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

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

Raspberries

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. 

Peas

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.

Chronic Heart Disease Occurs Frequently in Those with COPD

Heart Disease and COPD – Shared Risk Factors

Study: A December 1, 2016, article in the American Journal of Respiratory and Critical Care Medicine (volume 194; pages 1319-1336) reviewed information about cardiac disease in those with COPD. (DOI: 10.1164/rccm.201604-0690SO)

COPD and heart disease share risk factors that include:

  1. Older age
  2. Cigarette smoking
  3. Physical inactivity
  4. Low-grade inflammation in the body
Heart disease can occur in different parts of the heart.

Diagram of the heart

Heart disease is more common in those who have COPD (from 10 – 30%) compared with the adult population (about 1 – 2%). It contributes to the severity of COPD and is a common cause for hospitalization and death. Both heart disease and COPD can cause the same symptoms – shortness of breath and fatigue.

The three most common heart diseases in those with COPD are:

  1. ischemic disease (narrowing of the arteries in the heart)
  2. heart failure (pumping action of the heart is impaired leading to fluid build-up in the lungs)
  3. atrial fibrillation (irregular heart rhythm).

Atrial fibrillation

Atrial fibrillation is a common heart disease in COPD

The curved arrows in the right and left atrium (upper chambers) in atrial fibrillation indicate chaotic electrical activity.

This is the most common heart rhythm problem in the general population as well as in those with COPD. The atria (two top chambers of the heart) beat irregularly AND the the ventricles (lower two chambers of the heart) do not work in sequence (together) with the atria. In those with stable COPD, atrial fibrillation occurs in 5 – 15%. In those with very severe COPD, it occurs in about 20 – 30%. Atrial fibrillation can cause shortness of breath, low energy, and a feeling of skipped heart beats. There is a risk for blood clots developing in the atria. Usually, anticoagulant medications (commonly called blood thinners) are recommended to reduce the risk of clots.

What Can You Do?

Certainly, you need to reduce risk factors for both heart and lung problems if possible. That means: do not smoke; be physically active; and do whatever possible to reduce inflammation in your body. I suggest that you view the October 17, 2016, post on my website under Frequently Asked Questions (FAQs). This post describes numerous foods that are anti-inflammatory and can boost the immune system.

Finally, I encourage you to be proactive and ask your health care provider whether any shortness of breath or fatigue that you might experience could be due to a possible heart problem in addition to COPD.

 

 

 

Updated COPD Management Recommendations by GOLD

COPD Management Recommendations by GOLD Committee

On  World COPD Day (November 16, 2016) updated recommendations for management of those with COPD were released. The group of experts from throughout the world who made the recommendations is called the GOLD committee. GOLD stands for Global Initiative for Chronic Obstructive Lung Disease.

Bartolome Celli, M.D., of Brigham and Women's Hospital

Bartolome Celli, M.D., of Brigham and Women’s Hospital

Pulmonary physicians from the United States on the Board of Directors of GOLD include: Bartolome Celli, M.D., of Brigham and Women’s Hospital in Boston and Gerald Criner, M.D., of Louis Katz School of Medicine in Philadelphia.

Dr. Criner is on the Board of Directors which makes COPD management recommendations

Gerald Criner, M.D., Chair and Professor, Thoracic Medicine and Surgery

 

 

The COPD management recommendations can be found on the website: http://goldcopd.org. The major goals of treatment are to reduce symptoms (shortness of breath) and to reduce the risk of sudden worsening (called an exacerbation).

The following statements summarize the recommendations for personalized treatment of those with stable COPD.

  1. Long-acting bronchodilators (last 12 – 24 hours) are preferred over short-acting drugs (last 4 – 6 hours) for those with occasional shortness of breath.
  2. Either one or two long-acting bronchodilators may be used as initial treatment.  Increase to two bronchodilators is recommended if improvement is not achieved with one drug. The three approved dual bronchodilators available for prescription in the US are shown below.
    Anoro Ellipta enables patients to breathe easier with two bronchodilators

    Anoro Ellipta dry powder inhaler

    Stiolto Respimat delivers a fine mist.

