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(Dr. Peter Salgo)
Welcome to Second Opinion where each week our healthcare team solves a real medical mystery.  When we close this file in a half an hour from now, you’ll not only know the outcome of this week’s case but you’ll be better able to take charge of your own healthcare and doctors will be able to listen to patients more effectively.  I’m your host, Dr. Peter Salgo.  And you’ve already met our special guests who are joining our primary care physician, Dr. Lisa Harris.  Lisa, it’s good to see you back.
 
(Dr. Lisa Harris)
Good to see you, Peter.

(Peter)
Now nobody on this team knows this case and I’m going to get right to work.  Let me tell you a little bit about Elaine.  Elaine is fifty-six years old and she’s been a smoker for thirty years.  Three years ago, Elaine went to her primary care physician, Lisa, and she had the following symptoms.  She said, I’m short of breath with even small amounts of activity.  I’ve got trouble climbing stairs.  I have to stop and catch my breath.  I’m coughing all day long.  I wake up at night coughing.  Now I’m coughing up sputum she says, especially in the morning and its increasing and I can’t seem to clear it.  She’s 5’6” and 128 pounds.  Her blood pressure is 138/74.  Her pulse is 98.  Her respiratory rate is 24.  And when her doctor listens to her chest the description here is course rales and scattered wheezing.  What are rales?

(Lisa)
Well rales are defused sounds that you hear within the lung that tell you that there’s something happening.  It’s not very specific but it tells you that there’s something happening within the lung tissue itself.

(Peter)
Okay.

(Lisa)
I’m just a little curious as to, was this a sudden onset that she decided to come in now.  If she’s been smoking that long, she clearly must have had some symptoms prior to this.  I’m just wondering.

(Peter)
Just trying to get a flavor from the chart here, it sounds as if she’s been having some trouble and it finally got the point where she said this is the day I’m going to see my doctor.

(Lisa)
Right.  Absolutely.

(Peter)
Does that make a difference to you?

(Lisa)
Well sure.  I mean for patients that come into my office.  Anybody who presents with a respiratory symptom in my office will get a spirometry as well as an examination of me listening to their lungs and checking to see their saturation and what the oxygen looks like.

(Peter)
Okay.  You mentioned spirometry. 

(Lisa)
Yes.

(Peter)
Got a lot of lung doctors here but you’re the one doing the spirometry, so you tell me what it is.

(Lisa)
Well the spirometry is actually a test that allows us to look at what is the flow of oxygen through the airways and how quickly someone can expire the volume of oxygen out of their lungs at a certain amount of time.  And it tells us a little bit about the function of the lung.  If there’s restriction or if there’s bronchospasm or a little bit more about what’s happening within the lung.

(Peter)
Bronchospasm is tightness in the chest. 

(Lisa)
Tightness.  So it tells you a little bit about the function of the lung.

(Peter)
And you’re worried about the wheezing?

(Lisa)
Absolutely worried about the wheezing. 

(Peter)
Anything else anybody else wants to do?

(Dr. Make)
Peter, I’d be very concerned about.  Lisa mentioned this.  About whether this was, the onset was acute or was chronic.  Those lung sounds indicate to me she might also have pneumonia now and so I think it’s important to figure out what’s happening right now.

(Peter)
Okay.

(Dr. Make)
In terms of the acuity of the presentation. 

(Peter)
What else do you want to do?

(Dr. Levy)
Not to jump to any conclusions but when you hear a story of tobacco use over thirty years and shortness of breath on exertion you immediately start thinking of obstructive lung disease.  But rales on physical exam, as Barry was pointing out, are peculiar and you start wondering about does she have an acute pneumonia that’s going on right now.

(Lisa)
Or does she have congestive heart failure.

(Dr. Levy)
Right.

(Lisa)
There’s a lot of other things that you’d want to.

(Peter)
But they did do a spirometry.

(Lisa)
Okay.

(Peter)
And the results from the spirometry, I’ve got the actual numbers.  FEV1 over FVC, what’s that?

(Dr. Make)
That’s how fast the air comes out.  It’s a general measure of how much air comes out in the first second when you blow out hard and fast compared to the total amount of air.

(Peter)
Alright, forty-eight percent predicted and her’s was fifty percent.

(Dr. Levy)
So the ratio is fifty percent?

(Peter)
Correct.
 
(Dr. Levy)
Between the one second value and the total amount.

