Spirometry

A year or two ago, I wrote a few passionate posts regarding smokers and the risk for COPD.  Earlier this year, I wrote with similar passion when results from a national lung cancer screening trial suggested that smokers received CT scans as a measure to prevent lung cancer or lung cancer death.

My concern has always been the under use of the spirometer for lung function status. Forced Expired Volume or FEV is a measure of lung health (how much air can a person blow out in seconds).  The value is used to determine if one has COPD.  COPD is one of the leading causes of death in the USA.  More smokers are effected by COPD than lung cancer and many cases of COPD go undetected and thus untreated.  It is a devastating disease, but I have said all this in the past.

Today I am quite jazzed to report that a public service campaign is underway - I uncovered it by accident.  The public service announcement or PSAs appear to be grounded in sports.  

I am beyond thrilled to say that one of my favorite former NYGiants football players is part of the initiative.  

When I did presentations regarding the medical consequences of smoking, I often had my audience jog in place while breathing through a straw.  In the PSA I heard, Michael Strahan says that COPD is like breathing through a straw. 

I found the website associated with the campaign and you can visit it here.

The campaign or awareness goal is to get people tested - this is grand.  A lung function test is simple and cheap.  Keeping a person with COPD from having exacerbations is essential in preserving lung tissue and lung function.

Living Longer - but still terminal

NLST 

The published study is available by clicking the above link

My concern and or contention with using imaging to screen for lung cancer in high risk groups (i.e. smokers) is complex.  First, whether it be a chest x ray with minimal radiation exposure, low dose CT or a max dose diagnostic spiral CT - the screen itself can be carcinogenic, and second, it takes the focus off other smoking related lung diseases which impact a greater number and at lower dose of smoking.  Both COPD and Lung Cancer are irreversible, fatal conditions.  Lastly, more smokers die of heart disease than either of the above - when the death certificate is completed, anyways.

In an article regarding the recent results of the National Lung Cancer Screening Trial - a medical doctor (i.e. I am NOT a doctor) notes that lung cancer seems to be the cancer that gets the least respect.  He noted that mammograms are never questioned (except that these days they are), and maybe he has a point about lung cancer not being given respect.  When I read the article and the study results - which I will get to in a moment, I thought of my dearest Aunt Jay who did die of lung cancer after years of hardcore smoking.  If she had been the recipient of these screenings would that have saved her life, extended her life, extended it in a productive way that was free of pain?  Would it have made a difference?  Surely, if it would have, then I must rethink my stance.  I do not know the answer and I don’t think the scientists do either.  Lung cancer, specifically the small cell lung cancer that is most related to cigarette smoking - is nearly always fatal and fatal quickly.  That “quickly” is within years of diagnosis.  If we now diagnose it late and a person dies within five years, does earlier detection mean anything more than one will die within ten years instead of five?  Or perhaps, with an earlier diagnosis one could quit smoking and ease the suffering or intensity of what would surely come in any case?   I do not know.  I know this however - more persons who smoke have emphysema and chronic bronchitis and spirometry is a cheap and non invasive procedure that can detect it in order to treat it.  No one seems outraged about its lack of use in high risk groups.  Indeed, COPD seems to be the lung illness that gets no respect.  Is it a financial thing?  Certainly the spirometry industry isn’t going to make a lot of money if we make sure all smokers get THAT test.

As a public health educator/health promoter (and not a health care professional) I do not at this time have any positive thought on CT screening for lung cancer in smokers as a preventative measure. The only preventative measure that I endorse for lung cancer is quitting smoking or never starting.

From the now published results of the NLST I offer a few points that I consider important.  Usually when reviewing a research article the first things review are what they did and what they found

That gives you a heads-up on the subject matter - to see if it is of interest to you.  But to see if the findings are of any real value it is better to look at HOW they did what they did and WHO they did it with.