    Stiolto Respimat delivers a fine mist.

     

    Bevespi contains two different bronchodilators in a single device

    Bevespi is a pressurized metered-dose inhaler

  3. For those who have a history of sudden worsening of COPD (exacerbation), use of an inhaled corticosteroid may be considered in addition to a long-acting beta-agonist bronchodilator (Advair, Symbicort, and Breo).
  4. For severe hereditary alpha-1 antitrypsin deficiency, replacement therapy (also called augmentation therapy) should be considered.
  5. Medicines to suppress coughing (called antitussives) are not recommended.
  6. If breathing difficulty is severe and disabling, low dose narcotics (opioids like morphine) may be considered.

These COPD management recommendations are based on the results of published clinical trials.   

Recurrent Chest Infections due to Acquired Immunodeficiency

Recurrent Chest Infections – Need to Test Immunoglobulin Levels

Background: Recurrent chest infections in those with COPD can cause coughing, chest congestion, shortness of breath, and “feeling sick all of the time.” These symptoms may improve with courses of antibiotics and prednisone, but may recur weeks after these medications are stopped.

One possible cause for repeated chest infections is a low level of antibodies.

Plasma cells, which are part of the body’s immune system, makes antibodies to fight off bacteria, viruses, and other invaders that could harm overall health.

The body makes several types of immunoglobulin antibodies called A, G, and M. They are abbreviated as IgA, IgG, and IgM. IgA is found at high levels in saliva, tears, and nasal secretions. IgG is found in blood and in tissue, while IgM is found in blood.

In some individuals, plasma cells do not produce normal levels of antibodies. This medical condition is called common variable immunodeficiency (abbreviated CVID). It is estimated that CVID occurs in one out of 50,000 individuals in North America.

Case Report: I recently saw a 69 year old female in my practice who was referred for repeated episodes of pneumonia. She reports five different times she was sick with pneumonia in the past 11 months. Main symptoms are cough which may or may not be productive of mucus, more shortness of breath, feeling tired, and low grade fever. Recent x-rays of the chest showed shadows in the right lower lung area. For each episode her primary care physician prescribed an antibiotic and higher doses of prednisone.

She also has severe COPD based on results of breathing tests. She smoked one and one-half packs of cigarettes per day for 35 years, but quit 9 years ago. She did not report any heartburn symptoms to suggest possible acid reflux.

As part of her evaluation, I ordered blood tests to measure levels of immunoglobulins. Her IgG level was below normal, while IgA and IgM levels were in the normal range. I made the diagnosis of  common variable immunodeficiency and ordered: a CT scan of the chest to look for bronchiectasis; and replacement therapy with IVIG (immunoglobulin G).

Discussion: CVID was reviewed recently in the November-December 2016 issue of the Journal of Allergy and Clinical Immunology: In Practice (volume 4, pages 1039-1052). Usually, the person has recurrent sinus and/or chest infections. In the lungs, these repeated infections can cause thickening of the walls of breathing tubes and damage air sacs which creates a reservoir for bacteria (bronchiectasis) as shown in the figure below.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

To diagnose CVID, your health care provider should measure levels of immunoglobulins (IgA, IgG, and IgM) in blood.

Replacement therapy is available if a person has a low level of IgG. The goal is to increase blood levels of IgG to normal to prevent future sinus and respiratory infections. Treatment is given intravenously (through an arm vein) every 4 weeks. This can be done at home or in an infusion center at the hospital. Studies confirm that IgG replacement reduces infections in those with CVID.

Cystic changes in the lungs due to bronchiectasis.

CT scan of the chest shows cystic changes in the lungs due to bronchiectasis.

