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.  

CT scanner for lung cancer screening.

CT scanner

 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

Review of 25 Studies Shows 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 our 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.

Vitamin D supplements reduce respiratory infections

Vitamin D capsules in a spoon

 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. 

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: Estimate 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.

Man seated on stool illustrating sitting time

Man seated on stool

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. 

Stand up desk to reduce sitting time

Stand up desk with adjustable height

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.

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

Leonarndo M. Fabbri, M.D., of the University of Moderna is one of the authors of the article

Leonarndo M. Fabbri, M.D., of the University of Moderna is one of the authors of the article

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: 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 dry powder inhaler

    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

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:

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.

Resveratrol Reduces Inflammation in the Airways of Mice

Resveratrol is Found in Grapes, Berries, and Nuts

Background: Inflammation (redness and swelling) is prominent in the breathing tubes (airways) of those with COPD. Cigarette smoking, inhaling irritants in the air  (dust, second hand smoke, fumes,etc.), and a chest infection all cause inflammation in the lungs. Some treatments for COPD aim to reduce inflammation in the breathing tubes.

Resveratrol is a phosphodisesterase (PDE) inhibitor that has potential as a therapy to reduce airway inflammation. It is in found in the skin of grapes, blueberries, raspberries, and nuts.

The skin of purple grapes contain resvetrol

Purple grapes

Study: Dr. Carla Andrews and colleagues at Georgia State University in Atlanta studied the effects of resveratrol on the cells lining the inside of the breathing tubes of mice. The study was published in the September 28, 2016, issue of the journal Nature.

Results: In brief, resveratrol reduced the levels of two different inflammatory mediators. In addition, it had anti-inflammatory effects on the airways or mice after infection with the bacteria Haemophilus influenzae.

Raspberries contain resveratrol

Raspberries contain resveratrol

My Comments: At the present there are two different anti-inflammatory medications approved to treat those with COPD. One is inhaled corticosteroids which are combined with an inhaled bronchodilator (beta-2 agonist). The other is roflumilast – a pill which is used to reduce the risk of a flare-up (exacerbation) of COPD.

In addition, oral and intravenous corticosteroids are used to treat those with COPD who have a sudden increase of shortness of breath, cough, and mucus production (exacerbation). These medications are typically prescribed for a short time (5 – 14 days).

To my knowledge, there are no scientific studies that have examined whether eating foods containing resveratrol has a direct effect on those with COPD. However, grapes, berries, and nuts are foods that promote good health. Red wine is also a good source of this substance.

Hopefully, in the future researchers will study the effects of resveratrol on the lining of the breathing tubes on humans who have COPD.

Emotional Intelligence is Associated with Wellbeing and Self-Management

Emotional Intelligence Is Important in COPD

Background: Emotional intelligence is the ability to understand and manage personal thoughts and feelings. It can influence your communication with others. It is a trainable skill that has been used in corporate business to improve well-being and performance.

first author of study evaluating emotional intelligence.

Dr., Roberto Benzo of the Mayo Clinic.

Study: Dr. Roberto Benzo from the Mayo Clinic studied 310 patients with COPD who were 69 years of age on average. The key breathing test (FEV1) was 42% of the predicted value on average. All subjects answered numerous questionnaires. The study findings were published in the Annals of the American Thoracic Society in January 2016 (volume 13, pages 10-16).

Findings: Emotional intelligence was significantly and independently associated with self-management abilities, quality of life (shortness of breath, fatigue, emotions and mastery) after adjusting for age and breathing test results.

Conclusions: Dr. Benzo and his team concluded that emotional intelligence is important for those with COPD. The authors commented that attention to it may address the current gap that exists in the treatment of emotional parts of COPD which is related to decreased quality of life and increased health care use.

Store employee tying shoe of elderly shopper.

Store employee tying shoe of elderly shopper

My Comments: I congratulate Dr. Benzo and his colleagues on addressing a novel feature of COPD that has not received much attention in daily care and management efforts.

