The Role of Telemedicine in Extending and Enhancing Medical Management of the Patient with Chronic Obstructive Pulmonary Disease

medicina Review The Role of Telemedicine in Extending and Enhancing Medical Management of the Patient with Chronic Obstructive Pulmonary Disease Claudio F. Donner 1,*, Richard ZuWallack 2,3 and Linda Nici 4 1 Fondazione Mondo Respiro ONLUS, Via Monsignor Cavigioli, 10, 28021 Borgomanero, Italy 2 Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT 06015, USA; [email protected] 3 University of CT, Farmington, CT 06030, USA 4 Pulmonary and Critical Care Section, Providence Veterans Administration Medical Center, Brown University, Providence, RI 02908, USA; [email protected] * Correspondence: [email protected] Abstract: Medical management of a chronic obstructive pulmonary disease (COPD) patient must incorporate a broadened and holistic approach to achieve optimal outcomes. This is best achieved with integrated care, which is based on the chronic care model of disease management, proactively addressing the patient’s unique medical, social, psychological, and cognitive needs along the tra- jectory of the disease. While conceptually appealing, integrated care requires not only a different approach to disease management, but considerably more health care resources. One potential way to reduce this burden of care is telemedicine: technology that allows for the bidirectional transfer Citation: Donner, C.F; ZuWallack, R.; of important clinical information between the patient and health care providers across distances. Nici, L. The Role of Telemedicine in This not only makes medical services more accessible; it may also enhance the efficiency of deliv- Extending and Enhancing Medical ery and quality of care. Telemedicine includes distinct, often overlapping interventions, including Management of the Patient with telecommunication (enhancing lines of communication), telemonitoring (symptom reporting or the Chronic Obstructive Pulmonary transfer of physiological data to health care providers), physical activity monitoring and feedback to Disease. Medicina 2021, 57, 726. the patient and provider, remote decision support systems (identifying “red flags,” such as the onset https://doi.org/10.3390/ of an exacerbation), tele-consultation (directing assessment and care from a distance), tele-education medicina57070726 (through web-based educational or self-management platforms), tele-coaching, and tele-rehabilitation (providing educational material, exercise training, or even total pulmonary rehabilitation at a dis- Academic Editor: Sabina Antonela Antoniu tance when standard, center-based rehabilitation is not feasible). While the above components of telemedicine are conceptually appealing, many have had inconsistent results in scientific trials. Received: 11 June 2021 Interventions with more consistently favorable results include those potentially modifying physical Accepted: 13 July 2021 activity, non-invasive ventilator management, and tele-rehabilitation. More inconsistent results in Published: 18 July 2021 other telemedicine interventions do not necessarily mean they are ineffective; rather, more data on refining the techniques may be necessary. Until more outcome data are available clinicians should Publisher’s Note: MDPI stays neutral resist being caught up in novel technologies simply because they are new. with regard to jurisdictional claims in published maps and institutional affil- Keywords: telemedicine; telehealth; integrated care; COPD iations. 1. A Brief Review of COPD Copyright: © 2021 by the authors. Chronic obstructive pulmonary disease (COPD) was conceptualized by the Global Ini- Licensee MDPI, Basel, Switzerland. tiative for Chronic Obstructive Lung Disease (GOLD) in 2021 [1] as a common, preventable, This article is an open access article and treatable disease characterized by persistent symptoms and airflow limitation. It goes distributed under the terms and on to say that the airflow limitation can be due to combinations and varying degrees of conditions of the Creative Commons alveolar abnormalities (i.e., emphysema) and small airway obstruction. Both of these Attribution (CC BY) license (https:// processes are underpinned by chronic inflammation. However, the authors of GOLD point creativecommons.org/licenses/by/ out that the terms “emphysema” and “chronic bronchitis” are not used in the current 4.0/). Medicina 2021, 57, 726. https://doi.org/10.3390/medicina57070726 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 726 2 of 13 definition of COPD, because emphysema is a pathological term (distension and destruction of alveolar units) that is often misused clinically, and chronic bronchitis is a clinical term (cough and sputum production for at least 3 months over 2 consecutive years), is not particularly common, and can be present without