This study has some good qualities in that in took a large group of volunteers who met certain criteria and with their consent, randomly assigned them to two groups.  The follow up that occurred for the next six to seven years included a once a year screen (CT or  X ray) for three years.  The people were followed to see who among them was diagnosed with lung cancer (who lived, who died) in that seven years and if the CT found more of those cancers sooner than the Xray.  It did, but it also found a whole lot of lung cancers that were NOT lung cancers.  Those false positives would have to be ruled out with additional diagnostic examinations, including more imaging.  In the CT group there were more positive findings for each of the three years in which screens were conducted.  However, the rate of false positives was high for BOTH the Xray and the CT - 94 to 96 % respectively.

As mentioned above, it is important to know who the study involved.  In this case, there were over 53,000 persons.  The persons enrolled had to be considered heavy smokers or smokers who had been heavy smokers and quit in the last 15 years or less.  That is important.  They chose the people that they thought were most at risk for getting lung cancer during the study period of less than ten years.  To be considered a heavy smoker the person had to have a 30 pack-years history.  That means that they had to smoke one pack a day for 30 years or two packs a day for 15, etc.  A plurality of participants were between 55 and 59 years of age (42%) and another between 60 and 64 (30%).  Six of the people were under age 55 and 4 were over age 75.  A majority of the participants were male (60%), white (90%) and 48% were current smokers.

Looking over the study again - I read this sentence …“Small-cell lung cancers were, in general, not detected at early stages by either low-dose CT or radiography.”  Well - that is something that is not talked about so much in the news reports of the study. 

The published article also has a figure with two graphs comparing the screenings.  In the top graph are the number of lung cancer cases found (y axis).  There is a line for the CT and a line for the X ray.  In the bottom graph is the number of lung cancer deaths and again, a line for CT and a line for X ray.  The horizontal axis is the years since the participants were in the study 0 to 8.  In the lung cancer cases the CT line is on top (finding more) and in the lung cancer deaths, the Xray line is on top. In other words, during the study period of less than 8 years, there were more deaths in the x ray screened lung cancer cases than the CT screened cases.  This only convinces me that the CT group is living longer with a diagnosis - not that they are living longer than they would have without the CT scan.

It Ends With The Grave

I am going to share another man's story tonight. It won't take that long. I met this man in a class that I teach, I believe I have mentioned this class in the past. The purpose of the class is to educate tobacco users on the health consequences of said use, the benefits of quitting, some evidenced based methods for quitting and to to inform them of community and company resources that might assist them in this process. It is NOT a quit smoking or tobacco cessation class. Everyone in the class either uses tobacco or is exposed to enough second hand smoke to test positive for the nicotine metabolite, cotinine. (yes those people exist)

The gentleman that I am referring to is over fifty, possibly sixty, years old. In tonight's class we talked about reasons that people may be motivated to quit tobacco. The usual reasons are always to save money, improve health, set a better example and to be free of the addiction (the compulsion to use). I will call my gentleman, Bob. Bob said much of those same things and I asked him, "Can you stop before you get one of those diseases or do you have to have the diagnosis first?" He smiled and said, "I think I might need to have a touch of something first." Ah, that is too bad. Then Bob told us about his brother. His brother died at the age of 63. He was a smoker and he suffered from and died from COPD - most likely emphysema. Bob took care of his brother. "I watched him as he gasped for breath, folded over his walker." Bob helped him with his oxygen that he had to use all the time. He helped him with his rescue treatments when he could barely breathe at all. "My brother kept smoking, he couldn't even breathe but he would smoke." Bob smoked too. Bob smoked then and Bob smokes now. Bob said that his brother couldn't smoke. He couldn't. He also did not have cigarettes. "He would go out on the porch and take my old cigarette butts out of the ash tray and smoke them."

Our class tonight had been about addiction and I think there is no clearer example of the powerful nature of nicotine. Bob's brother died about a year ago. Bob told the class that he would stop smoking before he got that way. He said that he would never do what his brother did. I asked Bob, "Did your brother not say the same things?" There are some people, as Bob brother shows, who will quit only when they are in the grave. I said that to Bob, I said that I hoped he would not be one of those people.