Emotional intelligence affects:

  • Performance at school or work. Emotional intelligence can help you navigate the social complexities of the workplace, lead and motivate others, and excel in your career. In fact, when it comes to gauging job candidates, many companies now view emotional intelligence as being as important as technical ability and use testing before hiring.
  • Physical health. If you’re unable to manage your emotions, you probably are not managing your stress either. This can lead to serious health problems. Uncontrolled stress can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. The first step to improving emotional intelligence is to learn how to relieve stress.
  • Mental health. Uncontrolled emotions and stress can also impact your mental health, making you vulnerable to anxiety and depression. If you are unable to understand, be comfortable with, and manage your emotions, you’ll be at risk of being unable to form strong relationships which can leave you feeling lonely and isolated.
  • Relationships. By understanding your emotions and how to control them, you’re better able to express how you feel and understand how others are feeling. This allows you to communicate more effectively and forge stronger relationships, both at work and in your personal life.

Vaping Electronic Cigarettes Help People Quit Smoking

Two Reports Show Vaping Electronic Cigarettes Helped People Quit Smoking

Background: E-cigarettes heat liquid laced with nicotine into a vapor. The global market for vaping products is estimated at around $7 billion in 2015. Vaping electronic cigarettes have been used by some individuals as a way to help quit smoking tobacco products. How effective e-cigarettes are for this purpose is unknown.

There are numerous types for vaping electronic cigarettes.

E-cigarettes are displayed in a store.

 Study 1. Researchers at University College London analyzed results on smokers who participated in the Smoking Toolkit Study – a survey of households of those 16 years of age and older in England. Information was collected on about 170,490 smokers between 2006 and 2015.  21% were current smokers. The authors estimated that in 2015 e-cigarettes alone may have helped about 18,000 smokers quit cigarettes who would not otherwise have quit. The study was published in the British Medical Journal on September 13, 2016, volume 354 (doi: 10.1136/bmj.i4645)

Person vaping electronic cigarette

A person vaping e-cigarette.

Study 2: A Cochrane review evaluated 11 new studies about electronic cigarettes published since 2014. The review found that electronic cigarettes that contain nicotine can help people stop smoking. The Cochrane committee stated, “There was no evidence of serous side effects form e-cigarette use over a two year period.” 

Comments: Dr. John Britton, Director of the UK Centre for Tobacco and Alcohol Studies at the University of Nottingham, commented about the Cochrane report, “The evidence is clear, smoking kills. If you can’t stop smoking, if you can switch to another form of nicotine and that lets you stop smoking, then that is great.”

Ms. Deborah Arnott, chief executive of the health charity Action on Smoking and Health, said, “Taken together, the Cochrane review and the BMJ article provide further reassurance that e-cigarettes are not undermining quitting. Indeed, the evidence from England, where smoking prevalence is continuing to decline, is the e-cigarette use is associated with a higher rate of successful quit attempts by smokers.”

Health Coaching Reduced COPD-related Hospitalizations

Study Shows Benefits of Health Coaching Plus a Written Action Plan

Background: There is considerable attention focused on preventing hospital readmissions for COPD. One factor is that hospitals are penalized by lower reimbursement for services if there is a high readmission rate.

first author of study evaluating health coaching

Dr., Roberto Benzo of the Mayo Clinic.

Study: Dr. Roberto Benzo and colleagues at the Mayo Clinic in Rochester, MN, studied a total of 215 patients hospitalized for a COPD flare-up (called an exacerbation). At discharge from the hospital, one-half were assigned to health coaching and a written action plan for any flare-up OR usual care. 

The health coach met with each patient in the hospital for 2 hours and at least once in person after discharge. At the first visit, the patient was provided with prednisone and an antibiotic to be started if the individual experienced a flare-up. Also, during the visit self-management concepts, goal setting, action planning, and details of the telephone sessions to come were discussed. All subsequent sessions were conducted by telephone.

The study was published in the September 15, 2016, issue of the American Journal of Respiratory and Critical Care Medicine (volume 194; pages 671-680).

Health coach aims for healthy lives.

A health coach can help someone achieve a healthy life.

