Home-based Pulmonary Rehabilitation: Benefits Similar to a Standard Program

Home-based Pulmonary Rehabilitation: An Alternative Approach

Background: Unfortunately, overall participation in standard pulmonary rehabilitation programs is low. The many reasons include no interest, “I am too busy,” travel time, inconvenience, and cost, depending on the individual’s medical insurance.

Although home-based pulmonary rehabilitation offers an alternative, there is little information about its benefits. Does it work as well as a person going to the hospital or facility with an experienced nurse, respiratory therapist, and/or an exercise specialist?

Dr. Elizabeth Horton

Dr. Elizabeth Horton is Senior Lecturer in Exercise and Health at Coventry University

Study: Dr. Elizabeth Horton and colleagues from the Faculty of Health and Life Sciences, Coventry University, and the Centre for Exercise and Rehabilitation Science, University Hospitals Leicester NHS Trust, in the United Kingdom performed the study. 187 patients with COPD referred to their hospitals for pulmonary rehabilitation were assigned to either a standard program supervised by trained professionals OR to a structured unsupervised home-based pulmonary rehabilitation program. Shortness of breath with activities was selected as the main outcome to compare whether the home-based program was “as good as” the hospital-based program.

The home-based pulmonary rehabilitation program included one hospital visit with a health care professional trained in motivational interviewing, a self-management manual, instructions on exercise, and two telephone calls over the 7 weeks.

Different exercises as part of a home-based pulmonary rehabilitation program

Different types of exercises can be performed as part of a home-based pulmonary rehabilitation program

The study was published on-line on July 29, 2017, in the journal Thorax (doi: 10.1136/thoraxjnl-2016-208506).

Results: Both groups of patients had significant, but similar, gains in shortness of breath measured on the Chronic Respiratory Questionnaire Self-Report after 7 weeks. The authors did not report on changes in other outcomes such as exercise ability or albuterol rescue use.

Conclusions: The authors concluded that a structured home-based pulmonary rehabilitation program was “as good as” the standard hospital-based program for improving daily shortness of  breath.

My Comments: Not everyone with COPD is interested or able to perform physical activities for a variety of reasons. For almost all patients with COPD whom I see in my practice, I recommend participation in a standard pulmonary rehabilitation program . Major benefits include: better breathing; better quality of life; less frequent flare-ups (exacerbations); and the ability to do more physical activities.

Water exercise may be part of a home-based pulmonary rehabilitation program

Water Aerobics may be part of a home-based pulmonary rehabilitation program

If this is not possible, then I encourage the person to “do more” on their own. This may using a treadmill or exercise bike in their apartment or home, going to a community fitness center, and/or using an available swimming pool. I ask the person to write down these activities on paper or on the computer and bring this information at their next appointment.

Damp, Moldy Homes Are Associated with Sinus Problems and Bronchitis

Damp, Moldy Homes Tied to Respiratory Symptoms

Background: Many individuals believe that exposure to mold in their apartment or house contributes to breathing complaints, including cough, shortness of breath, and chronic bronchitis. Although dampness at home has been associated with respiratory conditions in children, there is little information about damp, moldy homes and chronic respiratory symptoms in adults.

Evidence of damp, moldy homes

Mold on wall behind couch

Study: Dr. Caroline Pind and colleagues at Uppsala University sent questionnaires to residents of four cities in Sweden about respiratory symptoms, smoking, education, and environmental exposures. The questionnaire identified dampness by asking about visible water damage, floor dampness, or visible mold in the home during the last 12 months. The study results were published on-line on July 11, 2017, in the journal Clinical & Experimental Allergy (DOI:10.1111/cea.12976).

Evidence of damp, moldy homes

Black mold on ceiling due to leaky roof

Results: Over 26,000 adults living in Sweden answered the questionnaire. Overall, 11% reported signs of dampness. Dampness was more common in humid or mild climates compared with areas of the country with longer, colder winters. Compared with non-smokers with no signs of any dampness, 90% of non- smokers with any dampness in their home were more likely to have nighttime shortness of breath, while 67% were more likely to have chronic bronchitis. There were higher rates of wheezing, nighttime coughing, and asthma in the group with signs of dampness at home.

Conclusions: The study showed an association between dampness at home and chronic respiratory symptoms in adults. The authors suggested that these findings support reducing indoor dampness. Dr. Jouni Jaakkola of the University of Oulu in Finalnd commented that, “I found it interesting and alarming that the adverse effects were stronger among people of low socioeconomic status due to limited possibilities for moving to a better home or making needed renovations.”

My Comments: This study points out the ill health effects of exposure to mold where you live. It is important to locate moisture problems, removing molds, and controlling excessive water and condensation at home. Leaky pipes and roofs are often the problem. The U.S. Environmental Protection Agency has information on controlling mold on-line: EPA.gov(bit.ly/29fx)4Y) as does the U.S. Centers for Disease Control and Prevention on CDC.gov (bit.ly/2lxArWu).

Yoga in COPD: Results of Two New Studies

Yoga in COPD: Benefits with Yoga at Home 

Background: Yoga is a form of physical movement and posture that includes meditation and spirituality. The word – yoga – means “to add,” “to join,” “to unite,” or “to attach.” There is limited information about the practice of yoga in COPD patients.

Pranayama is a traditional yoga practice of controlling breathing. In general, the focus is on slowing and extending the breath, particularly during meditation. It emphasizes that when you breathe in, you bring in energy to your body; and when you breathe out, you allow stress to leave your body.

Example of Pranayama yoga in COPD

Woman in yoga pose

Pranayama is more than simple awareness of the breath. It involves specific rhythms and techniques to bring the following benefits.

  • Calms the mind, reducing worries and anxieties
  • Improves focus and attention, removing brain fog
  • Increases energy, bringing enthusiasm and positivity
  • Boosts the immune system
  • Rejuvenates the body and mind
  • May even slow down the aging process


Dr. kanminsky is first author of study of yoga in COPD

David Kaminsky, M.D., Professor of Medicine at the University of Vermont College of Medicine

Studies: Two recently published studies evaluated yoga in COPD performed at home. 1. Dr. David Kaminsky and colleagues at the University of Vermont College of Medicine evaluated whether the practice of pranayama, or yoga breathing, could be done at home as an alternative to pulmonary rehabilitation. There were two groups of patients with moderate to severe COPD. One group participated in pranayama yoga plus education for 12 weeks; the other group received education alone.

The study was published on-line on July 17, 2017, in the Journal of Alternative and Complementary Medicine.

Drr.Donisky is first author of study on yoga in COPD

DorAnne Donesky, RN, Ph.D., NP, Adjunct Professor of Physiological Nursing at UCSF School of Nursing

2. Dr. Donesky and colleagues at the Department of Physiological Nursing, University of California in San Francisco, evaluated whether those with COPD and heart failure could perform yoga at home. One group participated in one hour of TeleYoga classes two times a week. Yoga instructions were provided by live video connected to home televisions using the Internet. In the other group, each participant received educational materials by mail and a weekly phone call to discuss education information.

This study was published on-line on June 27, 2017, in the Journal of Alternative and Complementary Medicine.

Example of yoga to improve breathing. Can also be used as yoga in COPD

Women performing Bhastrika yoga

Results: Study 1. Those in the pranayama group increased the distance walked in six minutes by an average of 31 meters, while the education group had a decrease of 16 yards after 12 weeks. This difference was almost statistically significant. Both groups improved shortness of breath with activities. Study 2. There were 14 participants with COPD and heart failure. Those who received TeleYoga were able to safely participate in the classes, found the 8-week program enjoyable, and were less short of breath with activities.

Conclusions: Study 1. This pilot study demonstrated that pranayama yoga in COPD patients was associated with improved exercise tolerance.  Study 2. Despite frailty, those with both COPD and heart failure were able to perform yoga safely at home using instructions on television.

My Comment: You may wish to consider the benefits of yoga in COPD  either by itself or in addition to your current exercise program.

Combination Bronchodilators – An Analysis of Benefits

Combination Bronchodilators Improve Lung Function, Quality of Life, and Shortness of Breath

Background: There are two different types of bronchodilators (inhaled medications) that relax the muscle that wraps around the breathing tubes to allow more air to go in and out of the lungs. One type is called a beta2-agonist, and the other type is called a muscarinic antagonist.

Respiratory system - shows where combination bronchodilators work to open airways

Most of the 23 branches (divisions) of breathing tubes have muscle that wraps around the outside.