If the person also has bronchiectasis, it is important to obtain a sample of sputum to identify the specific type of infection. Antibiotic therapy may be necessary for weeks to months.

Endobronchial Valve Therapy for Diffuse Emphysema

Benefits of Endobronchial Valve Therapy: Results of the IMPACT Study

Reason for the Study: Placement of an endobronchial valve into the breathing tube has been shown to improve lung function and shortness of breath in those with emphysema mainly in the upper parts of the lung (called heterogenous emphysema). Whether this therapy is beneficial in those with diffuse emphysema (damage throughout the upper and lower parts of the lung) is unclear.

Study: This study was conducted in Austria, Germany, and the Netherlands. All subjects had severe emphysema with lung function [how much air was exhaled in one second (FEV1)] between 15% to 45% of the predicted value. A CT scan was performed in all subjects to assess the extent of emphysema. Only those with less than 15% difference in emphysema scores between the target lobe of the lung and the same lobe on the other lung were included.

All subjects were assigned by chance to receive placement of the Zephyr endobronchial valve (EBV) in one lobe of the lung OR usual care.

The study was reported in the November 1, 2016, issue of the American Journal of Respiratory and Critical Care Medicine, volume 194, pages 1073-1082.

Endobronchial valve used in the study

Zephyr endobronchial valve used in the study

Results: Of the 93 subjects, 50 received usual care and 43 received endobronchial valve placement. 17 subjects who were initially assigned to have a valve placed could not participate because they were found to have collateral ventilation (See post on 12/27/15 on measuring collateral ventilation and what it means).

On average, four valves were placed in each of the 43 subjects in the EBV group. After 3 months of treatment, there was improvement of 14% in FEV1 in the EBV group, while FEV1 declined by 3% in the usual care group. This 17% difference between groups was statistically significant.

Zephyr valve prevents air from entering the lung. Air can only move out of the lung, resulting in collapse of emphysema lung.

Zephyr endobronchial valve prevents air from entering the lung. Air can only move out of the lung, resulting in collapse of emphysema lung.

More subjects in the EBV group improved in walking distance for 6 minutes by 26 meters or more (50% versus 14% in usual care) and for quality of life by 4 points or greater (57% versus 25% for usual care).

Adverse Events: Over the 3 months period, 44% of the EBV group and 12% in the usual care group had serious adverse events. There were 12 pneumothoraces (air in the lining around the lung) in 11 subjects in the EBV group. All of these required the subject to be treated in the hospital with a tube placed between ribs to drain the air. In five of these subjects, one or more valves had to be removed.

Pneumothorax in right lung. Black arrow shows collapsed lung.

Pneumothorax in right lung. Black arrow shows collapsed lung.

Diagram of pneumothorax in left lung

Diagram of pneumothorax in left lung

Conclusions: Endobronchial valve therapy can provide meaningful improvements in lung function, exercise tolerance, and quality of life in those with diffuse emphysema without collateral ventilation. Some subjects experienced serious adverse events, mainly pneumothorax (see chest xray above and diagram on left). 

My Comments: Placement of endobronchial valves for those with advanced emphysema is common and considered standard of care in in many European countries. In the United States, this procedure is investigational as it has not been approved by the Food and Drug Administration. Studies are underway in the US to further evaluate endobronchial valve therapy.

150 Lung Cell Mutations Each Year from Cigarette Smoking

Smoking Causes Cell Mutations or Genetic Damage

Background: A cell mutation is the permanent change in the sequence, or order, of the DNA in genes within a cell. Cell mutations play a part in both cancer and the immune system (fights infection and inflammation). Mutations may be harmless, but the more there are, the greater the risk that one or more of them will wind up causing cancer.

Cigarette smoking causes 150 cell mutations each year

Cigarette smoking causes 150 cell mutations each year in the lung

Study Results: On November 3, 2016, researchers reported in the journal Science a direct link between the number of cigarettes smoked in a lifetime and the number of mutations in cells. The findings are based on a genetic analysis of 5,243 cancers, including 2,490 from smokers and 1,063 from patients who said they had never smoked tobacco cigarettes.