airflow limitation. Rather, the GOLD contributors emphasize the need for the spirometric demonstration of airway obstruction in the appropriate clinical setting. Using an analogy for a systemic hypertension diagnosis (perhaps a bit outdated) the “140/90” for COPD is a forced expiratory volume in one sec- ond (FEV1)—a forced vital capacity FVC ratio (FEV1/FVC) < 0.70 on post-bronchodilator spirometry. Spirometric severity is then determined using the percent predicted FEV1 based on comparison with normative reference values. The most common and frequently overriding symptom in COPD is exertional dyspnea. As stated above, post-bronchodilator spirometry is necessary to confirm the diagnosis of COPD (in the appropriate clinical setting) and determine the degree of airway obstruction. This information, although necessary, is not sufficient to capture the full impact of this disease on the individual. With respect to respiratory physiology, dynamic hyperinflation of the lung is at least as prominent a factor in exertional dyspnea and exercise limitation as the degree of airflow limitation [2,3]. Furthermore, COPD is best considered a disease that has additional effects apart from just the respiratory system, with frequent associated systemic and co-morbid conditions [4,5]. Some of the systemic consequences or co-morbid associations contribute significantly to dyspnea; these include reductions in ambulatory muscle mass or oxidative enzymes, associated cardiovascular disease, fear of dyspnea- producing activities, and improper pacing techniques, to name a few. [6–8] Although exercise training, as delivered in a comprehensive pulmonary rehabilitation program, does not affect airflow limitation, it nevertheless results in reductions in dyspnea—presumably through mitigating the effects of the above-mentioned conditions. Systemic effects of COPD, in addition to aggravating exertional dyspnea, lead to detrimental outcomes in other ways. For example, it has been known since 1996 that a low timed walk distance, arguably a measure of the overall “protoplasm” of a patient, was a stronger predictor of mortality than FEV1 in COPD patients completing pulmonary rehabilitation [9]. This was exemplified by the development of a multi-component staging system, BODE (body mass index, airway obstruction (FEV1), dyspnea (Medical Research Council rating), and exercise capacity (six minute walk distance)) which was a stronger predictor of survival in COPD than any component alone [10]. Other studies showed that dyspnea level, leg or arm muscle depletion, depression, and co-existing cardiac disease also predict all-cause mortality in COPD [11–16]. Finally, COPD can be characterized not simply as a progressive disease that leads eventually to an increasing symptom burden, but one that is commonly punctuated by exacerbations. A universally accepted definition of COPD exacerbation unfortunately does not exist, probably reflecting the heterogeneity of COPD phenotypes in general and the exacerbation symptoms in particular. Two basic categories of exacerbation definitions exist: symptom-based and health care-utilization-based. The former refers to the increased symptom burden of the exacerbation, while the latter (often used in pharmaceutical research studies) refers to associated increases in health care resources, such as bronchodilators, antibiotics, or health care visits. Neither is perfect. One relatively new suggested definition is increased sputum volume or sputum purulence that is sometimes, but not necessarily, accompanied by an increased cough, assuming other etiologies (such as heart failure) are ruled out [17]. Regardless of its definition, exacerbation is a major driver of increased symptom burden, reduced health-related quality of life, reduced functional status, and increased health care utilization and mortality risk. There is some evidence that its early recognition—and resulting early treatment—may reduce its severity. Because of this, collaborative self-management strategies, resulting in early detection by the patient and establishing effective lines of communication with the health care provider, are essential components of an effective COPD management strategy. Medicina 2021, 57, 726 3 of 13 The “take home message” from the above very brief review of COPD is that, for optimal clinical management, focusing simply on airway obstruction or even on the respiratory disease is too short-sighted. Instead, a broadened, more holistic approach is necessary to achieve optimal outcomes. Enhanced care of this type may benefit from the integration of care, perhaps augmented by newer technologies, such as telemedicine. This will be the main focus of the remainder of this review. 2. Integrated Care and the Chronic Care Model of Disease Management A workshop on the

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