Why is This Is Important for You to Know? Because these two types of bronchodilators work in different ways to open breathing tubes. In the US, there are currently 4 available combinations of these two types of bronchodilators in a single inhaler device. In alphabetical order, the brand names are: Anoro; Bevespi; Stiolto; and Utibron.

Study: Because these combination bronchodilators are relatively new, Dr. Oba and colleagues at the University of Missouri School of Medicine reviewed 23 different studies that compared combination bronchodilators with one bronchodilators (called monotherapy). The analysis was published in the journal Thorax; year 2016; volume 71; pages 15-25.

Results: A total of 27,172 patients with COPD were included in the analysis. The combination bronchodilators had significantly greater improvements in breathing tests, quality of life score, and shortness of breath with daily activities compared with just one bronchodilator. In addition, there were fewer moderate-to-severe flare-ups (called exacerbations) with combination therapies compared with long-acting beta2 bronchodilators, but not compared with long-acting muscarinic antagonists.

Finally, there were no differences in safety with combination bronchodilators compared with a single medication.

Conclusions: Combination therapy was most effective in improving breathing tests, ability to breathe easier with daily activities, and overall quality of life. Safety was similar between combinations and monotherapy.

Like lollipops, combnation bronchodilators are better than one

Child holding two lollipops

My Comments: These findings support the simple observation that 2 is better than 1 with most things in life, including bronchodilators. Certainly, most children would rather have two lollipops than just one. The same concept applies to combination bronchodilators for those with COPD. Make sure to ask your health care professional whether you would benefit from combination therapy.

Air Quality is “Double Whammy” – Due to Smog and Ragweed

Air Quality is “Double Whammy” – Affects 4 in 10 Americans

The Natural Resources Defense Council (NRDC) released a report on July 11, 2017, that 4 out of 10 Americans live in counties with unhealthy levels of smog and ragweed pollen. The report can be found at: (http://www.nrdc.org/experts/kim-knowlton).

Both smog and ragweed pollen contribute to poor air quality is double whammy

Smog obscures view of downtown Los Angeles.

Kim Knowlton, a senior scientist at the NRDC, who oversaw the project,

D.r Kim Knowlton commented on air quality is double whammy

Kim Knowlton, Ph.D., is Senior Scientist and Deputy Director of Science Center of the Natural Resources Defense Council

said that, “Today, 127 million Americans live where ragweed and ozone can threaten their next breath. This health threat will just get worse if we don’t curb climate change soon.”

The report indicated that burning of fossil fuels such as oil, gas, and coal, worsen ozone pollution and extends the ragweed season. Ragweed was selected instead of other pollens, such as tree and grass, because more people are allergic to it than all the others combined. Ragweed comes out toward late summer when temperatures, and thus smog levels, are highest. It means that air quality is a “double whammy.”

air quality is double whammy

Dr. Perry E. Sheffield, Assistant Professor at Icahn School of Medicine at Mount Sinai

Smog forms on warm, sunny days and is made worse from the chemicals that come of vehicle tailpipes and from power plant and industrial smokestacks. According to Dr. Perry Sheffield, a pediatrician at Mount Sinai in New York, “It worsens respiratory illnesses such as asthma and COPD.”

The report listed the 15 worst states where smog and pollen are bad – meaning that air quality is “double whammy.” Those, listed in order with the worst, are: the District of Columbia, Connecticut, Rhode Island, Illinois, Pennsylvania, Utah, Ohio, Arizona, Michigan, Massachusetts, Delaware, Wisconsin, New Hampshire, Indiana, and Kansas.

What Can Be Done?

Ms. Juanita Constible of the NRDC commented that, “The federal government should focus on limiting smog, curbing power plant pollution, and increasing fuel efficiency.”

I encourage you to view my post on April 23, 2017, that describes a report   from the American Lung Association on air pollution. I listed 5 things that each of us can do to help reduce – air quality is a “double whammy” – so that we can all Breathe Easy.


Does COPD Cause Pain?

Prevalence of Pain is More Common in COPD (41%) Than Healthy Subjects (29%)

Background: Pain and shortness of breath are both unpleasant experiences which affect an individual’s quality of life. In different studies, the frequency of pain ranges from 44% to 88% in those with COPD.

Study: Dr. Annemarie Lee and colleagues at the West Park Healthcare Centre in Toronto studied 64 patients with COPD referred to a pulmonary rehabilitation program and 64 healthy subjects of the same age. All answered questionnaires about pain over a one week period, including location, its frequency, and how long it lasts, as well as questionnaires about shortness of breath, quality of life, etc..

The study is published on-line in the Journal of the COPD Foundation [2017; 4(3): In press. doi: http://doi.org/10.15326/jcopdf.4.3.2016.0172]

Results: Age range was 48 to 91 years in the COPD group and 47 to 94 in the healthy group. Those with COPD had either severe or very severe COPD based on results of breathing tests. Pain frequency was 41% of those with COPD and 29% in healthy subjects.

anatomical locations for chest and upper back pain

Chest and upper back pain are more common in those with COPD

Pain was more common in the chest and upper back areas in those with COPD compared to healthy subjects. It was described as aching (30%), tiring (17%), and penetrating (17%). The location in the chest and upper back was associated with more air in the lungs (higher total lung capacity) as measured on breathing tests.

Those with painful experiences also had more shortness of breath with activities and higher depression scores.

Locations of the chest for pain

Rib cage

Conclusions: The authors proposed that hyperinflation of the lungs (too much air trapped in the lungs) could cause stretching of the chest wall and cause strain on ligaments between ribs as well as excessive forces on the joints.

My Comments: Unfortunately, the researchers did not evaluate the cause of pain experienced by the subjects. For example, could some of those with COPD have arthritis of the spine? 

It is important to remember that there are no pain sensors in the lung itself, but rather in the lining around the lung (called the pleura) and in areas of the muscles, joints, and ligaments in the chest wall. The treatment for too much air trapped in the lungs includes bronchodilators (inhalers that open up the breathing tubes allowing more air to exit), oxygen, and exercise training.

Depression in COPD: Benefits of Treating Both Conditions

Depression in COPD: Treatments Reduce Visits to Emergency Department

Background: Depression is common in any chronic illness, including COPD. For example, in a three year study of 1,589 individuals with COPD about 1 in 4 individuals with COPD had persistent symptoms of depression over a three year period (CHEST 2016; volume 149: pages 916-926). Those with persistent or new-onset depression experienced more flare-ups (exacerbations) and a reduced walking distance.

Dr. Albrecht wrote about depression in COPD

Jennifer S. Albrecht, Ph.D., Assistant Professor at the University of Maryland School of Medicine

Study: Dr. Albrecht and colleagues from the University of Maryland School of Medicine reported on adherence to medications prescribed to treat both COPD and depression in the same individuals. Adherence refers to whether  you are taking the medications on schedule as prescribed by your health care professional.

The authors examined a random sample of those receiving Medicare who had two or more prescriptions filled for both COPD maintenance medications and anti-depressants. These individuals were followed for 12 months.

The study was published on-line in the journal Respiratory Medicine.

Results: Of the 16,075 individuals receiving Medicare, only 21% took their medications at least 80% of the time for COPD, and only 55% took their  anti-depressants at least 80% of the time. Compared to no use of medication and controlling for adherence to anti-depressants, higher levels of taking COPD medications were associated with a decreased risk of going to the Emergency Department (ED) and hospitalization. Also, higher levels of taking anti-depression medications led to fewer visits to the ED and hospitalizations compared to no use.

Depression in COPD in a woman

Woman with depression

Conclusions: Depression in COPD is common. Taking prescribed daily medications for both conditions – COPD and depression – can reduce the need for emergency visits and hospitalizations.

My Comments: There are many different reasons why someone does not take medications as prescribed even to help relieve symptoms (COPD → difficulty breathing; depression → feeling bad).

Some of the common reasons shared by patients in my practice for not taking medications are: cost (“It is very expensive”), lack of efficacy (“It doesn’t seem to work”), “I forget to take it,” and concern of side effects (“The TV add says that it may cause death”).

However, I often explain why I prescribe a particular medication, and review how to use a specific inhaler correctly. I ask the person to try the inhaler for 2-3 weeks (I usually give a sample), and that I will prescribe a different inhaler if it does not help with shortness of breath and/or reduce flare-ups (exacerbations).

Smoking in the US: Higher in Poor and Less Educated

Smoking in the US: A Socioeconomic Gap

A June 13 article in the Washington Post described America’s new tobacco crisis. As the headline stated, “The rich stopped smoking, the poor didn’t.”