Results: There was a significant reduction in hospital readmissions at 6 months, but not at one year, in the group who received health coaching compared with usual care. The health coaching group also had better quality of life than the usual care group. 

Conclusions: The authors concluded that their study was the first to show the benefits of “a feasible, innovative, and effective intervention designed to reduce short-term readmissions for those with COPD.”

My Comments: Health coaching is popular in managed care and accountable care organizations (ACOs) in an effort to improve care and to reduce costs. Health coaching is patient-centered, individualized, and aimed at improving health behaviors. For those with COPD, a health coach may assist the individual with quitting smoking, increasing physical activity, and starting early treatment for a flare-up. Whether health coaches will become an integral part of medical practices in the future is unknown.


According to the CDC, COPD Deaths Down for Most Americans

From 2000-2014, 12% Drop in COPD deaths in the US

Background: COPD is the 3rd leading cause of death in the United States after heart disease and cancer. None of the available medical treatments for those with COPD, such as inhaled medications, have been shown to affect mortality.

Report: The Center for Disease Control and Prevention, known as the CDC, reported on September 8, 2016, that between 2000 and 2014, there was a 12% overall drop in COPD deaths. Dr. Hanyu Ni, a co-author of the findings, commented that the findings were not unexpected because, “they are consistent with the declines in the prevalence of current smoking for men and women in the United States.” The results were reported in the US National Center for Health Statistics.

COPD includes chronic bronchitis and emphysema.

COPD includes chronic bronchitis and emphysema.

COPD deaths were analysed by sex and race. For women, there was little change for Caucasians, while African-Americans had a 4% increase in death rate over the 14 years. For men, Caucasians experienced a drop of 21%, and African-Americans had a decline of about 24%.

Reduced smoking may explain the overall decline in COPD deaths.

Man and woman smoking a igarettte

Dr. Ni commented that the analysis did not explore the reasons for the trends. However, he stated that the figures weren’t unexpected noting that the declines in COPD deaths are consistent with fewer women and men currently smoking in the U.S.

David Mannino, M.D., Professor and Chair of the Department of Preventive Medicine and Environmental Health at the University of Kentucky.

David Mannino, M.D., Professor and Chair of the Department of Preventive Medicine and Environmental Health at the University of Kentucky.

Dr. David Mannino suggested that additional factors unrelated to smoking might affect COPD deaths. He proposed that poverty and/or lack of access to health care “may explain some the racial differences.”

Less than 20% Receive Education About Monitoring a COPD Flare-up

Results of Study Show Need for a COPD Flare-up Action Plan

Less than 1 of 5 patients with COPD received information from their doctors on how to self-monitor for signs of an impending COPD flare-up according to Anja Frei, Ph.D., of the University of Zurich. Dr. Frei presented these findings at the International Conference of the European Respiratory Society in London. A flare-up means an increase in cough, mucus production, and/or more short of breath. About 2/3 of flare-ups are due to a chest infection (bacterial or viral), while about 1/3 are due exposure to air pollution. The medical word for a COPD flare-up is an exacerbation. 

Photo on right shows acute bronchitis with yellow mucus inside the airway

Photo on right shows acute bronchitis with yellow mucus inside the airway. This can cause a COPD flare-up.


Of 317 individuals with COPD living in Switerzerland who were surveyed,  just 53 remembered ever being told to monitor their own symptoms. About 36% recalled being given instructions to change medications in case of deteriorating breathing. 29% of those COPD took action when a flare-up occurred; some called their primary care provider, some used short-acting albuterol inhaler for relief, and others avoided aggravating situations.

Primary care providers discussing Action Plan for COPD flare-up

Primary care providers discussing Action Plan for COPD flare-up

According to Claudia Steurer-Stey, M.D., “We have a lot of work to do in education of these patients. The general practioner who sees the majority of their patients is a very important target of our work so they can improve the quality of primary care.”

My Comments: All those with COPD should have a written action plan for what to do if/when they an experience a COPD flare-up.