In lung cells, there were on average 150 mutations in each cell each year with smoking a pack of cigarettes per day. Smoking did not only affect cells in the lung. On average, there were 97 mutations in each cell of the larynx (voice box), 39 mutations for the pharynx (throat), 18 for the bladder, and 6 mutations in every cell of the liver each year.

Number of cell mutations due to smoking a pack per day

Number of cell mutations due to smoking a pack per day

Conclusions: “The way tobacco smoking causes cancer is more complex than we thought,” commented study coauthor Dr. Mike Stratton, director of the Wellcome Trust Sanger Institute in England.

The researchers said they think these kinds of mutations have the effect of speeding up the “clock” inside of cells. The faster a cellular clock runs, the more chances the cell’s DNA has to mutate.

My Comments: This study provides clear proof that cigarette smoking causes cancer. Smoking kills 6 million people a year worldwide. If the current trend continues, the World Health Organization predicts more than 1 billion tobacco-related deaths in this century.

If you smoke, ask your health care provider for help to quit. Medications are available to help people quit smoking, while numerous professional organizations offer various support services.

 

Results of Long-Term Oxygen Therapy in COPD

Oxygen Therapy: No Benefit for Time to Death or Time to Hospitalization IF Oxygen Saturation is Slightly Reduced

Background: A pulse oximeter is placed on the finger to measure the amount of oxygen bound to red blood cells. The measurement is simple and non-invasive. The value is called oxygen saturation and abbreviated SpO2; normal is 95 – 97%. 

Oximeter is used to assess the need for oxygen therapy

Oximeter measures the percentage of oxygen being carried by red blood cells

Based on the results of studies conducted in the 1970s, insurance companies along with Medicare/Medicaid pay for oxygen therapy IF:

REST: SpO2 is equal to or less than 88%

DURING SLEEP: SpO2 is equal to or less than 88% OR if there is a fall in SpO2 of at least 5% with evidence of restlessness, difficulty sleeping, or impaired thinking

DURING EXERCISE: SpO2 equal to less than 88% OR if the person has shortness of breath and high levels of breathing during exercise and the use of oxygen allows the person to increase exercise endurance.

Study: The National Heart, Lung, and Blood Institute (supported by your and my tax money) sponsored a study to evaluate if oxygen therapy was beneficial for those just above the 88% cut-off value. The investigators studied those with COPD who had SpO2 of 89 – 93% at rest – who were supposed to use oxygen therapy 24/7 – OR those with SpO2 less than 90% for at least 10 seconds during a 6 minute walk test – who were supposed to use oxygen therapy during exercise and sleep.

Women using portable oxygen therapy

Woman using portable oxygen system

One-half of the subjects were treated with oxygen therapy, while the other one-half received no treatment. The study outcomes were time to death and time to first hospitalization for any cause.

The study results were published in the October 27, 2016, issue of the New England Journal of Medicine (volume 375; pages 1617-1627). DOI: 10.1056/NEJMoa1604344.

Results: A total of 738 patients at 42 different medical centers or clinics were followed for 1 – 6 years. There were no differences between the oxygen group and the no oxygen group for time to death or time to first hospitalization. Also, there were no differences in quality of life or 6 minute walking distance between the two groups.

Woman using oxygen at rest

Woman using oxygen at rest

Conclusion: The use of oxygen for those with moderately low levels of oxygen saturation did not provide any benefit.

My Comments: The investigators questioned if the benefits of oxygen might help those with reduced SpO2, but above the cut-off of 88%. They did not find a difference in time to death or time to being hospitalized.