Smoking in the US has decreased to an overall rate of 15% of adults. However, the socioeconomic gap has become bigger. The figure below shows that those who attended college or have a college degree have quit smoking at a greater rate than the less educated.

Smoking in the US

Smoking rates in the US from 1966 to 2015

It Wasn’t Always This Way

In the 1900s it was glamorous to smoke. It was a habit of the rich, and many Hollywood stars were happy to be photographed smoking. Then came the 1964 Surgeon General’s Report of its deadly effects. During the next 3 decades, smoking in the nation’s highest income families fell by 62%. Among families of the lowest income, it decreased by just 9%.

The Tobacco Industry

Cigarette companies are focusing their marketing on lower socioeconomic communities to retain their customer base. The tobacco industry has also invested money in lobbying against smoking restrictions and taxes, especially in poorer, rural, and often Southern states where smoking remains the highest.

Why the Difference?

One person smoking the US

Victoria Cassell, featured in the newspaper article, smokes a cigarette on the back deck of her house in Bassett, Va.

Debbie Seals, age 60 years, has traveled in rural Virginia to promote smoking cessation and a healthy life style, especially in the foothills of Virginia’s Blue Ridge Mountains. Seals noted that cigarettes are everywhere in Martinsville, a former booming center of textile mills and furniture factories, which now has abandoned factories and vacant storefronts. “People down here smoke because of the stress in their life,” Seals says. “They smoke because of money problems, family problems. It’s the one thing they have control over. The one thing that makes them feel better. And you want them to give that up? It’s the toughest thing in the world.”

The Solution

“The frustrating thing for folks in the public health community is we know from research exactly what would make the biggest difference,” said Brian King, deputy director for the Center for Disease Control and Prevention in Atlanta. “It’s bread-and-butter strategies like getting states to pass smoke-free laws, increase cigarette taxes, and funding tobacco cessation and prevention.”

Cost of Inhalers – Many Medicare Beneficiaries With COPD Struggle To Pay For Inhalers

Cost of Inhalers – A Problem for Many with COPD

Kaiser Health News reported many Medicare enrollees with COPD struggle to pay for the inhalers they need. The article reports that some patients skip doses or rely on physicians to provide them free samples for some doses, because of the high cost, which drives some patients into Medicare’s “doughnut hole.”

The article commented that many of those with Medicare insurance are on fixed income that needs to pay for rent/mortgage, car payment, Medicare premiums, and other living expenses. As one 67 year  old woman stated in the article, “I got to stretch out that, plus I have the less costly medicines that I have to pay for and also my oxygen. You can only stretch it so far.”

Woman comments on the cost of inhalers

67 year old woman with COPD commented about the cost of inhalers in the Kaiser Health News report

Medicare Spends Billions

What Can You Do? 

Even with only monthly co-pays, many Medicare enrollees can’t afford their inhalers. Here are FIVE options to consider: 1. Ask your health care professional whether he/she has samples of the inhaler. In my practice, I usually provide samples for 2 – 4 weeks of a particular inhaler and schedule the person to return to hear whether the medication has made it easier to breathe. 2. Many pharmaceutical companies provide vouchers that cover the cost for the first month (or more) of a new prescription. Ask you health care professional if he/she has vouchers. 3. Look on line-in for coupons that provide a discount of the cost of the inhaler. 4. Pharmaceutical companies may offer a patient assistance program. I have some patients who receive free supplies of one or more inhalers if he/she qualifies for assistance. You will required to provide personal financial information on an application. The information is typically available on-line or you can contact a social worker to help with the application process. 5. The website – www.needymeds.org – invites viewers to request a Drug Discount Card that may save on the cost of prescribed medications.

Hookah Smoking Is Risk Factor for Chronic Obstructive Pulmonary Disease

Hookah Smoking 

Owner of cafe for hookah smoking

40 year old owner of cafe in United Kingdom with hookah pipe

Background: Hookah smoking involves inhaling flavored tobacco from a Turkish water pipe. It is also called “hubbly-bubbly” or “shisha” and is becoming fashionable among young people, especially in cities.

The World Health Organization has warned that a one-hour session of hookah smoking can be as harmful as smoing 100

Cigarette smoking versus hookah smoking

Smokers typically take in 12 puffs on a cigarette compared to up to 200 for hookah pipes

cigarettes. This is because a cigarette smoker typically takes between 8 to 12 puffs. In contrast, during a typical hour long hookah session, smokers may take up to 200 drags.

Hookah tobacco tastes nicer than cigarettes because of the flavor, but contains all of the same toxins known to cause lung cancer, heart disease, and COPD.

Study: In the May 23, 2017, issue of the journal Chronic Respiratory Disease, Dr. Bahtouee and colleagues from the Bushehr University of Medical Sciences in Iran reported on the frequency of COPD in hookah smokers. These researchers performed breathing tests in 245 subjects who were at least 35 years of age who were taking hookah for at least 15 years and in 245 subjects who did not smoke hookah.

Results:  Ten percent of the chronic hookah smokers had COPD. The rate was higher in those with older age, 3 or more hookahs each day, number of years of hookah smoking, daily cough of mucus and shortness of breath for two or more years.

Conclusions: Hookah smoking significantly increases the risk of COPD.

My Comments: Smoking flavored tobacco from a water pipe occurs throughout the world. A review shows that current hookah smoking among university students is 6% in the Persian Gulf region, 8% in the United Kingdom, and 10% in the United States.  States with highest prevalence were the District of Columbia (17%), Nevada (16%), and California (16%). Current hookah smoking among high school students in the US is 5.4%.

It is important to educate everyone that hookah smoking causes COPD as well as other diseases associated with cigarette smoking.

COPD National Action Plan Announced at American Thoracic Society Meeting

COPD National Action Plan 

COPD is the third leading cause of death in the United States. It affects 16 million Americans, while millions more have not been diagnosed. COPD can limit a person’s ability to breathe and dramatically reduce quality of life.

James P. Kiley, Ph. D., Director of the Division of Lung Disease at the National Institute of Health

On May 22, 2017, at the International Conference of the American Thoracic Society in Washington, DC, Dr. James Kiley announced the COPD National Action Plan by the National Heart, Lung, and Blood Institute (part of the National Institute of Health). The COPD National Action Plan is the first-ever blueprint for a unified fight against the disease. It was developed at the request of Congress and provides a comprehensive framework for action by those affected by COPD and those who care about reducing its burden.

promo of COPD National Action Plan

Announcement of COPD National Action Plan

The plan calls on healthcare providers to standardize existing training, clinical care tools, and policies and incorporate them into national standards of care guidelines.

COPD National Action Plan Goals include

" "
Empower people with COPD, their families, and caregivers to recognize and reduce the burden of COPD.
" "
Improve the diagnosis, prevention, treatment, and management of COPD by improving the quality of care delivered across the health care continuum.
" "
Collect, analyze, report, and disseminate COPD-related public health data that drive change and track progress.
" "
Increase and sustain research to better understand the prevention, pathogenesis, diagnosis, treatment, and management of COPD.
" "
Translate national policy, educational, and program recommendations into research and public health care actions.

“COPD is the third leading cause of death in this country. It is right behind heart disease and cancer,” Dr. Kiley said, adding that unlike those diseases, COPD prevalence and deaths continue to rise.

Harold P. Wimmer, national president of the American Lung Association, said the action plan should be viewed as an opportunity to improve prevention, detection, treatment and management of COPD.

My Comments: A COPD National Action Plan is long overdue. Hopefully, this plan developed by the National Institute of Health, supported by federal taxes, will promote better care of patients with COPD throughout the country, particularly by primary care professionals.

This plan should increase attention to the disease so that everyone will know what the letters – COPD – mean. Although new medications are expensive, pharmaceutical companies have invested in research programs to develop new and better treatments which I have highlighted in postings on this website. 

Correct Inhaler Use: Study Shows Poor Adherence in Many Patients with COPD

Correct Inhaler Use: Factors of Poor Adherence

Background: Many studies show that correct inhaler use is poor in those with COPD. The technique of using inhalers can be challenging because there are four different kinds of ways that inhaled medications can be delivered. These include metered-dose inhalers, dry-powder inhalers, soft mist inhalers, and by a nebulizer.

In my practice, I always ask the patient, “Does the inhaler help your breathing?” If the person answers, “No,” or “I don’t know,” then I ask – “How are you using the inhaler?” Certainly, if the medication does not get deep into the lungs, it can not relax the muscle that wraps around the breathing tubes to open up the airways.