I will close with my newest assertion about cigarettes. You may have heard me say this recently, but only in the last few months. I do NOT fault tobacco companies for marketing, even aggressively, a product that they are legally allowed to sell. Instead, I fault the government for allowing them to do so at all.

Bob's brother was simply too young to die. Remember death in old age is the only death we are powerless over.

COPD lite

My first intention for tonight, as I mentioned last night, was to repost my Saturday COPD post. However, I had an encounter with an accidental editor - my Mom. Yesterday she mentioned that she read my blog - "long - boy that was long - it just went on and on, I finally gave up." OUCH. I said that yes it was and I knew it was, but I had read over 100 pages of stuff so I had to get it out there. Then I asked Mom a few carefully worded questions to see if my main points were absorbed, and ah - NO, they were not. This is, of course, a reflection of the writer, not the reader - so that being said - please DO read the whole post if this is an issue that you may be at risk for, know someone who may be at risk for it, or have an educational role in your life. Otherwise - my main points are:

COPD stands for Chronic Obstructive Pulmonary Disease. This condition is usually found after a person has entered a more serious stage. Signs at the time will be shortness of breath, especially with activity and sometimes a chronic cough. Anytime you have cough with phlegm, sputum, gook - see a doctor. It could be acute bronchitis - or chronic. Chronic bronchitis and emphysema are considered to be COPD.

A person with COPD has trouble breathing and this difficulty is not completely resolved with a medicine called a bronchodilator. COPD can lead to significant lung changes - scarring, swelling, mucus entrapment, inflammation, destruction, increased volume and collapse.

The risk factors, in order of most causes to least:
tobacco smoke
indoor air pollution from heating or cooking with biomass fuels -
coal, straw, dung, wood
work related chemical and gas exposures
infections - esp from the adenoids
gender can play a role as well
genes

All of us lose some amount of lung function over time - we have a lung age that is based on years of life and gender - that lung age is what a lung function test will compare to. COPD is diagnosed through clinical exam and especially through spirometry -

The spirometry test and the diagnosis includes two values. When one blows into this device the first thing it measures is FEVone - or the amount of air you can force out in one second. The second measure is FVC or the amount you can blow out - completely - your total expiration.

The FEVone is divided by the FVC and that score is what defines COPD. If it is less than .70 it can indicate the disease. The second measure determines the stage of COPD. The FEVone is compared to FEVone of people similar to you who are healthy. Having 80% or less of that predicted value is stage one. Having between 50-80% is stage two and so on.

Treatment exists for COPD. The most important thing is to stop any exposure to the cause - tobacco smoke, fuels, chemicals. It is also important to prevent worsening conditions - so disease monitoring and medication management are important.

I am going to stop now. References and links are in the previous post which was linked earlier.

COPD

[with gratitude and thanks to Dr. Stephen Rennard – pulmonary specialist, scientist and professor – he sent me research articles, a book chapter and some email clarifications]

I have worked on this post for some time now. I hope that I can share the important characteristics of the disease, its causes, how it is diagnosed, prevalence, treatment guidelines and maybe USA mortality and morbidity statistics.

There are still things that I do not understand – mostly because of the highly technical material I read which did increase my vocabulary when it did not overwhelm me. There came a point when I had to admit, I really did NOT have to know ALL of those details to do my job or write this blog.

I do think that this was somewhat harder to process than the information related to heart disease and smoking which I shared back in February. With regard to the heart, there is endothelial damage and with the lungs it is mostly epithelial. This helps me to recognize the difference better – epithelial is tissue and organ cells – like the lungs and endothelial has to do with blood vessels!

So let me begin:

COPD stands for Chronic Obstructive Pulmonary Disease and is included in the CLRD category of the leading causes of death. It is the fourth leading cause of death in the USA after heart disease, cancer and stroke. In the world, it can be THE leading cause of death in low income countries.

The established definition of COPD is as follows:
Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles and gases. (book chapter -see end notes)

There are two main diseases in this disease categorization – chronic bronchitis and emphysema. I have at times been confused with regard to where asthma fits in. The main difference between COPD and asthma is irreversibility. Both diseases involve an obstructed airway, but most often asthma will respond with a complete reversal with a medicine referred to as a bronchodilator. In other words, a medicine that opens the airways. Probably because, in mild to moderate asthma, the airways are blocked from muscle spasms, not damage and once those passage ways are relaxed, normal breathing can resume.

