Dr. Ronald Green joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. He talked about COPD, chronic obstructive pulmonary disease.
Read the transcript of Dr. Green's talk on COPD on Health Matters radio or listen here
Health Matters: All right. Welcome back to Health Matters with Maury Eskenazi and Shannon O'Kelley. We are joined by a doctor who has been on with us before. He is from The Everett Clinic. He is pulmonary and sleep specialist Dr. Ronald Green joins us again. Health Matters: We are going to talk about COPD. Tell us what COPD means.
Dr. Green: COPD, chronic obstructive pulmonary disease. And I just, I wanted to read to you this big giant medical terminology definition and then I'm going to take it apart and speak in English because I think it's very helpful. So, there is an organization, the Global Initiative for Chronic Obstructive Pulmonary Disease and they call it GOLD, another acronym, and this was a project from the World Health Organization and the National Heart, Blood and Lung Institute in Washington, DC. So, COPD, is a common preventable and treatable disease characterized by airflow limitation, usually progressive, associated with enhanced chronic inflammatory response in the airways and the lungs to noxious particles or gasses, exacerbations and comorbidities contribute to the overall severity in individual patients. That is a mouthful. So, we will take it apart now. It's a common disease. It's the third leading cause of death in the United States of America, killing more than a 120,000 people annually. It is preventable. Eight percent of people in this country that get COPD, get it because of smoking. It is a smoking-related lung disease. Eighty percent of the people that have it are smokers. It is treatable by quitting smoking and with inhalers. It is characterized by airflow limitation which means that your bronchial tubes are damaged and narrowed so you can't breathe as much, especially breathe out and you tend to wheeze when you exhale. It is progressive. The more you smoke, the worse it gets. It is associated with an enhanced chronic inflammatory response in the airways which means the airways are swollen and when the airways get swollen, there are little muscles around the airways and those muscles get very upset and they constrict and when they constrict your breathing gets even worse and it gets even worse when you are exposed to what we call noxious particles or gasses such as cigarette smoke or diesel fumes or strong perfumes or strong-smelling flowers. Exacerbations and comorbidities. Exacerbations are it gets worse when you have a cold for example, you get an exacerbation which means all of a sudden you get so sick you may end up in the hospital. And comorbidities mean that people that smoke also have other diseases such as high blood pressure and heart disease and strokes and so it increases your risk of dying. That is the definition of COPD.
Health Matters: So, who is at risk? What age group? Is it the elderly that gets this more?
Dr. Green: No one is exactly sure how many packs per day you have to smoke for how many years to get COPD. If you smoke one pack of cigarettes for one year that's called 1-pack year. If you smoke two packs of cigarettes for one year that's called 2-pack years. So the thought is that people that smoke 10 to 15 pack years of cigarettes or more are at risk for that. You have to have some smoking under your belt. If you smoke 40 pack years or more, your risk is much, much higher. That's why it tends to show up in older people. Now, the issue with COPD is that often times it just presents with shortness of breath. You ask someone if they are short of breath of breath and they say, “No, I'm not short of breath unless I get up and walk up stairs or walk up hills or do something.” At rest, often times, people with COPD have no symptoms at all and often times they are not very active and then they get short of breath if they get active. Often times the diagnosis is delayed.
Health Matters: So, I'm interested in, drilling down into the lung tissue, you talked about the airways…what is it about the smoke or the environmental factors that irritates the lining? What does that ultimately lead to because you talked about, I understand people can breathe in, it's the breathing out aspect.
Dr. Green: Right. The airways get narrowed and it's harder to push the air out if the airways are narrow. What happens is that we have in our bodies the ability to repair damage all of the time. So, our bodies are getting damaged and repaired constantly. That happens in the lungs as well. There are enzymes in the lungs that help break down damaged tissue and repair that damaged tissue. What happens in COPD people is that the enzymes, the proteins that break down damaged tissue, kind of go nuts and actually digest normal lung. So the lung in COPD is essentially being digested. It's being destroyed and that's where emphysema comes in. COPD is really a spectrum disease. On the one hand, you have emphysema where the lung itself is destroyed and on the other end of the spectrum you have what's called chronic bronchitis where the airways are swollen like I was talking about and inflamed and it's hard to breathe out. You have this destruction that can occur and you have the inflammation that occurs and some people are in between the spectrum of those two things and that's what's going on. With chronic bronchitis, what happens is the cigarette smoke stimulates the cells in the lungs that make mucous and they make much, too much mucous and you end up with a chronic cough and sputum production.