Advair was used in a study to assess correct inhaler use

Advair Diskus is a dry powder inhaler

Study: Dr. Sulaiman and colleagues at the Royal College of Surgeons in Dublin, Ireland, evaluated the correct use of the Advair Diskus in patients after discharge from the hospital for either a flare-up of COPD or for another reason. The reason for the study was to ask the question, “Why inhalers may not help?” for those with COPD. While in the hospital, patients were repeatedly shown how to use the inhaler each time the medication was taken, and a check list was used to make sure that the person was using the inhaler correctly.

Patients were instructed to use the inhaler as they had been shown in the hospital twice per day, and that someone would collect the inhaler between 26 to 30 days later. An electronic recording device was

Device to check correct inhaler use

Example of electronic audio recording device compared with size of a paper clip

attached to the Diskus at discharge from the hospital.  Each time that the person opened the inhaler, electronic recordings were made to calculate the time of use, the time period between doses, and whether the person used it correctly.

The study was published in the May 15, 2017, issue of the American Journal of Respiratory & Critical Care Medicine (volume 195; pages 1333-1343).

Results: There were 244 patients in the study; their mean age was 71 years. The authors calculated adherence which means whether someone is using the inhaler exactly as instructed. Actual adherence was 23% of expected if the doses were taken correctly and on time. Analyses showed three different patterns among the subjects: 1. 34% had low inhaler use and high error rates; 2. 25% had high inhaler use and high error rates; and 3. 36% had overall good adherence. Older age, mental impairment, and poor lung function on breathing tests were common in those with poor adherence and frequent errors.

 Conclusions: This study demonstrates that many patients with COPD fail to follow instructions for correct inhaler use despite repeated instructions. The results also help health care professionals understand why a inhaler may not be effective.

My Comments: These results are disappointing. It appears that some or many patients have physical and/or mental limitations that prevent correct inhaler use. This emphasizes that a spouse, family member, or caregiver should supervise their loved one when he/she uses the inhaler. In some cases, it is reasonable to try a different delivery system for the bronchodilator medications.  

Greater Activity Levels in Those with COPD are Related to Active Loved Ones

Greater Activity Levels in COPD If Loved Ones Are Active

Background: Patients with COPD are less active compared with healthy subjects. This may be due to symptoms of

Greater activity levels possible with loved ones

Man pedaling stationary cycle being supervised by daughter

breathlessness and fatigue. Adopting a healthy lifestyle with more physical activity is one of the main goals of a COPD management plan. Family members and loved ones may play an important role in helping patients with COPD achieve greater activity levels.

Study: Mr. Mesquita, a physical therapist, and colleagues at the Department of Respiratory Medicine in Maastrict, the Netherlands, studied light and moderate to vigorous physical activity in 125 patients with COPD and a loved one over 5 days. The findings were published in the May 2017 issue of the journal CHEST, volume 151, pages 1028-1038.

Woman with COPD with greater activity levels.

Woman with COPD walking with grandson

Results: Patients with COPD spent more sedentary time (being inactive) than their loved ones. However, those patients with an active loved one spent more time in moderate to vigorous activities than did those with an inactive loved one after controlling for age, body mass, and severity of COPD.

Conclusions: The authors concluded that in general patients with COPD are less active than their loved one despite similar exercise motivation. Those with an active loved one have greater activity levels.

My Comments:  It is very common for those with COPD to reduce activities to avoid the unpleasant feeling of breathing difficulty or shortness or breath. This can lead to a downward spiral as shown below.

Greater activity levels

Downward Cycle of Breathing Difficulty Leading to Reduced Physical Activity and Deconditioning (“out of shape”). Taken from page 70 of COPD: Answers to Your Questions (with permission).


Getting started in a pulmonary rehabilitation program is one of the best ways to reverse this downward spiral. Studies clearly show that regular exercise provides greater benefits for those with COPD than any inhaler. I encourage you to be as active as possible.

Female Smokers At Greater Risk for COPD Than Male Smokers

Female Smokers Have Higher Risk of COPD For Same Amount of Smoking Than Male Smokers

Background: Narrowing of the breathing tubes is called airflow obstruction. This is determined by having a person blow into a machine (called pulmonary

Spirometry performed to assess why Breathing is Worse

Woman performing breathing test.

function testing). Airflow obstruction is required to diagnose COPD – which is the 3rd most common cause of death throughout the world. Some researchers have suggested that women are more susceptible to the harmful effects of tobacco than men.

Study: Dr. Amaral and colleagues from the National Heart and Lung Institute in London, United Kingdom, analyzed over 149,000 women and over 100,000 men taking part in a study on smoking. All subjects had breathing tests performed. The results were published in the May 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine, volume 195, pages 1226-1235.

Female smokers are at increased risk of COPD

Two women smoking

Results: Airflow obstruction was higher in those currently smoking (women: 21%; men: 19%) than in ex-smokers. Overall, the association of airflow obstruction with smoking status was greater in women than men. Those who started smoking before age 18 years were more likely to have COPD.

Conclusions: For the same exposure to cigarettes, female smokers had a greater risk of airflow obstruction. With increasing rates of smoking among women in developed and developing countries, the authors suggested that it is important to create anti-tobacco campaigns.

My Comments: The reasons that women appear to be more susceptible to cigarette smoke is unclear. However, there are several possible explanations. 1. Women have smaller lungs than men and the concentration of cigarette smoke in the breathing tubes is therefore greater. 2. Genetic factors linked to the X chromosome may predispose women to greater damage to the lungs with smoking. 3. Hormonal factors may affect metabolism (break down) of cigarette smoke. 

Pulmonary Embolism Can Cause A COPD Flare-up (Exacerbation)

Pulmonary Embolism Cause of 16% of Unexplained COPD Flare-ups

Background: About 70% of flare-ups of COPD (called exacerbations) are usually due to chest infections (bronchitis or pneumonia). In 30% of the time, there is no clear cause or explanation. One possibility is inhaling irritants in

Deep vein thrombosis can break off and cause pulmonary embolism

Swelling of right leg due to blood clot (called deep vein thrombosis)

the air. Another possibility is a pulmonary embolism – the medical term for a blood clot that usually starts in the legs (called deep vein thrombosis), then breaks off, and travels to the lungs. This can cause sudden shortness of breath as well as chest pain.

A blood clot in the legs can cause swelling of the leg as seen in the photo on the right. A diagram of a blood clot in a blood vessel in the leg is shown below.

Blood clot can break off and cause pulmonary embolism

Blood clot is shown above left knee.





A blood clot in the lung is typically diagnosed by a CT scan of the chest with injection of dye (contrast) into a blood vessel of the arm.

Study: Dr. Aleva and colleagues from Nijmegen, The Netherlands, performed an analysis of seven published studies examining causes of COPD flare-ups. This is called a meta-analysis. The results were published in the March 2017 issue of the journal CHEST (volume 151; pages 544-554).

Results: Of 880 patients with an unexplained flare-up of COPD, 16% were due to pulmonary embolism. In one study, those with pulmonary embolism were more likely to have chest pain when breathing in (81%) compared with those who did not have a pulmonary embolism (40%). Also, those with pulmonary embolism were less likely to have symptoms of a respiratory infection (coughing up yellow-green mucus and chest congestion).

Conclusions: Pulmonary embolism is a frequent cause of unexplained flare-ups of COPD. The authors suggest the health care providers consider this diagnosis especially when someone has chest pain and signs of heart failure and when a chest infection appears unlikely.

My Comments: If you have a flare-up of COPD and do not have an apparent chest infection, you should be aware that a blood clot in the leg may travel to the lungs and cause shortness of breath and possible chest pain. A CT scan of the chest is typically performed to look for this problem. If found, then blood thinning medication (called anti-coagulation) is required to prevent new blood clots from forming. The body will then dissolve the blood clots in the leg and chest.

Air Pollution in United States: 2017 Report from the American Lung Association

Air Pollution in United States: More than 4 out of 10 Breathe “Bad Air”

On April 19, 2017, the American Lung Association issued a report of air pollution in United States during 2013-2015. The “State of the Air 2017” report looked at levels of ozone and particle pollution found in official monitoring sites across the United States in 2013, 2014 and 2015. View my post on August 29, 2016, which describes the different types of air pollution.