There is a respected global non profit organization or consortium that includes the USA’s NHLBI and NHI as well as the WHO. The entity is called GOLD for Global Initiative for Chronic Obstructive Lung Disease. GOLD has clinical practice guideline for identifying, preventing and treating COPD. Most of the research literature on COPD will refer to the GOLD standards for identification and treatment. For that reason, they should be noted. These signs and symptoms below are clinical indicators of disease, however, it is protocol that a person with them be considered as having COPD with a lung function test to confirm. Significantly, a person who does not have the signs but has been exposed to risk factors such as chemicals, dust and tobacco smoke should also be evaluated.

The signs are:
Shortness of breath or feelings of breathlessness often referred to as dyspnea
Chronic cough (may come and go and may not produce any phlegm)
Chronic sputum production (any time this occurs it is a WARNING for COPD)
The risk factors are:
Tobacco smoke (the number one cause of COPD and possibly the cause of 50% of all cases)
Exposure to dust and chemicals on the job (occupational exposure)
Smoke from home cooking or heating, especially in some countries where biomass fuels, such as coal, wood, straw and animal dung are used.
Risks that may be less common or more likely to be synergistic include:
Gender, genes, infections, outdoor air pollution, asthma and being poor or living in an impoverished nation.

The lung function test and the parameters for diagnosis are spirometry and FEV1/FVC.
Let me explain. The spirometer is a device that the patient blows into and it provides the clinician with a reading. There are specifics on how one inhales and exhales or blows for the test, but they are not necessary here. The letters stand for Forced Expired Volume in one second and Forced Vital Capacity. COPD as defined by the GOLD standards, has four stages. The stages are based on the FEV1/FVC score. All stages have FEV1/FVC less than .70 and then they have an additional predicted value of the FEV1 which is diagnostic.
1- Mild - the persons FEV1 is 80% or more of what similar persons (without disease) would score. There may be no other signs and a person may not complain. It is very important then that providers know about the risk factors and DO use the spirometer in said patients to catch the disease early and treat accordingly.
2- Moderate- the FEV1 is now between 50 and 80 % of predicted and shortness of breath is more common, especially when the person is active. There may be cough with sputum or discharge and this is when a patient often seeks help.
3- Severe – the patient’s air flow is limited further and the value is below 50% of predicted but above 30%. Now a person’s health quality and activities of daily living are adversely affected.
4- Very severe- the patient has significant obstruction and a predicted FEV1 of less than 30 or less than 50 with other complications, such as acute respiratory failure. This stage can have many exacerbations or worsening for the person and can be life threatening.

So as you can see, the spirometry is the standard method for diagnosing COPD and for staging its course. There are other diagnostic tests and imaging that can be used to get more details on disease. Those can be explored elsewhere.

The absolute most important thing to be done at ANY stage and immediately is to STOP the exposure to the toxicant. In other words, stop smoking. In the USA and several other countries work exposures are limited – for instance, some chemicals are banned and some regulations require masks and ventilation. Coal miners are a group that continues to have work exposure that can lead to COPD as well as Black Lung. In some countries, however, no occupational safe guards exists and there are no other options for heating and cooking – this is a significant health threat to those individuals. Outdoor pollution is less a threat to cause COPD, but may lead to exacerbations of illness.

Do NOTE: We all lose a certain amount of our lung function as we age and thus the FEV1 predicted value difference can show the acceleration especially in smokers. Smoking cessation (quitting) can prevent progression of emphysema only in its earliest stages. But cessation always improves treatment outcomes. A person who quits smoking by age 30, in at least one clinical trial, shows no difference in lung aging than a healthy non smoker! (if they do not already have disease)

Treatment includes oral medications,(pills or inhalations) and most often does not include nebulizors. The standard pharmacotherapy includes bronchodilators of two types as well as long and short acting ones. In other words, a person can take a daily formulation of a bronchodilator and then use a short acting one as needed or in crisis. Other meds used, especially in later stages, include inhaled glucocorticosteroids and then systemic steroids. Treatment can include the use of oxygen therapy as well – as needed or at night, or continuous. Oxygen use is based on the person’s oxygen and carbon dioxide levels. People with COPD are especially encouraged to be vaccinated against the flu and less strongly pneumonia. Lung volume reduction, lung transplants and other invasive surgeries can also be performed.