Health Matters: COPD is kind of the global definition of the lung dysfunction which could be emphysema and/or chronic bronchitis?
Dr. Green: Right or a combination of both.
Health Matters: So, why do you get the bronchitis versus emphysema? Do they go hand in hand?
Dr. Green: It must be based on genetics of some sort. No one really understands quite frankly why people manifest in one way or the other. The other important point, too, is that not everybody that smokes gets COPD. So, there's a lot more to it than just one process in every person. People's bodies respond differently to cigarette smoke. Some people end up with lung cancer. Some people don't. Some people will end up with coronary artery disease and a heart attack. Some people don’t. Some people end up with COPD and some people don't from smoking.
Health Matters: Let me ask you a question, all us ex-smokers are thinking, if you've quit for a while, are your chances of getting it down the road decreased?
Dr. Green: If you have not developed COPD and you quit smoking, your chance of developing it is essentially zero.
Health Matters: Okay. That's good to know. So, the best thing to do is quit.
Dr. Green: It's a good comment. There was a big study in the 1970s called the Lung Health Study, and they looked at people with normal lungs and smokers. People that are developing COPD, year after year, are losing lung function much more rapidly than a nonsmoker. If you quit smoking, it showed that those same people, that rapid decrease in lung function stops when you quit. The process of COPD of destruction of that lung with cigarette smoking stops pretty much very quickly after you quit smoking. That's the best way to prevent it, actually, so, you are not at risk for it down the line. There are 20% of people that get COPD that don't smoke.
Health Matters: My dad has it, and he never smoked cigarettes. He smoked pipes and cigars.
Dr. Green: That's still smoke exposure.
Health Matters: So, now we know COPD is a disease that is preventable and also treatable. So, if you have it and you stop smoking, what is your quality of life like with medication? Dr. Green: It depends on how bad your COPD is. The definition is really when you blow your air out if that air coming out comes out slower than about 80 to 100% of what would normally come out when you're breathing out. There are some people that have lung function at 75% that are not going to be very symptomatic. Then I see people that have lung function at 29%. They are going to be very symptomatic. The mainstay of treatment besides quitting smoking is inhaler therapy. There are different inhalers that we use to treat COPD. Believe it or not, there are so many inhalers that work and some people need so much therapy that treating COPD is actually more expensive than treating diabetes, the medications are, the inhalers. There are basically three general types of inhalers we use. One inhaler decreases the swelling in the airways, the inflammation. That is an inhaled steroid medication. It does not get absorbed in your body. You don't end up looking like a body builder or lose muscle mass.
Health Matters: Different steroid.
Dr. Green: Different steroid. Very safe to use. Steroid inhaler #2 helps relax the muscles. There are two different nerve transmitters on the muscles that cause the relaxation, so there are two different types of medications that people inhale that prevent that from happening and help it.
Health Matters: So, you have medication...
Dr. Green: Right.
Health Matters: And, you've seen people, I guess, give us a testimonial. I mean, you've probably seen people in your practice that have been smokers. You get them to stop smoking. They have a little bit of COPD disease and you treat them. Do they return to activity or can they be active?
Dr. Green: They can be active. I'm going to answer that question more specifically in a minute, but I want to get back to something that's really, really important and that is actually activity and getting out of shape. It's pretty darn scary to be short of breath.