Overall Findings The report shows that cleaning up pollution continues to be successful in much of the nation. In the 25 cities with the worst ozone and year-round particle pollution, the majority saw improvements. Many cities reached their lowest levels ever of widespread air pollution.

Worst Cities for Particle Pollution

Worst cities for air pollution in United States

Six of the ten cities with the worst air pollution in United States are in California. Bakersfield again holds the distinction of having the most days of highly polluted air.

Aerial view shows air pollution in United States - Los Angeles

Aerial view of downtown Los Angeles skyline with San Gabriel mountains in background

Key Findings  1. Despite improvements in air quality over the three years, more than 4 of 10 people breathe unhealthy levels of air pollution. 2. Air pollution increases the risk of early death, lung cancer, breathing attacks for those with asthma or COPD, and heart disease. 3. Breathing ozone irritates the lungs resulting in something like a “bad sunburn.” 4. Particles may be smaller than 1/30th of the size of a human hair. When inhaled, they are small enough to get past the body’s natural defenses. 5. People of color and those earning lower incomes are often affected by air pollution.

What Can You Do  1. Check daily air quality forecasts in your area. 2. Use less electricity. Use of electricity creates air pollution. 3. Drive less. Try to share rides and combine trips to reduce total driving. 4. Don’t burn wood or trash as these are among the major sources of particle pollution. 5. Don’t let anyone smoke indoors and support measures to make all public places tobacco free. 6. Make sure your local school system requires clean school buses.                                                                                       


Bronchiectasis Can Cause Frequent Flare-ups of COPD: Results of New Study

Bronchiectasis Can Cause Frequent Flare-ups: Need CT Scan of Chest for Diagnosis

Background: Bronchiectasis (pronounced bron-kee-eck-tuh-sis) is a lung condition in which the breathing tubes (airways) are damaged and widened along with inflammation and chronic bacterial infection.

bronchiectais can cause frequent flare-ups of COPD

Bronchiectasis with widening of the breathing tube (airway) and thickening of the wall.

Bronchiectasis may occur as a result of pneumonia. This can happen in otherwise healthy individuals as well as those with COPD. Those who have bronchiectais typically have a chronic cough that usually produces yellow or green mucus and are prone to recurrent chest infections.

Study: Dr. Minov and colleagues from Macedonia compared flare-ups (exacerbations) of COPD over 12 months. The study results were published in the journal Medical Sciences 2017, volume 5 (doi:10.3390/medsci5020007)

Results: Of the 54 subjects, 27 had bronchiectasis on CT scan of the chest, and 27 did not. Those with bronchiectasis had more frequent flare-ups that generally lasted longer (6.9 days compared with 5.7 days).

Conclusions: The authors concluded that bronchiectasis can cause frequent flare-ups of COPD. These episodes may last longer than in those who do not have bronchiectasis.

My Comments: With frequent flare-ups of COPD, consider

bronchiectasis can cause frequent flare-ups of COPD

Cystic changes in the lungs due to bronchiectasis.

bronchiectasis. Recurrent chest infections are common in those with bronchiectasis because bacteria live in damaged area of the lungs. Symptoms are a persistent cough that raises yellow-green mucus. Your health care provider should order a CT scan of the chest to make a diagnosis. Next, he/she should request a sample of mucus to send to the laboratory to identify a specific bacteria.  This information helps to select the best antibiotic.

Long-term antibiotic therapy is typically required to reduce the number of bacteria in the damaged breathing breathing tubes and lung tissue. All bacteria can never be totally eliminated from the lung.

In an April 2017 issue of the American Journal of Respiratory and Critical Care Medicine (volume 195, pages P15-P16), Patient Education materials address, “What is Bronchiectasis?”


Stem Cell Treatments for COPD: An Update from the American Thoracic Society

Stem Cell Treatments for COPD: What’s New

The American Thoracic Society recently published an update on stem cell treatments for those with lung disease. The report appeared in the Public Health Information Series in the journal American Journal of Respiratory and Critical Care Medicine, volume 195, pages 13-14.

Stems cells can be used for stem cell treatments

Stem cells can become any tissue in the body

What are Stem Cells? Every organ in the body has a small number of stem cells that can replace or repair damaged tissue. However, there is still a lot to learn about stem cell types and how they work. Researchers are actively working to find a way to stimulate stem cells to repair parts of the lung.

Are Stem Cell Treatments a Possibility for COPD? In theory, yes. At the present time, there are NO proven stem cell therapies for any lung disease. The best way to find whether stem cell treatments are effective and safe is by research studies.

Are There Unproven Stem Cell Treatments? Unproven means that the therapy has not been shown to work or be effective. Hundreds of clinics offer unproven treatments using stem cells in the United States and elsewhere. Typically, cells are removed from a person’s fat or bone marrow, and then the cells are given back to the person in the blood (intravenously). This approach has not been approved by the U.S. Food and Drug Administration.

Could Stem Cell Treatments be Harmful? Risks include cells sticking or clotting in the blood vessels of the lungs and cells causing abnormal growth including tumors. In addition, some clinics may not meet normal standards of sterility (preventing infection),

Are Unproven Stem Cell Treatments Covered by Health Insurance? No. Those who choose to receive such treatments have to pay all costs on their own and will not be reimbursed by insurance companies.

Summary Stem cell treatments are not approved by the U.S. Food and Drug Administration for treatment of any lung disease including COPD. The only option is to participate in a clinical research study. Information about such trials can be found on the website – www.clinicaltrials.gov.

Dry Powder Inhalers: You Need to Breathe In “Hard and Fast”to Get the Powder Deep into the Lungs

Dry Powder Inhalers Have Internal Resistances

Background: Inhaled bronchodilators are the cornerstone for treatment of those with COPD. However, it is important that the person be able to inhale the medication deep into the lungs in order to open the airways and make it easier to breathe.

Of the four different inhaling devices for bronchodilators, the most common is called the pressured metered-dose inhaler shown in the figure below. Simply pressing the canister down releases a spray (aerosol) from the mouthpiece.

Example of metered-dose inhaler. This is a different system than dry powder inhalers.

Pressurized metered-dose inhaler.

Many bronchodilators are available in dry powder inhalers (see below). All dry powder devices have an internal resistance. As a result, you need to inhale “hard and fast” to literally pull the powder out of the device and inhale it deep into the lungs.

Different dry powder inhalers

Dry powder inhalers have an internal resistance.

There is a simple breathing test to determine if you have enough inspiratory force to inhale the powder successfully out of the inhaler. This test is called peak inspiratory flow rate (abbreviated PIFR). Here is a picture of the In-Check DIAL used to measure PIFR.

In-Check DIAL to measure the resistance of dry powder inhalers

In-Check DIAL to measure peak inspiratory flow rate

Study: Dr. Loh and colleagues at the Winston-Salem Baptist Medical Center in North Carolina measured PIFR in patients just before discharge from the hospital for a flare-up (exacerbation) of COPD. The study results are published on-line in the Annals of the American Thoracic Society on April 13 (doi: 10.1513/AnnalsATS.201611-903OC).

Results: 52% of the 123 subjects had a PIFR below 60 liters/min. A value of 60 or higher is considered “optimal” to inhale the powder deep into the lungs.   Those with PIFR less than 60 liters/min were more likely to be readmitted to the hospital over 90 days for another COPD flare-up (28%) compared with subjects who had PIFR at least 60 or higher (14%).

Conclusions: The authors concluded that a low PIFR is common in those admitted to the hospital for a COPD flare-up. They recommended that the medical team measure PIFR before discharge, especially if a dry powder is being prescribed.

My Comments: With a PIFR of less than 60, it more likely that some or most of the powder stays in the mouth and throat. IF you are taking a dry powder bronchodilator and IF you find that it does not help you breathe easier, then you should ask your health care provider to measure your PIFR. If an In-Check DIAL is not available to test your PIFR, then you should ask about a different delivery system – possibilities include a pressurized metered-dose inhaler, a soft mist inhaler, or a nebulizer.

Woman inhaling aerosol from nebulizer

Soft mist inhaler

COPD in Women: Key Findings

COPD in Women Increasing More Rapidly Worldwide

Background: COPD in women receives little attention as a health issue even though more women die of COPD each year than of breast cancer and lung cancer combined. The general perception that COPD is a disease of older men is outdated. Throughout the world, COPD is increasing more rapidly in women than in men. Since 2000, more women than men in the United States die of COPD.

Dr. Jenkins has written about COPD in women

Professor Christine Jenkins

Review: Dr. Christine Jenkins of Sydney, Australia, and co-authors described the impact of female sex on COPD in a review article in the March 2017 issue of Chest, volume 151; pages 686-696.