Here is a Simple COPD Action Plan if You Have a Flare-up

♦ If you are more short of breath, use albuterol sulfate and/or ipratropium bromide inhalers every 2 – 4 hours as needed

Albuterol sulfate – brand names are ProAir, Proventil, and Ventolin

Ipratropium bromide – brand name is Atrovent

Combination of albuterol sulfate and ipratropium bromide –

brand names are Combivent Respimat and DuoNeb solution (in nebulizer)

♦ If you cough up yellow or green mucus, call or see your health care provider to ask if an antibiotic is appropriate.

♦ If use of albuterol sulfate and/or ipratropium bromide does not help improve your breathing difficulty, call or see your health care provider to ask if prednisone is appropriate.

♦ If you cannot speak in full sentences or cannot fall asleep at night because of breathing difficulty, call or see your health care provider, go to an Urgent Care center, or go to the nearest Emergency Department.





The Perils of Hookah Smoking: Results of New Study

Light-use, Hookah Only Smokers Have Symptoms and Reduced Lung Function

Background: The hookah, also called a waterpipe, shisha, or narghile, is used for smoking fruit-flavored tobacco by millions of people worldwide. Tobacco is placed in a bowl surrounded by burning charcoal. When the smoker inhales, air is pulled into the bowl holding the tobacco. The resultant smoke is bubbled through water, carried through a hose, and inhaled. It typically includes tobacco products equivalent in a single bowl waterpipe session over 45 – 60 minutes to one pack of cigarettes together with carbon monoxide and charcoal components.

Hookah in restaurtant in Nepal

Hookah in restaurtant in Nepal

Components of a hookah

Components of a hookah

While hookah smoking is commonly associated with the Middle East, the use of waterpipes is becoming more common in the United States. For example, 9 – 20% of young adults in the US report that they have used waterpipes, and hookah “bars” are common in many US cities. Many smokers believe that the water filters “toxins” from the smoke, making it safer than smoking cigarettes. However, this is a myth.

Study: Researchers from the Weil Cornell Medical College studied 19 never smokers and 21 self-reported hookah smokers only from the general population of New York City by posting advertisements in local newspapers, eletronic bulletin boards, and waterpipe bars. All subjects answered questions, performed breathing tests, had a high-resolution CT scan of the chest, and had samples obtained from the lower breathing tubes by bronchoscopy (having a scope passed into the mouth and deep into the lungs). The study was published in the September 1, 2016, issue of the American Journal of Respiratory & Critical Care Medicine.

Findings: Compared with nonsmokers (average age = 33 years), the waterpipe smokers (average age = 25 years) had: more cough and sputum (mucus); reduced transfer of gas across the air sacs and blood vessels (called the diffusing capacity); and abnormal cells in the lower lung.

Conclusions: Young. light-use, hookah only smokers have multiple lung abnormalities suggesting that even limited use can have serious consequences.

My Comments: Two factors have increased  the popularity of hookah or waterpipe smoking among school-aged children and young adults throughout the world. One is the introduction of different flavors (lemon, apple, orange, cherry, etc.). Two is as the belief that waterpipe smoking is safe as it filters all noxious substances because it passes through water.

Studies have compared the effects of a single session of waterpipe smoking with smoking one cigarette. The inhaled smoke volume is 123 times greater with hookah smoking and is associated with 2.3 times more inhaled nicotine and 25 times more inhaled tar.

Once again, any type of smoking can damage the lungs and should be avoided for lung health.

Outdoor Air Pollution and COPD-related Hospital Admissions

Outdoor Air Pollution Is Associated with Increase in Emergency Department Visits and Hospital Admissions

What is Air Pollution? An air pollutant is a substance in the air that can have affect humans and the ecosystem. The substance can be solid particles, liquid droplets, or gases. A pollutant can be of natural origin or man-made.