____________ A little pause to note that I have far more information that is needed for a blog post – And I have three more things to cover______________

Prevalence
Disease type
Exercise Therapy

Prevalence is the term used to describe the number of persons living with a disease at a certain time point – like now or when the statistic was last available. This is different than incidence, which is the number of new cases, usually offered by year or projected into a decade. The prevalence will differ by nation. I have to say that there is a concern in the scientific community that the prevalence is grossly UNDER estimated based on the fact that spirometry is NOT used and that many persons with the disease are not unidentified at the earlier stages. For that reason it is better to tell you the differences as offered in a Lancet journal article forwarded to me by Dr. Rennard. The chart offered there has cases per 100,000 persons and includes only stage 2 or higher COPD. There is a gender difference sometimes extreme sometimes slight. The highest prevalence is noted in South Africa which is probably related to home fuels and the lowest is in Mexico which I speculate has a low smoking rate. The USA is center left – i.e. closer to South Africa than Mexico and for some reason the UK is not on that chart. The USA is one of only a handful of countries where the rates in women is higher than men. For a look into the mortality rates of COPD in the USA please view this MMWR from the CDC.

The differences between chronic bronchitis and emphysema are significant. I am afraid that if I try to offer much detail I may make mistakes – and I have read and read and read in an attempt to grasp this fully.

Chronic bronchitis has to do with a buildup of mucus in the lungs. Certain cells in the tissue will react to irritants and cause mucus secretion which under normal circumstances will help to clear out toxic or irritating substances. The bronchial tubes swell also and this mucus and swelling makes the airways smaller. This is now the lungs are obstructed. Chronic bronchitis is the type of COPD that is associated with coughing and sputum. It can also be exacerbated by a virus or bacterial infection.

Emphysema is noted for being the disease in which the alveoli or little air sacs are destroyed. There is a lot that goes on with both diseases that leads to oxidant stress, inflammation, scarring and dysfunction. As the lungs lose elasticity in emphysema and air sacs are destroyed, the lungs have more volume – but that is a negative thing. There is a treatment, rather invasive, to remove the damaged lung and it is called Lung Volume Reduction Surgery. People with emphysema sometimes describe their breathlessness as feeling like they are drowning. The lungs do not fully expand or relax and normal breathing is compromised.

There are treatment options beyond the medications or procedures listed above which include controlled coughing and controlled breathing – these are actual physical techniques learned by the patient.

Of utmost important with regard to health quality is returning the patient to a level of functioning that is independent and retains quality. In that regard, as indicated in the book chapter written by Shapiro, Reilly and Rennard , “exercise conditioning is the single most important aspect of rehabilitation and has been repeatedly shown to improve exercise capacity and endurance….as with any exercise program, gains in conditioning are lost if the exercise program is stopped.” Read that last part again people – that applies to ALL of us.

There is so much more to know about this disease. You can take this free course on it if you like – you can visit the website of GOLD – you can review the articles I have read and you can view this website recommended by Dr. Rennard.

The articles are:
The natural history of chronic airflow obstruction revisited. Am J Crit Care Med Vol 180 pp. 3-10, 2009
At A Glance outpatient management resource for COPD. GOLD Report 2009.
COPD: the dangerous underestimate of 15%. The Lancet. April 15,2006.
Global burden of COPD: risk factors, prevalence and future trends. The Lancet, Vol 370. September 1, 2007.
Chapter 39 (book title unknown -personal correspondence) Chronic Bronchitis and Emphysema, Shapiro, Reilly and Rennard. Current.