Key Findings about COPD in Women: 1. For the same amount of smoking or exposure to irritants in the air, women are more susceptible to developing COPD. 2. The reasons for smoking may differ between sexes. Dr. Jenkins proposed that female empowerment through tobacco smoking and weight control are likely two reasons that women smoke. 3. Women with COPD are generally younger, smoke less, and have a lower body weight for their height than men. 4. Women tend to have more shortness of breath than men for the same level of breathing tests results. 5. In a 3-year study in the US, it was found that women had more frequent flare-ups (exacerbations) of COPD than men.

Female with COPD

How Does COPD Affect Women? In many studies it was noted that women have poorer health status and quality of life compared with men. Women with COPD report higher levels of anxiety and depression than men with COPD which adds to the burden of the disease in women.

Treating Women with COPD: Smoking cessation is an important treatment for anyone with COPD. However, women may be less successful with long-term smoking cessation than men, especially with nicotine replacement therapy. Current evidence shows that inhaled bronchodilators work the same in women as in men.

COPD in Women

Summary: The authors concluded that it is important to raise awareness of COPD in women and to develop new strategies to prevent the disease.  They also emphasized the need for educational programs for women with COPD and their families to manage their disease better.

My Comments: I offer the following two general impressions based on my pulmonary practice, although I have no explanation for these observations. 1. Women with COPD seem more motivated to “get better” and use prescribed inhalers as recommended. 2. Women are more likely than men to actually participate in pulmonary rehabilitation programs.


Breathe Easier with Two Bronchodilators: Less Shortness of Breath and Less Albuterol Use

Breathe Easier with Two Bronchodilators

Background: About 90% of patients with COPD are still short of breath with activities if using a single long-acting bronchodilator (either a beta-agonist or a muscarinic antagonist). In such situations, the 2017 GOLD statement recommends use of a combination of both classes of bronchodilators to achieve the best effects (see my post under the heading COPD News on December 3, 2016). Thus, the experts on the GOLD committee agree that you should be able to breathe easier with two bronchodilators. 

Study: Dr. Edward Kerwin and co-authors who work at GlaxoSmithKline pharmaceutical company studied a total of 494 patients with COPD who reported that they experienced at least some shortness of breath despite taking a long-acting bronchodilator tiotropium (brand name: Spiriva) in the HandiHaler device for at least three months. Patients were assigned by chance to either continue Spiriva HandiHaler OR to use a combination of

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta contains two different bronchodilaors

two bronchodilators (brand name: Anoro Ellipta). The study results were published in the International Journal of COPD, 2017, volume 12, pages 745-755.

Results: Compared with a single bronchodilator (brand name, Spiriva HandiHaler), there were significantly greater improvements in breathing tests (lung function), the need to use albuterol as a rescue inhaler, and in shortness of breathe with activities of daily living. There were no differences is side effects between treatments.

Conclusions: Two different classes of bronchodilators provide greater benefits, including being able to breathe easier, than one bronchodilator.

My Comments: The results of this study are consistent with several other trials showing quite simply that “two is better than one” in most things in life including inhaled bronchodilators.

Bevespi contains two different bronchodilators in a single device

Bevespi Aerosphere contains two different bronchodilators

At the present time there are three available “two in one” bronchodilator inhalers – brand names are Anoro, Stiolto, and Bevespi. A fourth one called Utibron should become available in the near future.

Stiolto Respimat contains two different bronchodilators

If you are taking a single inhaled bronchodilator and have shortness of breath, I suggest that you ask your health care professional whether a trial of a “combination bronchodilator” is reasonable. At least one of these options should be covered by most health insurance policies.


Physical Activity in COPD is Associated with Grandparenting and Dog Walking

Greater Physical Activity in COPD Related to Grandparenting and Dog Walking 

Background: There is less physical activity in COPD than others of similar age who are healthy. There are many reasons for this including shortness of breathing with activities, muscle weakness, other medical problems, and behavioral changes. However, being physically active in COPD is critical for a good quality of life and overall health. Although participation in a pulmonary rehabilitation program is recommended for all patients with COPD, this is not always possible for a variety of reasons.

Study: Investigators in Spain wanted to find out what socio-environmental factors were related to the amount and intensity of physical activity in COPD. A total of 410 patients with COPD answered questions and wore an activity monitor for one week. Other factors considered were outdoor green (parks, forests, agricultural land, and pastures) and blue (water bodies) areas. The findings were published on-line on March 1, 2017, in the journal Thorax.

Grandparenting associated with greater physical activity in COPDResults: All participants lived in a seaside community in Catalonia that included Barcelona. 85% of the patients were men; the average age was 69 years. Average lung function was 56 percent of predicted. After adjusting for age and socio-economic status, both grandparenting (being active with grandchildren) and dog walking were significantly associated with an increase in time in moderate-to-vigorous physical activity. Being close to green and blue areas was not associated with physical activity.Woman walking a dog - greater physical activity

Conclusions: The authors concluded that grandparenting and dog walking are associated with a greater amount and intensity of physical activity.

My Comments: Grandparents typically want to “do things” with their grandchildren simply because it is fun and provides meaning in their lives. In fact, patients with COPD report that caring for their grandchildren is a motivator to participate in a pulmonary rehabilitation program (British Journal of General Practice; 2008; volume 58; pages 703-710).  Likewise, having a dog is enjoyable and requires going for walks or taking the dog to a park for exercise.

The overall message of this study is “be active.”


Lung Cancer Screening With a Counseling and Shared Decision-Making Visit

Lung Cancer Screening: Impacts of a Counseling Visit

Background: In 2013 the American Cancer Society issued an initial guideline for lung cancer screening. These recommendations were a result of the National Cancer Institute’s National Lung Screening Trial.  The findings indicated that lung cancer screening could save lives.

The guideline recommended that health care professionals should talk about screening with apparently healthy individuals between 55 and 74 years of age who have smoked at least a pack of cigarettes per day for 30 years (or equivalent) and who currently smoke or have quit in the past 15 years.  A counseling and shared decision-making visit with a health care professional has been mandated to help individuals with the decision whether to have low-dose computed tomography (CT scan) screening or not.  

 Study: In the March 2017 issue of the journal CHEST, Dr. Mazzone and colleagues at the Cleveland Clinic reported on their experience with lung cancer screening counseling and shared decision-making visits. 

Results: A total of 423 patients had a shared decision-making visit between April 2015 and April 2016. Of these, 23 individuals, or about 5%, decided not have low-dose CT scan of the chest. Eleven of the 23 chose not to proceed with the CT scan after the discussion. Nine of the 23 did not meet the screening requirements. 

Starting in November 2015, patients were asked to complete a survey about their knowledge of lung cancer screening before and immediately after the visit. Prior to the visit, most patients had a poor understanding about the required age and smoking history to be screened as well as the benefits and harms of screening. There was a significant improvement in the knowledge of patients about these requirement after the visit.

Conclusions: The authors concluded that a counseling and shared decision-making visit improves the knowledge of patients about who is eligible for screening as well as benefits and possible harms of CT scan screening.

My Comments: The mandated visit for lung cancer screening counseling and shared decision-making is typically available at academic medical center or large teaching hospitals.

Anyone who has COPD due to smoking cigarettes has an increased risk of lung cancer.  The purpose of screening with CT scan is to find a lung cancer early with the hope that surgical treatment will remove it completely. However, if you have advanced COPD, it is likely that your lung function would be too low to tolerate possible lung surgery. If so, lung cancer screening would not make sense.

Maintenance Pulmonary Rehabilitation in COPD is Beneficial for Two Years

Maintenance Pulmonary Rehabilitation Increases Walking Distance

Background: Whether maintenance pulmonary rehabilitation programs help to sustain the short-term benefits is unclear.

Study: Researchers in Spain studied patients with COPD over 3 years after they completed a standard 8-week pulmonary rehabilitation program. Subjects were randomized (divided by chance) into two groups: those who received maintenance therapy and those in a control group (no maintenance).

Cycle ergometer for maintenance pulmonary rehabilitation

Cycle ergometer

What was the maintenance program?  Patients exercised at home three times a week doing: 15 minutes of chest physiotherapy; 30 minutes of lifting weights (which were bought by patients); and 30 minutes of riding a stationary cycle (provided by the hospitals). A physiotherapist called the patients every 15 days; during the alternate week, patients went to the hospital for a supervised training session.