Portable oxygen concentrator which provides continuous flow 1-3 l/min or pulse flow 1-9 l/min

Portable oxygen concentrator which provides continuous flow 1-3 l/min or pulse flow 1-9 l/min

These results will not change current practice. There is good evidence that oxygen therapy enables those who have a SpO2 of 88% or lower with activities to walk farther/longer with less shortness of breath.  I and other health care providers will continue to prescribe oxygen based on current standards as listed in Background.

Regular Dental Care Can Reduce Risk of Pneumonia

Dental Visits Cut Risk of Pneumonia

Dr. Michelle Doll and colleagues from Virginia Commonwealth University in Richmond analyzed information on 26,687 individuals from the Medical Expenditure Panel – a set of surveys of families and individuals across the United States – to look for factors that could reduce the risk of pneumonia.

The researchers were able to determine the number of dental visits in a year and compared this information with medical diagnosis codes for bacterial pneumonia. 441 individuals of the group had an episode of pneumonia in the same year as information was available about dental visits.

Dental care visit that may reduce the risk of pneumonia

Dental care visit

Results: Of those who developed pneumonia, 34% reported having at least two dental checkups a year compared with 46% of those who did not have regular dental visits. For those who never had a dental visit in the year, the risk of pneumonia was 86% higher than those who had two visits to the dentist in the same year.

Additional analysis showed that white race, older age, other medical problems, and lower health status were statistically associated with an increased risk of pneumonia.

These findings were recently presented at the Annual Infectious Disease (ID) Week meeting in New Orleans.

Arrows show pneumonia in the fight lung

Arrows show pneumonia in the right lung

My Comments: Bacterial pneumonia is a serious illness, and may be life threatening in those who have COPD. Anything that can be done to reduce the risk of pneumonia is important. There is a direct link or conduit between the mouth and the lungs.

Most episodes of bacterial pneumonia are due to bacteria in the mouth “slipping down” into the lungs. This is called aspiration. This process typically happens during sleep. As long as the number of bacteria that reach the lungs is small and as long as the immune system (fights infections) of the person is good, pneumonia does not usually occur.

Make sure to practice good dental hygiene and have regular checkups with your dentist.

 

Bronchiectasis Can Cause Frequent COPD Flare-ups

Bronchiectasis Is Linked to Increased Risk of a COPD Exacerbation

Background: Bronchiectasis is a chronic condition in which the walls of the breathing tubes are thickened from long-term inflammation and scarring. Typically, bronchiectasis is a result of a pneumonia which damages parts of the lung. As a result of the damage, mucus produced by the cells lining the breathing tubes does not drain normally. Mucus build-up can lead to a chronic infection. A cycle of inflammation and infection can develop, leading to loss of lung function over time.

CT scan shows cystic bronchiectasis

A slice of the chest on a high-resolution CT scan in a 62 year old with cystic bronchiectasis. The cysts are seen on the lower portions of both lungs.

Different types of bacteria and mycobacteria can infect the damaged areas of the lung causing:

  1. chronic coughing
  2. coughing up blood
  3. shortness of breath
  4. chest pain
  5. coughing up large amounts of mucus daily
  6. weight loss
  7. fatigue
  8. thickening of the skin under the finger nails and toes (called clubbing)

Poster Presention at CHEST meeting October 25, 2016, in Los Angeles: Dr. Kosmas of the Metropolitan Hospital in Piraeus, Greece, presented findings in 855 individuals with COPD 

42% of the patients were found to have evidence of bronchiectasis on CT scan of the chest. About 20% had experienced more than one flare-up (exacerbation) of COPD in previous year. The investigators also found that the severity of COPD predicted the increased likelihood that a person would have bronchiectasis.

Dr. Kosmas commented at the poster presentation that, “Bronchiectasis is an area in the lung that is destroyed by pneumonia, and bacteria reside there. It results in a low-grade infection, and can then lead to inflammation and an exacerbation.”

My Comments: The symptoms of bronchiectasis usually start off as mild with a persistent cough that produces yellow or green mucus. An antibiotic may help to clear up the mucus, but typically the yellow or green color returns after a few weeks.

