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Chronic obstructive pulmonary disease, or COPD, has skyrocketed over the past 35 years. Dr. Matthew Schreiber discusses what it means for D.C., and how you can be as healthy as possible if you have the disease.
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Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We're talking to Dr. Matthew Schreiber, associate director of the Medical ICU and an attending physician in Pulmonary Disease/Critical Care Medicine at MedStar Washington Hospital Center. Welcome, Dr. Schreiber.
Dr. Schreiber: Well, thank you for having me.
Host: Today we're talking about a September 2017 report that showed that the number of Americans who died from chronic respiratory diseases, particularly chronic obstructive pulmonary disease known as COPD, skyrocketed over the past 35 years. In 2014, 53 people out of every 100,000 died of a chronic respiratory illness, up from 41 in 1980, a 31% spike. 85% of those deaths were from COPD, which is now the third leading cause of death in the U.S. Dr. Schreiber, how does Washington, DC compare to the national rates of chronic respiratory diseases and COPD?
Dr. Schreiber: Well, Washington DC, if you were to just look at it as a city, it's doing great. The CDC and the NIH did a report starting in 2011 that talks about state by state, how much COPD is there, and I think when you're talking about chronic respiratory diseases, COPD is really kinda the marker for what you're talking about. There are a ton of different things that are chronic diseases in the lung, but the biggest bulk of them is going to be COPD, and even if someone had asthma their whole life, they can later have COPD, because of the chronic nature of that destructive disease. Coming back to what you asked, DC is ranking in with only 4.6% of its residents having COPD and that's actually pretty darned good, if you look at our neighboring states. It's 5.9% in MD; 6.1% in VA; and 8.9% in WV. If you dive into the data a little bit deeper though, DC is a tale of two cities. There are a number of things that the CDC and the NIH found had associations with being diagnosed with COPD, and what they found was that in Washington, you had 2.1% of white respondents saying they had COPD, but up to 6.7% in the African American population, and they didn't report on other ethnic backgrounds. So, 4.6 sounds awfully nice, it's at the low end of the national levels, but then when you start breaking that down, there are definitely some groups in our district who are suffering from this condition, uh, at higher than average levels for the nation. If you look at people who are unable to work, and this might be because of their lung disease, but, of course, being unemployed can have any number of reasons—19.9% of folks that were unable to work reported being diagnosed with COPD. If you had less than a high school education, 9.6%. Nearly 1 out of 10 people with less than a high school education had been diagnosed with COPD, and age was a big factor. If you looked at folks 18-44, it's down to 2.2%, but once you're over 75, almost 10. So, even though you could say we're doing great, being at the low end of the national level, we've got some work to do.
Host: Why would there be such disparity between the education and the types of work that people are doing? Is there some kind of a cause environmentally?
Dr. Schreiber: COPD is a condition that no one can say they know absolutely what causes it. There's a number of theories behind it. What I can tell you is COPD is exactly what the name says. It's chronic, so once you have it, you have it. It doesn't get cured, it doesn't go away, it might not progress very fast, but you have it, and it's all about obstruction. The 'O' in the name says the whole thing. People with COPD have trouble moving the air in and out of their chest. And so, if you can't move the air out, and you're trying to do some activity or exercise, the faster you're breathing, the more air that you're breathing in that you can't then get out, and you get short of breath. And it's pulmonary disease, lung disease. So, if you look at it as a pure aspect like that, this could be caused by inhaling something that can damage your lungs over and over again. Cigarettes are the model example for that, and in truth, this seems like common knowledge to a lot of people now, it's new. We didn't have studies that showed cigarettes caused things like lung cancer until the 1950s. And we didn't have a surgeon general's warning about the damages of smoking until the 1960s and 70s, so progress has been made. But you've got a lot of history in the United States with tobacco use and tobacco exposure, and a lot of science going into cigarettes since the early 1900s, that have done its job, so to speak, on getting people to use cigarettes, and the consequences of that use, that we're only now seeing. When you think about other types of inhaled irritants, different jobs can cause different problems. I ask in my clinic all the time, 'What kind of work have you done through your whole life?' And people will focus on the things they might have enjoyed or liked and then I always come back, 'Did you ever do anything that was around smoke, around fires, around a lot of chemicals, around inhaled irritants where you had to wear a mask, or maybe wish you had worn a mask?' And people will think about what they did earlier in their life. And the lungs are remarkable things. We have "extra," so to speak, that when you look at the lifelong duration of how much lung function you have and when it would have to get low enough to cause symptoms, we're all, for the most part, born with enough lung and develop enough into our late teens early twenties that we can all fortunately die of something else before our lungs become an issue. But when you have these exposures or even some people who just have genetics that predisposes their lungs to dropping off function faster than the average person, when you get to later in life, you start to have this obstruction and then these symptoms, and that's where people come in and we make this diagnosis.
