is to provide better technology.
By Greg Thompson
Chronic obstructive pulmonary disease (COPD) repeatedly brings patients back to the hospital where the majority of RTs ply their trade. In a controlled setting, the progressive disease can be treated in a variety of ways. Problems arise when patients get back home.
Regina Gillispie, RRT, has seen the pattern too many times. “Hospital RTs are not always trained on the home care equipment,” said Gillispie, CEO and owner of Best Home Medical, Barboursville, WV. “In homecare, you have to modify and adapt.”
As an umbrella diagnosis, COPD includes chronic bronchitis and emphysema, and some patients develop bronchiectasis as a complication of COPD. In the home or the hospital, airway/secretion clearance often becomes an immediate need for patients in the middle and latter stages of COPD and bronchiectasis.
“In the home, patients would use nebulizers to take their breathing treatments with bronchodilators or medications that may have steroids or other medications that will help break up secretions so they can cough it up,” Gillispie said. “We teach patients how to take the treatment at home and how to clean and disinfect equipment at home. In the hospital, they throw the medicine cup and the circuit and everything else away every day. In the homecare setting, patients and caregivers must learn how to clean, disinfect, and reuse to prevent reinfection.”
RTs at Best Home Medical educate patients about how to reuse equipment safely and effectively for optimum outcomes. “When we set patients up on nebulizers, we instruct them on how to do deep breathing and coughing and why that’s important,” Gillispie said. “We don’t put many incentive spirometers out, but hospitals use them post operatively, and they help to exercise and strengthen lungs so patients can cough more effectively. If they can cough effectively, that’s the best way for COPD patients to clear those airway secretions.”
When exercise and strengthening are not enough, Gillispie relies on technology such as the AffloVest mobile, mechanical HFCWO (high-frequency chest wall oscillation) vest. Manufactured by International Biophysics Corp, Austin, Texas, the Afflovest is battery operated and mobile.
Neal Smith, director of Marketing for International Biophysics Corp, explains that the Afflovest has been available since 2013 and is currently in its fifth generation. He said the current version is “lighter and more ergonomic for better fit and more powerful than our previous generations.” According to Smith, AffloVest’s Direct Dynamic Oscillation technology provides eight anatomically positioned oscillating motors that target the five lobes of the lungs, front and back, to thin, loosen, and mobilize lung secretions through three different modes—percussion, vibration and drainage.
“Patients wear the vest a couple of times a day depending on what the doctor prescribes,” said Gillispie, winner of the 2018 Van Miller Homecare Champion Award. “It vibrates and percusses the chest wall to mobilize and loosen up those secretions so patients can cough them up. The vest has really come a long way. It’s one of the newest treatments for COPD to mobilize secretions.”
Vest technology is a long way from the “cupping hand” method that moved patients from side to side. COPD patients now can get the vests at home as long as they have a diagnosis of COPD and a CT scan that verifies the diagnosis. “A lot of patients don’t know that, and a lot of RTs in hospitals don’t know that patients can qualify for those vests at home now,” Gillispie added. “It’s really important, now more than ever, because hospitals are getting dinged on readmissions. If they can keep COPD patients from developing pneumonia and reinfections by keeping them coughing and mobilizing their secretions, that hopefully will decrease readmissions, which will save the hospital money.”
Similar to Gillispie’s experience, Tanya Hughes, RRT, typically starts COPD patients with a nebulizer or oxygen machine soon after diagnosis. As the disease progresses, equipment needs increase. “Patients typically end up on a noninvasive ventilator with us,” said Hughes, complex respiratory manager for Major Medical, a regional durable medical equipment (DME) company with nine locations in Colorado.
Hughes also uses an Afflovest for secretion mobilization/percussion therapy. If patients need suction or cough assist therapy, she uses a Devilbiss Suction machine or a Philips Respironics T70 cough assist device. “If you’re talking secretion clearance, ventilators will help to open up the airways, but it’s not going to remove secretions per se,” Hughes said. “In homecare, COPD is probably the most undermanaged disease we have.”
Too often the problem goes back to a lack of education as to what must be done in the home. “When patients go into the hospital, medications are managed very specifically,” Hughes explained. “Hospital-based RTs are putting patients on ventilators and managing secretions using suction and cough techniques. They get the patients better and send them home on the old routine. Patients end up right back in the hospital because their old routine was not sufficient—or the patients are not being followed.”
Part of the problem is that there is no Medicare billing code for respiratory therapy in the home. “RT in the home is not a covered benefit; it’s not a benefit at all,” Hughes lamented. “My services come with the ventilator, but it’s really to maintain the ventilator. It’s not to provide a pulmonary rehab program for patients and assist with airway/secretion clearance.
“The result is that patients are not maintaining their medications and not maintaining their pulmonary rehab—unless they are in some pulmonary rehab program where they typically have to go to a doctor’s office or a hospital,” Hughes continued. “That’s rare, because a lot of them don’t drive.”