Particulate matter coming out of smokestacks in city

Particulate matter coming out of smokestacks in city

There are three major air pollutants. 1. Particulate matter (PM) are tiny particles of solid or liquid suspended in a gas. Some particulates occur naturally, originating from volcanoes, dust storms, forest and grassland fires, living vegetation, and sea spray. Burning of fossil fuels in vehicles, power plants and various industrial processes also generate significant amounts of aerosols. 2. Nitrogen dioxide (NO2) are expelled from high temperature combustion, and are also produced during thunderstorms and by electric discharge.  They

Particulates in the air causing shades of grey and pink during sunset

Particulates in the air causing shades of grey and pink during sunset

can be seen as a brown haze dome above cities. It has a reddish-brown toxic gas has a characteristic sharp, biting odor. 3. Sulfur dioxide (SO2) is produced by volcanoes and in various industrial processes. Coal and petroleum often contain sulfur compounds, and their combustion generates sulfur dioxide. 


Study: Dr. DeVries and colleagues at Department of Work Environment, University of Massachusetts in Lowell reviewed 37 published studies to evaluate any association between short-term exposures of the three major air pollutants and COPD-related use of health care services. This included over 1 million COPD-related events. The study was published on-line in the journal COPD August 26,2016.

Results: Increases of PM, nitrogen dioxide, and sulfur dioxide were associated with 2.1% to 4.2% increases in Emergency Department visits and hospital admissions related to COPD (shortness of breath or a flare-up). Similar effects were found for each pollutant and COPD-related mortality.

Conclusions: The authors concluded that air pollution presents an on-going threat to the health of those with COPD.

My Comments: Outdoor air pollution conditions are reported daily as the Air Quality Index (AQI). Be sure to check on outdoor air pollution in your area.

  • AQI on the Internet. An AirNow Web site provides easy access to air quality information. On the web site, you will find daily AQI forecasts and real-time AQI conditions for over 300 cities across the United States, with links to more detailed state and local air quality Web sites. AIRNow’s reports are displayed as maps you can use to quickly determine if the air quality is unhealthy near you.
  • AQI via e-mail. You can sign up for a free email service using EnviroFlash ( This will alert you via e-mail when air quality is forecast to be a concern in your area.
  • AQI in the media. Many local media—television, radio, and newspapers—and some national media (The Weather Channel) provide daily air quality reports, often as part of the weather forecast.

If the air quality is “bad” in your area, stay indoors as much as possible. Wait to go shopping or do other activities when the air quality has improved.

Bagpipe Lung Disease from Inhaling Mold and Fungi

61 year-old Player Died of Bagpipe Lung Disease

Report: Dr. Jenny King of the University Hospital of South Manchester in the United Kingdom reported on a 61 year-old man who died of an inflammatory lung condition that researchers called “bagpipe lung.” The report was published on-line on August 22, 2016, in the journal Thorax (10.1136/thoraxjnl-2016-208751).

Man playing bagpipe at wedding

Man playing bagpipe at wedding

In brief, this man had a 7-year history of a dry cough and shortness of breath leading to a major reduction in ability to perform activities. He was a life-long non-smoker, but played bagpipes daily as a hobby. During a hospital admission for worsening breathing, samples were taken from his bagpipes which grew numerous fungi. The man died from scarring of the lungs (interstitial fibrosis) which was thought due to repeated exposure to inhaling fungal spores from the bagpipe.

The authors commented that the moist air in the bagpipes promoted yeast and mold to grow. Cases similar to bagpipe lung disease have been described in saxophone and trombone players. They emphasized that cleaning musical instruments immediately after use and allowing to drip-dry should reduce the risk of bacterial and fungal growth.

My Comments: This report shows that it is important to be aware that wind instruments can be contaminated with yeasts and molds that can infect the lungs or cause lung inflammation/scarring. Certainly, anyone who has COPD needs to be careful about inhaling irritants in the air as well as bacteria and molds. Potential sources include exposure to droppings of  birds and pigeons, hot tubs, and areas of water damage. 

Marijuana Research to be Expanded for Medical Use

DEA to Allow Universities to Apply for Marijuana Research

On August 10, 2016, the New York Times ( announced that the Drug Enforcement Administration (DEA) will allow universities to apply to grow marijuana for use in federally funded research. At the present time, the University of Mississippi is the only institution authorized to grow it for use in medical studies.

Researchers at the University of Mississippi and their approved garden.