Host: What can a person do to reduce their risk for COPD?
Dr. Schreiber: Quit smoking. That's clearly from a research based standpoint, the thing that can have the greatest impact on reducing your risk. If you have a strong family history, you know, 'both my parents and one of my brothers has been diagnosed with COPD.' If that's your story, you can talk to your professionals in your clinics and your primary care, uh, centers to say, 'Is there anything that I should be tested for because it seems like everyone in my family is getting COPD or getting it at a young age,' or 'I have a non-smoker in my family who's been told they have COPD.' They're a deficiency; something called alpha-1 antitrypsin. Incredibly rare disease, but important enough because of how it gets passed along in families that it's something you can consider having testing for if it seems like there's a higher than average risk for COPD in your family. Um, if you are in a career path or a job that gives you a lot of, what we call occupational lung exposure - you're around something where you're just breathing in things that seem to irritate you all the time, or, you know, in the back of your head, you're just saying 'Gosh, I'm breathing a lot of this stuff,' it's…it's worth it to come talk to your primary care physician or if you have a pulmonologist you can see otherwise, to talk about your risks and being tested. The American Academy of Family Practitioners recommends that anyone who has ever smoked, meaning 100 cigarettes in their life, so the, 'Well, I only have a cigarette or two if I'm out on the weekends at the bar,' well that only takes two years of weekends before you've had a hundred cigarettes.
Host: That's five packs.
Dr. Schreiber: There ya go! And a cough should be tested because we want to catch people early in COPD so we can both manage their symptoms and encourage them to make lifestyle changes that will hopefully not let the disease progress.
Host: So, you talked about some disparities in education and across the work force. Who's most at risk for developing chronic respiratory diseases and COPD?
Dr. Schreiber: The research shows that far and away the most at risk are still going to be the smokers. Now the question is, who becomes the smokers? There are a number of scholars that have looked into the impacts of tobacco on public health. So, they point out that there's a disproportionate, meaning a lot more than you'd expect, of advertising for tobacco products in poor neighborhoods. Their arguments that things like menthol cigarettes are targeted at particular socioeconomic or racial backgrounds and advertising has been done in a way to actually target different groups. Now, these are all theories. I…I can't overtly say there's proof, but, I think if you walk around a neighborhood that may be lower on the socioeconomic scale, and walk around a very affluent neighborhood, you will notice there are more billboards in some than others, that there are more advertisements on your corner store for cigarettes than in others, and in fact, this has gotten to the point where laws had to be passed about advertising cigarettes in certain proximities to schools and daycares, because of how it seems that there's not only this risk of socioeconomics and education having to do with developing COPD and as a proxy of that, maybe using tobacco products, but also the way that marketing is being applied because of how those populations are vulnerable when more people may have this condition and smoking and you add fuel to the fire. So, it is a bigger question of social structure than I think I could ever answer, but there are a lot of people very interested in why these disparities are there.
Host: If a person has smoked in the past and they quit, maybe they quit ten years ago, or they used to work in a chemical plant or a place where they're exposed to smoke, is there anything particular that they can do to either be screened or to reduce the effects of that damage?
Dr. Schreiber: Being screened, absolutely. The only way to diagnose COPD is with something called spirometry. It's a breathing test. It's looking for that obstruction. We have someone basically blow into a tube connected to a small computer, and we see how much air came out and how much came out in the very first second. Because someone with COPD, they can get all the air out, they just can't do it quickly, and if I asked you to blow out for the six seconds it takes for that test and you have normal lungs, it's hard. Like at the end you're really trying to push out that last bit. People that have obstructions, I've read results from these tests and they're still breathing out at 13, 14, 15 seconds because that's how long it takes to get the air out because of the slowness of it. You can't diagnose COPD with a cat scan, an x-ray, a stethoscope, a physical exam, a history – unfortunately, that still happens all the time. In the NIH/CDC data talking about COPD in all these different states, DC for example - three out of ten people reported never having had spirometry, yet were given a diagnosis of COPD. I would bet they probably have it based on the symptoms they had, but there are other things that could be going on and getting tested with spirometry, which can be done in the clinic, you don't necessarily have to get what we call full pulmonary function tests which are done in the hospital, um, not as an admitted patient, but just in…in our hospital facilities, to get some of that answered. And a number of primary care clinics can do spirometry in the office. Um, we can do it in our pulmonary clinic, if that's all the information we need. Or we can send people for additional testing with full pulmonary function tests. What can somebody do to slow the effects? That's the tough part. There was a…a landmark study that gets talked about all the time in healthcare where a group of researchers developed a diagram showing the natural history of what happens to lungs. It's called the