A CT scan of the chest is important to diagnose this condition. Then, a fresh sample of the mucus should be obtained to send to the laboratory to identify the specific type of infection (sputum culture). Different blood tests should also be ordered to look for possible medical conditions that may contribute to bronchiectasis (for example, cystic fibrosis, immunodeficiency, HIV infection, alpha-1 antitrypsin deficiency, rheumatoid arthritis, and inflammatory bowed disease).

If you experience frequent chest infections, or continue to cough up yellow-green mucus persistently, ask you health care provider to consider bronchiectasis.

November is National COPD Awareness Month: Wear Orange

World COPD Awareness Day is November 16 

An estimated 24 million Americans suffer from COPD, while almost one-half have not yet been diagnosed. It is likely that these individuals who don’t know that they have COPD blame their shortness of breath on “getting older” or being “out of shape.”

With early diagnosis and treatment, people with COPD can improve their quality of life and begin to breathe a little easier.

Woman promoting COPD awareness

Woman with COPD using portable oxygen system

As part of National COPD Awareness Month, many organizations and individuals are trying to raise COPD awareness by hosting events, leading discussions, and conducting other outreach activities to help people take the first step toward improving the lives of those with COPD.

The US COPD Coalition urges the nation to “GO ORANGE” for COPD in November. The color ORANGE calls attention to and provides visual solidarity among efforts across the nation. ORANGE is also the color that the U.S. Environmental Protection Agency’s Air Quality Index uses to represent days with unhealthy air quality for sensitive groups, including people with lung disease.

Breathe New Hampshire
is sponsoring a COPD Wellness Workshop from 10 am – 12 noon on November 19 @ 145 Hollis St., Unit C, Manchester, NH  03101
603-669-2411 or 800-835-8647  email info@breathenh.org

I and other panelists will be presenting information about COPD and will answer questions. I hope to see you there.

Key facts about COPD:

  1. It is the 3rd leading cause of death in the US.
  2. 5.2% of adult men and 6.7% of adult women have COPD.
  3. Alpha-1 antitrypsin deficiency is a genetic risk factor for emphysema/COPD. If you have not been tested, ask your health care provider to order the blood test.

Additional information is available on the COPD Foundation website: http://www.copdfoundation.org

E-cigarette Explosion Injuries due to Lithium-Battery Overheating

E-cigarette Explosion Injuries to Face, Hands, and Thighs

Vaping e-cigarette may cause e-cigarette explosion

A person vaping e-cigarette.

The use of e-cigarettes is increasing among current, former, and never smokers. Components include an aerosol generator, a flow sensor, a battery, and a solution storage area. Many users do not understand the risk of “thermal runaway,” whereby internal battery overheating causes a battery fire or explosion.

Components of an e-cigarette

Components of an e-cigarette

Elisha G. Brownson, M.D., and colleagues at the University of Washington Medical Center in Seattle described injuries to 15 patients from e-cigarette explosions due to the lithium-ion battery component between October 2015 through June 2016. The letter to the Editor was published in the October 6 issue of the New England Journal of Medicine.

The e-cigarette explosion injuries included flame burns (80%), chemical burns (33%), and blast injuries (27%) to the face, hands, and thighs. Blast injuries have led to tooth loss, traumatic tattooing, and extensive loss of soft tissue, requiring surgery.

The flame-burn injuries have required extensive wound care and skin grafting, and exposure to the alkali chemicals released from the battery explosion has caused chemical skin burns requiring wound care. Many of injuries occurred in young individuals.

E-cigarettes are largely unregulated. Recently, the FDA has extended regulatory authority to cover all tobacco products, including e-cigarettes. Although these explosions were previously thought to be isolated events, the injuries among the 15 patients in Seattle add to growing evidence that e-cigarettes are a public safety concern.

Both e-cigarette users and health care providers need to be aware of the risk of explosion associated with e-cigarettes.