(Peter)
Aha.

(Dr. Levy)
So that’s markedly reduced and the normal patient will generally be able to get at least seventy percent of their total lung volume out within that first second.  But for her to be cutting off at fifty percent, that’s really a sign of obstructed. 

(Dr. Make)
So if you think about it this way, the air passages are like tubes or pipes.  The smaller they are, the less fast the air comes out.  The bigger they are, the faster it comes out.  And this indicates the air’s coming out pretty slow, so there’s some problem with the air passages being smaller than they should be.

(Peter)
Well Elaine’s doctor makes a diagnosis on the basis of this alone.  I’ll tell you what the doctor said.  Said, Elaine, you’ve got asthma and I’m going to treat you for it.  Is there enough information here to say you’ve got asthma?

(Dr. Make)
No, not at all.

(Peter)
Anybody happy with this diagnosis?

(Dr. Make)
No, no.  This is actually a very common problem.  And in fact it’s more common in women than men.

(Peter)
Was it the wrong diagnosis or is there simply not enough information to make a diagnosis?  What do you think?

(Lisa)
This is not enough information here.  I mean the other thing that I would do, you know, if she had the spirometry and showed restriction of flow I would give her a nebulizer treatment, listen to her lungs again and repeat the spirometry to see if there was any reversibility or response.
 
(Peter)
Now Grace Anne, I noticed during this conversation you were beginning to smirk.
 
(Grace Anne)
That should be enough for a general practitioner or an internist to send the individual to a pulmonologist for a full range of pulmonary function tests.

(Peter)
Did something like this happen to you?

(Grace Anne)
Well yes, except that my family doctor did not have spirometry in his office and didn’t recommend that I go somewhere else.  So I, I left the office.  Was not asked to come back and I still couldn’t walk half a block without stopping to catch my breath. 

 

(Dr. Levy)
There’s a very important point here that just.  Spirometry, we talked about the mechanics of doing it.  It’s no different  than a blood pressure cuff measures blood pressure.  You can’t assess blood pressure by feeling someone’s pulse or looking at someone.  You can’t assess someone’s lung function without measuring it with a spirometer.  And that’s why we advocate in a symptomatic patient, that’s the real, only way to figure out how good their lung function is.

(Peter)
But you’ll forgive me.  Her doctor did spirometry.  And then said you got asthma.  And I’ll go further.  Her doctor sent her home with a diagnosis of asthma.  And I can tell you, sent her home with a combination inhaler, albuterol, a steroid, and oral pills, prednisone.
 
(Dr. Levy)
I mean I got to ask Barry, as a fellow pulmonologist, with rales on exam, with the wheezes, I’m not so sure I’d feel comfortable kind of jumping ahead without either more information, a chest x-ray, a temperature.

(Lisa)
As a primary care physician, I wouldn’t feel comfortable doing that, so certainly I would measure her temperature.  Absolutely she’d get a chest x-ray to make sure there wasn’t acute infectious process going on.  And then if all of that was negative, I might consider starting her on therapy for the symptomatic wheezing and.

(Dr. Make)
And I would get an EKG to assure that she didn’t have a heart attack recently.

(Lisa)
Well she’s my patient, so she’s already had this.

(Peter)
She has the perfect practitioner.  Now she’s home, albuterol, steroids, inhaled steroids, oral steroids.  And I got to tell you the chart indicates that she says she’s feeling better.  She’s doing great.

(Lisa)
Her physician gave her some very acute, quick acting medications that would mask some other chronic symptoms without really investigating more clearly what the underlining problem is.  She already gave you a very significant part of the history.  She’s been smoking for years.  But I’d want to know some other occupation history.  Was she exposed to fumes?  Where does she work?  People don’t just jump up with asthma out of the blue.  That is a chronic, ongoing problem. 

(Peter)
You’re sitting there like the conscious of the panel just sort of drinking this in.  What are you thinking?

(Dr. Fisher)
What’s striking to me about the smoking history is that she’s been smoking for thirty years but she didn’t start until she was twenty-six, which is sort of late.  And so I’m not sure what that means.  But from the prospective of the smoking I’d certainly be curious about that.