Fletcher Peto Curve. And, what they showed is that for a person with no lung disease, we have our best lungs at about 20-25 years old. And then it's literally all downhill from there. For somebody who has vulnerable lungs and has that bit of damage happening from smoking or whatever their particular cause is, if they can get away from that or quit smoking or get rid of that damaging effect, their lungs never grow back. The lungs aren't like skin and muscle and bones. You kinda have what you have after the age of 25, but the rate of decline slows down. And so, you ask…started off this conversation saying, 'Where is this large uptick in COPD coming from?' It's coming from us finally recognizing what's been going in a lot of people for probably the last twenty or thirty years. If you look at that Fletcher Peto graph and you say, 'Well ok, if a 50-yr. old quits smoking at age 50, they might not get bad enough lungs to have symptoms until they're 75.' It doesn't mean they didn't have COPD at 50, just wasn't causing them disability where they actually might have gone in and gotten tested for it. If you have someone who's 73 and maybe has no symptoms because they're one of those people that you've met that smoked their whole lives and did fine, then in 2 years later they start having lung problems, they had COPD all along. It's just they got so close to that symptom marker that now, you know, a year after they quit, they're on oxygen or can't go up the three steps to go in their house, and in truth, that's the scary thing. I don't understand the response sometimes from patients but they'll say something like, 'Well, I'm not worried because this family member, uh, did well with this or did well with that, and so I'm not worried about smoking.' But it's not about necessarily the death with COPD, it's the disability. Losing your independence and…and I've met people in my clinic who literally get short of breath eating. Taking a shower leaves them winded, and that's the kind of life changing event that is so horrible about COPD, that it takes away your freedom. And, people surveyed in DC talking about how COPD has affected them, almost 2/3 said they have some kind of exercise limitation because of breathing, and that's why we need people to get checked early, to hopefully get them to either start medication to prevent flare-ups and exacerbations or maintain their symptoms under control, or to make lifestyle changes that might slow the progression.
Host: How do you go about addressing that risk with your patients?
Dr. Schreiber: I spend a lot of the time counseling smoking cessation, and encouraging activity, referring people to something called Pulmonary Rehabilitation, which is different from just physical therapy because they'll have respiratory therapists and people that are trained on ways you can manage your breathing a little bit better and how to push your limits but not get exhausted, to still make progress. We talk about nutrition, and keeping people physically fit and being preventative, like getting vaccinations where they're appropriate. Um, so there's a lot of things when someone has COPD that we can offer them or counsel them to try to keep them as healthy as possible. Medications have been shown to help when you have COPD. And, it's an interesting split to me and…and I say this to my patients in the clinic all the time - you wouldn't wait until you're having a heart attack or a stroke to start taking your blood pressure medicine, even though you feel fine. For some reason with inhalers people say, 'Well, I'm breathing ok so why am I taking this inhaler every day?' But these are preventive medicines, and if I can stop you from having a flare-up this year, which then will affect your lung function next year, that's a win. And so, the things that we prescribe in the pulmonary clinic are not always just to make you feel better, they're also to prevent you from falling apart in some way, because nature is still going to cause those lungs to decline a bit, but if I can NOT have you in an urgent care or hospital with something that's gonna make it decline even faster, to then keep you independent and doing things, even though you quote 'feel like you're breathing ok,' then I'm doing my job. Taking a pill for folks just seems to be simpler than using an inhaler, and granted, there's a lot more coordination going on with using an inhaler, and a lot of people use them wrong, and there's no point in medicating the back of your throat when we need it to get it down into your lungs. But, it's another task in the day that takes a few more seconds than just swallowing something with water and, you know, it's something that I think when you look at a patient and they're using an inhaler, there might be social or, you know, other biases where you look at them and say, 'Oh, you're doing that, as compared to just discretely swallowing a pill with a glass of water.' And so, I think a lot goes into it. Um, it also comes back to that idea of 'well why am I taking this medicine if it's not making me feel better?' And, with the way that our society, uh, has a healthy and appropriate fear of heart disease and strokes and diabetes and hypertension, um, medications for those, I think, are something people buy into and I don't think we're there yet with breathing disorders to say, 'This is something that you really should do and here are the risks and here are the dangers and here's why.' I think, in some ways, that's a…a blessing, that this is a new enough common disease, so to speak, that we've only been dealing with this for forty or fifty years, um, that people don't have a hundred years of being afraid of heart attacks and strokes the way that, uh, they don't necessarily have that fear with COPD, but it means we've got a lot of catching up to do really quickly.
Host: Thank you for joining us today, Dr. Schreiber.
Dr. Schreiber: No, it's been my pleasure. Thank you.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.