Researchers at the University of Mississippi and their approved garden.

According to John Hudak, a senior fellow at the Brookings Institution, “It will create a supply of research-grade marijuana that is diverse, but more importantly, it will be competitive and you will have growers motivated to meet the demands of researchers.”

At the same time, the DEA has turned down requests to remove marijuana from “Schedule 1” classification. According to the DEA, the drug has “no currently accepted medical use” in the United States. However, the Department of Justice has made it clear they will not prosecute as long as patients and doctors follow state law.

My Comments: In my practice I see patients who live in New Hampshire and in Vermont. Both states have legalized marijuana for medical use.  Approved use includes cancer, glaucoma, AIDS, as well as other conditions.

Although shortness of breath, or breathing difficulty, is not an approved use in either state, it is possible that anyone with COPD may qualify for another or a related reason.  For example, in Vermont medical marijuana is approved for a medical condition with one or more of the following intractable symptoms: “cachexia (weight loss) or wasting syndrome, severe pain or nausea or seizures.”

At the present, I have one patient who lives in Vermont and has severe COPD and uses oxygen 24/7. He/she is using cannabis oil for cachexia (weight loss and wasting). A drop of the oil is placed under the tongue each night for persistent breathing difficulty. He/she has reported marked improvement in his/her shortness of breath.

Approved garden for growing marijuana plants.

Approved garden for growing plants.

It is unclear how many universities will receive licenses to grow marijuana. Researchers will have to receive approval from the DEA and the Food and Drug Administration to perform medical studies. Hopefully, scientists will study the effects of oral marijuana on shortness of breath.


Primary Care Providers’ Knowledge and Beliefs about COPD

Survey of 426 Primary Care Providers about COPD

Background: Primary care physicians, nurse practitioners, and physician assistants provide the majority of care for those who have COPD. Thus, it is important to ask these primary care providers about their overall knowledge and beliefs about diagnosis and treatment of COPD.

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Study: Barbara Yawn, MD, MSc, and colleagues at the Olmstead Medical Center in Rochester, MN, surveyed 426 primary care providers at 3 different medical meetings in 2013 and 2014. The survey asked questions about perceived barriers to diagnosis of COPD and beliefs concerning the value of available COPD medications. The findings were published in the August 2016 issue of the Journal of the COPD Foundation (volume 3; pages 628-635).

Results: Of the 426 people who answered the questions on the survey, there were 278 medical doctors (MDs) and doctors of osteopathic medicine (DOs) and 148 nurse practioners (NPs) and physician assistants (PAs). 

The two most common barriers to making a diagnosis of COPD were: ♦ patients had many chronic medical conditions, not just COPD; and ♦ patients often failed to recognize and report breathing difficulty. These barriers were similar between MDs/DOs and NPs/PAs.

Woman performing breathing test.

Woman performing breathing test (spirometry).

About one-half of the clinicians said that they had equipment (spirometry) in their office, but less than 2/3 reported using testing to diagnose COPD.

Only 10% of those answering the survey reported ordering blood tests (screening) for alpha-1 antitrypsin deficieny, a hereditary form of emphysema.

About 75% said that there were available treatments to reduce shortness of breath, and 85% answered that medications for COPD could reduce exacerbations (flare-ups) of COPD. Some of these medications are shown below.

Examples of dry-powder inhalers

Examples of dry-powder inhalers

Conclusions: Primary care providers continue to report multiple barriers to diagnose COPD including easy access to testing equipment. However, most respondents noted that effective medications were available to improve breathing difficulty and to reduce the risk of a flare-up.

My Comments: In the past, many primary care providers felt that diagnosing those with COPD was not important because: COPD was self-inflicted by smoking; and treatments for COPD were not generally effective.

This survey shows that knowledge and attitudes among primary care providers have changed. Primary care providers do not need to have testing equipment (spirometers) in their offices, but instead can refer patients for testing at the local hospital.

If you have told that you have COPD and have not had breathing tests, ask your health care provider to order testing. Ask about what treatments are available to “make it easier to breathe.” BE PROACTIVE.