Patients assigned to maintenance pulmonary rehabilitation did arm training with weights

Woman with COPD doing arm curls with hand weights.

What did the control group do? Patients in the control group were advised to exercise at home without any supervision. They were encouraged to walk or buy a stationary cycle for home use.

The study results were published in the March 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (pages 622-629).

Results: For the total of 138 patients, average age was 64 years, and the amount of air exhaled in one second (FEV1) was 34% predicted. There were 68 patients in the treatment group, and 70 in the control group. More than 50% of those who started the study failed to complete the 3 years. Main reasons for stopping were a COPD flare-up (exacerbation), other medical problems (called co-morbidities), and death.

Those in the treatment group improved significantly more than the control group for: 1. distance walked in 6 minutes and 2. the BODE index [B = body mass index (weight and height); O = FEV1; D = breathlessness; E = 6-minute walking distance]. However, there were no differences in health-related quality of life between the two groups.

Conclusions:  The authors concluded that the 3-year maintenance pulmonary rehabilitation program provided improvements in walking distance and the BODE index compared with usual care. These improvements lasted for 2-years; after that, there no longer was a beneficial effect.

My Comments: This study is notable because it has the longest follow-up period of any published randomized trial of maintenance pulmonary rehabilitation. The findings support the benefits of continued exercise following completion of a pulmonary rehabilitation program.

One limitation of the study is that it primarily involved men so that it cannot be assumed that women would experience the same benefits.  However, women may be more compliant than men and are likely to live longer.  

I recommend participation in pulmonary rehabilitation to all of my patients with COPD and strongly encourage maintenance after completing our 12-week program.

Eating Fruits and Vegetables Associated with Reduced Risk of COPD

Eating Fruits and Vegetables Reduces Chances of COPD in Smokers and Ex-smokers

Background: Oxidative stress due to smoking cigarettes is a recognized as a major factor in the development of COPD. Antioxidants in fruits and vegetables may protect the lung from damage and thereby prevent, or at least reduce the risk, of someone “getting” COPD.

Study: Researchers at the Karolinska Institute in Stockholm, Sweden, analyzed information in over 44,ooo men living in Sweden who had no history of having COPD at the start of the study. Fruit and vegetable consumption was assessed with a questionnaire. Subjects were followed for an average of 13 years. The study was published on-line in the journal Thorax in 2017.

Results: During the study period, 1,918 men were diagnosed with COPD. There was a strong inverse (opposite effect) association between total consumption of fruits and vegetables and COPD.  Each serving per day of eating fruits and vegetables reduced the risk of COPD by 8% in current smokers and by 4% in former smokers.

Eating fruits and vegetables have anti-inflammatory effects.


Eating fruits and vegetables is healthy.

Fruits and vegetables






Conclusions: The findings indicate that high consumption of fruits and vegetables reduced the risk of COPD in both smokers and ex-smokers. 


My Comments: There is emerging evidence that diet can play an important role in the development of COPD. For example, a “heart healthy” diet – fruits, vegetables, whole grains, cereals, and fish – is associated with a lower risk of impaired lung function and COPD compared with a “Western diet” – high consumption of white bread, processed meats, high fat dairy products, sugar, and chips.

In general, there are many health benefits of eating fruits and vegetables. These foods contain various anti-oxidants and have anti-inflammatory properties that are healthy for our bodies. This new study provides further evidence that a diet rich in fruits and vegetables can reduce the risk of developing COPD if you still smoke and if you have already quit.

Vitamin D Supplements Protect Against Respiratory Infections

Benefits of Taking Vitamin D Supplements

Background: It is well known that Vitamin D helps to protect bones from fractures. However, whether taking Vitamin D pills helps the immune system is controversial.

Study: Researchers at the Queen Mary University of London pooled results from 25 different studies to find out if Vitamin D supplements reduce the number of respiratory infections.

 The study results were published on-line in the February 15, 2017, issue of the British Medical Journal (doi: 10.1136?bmj.i6583).

Results: A total of 11,321 subjects were studied in the 25 different research trials. Taking Vitamin D supplements reduced the risk of a sudden (acute) respiratory tract infection among all subjects by 12%.  This change was statistically significant compared with those subjects taking a placebo (sham or pretend) treatment. The effect was stronger in those who had a low blood level of 25-hydroxyvitamin D (less than 25 nmol/liter). 

Conclusions: Vitamin D supplementation was safe and protected against acute respiratory tract infections. Those who were deficient in Vitamin D experienced the most benefit.

My Comments: The body produces it own Vitamin D when exposed to sunlight. Some foods in the US are fortified with Vitamin D, such as milk, orange juice, and cereals. Sardines and salmon naturally contain high levels of Vitamin D. 

Vitamin D supplements are one source of this vitamin

Sources of vitamin D – a pill, salmon, and sunshine

How much Vitamin D should I take if I decide to supplement? First, you may wish to ask your health care provider to measure your level of 25-hydroxyvitamin D in the blood to find out if you are low. People at risk of Vitamin D deficiency are those with celiac disease (a digestive disorder) and people who cover up most their skin or get very little exposure to the sun.

Dr. Steven Abrams of the Dell Medical School at the University of Texas at Austin commented on the study findings: “If you’re deficient, getting an adequate amount will make a difference.”

The Institute of Medicine recommends that most adults need about 600 international units (IU) of Vitamin D per day. Adults over 70 years of age are advised to increase their intake to 800 IUs. The Institute warns against taking more than 4,000 IUs a day.

Loss of Lung Function Noted with Flare-ups (Exacerbations) of COPD

Loss of Lung Function Greater in Mild COPD

Background: With a sudden flare-up of COPD, individuals have more shortness of breath, coughing, and/or wheezing. These are called an exacerbation. Studies show that flare-ups are associated with worse health status and are associated with increased risk of dying. However, it is unknown whether flare-ups cause more loss of lung function than expected with just getting older.

Study: The COPDGene study enrolled over 10,000 individuals who were current or former smokers with and without COPD. This report describes the first 2,000 patients with COPD who returned for a follow-up visit 5 years later. During the study, flare-ups were recorded by patients every 6 months.  The study was published in the February 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (volume 195; pages 324-330).

Results: More than 1/3 of subjects (37%) had a flare-up during the 5 years. These flare-ups were associated with greater excess decline (worsening) in the amount of air exhaled in one second (FEV1) in all stages (1, 2, and 3) of COPD.  This excess decline was greatest in those with mild COPD where each flare-up was associated with an additional 23 milliliters per year decline in FEV1. If the flare-up was severe and required the person to be hospitalized, there was an even greater decline in FEV1 of 87 milliliters per year.

Dr. Dransfield is first author of the article that describes loss of lung function with acute exacerbations of COPD.

Dr. Mark T. Dransfield, Professor of Medicine at the University of Alabama at Birmingham.

Conclusions: Dr. Dransfield and colleagues concluded that sudden flare-ups are associated with greater declines (worsening) of lung function in those with COPD, especially with mild disease. In contrast, there was no worsening of lung function when current and former smokers without COPD had similar respiratory infections.

My Comments: It is well known that flare-ups due to chest infections result in inflammation (redness and swelling) in the breathing tubes (airways).  This can cause narrowing of the breathing tubes and plays a role in the decline in how the lungs work.

Also, these findings raise the possibility that preventing flare-ups (exacerbations) could prevent worsening of lung function, and thereby slow or prevent progression of the disease. Treatment with medications may need to be considered in those with mild-moderate COPD and not wait until the condition is more severe. 

You may wish to discuss how you can reduce the risk of a flare-up with your health care professional.

Palliative Care: Increased Use for Hospitalized COPD Patients

Use of Palliative Care in COPD

Background: Palliative care focuses on providing people with relief from the symptoms, pain, physical stress, and mental stress of a serious illness.  It is provided by a team of doctors, nurses, occupational and physical therapists, and other health care professionals. It is appropriate at any age and at any stage in a serious illness.  It is not limited to only those as part of end-of-life care.  Palliative care can be provided at home, in the hospital, and in skilled nursing facilities.  

This care may be part of hospice services, but can be offered to any patient without restriction to the illness or outlook (prognosis).  For those with COPD, palliation typically focuses on relief of breathing difficulty and strategies for conserving energy.

Study: Dr. Barret Rush and colleagues at the University of British Columbia in Vanouver, Canada, recently published an analysis of the use of palliative care in the United States between 2006 to 2012. The findings were published in the January 2017 issue of the journal CHEST (volume 151; pages 41 – 46).

