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If only managing a patient with an obstructive lung disease — like asthma or chronic obstructive pulmonary disease (COPD) — were as easy as writing a prescription.

As it stands now, physicians also have to worry about whether their patients are using their inhalers correctly, or even taking their medications at all, as well as numerous other factors that can complicate their prognosis.

“Every patient is different,” said Amy Attaway, MD, a pulmonologist with Cleveland Clinic in Cleveland. “Every patient has these barriers that are impacting their COPD or asthma that is making it difficult to treat them optimally.” 

What Are Treatable Traits? 

A recent study published in the International Journal of Chronic Obstructive Pulmonary Disease described how many primary care patients exhibit various combinations of treatable traits, thus requiring personalized attention to help get their symptoms under control.

Attaway said she likes the treatable trait concept, which includes assessing each patient and developing personalized approaches for their specific issues. “If you don’t define a problem, it’s really hard to treat it,” she said. “This highlights that every patient is different, and you have to personalize their therapy.” 

The study authors specifically looked at the following traits in people with asthma, COPD, or a combination of both:

• Insufficient inhaler technique
• Poor adherence to lung medication
• Type 2 eosinophilic inflammation
• Current smoking
• Obesity
• Physical activity
• Reversible airflow limitation
• Anxiety and/or depression

All these treatable traits can pose challenges by themselves — potential combinations only drive up the complexity.

Primary care physicians are already addressing many of the treatable traits, such as obesity and physical activity, as well as anxiety and depression. But there are still ongoing challenges.

That’s particularly true for most patients with COPD because the condition often exists in tandem with other comorbidities that must be managed, according to Wilson Pace, MD, a family medicine physician and professor emeritus in family medicine at the University of Colorado Anschutz Medical Campus, Aurora, Colorado.

Then, there’s the time element — or the lack of time — as the case may be. “That’s the great burden of a primary care physician,” said Stephanie LaBedz, MD, a pulmonologist with UI Health in Chicago.

Having a checklist of treatable traits can help physicians keep track of all the factors that may be influencing their patients, said Attaway. But clinicians may not have the time in a single visit to address all of them. Even a short inhaler technique training session or refresher can take some time.

“If you see multiple patients a day, that 5 minutes really adds up,” said Edward Len, MD, a pulmonologist with the Mid-Atlantic Permanente Medical Group in Largo, Maryland.

Social determinants of health that affect medication adherence may also need addressing, said Len. For example, physicians may need to determine if their patients have transportation to and from a pharmacy to pick up medications, as well as money for the copays.

Medication Use Challenges

Some treatable traits may be harder than others to manage from a primary care setting.

Each type of inhaler requires a specific inhalation technique , and some patients must use multiple different types of inhaled medications to manage their obstructive lung disease — which requires them to master different techniques.

Additionally, age and cognitive function can also affect a patient’s ability to use their inhaled medications correctly, according to research.

“They don’t recognize that they don’t have optimal inhaler technique,” LaBedz said. “They think they’re doing it correctly.” 

Perhaps not surprisingly, perfect inhalation technique by patients is rare, which means that patients may not be receiving as much benefit from their inhaled medication as they should.

And that’s assuming that they’re diligent about trying to use their medications. Theaforementioned study cited people forgetting to use their medication as one of its treatable traits.

According to LaBedz, medication adherence among patients with COPD is below 50%.

In fact, some research estimates that adherence among patients with obstructive lung disease is between 10% and 40%, even though they’re more likely to experience exacerbations that lead to hospitalization when they’re not properly taking their meds.

“If they’re not using the inhaler, it’s not going to work,” said Len.

LaBedz said she would not expect a primary care provider to handle insufficient inhaler technique — at least not all by themselves. As a pulmonary specialist, she can offer an in-depth assessment of inhaler technique education and training.

However, while primary care physicians may not always have time, primary care practices can designate and train a nurse to educate patients on proper inhalation technique, Pace suggested.

“Well-running primary care practices try to make sure that everyone is working at the peak of their license,” he said.

Having in-house staff to work with patients on inhaler technique could also reduce the burden on the patient since they wouldn’t have to make an additional visit elsewhere to receive training, Pace said. It may also reduce the likelihood that a patient would be a no-show at their follow-up visit, which research suggests is a common phenomenon among patients who receive a referral from a primary care physician to see a specialist.

Getting Patients on Board 

One challenge not included in the above study’s treatable traits list: patient motivation.

Sometimes, physicians may find themselves having to persuade patients to make changes in their behavior, and that can be its own challenge.

“If they don’t care enough about it, getting them to change behavior is tough,” said Pace.

Even similar motivations can require different approaches. What works for one patient may not be as effective for another.

“You always have to come to the middle with patients,” said Geoffrey Chupp, MD, a professor of medicine in pulmonary, critical care and sleep medicine at the Yale School of Medicine, New Haven, Connecticut. “Everybody has their own journey. Some people are more adept at these things than others. You have to find what works for any core individual. You have to reinforce it and give them positive feedback.”