Dr. Green: When you are short of breath and you feel it, you do less. When you do less because you are short of breath, you get more out of shape and then when you do a little bit, you get more out of shape and you get more short of breath and you get more out of shape and more scared and then you end up on the couch. That is deconditioning. One of the key treatments of any type of lung disease is exercise. Just getting up and walking and moving. There are exercise programs at the hospital that we can send people to. Very, very effective. Beyond that, the medications do work. Think about COPD and one of the things that defines it is your lung function never gets back to normal with medication. That's what separates it out from asthma. With asthma, you can have an asthmatic, use medication and get normal lung function. People with COPD still have lung dysfunction. So, we are basically taking people who are very ill, very debilitated, can't do much and getting them back to some sort of activity level where they can actually function. I do have people that are so bad that they are actually on oxygen, using inhalers and still hold jobs down. The exercise is so important. Just the activity level. Some of the biggest improvements I've seen with medications is about a 40% improvement in lung function.
Health Matters: That's good. Like you said, when you can't get your breath, 40% is a lot.
Dr. Green: It's a lot. It's huge. Unfortunately, don't see it that often. Sometimes the medications don't work at all and we stop them if they don't.
Health Matters: We talked about ages that you are seeing. What's the average age of a patient that has COPD and what is the youngest that you've seen?
Dr. Green: Great question. There is a rare genetic COPD where that protein, that enzyme that dissolves the lungs is abnormal to begin with and very low. So, if they smoke, it's like they have a bonfire in their lungs, and they destroy their lungs very quickly. People like that can develop COPD in their 30s, actually, that badly. I saw a lady when I was in medical school at Columbia in New York who was 37 years old and she had lung cancer and COPD. Now, she was 37. She started smoking when she was about 10 years old and smoked a couple of packs a day. So, she had a good, you know, 30-pack years under her belt by the time it developed, but she was 37 years old. Usually, we see people present in their late 40s and early 50s with this. It depends on how active they are. And, the thing is, what they say often times is, you know, I was totally fine, nothing was wrong with me until I got a cold and then I couldn't breathe. It is a straw that broke the camel's back phenomenon. You lose lung function at a more rapid rate than normal. We have tremendous reserve in our lungs. You can remove somebody's lung, one lung, and they can live a normal life and not even know it. You lose lung function very, very slowly. Then you get to a point where the straw broke the camel's back. You start getting symptoms. You thought you were fine until then. Wrong. You've been losing lung function for 30 years and now you're symptomatic. And that happens in the 50s, usually, early 50s.
Health Matters: Eventually do you get pneumonia? Is there a chance of that?
Dr. Green: Yes, there is a chance of it. The thing about a destroyed lung is that you don't clear the junk out of your lungs that we all accumulate all day long.
Health Matters: That's an interesting question, though, people that have chronic lung disease are susceptible to a lot things that most healthy people would be able to fight off. I mean, flus, common colds these can become catastrophic.
Dr. Green: If they get sick, they have trouble fighting it off. That's the thing about our bodies. We have reserve in our bodies. If you get pneumonia and it affects half of one of your lungs, you can do okay if you have normal lungs. But, if you're starting at 50% or 40% of lung function and you get pneumonia, you don't have much reserve, and that's very bad, and then you end up in the hospital.
Health Matters: When does the decision to put someone on O2 for normal activities of daily living happen? Dr. Green: We have strict criteria to put people on oxygen and we basically check them in the office with an oxygen probe on their finger and have them walk up and down the hall and we see what their oxygen level shows. A normal oxygen level is in the high 90s. It shouldn't move at all when you exercise. People that have destroyed lungs when they exercise, their oxygen levels can drop. And, if you oxygen level drops below 89% with exercise then you should be on oxygen when you exercise and when you sleep, actually. Wrapping it back around to sleep disorders. When we sleep, you hypoventilate. We don't breathe as much when we sleep. So, if someone has COPD and requires oxygen with exercise during the day, they should definitely be using it at night when they sleep.
Health Matters: There you go. COPD.
Health Matters: Dr. Ronald Green, pulmonary, sleep specialist, everettclinic.com is where you want to go to get more information and you can probably set up an appointment.
Health Matters: So the key message that I heard is quit smoking.
Dr. Green: Prevention. Quit smoking.
Health Matters: It's always quit smoking.
Dr. Green: The first 10 recommendations are quit smoking. After that it's exercise, exercise, exercise then inhalers.