Results: From 2006 to 2012, the use of palliative care was 1.7% of the 181,689 patients with COPD hospitalized for a worsening of symptoms (called an exacerbation) and were also receiving oxygen at home. During this seven year period, there was a 4.5 times increase in referrals for palliative care.  In general, those referred for these services were older (75 years compared with 71 years) , had longer hospitalizations (5 days compared with 3 1/2 days), and were more likely to die in the hospital (32% compared with 2%).

Patient in the hospital receiving palliative care

Supportive care provided in the hospital

Conclusions: The use of palliative care increased dramatically during the seven year period. The barriers to receiving palliative care included race, low socioeconomic status, size of the hospital, and region of the country.

My Comments: Palliative care can provide important services for those with advanced COPD. The specialist will ask each person what are her or his major health concerns and goals. Usually, services focus on helping the individual breathe easier and on strategies for performing daily activities. In general, care referrals are greater in larger teaching hospitals. This reflects the presence of these services compared with smaller rural hospitals.

Obesity and Worse Outcomes in COPD: More Shortness of Breath

In COPD, A Link between Obesity and Worse Outcomes (more shortness of breath, poor Quality of Life, and reduced walking distance)

Background: Although obesity is common in the United States (see post on January 1, 2017 under COPD News), the association between obesity and worse outcomes in those with COPD  is unclear.

Study: Dr. Allison Lambert, Assistant Professor of Medicine at Johns Hopkins University, and colleagues analyzed information on 3,631 participants in the COPDGene study. A body mass index of 30 or higher was used to define obesity. The findings were published in the January 2017 issue of the journal CHEST (volume 151; pages 68-77).

Obesity and worse outcomes regardless of shape

Two common types of obesity – apple and pear shapes

Findings: Overall, 35% of participants in the study were obese – which is identical to the general population in the United States.  Increasing obesity was associated with worse quality of life, reduced distance walked in six minutes, more shortness of breath, and greater odds of a severe exacerbation (sudden worsening) of COPD. 

Conclusions: The authors concluded that obesity is common among individuals with COPD and is associated with worse outcomes. These include more shortness of breath with activities, poor quality of life, shorter distance walked in six minutes, and more frequent severe exacerbations.

Obese adults walking

My Comments: If you have COPD and are obese, I strongly encourage you to lose weight. Certainly, losing weight is hard work especially with food being a focus of celebrations including birthdays, holidays, anniversaries, etc. Studies show that the most effective way to lose weight is a combination of

Seniors participating in physical activity such as walking, biking, and swimming

Seniors Exercising

eating fewer calories and an exercise program. Regular exercise can burn some calories, but its major effect with weight loss is to increase the metabolic rate (which burns more calories throughout the day). Participation in a pulmonary rehabilitation program is a great way to start an exercise routine. Talking to a nutritionist may help you select healthy and low calorie foods.

Sitting Time and Obesity in Men Living in the United States

More Sitting Time for Men – More Likely to Be Obese

Background: The Center of Disease Control and Prevention (CDC) reported in November 2016 that over one-third (35%) of adults in the United States are obese. Obesity is typically defined by Body Mass Index (abbreviated BMI). BMI is calculated by weight in kilograms divided by the square of height in meters. You can ask your health care provider to calculate your BMI at your next appointment. A value between 25 and 30 means someone is overweight. A BMI value of 30 or higher indicates obesity.

Study: Dr. Carolyn Barlow and colleagues at the Cooper Institute in Dallas, Texas,  reported the results of a study which analyzed sitting time and body weight.  The study was published in December 29, 2016, issue of the journal Prevention of Chronic Diseases.  doi: 10.5888/pcd13.160263.

Results: Estimates of sitting time, measures of obesity, blood lipids, blood glucose, blood pressure, and exercise testing were collected in 4,486 men and 1,845 women. Nearly one-half of the men reported sitting three-fourths of the day, while only 13% of women said the same.

Men who sat almost all of the time were more likely to be obese as measured by waist size (circumference) or body fat compared with men who sat almost none of the time. Sitting time was NOT associated with other cardiac risk factors. For women, there was no significant association between sitting time and cardiac risk factors.

Conclusions: The researchers could not pinpoint a cause for the higher rates of obesity in sedentary men. Dr. Barlow said that one limitation of the study was that subjects were mainly white, generally healthy, and well educated. The authors suggested that reducing sitting time can be a first step in a plan for men to be more active.

Woman working at desk reduces sitting time

Woman working at stand up desk

My Comments:  In a previous study from the Cooper Institute (Mayo Clinic Proceeding, September 29, 2015), researchers showed that standing for at least one-quarter of the day was linked to a lower risk of obesity. For example, standing a quarter of the time was linked to a reduced chance of obesity (by 32% in men and by 35% in women) . If you sit at desk for work or for using a computer, consider getting a stand up desk with adjustable height that allows you to stand.

Arm Exercise Training Reduces Shortness of Breath in COPD

Studies Show that Arm Exercise Improves Breathlessness 

Background: Many individuals with COPD have difficulty performing arm activities due to shortness of breath and arm fatigue. As a result, upper limb exercise training is typically included in pulmonary rehabilitation programs.

Study: Dr. Zoe McKeough and colleagues from the University of Sydney in Australia reviewed all published studies on upper limb exercise training for at least four weeks. They examined: arm exercise (AE) compared with either no or sham (pretend) training; and combined arm and leg exercise compared with only arm exercise. The study was published in the November 15, 2016, issue of the Cochrane Database Systematic Reviews.

Arm crack machine used for arm exercise

Man performing arm exercise using arm crank machine

Findings: A total of twelve studies were included in the analysis. When AE training was compared with either no or sham training, there was a significant improvement in breathing difficulty (four studies of 129 subjects). When upper limb exercise combined with lower limb exercise was compared with AE alone, there was no difference in shortness of breath (2 studies of 55 subjects). There was no improvement in health-related quality of life with AE training.

When AE endurance training was compared with no or sham training OR with combined arm and leg exercise training, there was a large significant improvement in unsupported endurance arm capacity.

Conclusion: Some form of upper limb exercise training when compared with no training or a sham intervention improves breathing difficulty in those with COPD.

My Comments: Arm exercises are important for those with COPD who note breathing difficulty when performing arm activities such as lifting objects (like a grandchild), carrying a grocery package, and moving dishes from the washer and placing them in a cabinet. Also, arm exercise can substitute if someone can not perform leg exercises for whatever reason. This might include those with knee, hip, or back problems or those who use a wheelchair.

Stretch or resistance band for arm exercise

Using stretch or resistance bands at home is the easiest and least expensive way to do upper limb exercise. Ask a physical therapist to show you simple arm exercises to increase strength as well as endurance.


Women Who Never Smoked are Vulnerable to Develop COPD

African-American Women are Susceptible to COPD

Background: COPD is the 3rd leading cause of death in the United States and a main cause of disability.  The prevalence (how often it occurs) has been higher among women than men in most age groups for over 20 years. One reason is that females have narrower breathing tubes allowing cigarette smoke to be more concentrated in their overall smaller lungs. Although cigarette smoking is the major risk factor for the disease, never-smokers may also develop COPD.

Study:  Esme Fuller-Thomson, Ph.D., and colleagues from the University of Toronto published the results of an observational study to examine gender and racial differences for developing COPD among never smokers. The researchers reviewed information on 129,535 Caucasians and African-Americans who were 50 years of age and older who had never smoked. The findings were published in the 2016 International Journal of Chronic Diseases.  http://dx.doi.org/10.1155/2016/5862026

Never-smoking African-American women are at risk for COPD

African-American woman at risk for COPD

Results: Women had a significantly higher chance of developing COPD than men. In particular, African-American women had the highest prevalence of COPD (7.0%) followed by Caucasian women (5.2%), Caucasian men (2.9%), and African-American men (2.4%).

Discussion: The authors suggested that differences in lung size may be a factor for higher likelihood in females. Other possibilities are the role of hormones and exposure to second-hand smoke. Dr. Fuller-Thomson commented that, “We cannot determine causality with this data set, but poverty is associated with increased exposure to city environments. Future research needs to investigate if these factors play a role in the greater vulnerability of African-American females.”

My Comments: These results raise many questions. Why are there sex differences in never smokers developing COPD? Why are there differences in COPD between Caucasian and African-American females?

It is important that health care professionals consider testing older individuals who complain of shortness of breath or persistent cough including those who are never smokers.