Hughes is largely satisfied with the level of airway/secretion clearance technology currently on offer, but she sees room for improvement. “The technology could be better if it were more portable and lighter weight,” she said, “so these patients could use the therapy when they are out and about and not just in their chair or in their bed.”
For Chris Brooks, chief strategy officer at Seattle-based Ventec Life Systems, technology falls into a combination category with the company’s VOCSN, which stands for Ventilation Oxygen Cough Suction Nebulizer. VOCSN combines five pieces of respiratory equipment that traditionally are required for patients using mechanical ventilation. “The ability to have all of these therapies in one device offers a lot of convenience, but also supports better compliance,” Brooks said. “Often patients at home are being cared for by friends and family, so you want a device that is easy to learn, easy to use, and with them at all times so that patients actually use their devices.”
VOCSN became available in 2017, but the Ventec team continues to update the relatively new device based on feedback from patients and caregivers. Brooks explained: “We have rolled out multiview, which is the first ever holistic monitoring of ventilator patients. This is key to the COPD ventilator population. They are frequent fliers back to hospitals. They are discharged from the hospital, go to homecare, a DME provides equipment in the home, and then they have an exacerbation and they end up back in the hospital.
“Readmissions are due to a variety of complicating factors,” Brooks continues, “but one of the ways to mitigate readmissions is to provide better technology to care for and monitor these patients. Beyond just monitoring ventilation, that monitoring includes medication delivery with oxygen and nebulizer usages—and secretion management with cough and suction usage.”
Within the more controlled setting of a pulmonary specialty group, Jeni Brooke, RRT, University of Washington Medical Center, Seattle, treats patients with cystic fibrosis, lung transplants, interstitial lung disease, COPD, and Bronchiectasis (sometimes a complication of COPD) and more. Secretion clearance issues come up frequently within the COPD and bronchiectasis disease processes, and the first technology-free line of defense is huff coughing.
The series of inhales with forceful exhales can force secretions to the upper airway, and RTs know it well as a classic first step. From there, it’s postural drainage along with chest physiotherapy (CPT). “The next thing would be positive expiratory pressure [PEP] therapy, and within PEP therapy are many different tools,” said Brooke, who works at the Medical Specialties Pulmonary Clinic within the UW Medical Center. “One of the name brands you see in hospitals is The Acapella Choice airway clearance device from Smiths Medical. Another brand is Aerobika.”
If those are not working, Brooke moves on to the familiar vest therapy. The first type involves pneumatic flow, or air flow. “A vest is put on that covers the lung field,” she explained. “As patients wear the vest externally, it shakes/vibrates their lungs as they are breathing to help loosen secretions that are stuck to the airway walls—eventually making it easier to cough.”
Another form of HFCWO vest therapy is the Philips InCourage system, which uses a patented technology called triangle waveform to deliver brief, intense thumps to the chest, similar to CPT.
“Research has shown triangular waveform technology clears up to 20% more mucus than competing technology,” said Gary Hansen, PhD, director of Scientific Affairs, RespirTech, a Philips Company. “In addition, the InCourage system features active venting, which is designed to enable deep breaths during therapy, enhance comfort, and help encourage adherence…We believe that HFCWO therapy is an important form of treatment for a growing number of pulmonary diseases.”
Chicago-based Hillrom offers two devices for airway/secretion clearance: The Vest Airway Clearance System and The Monarch Airway Clearance System. “While not all COPD patients require airway clearance, an appreciable portion of patients with COPD also have bronchiectasis,” said Andy Reding, vice president and general manager, Respiratory Health, Hillrom.
The Vest Airway Clearance System and The Monarch Airway Clearance System are specifically designed to assist patients in the mobilization of retained secretions that, if not removed, may contribute to increased rates of respiratory infection, hospitalization, and reduced lung function.
“The Vest system is based on HFCWO technology, which Hillrom pioneered,” Reding explained. “HFCWO technology generates increased airflow velocities to create cough-like shear forces and decreases secretion viscosity. This assists patients in moving retained secretions and mucus from the smaller airways to larger airways where it can be cleared by coughing or suctioning.”
While embracing all the new technology, Jeni Brooke at the University of Washington is keen to point out that all therapies rely on an “intact cough” to be effective. Brooke uses a peak expiratory flow device to measure cough function. The unit is plastic and inexpensive but the measure of peak cough flow is key to determining whether patients have enough “umph.”
“All of these therapies—huff coughing, CPT, postural drainage, PEP, and vest therapy—are designed to take retained secretions in the lungs, shake them loose, and make it easier to cough them up and out,” Brooke said. “Even if we shake secretions loose with the vest, we need to know if the cough is strong enough to get those secretions up and out.”
Greg Thompson is a contributing writer to RT. For more information contact [email protected].