(Peter)
Her doctor makes no note in the chart about, you know, stopping smoking.  At least not a lot in here, so she still smokes.  Sometimes her breathlessness and coughing are worse, sometimes it feels worse for days on end.  But she keeps renewing her prescriptions, including the steroids and going back to the doctor.  And as time goes by, her symptoms begin to get a little worse and a little worse. She’s beginning to gain weight now.  And she’s starting to get a little depressed.  Now what’s happening. 

(Dr. Make)
So I think one of the things that’s not in the chart you haven’t told us about, is follow up.  You know we’re very good at treating patients acutely and then we say, okay this will make you better but don’t think about the chronicity of the process that we all talked about.  And I think the key here is having her come back, first to make sure she’s better.  And second, to see what’s going on more long term.

(Dr. Levy)
And then you’d love to get a repeat spirogram on her.

(Lisa)
Absolutely.

(Dr. Levy)
To see how is her lung function going to settle out after this acute episode has been solved. 

(Peter)
By spirogram, you mean do the spirometry again?

(Dr. Levy)
A second spirometry.

(Peter)
So one is not sufficient?

(Dr. Levy)
It’s no different than if you measured high blood pressure today and treated a patient, you have to have them come back and make sure it’s normalized.

(Peter)
Grace Anne, I want to go onto you.  You initially got a diagnosis which was not satisfactory and eventually you were lead to the correct diagnosis.

(Grace Anne)
I got no diagnosis.  I was.  I was told after what was considered to be a full physical exam.  I got blood work.  I got chest x-rays, EKG, proctology, and was told that if I lost ten pounds I’d feel like a new woman. 

(Peter)
I can tell you a little bit more about Elaine.  Three years have lapsed since the chart indicates she came to see her physician and her kids have brought her to the emergency room because she is lethargic, she is confused, she’s having trouble breathing, and they think her skin looks a bit blue.  A little cyanotic.  Is this all from asthma?

(Lisa)
Yes she’s a little cyanotic and I’m concerned that now she has end stage emphysema or end stage lung disease. 

(Peter)
What do you want to do, Lisa?

(Lisa)
Well she’s in the emergency room.  We absolutely need to get a temperature, vital signs.  We need to know what her respiratory rate, what her oxygen saturation is. She needs a chest x-ray and they are not going to do a spirometry in the ED.  We might get a peak flow that will.

(Peter)
I can give you some of the information that you’re asking for.  She’s using “accessory muscles to breath”.  That is she’s breathing with her shoulders and her abdomen.  Her chest looks really hyper-inflated, kind of barrel looking.  Her heart rate is fast. She does not have pink frothy sput.  I’m going to make a note of that.  They also say therefore she’s not in pulmonary edema.  They say she doesn’t have an S3 and they conclude that’s a heart sound, she doesn’t have congestive heart failure.  Her oxygen saturation on room air is about seventy-five percent. She has rales again but this time they’re localized in her right lower lobe.  Diminished breath sounds all over the place.  You asked for a cardiogram and it showed right heart strain.  I’m going to give you everything here.  Chest x-ray right lower lobe pneumonia and yes she has a fever, one hundred and one.  Her white count’s nineteen six.  And who wants a blood gas?  You can all raise your hands.

(Lisa)
Absolutely.

(Peter)
I’m sure you all want a blood gas.  This is a measure of the oxygen in her blood on the arterial side, not on the veins.  Her PH is 728, she’s a little acidotic.  Her oxygen on room air is 60, its low.  Her PCO2, the carbon dioxide in her blood is 55 and her bicarbonate is 34.  There.  There’s a battery of stuff.  Who wants to chew on this one?

(Dr. Make)
She has pneumonia.  And she has pneumonia, which has caused significantly more respiratory compromise in her baseline condition, because she probably has underlying COPD.  And now those blood gases say that she has respiratory failure, which is a medical term to say she’s severely ill.
 
(Peter)
Elaine’s been told she has asthma.  Suddenly I’m hearing something, COPD, which is Chronic Obstructive Pulmonary Disease.  You want to give me a quick definition and we’ll move forward, because I can tell you more about Elaine.

(Dr. Make)
So COPD stands for Chronic Obstructive Pulmonary Disease.  Largely it’s related to disorders that people think about and may know best about called emphysema but it’s not only emphysema.  A better term is COPD. And a lot of it is caused by smoking.  In fact 85% of people who have COPD is related to cigarette smoke.  COPD is a syndrome and it’s not only related to the lungs.  Often people have other disorders at the same time that we actually think now are part of COPD.  Depression, for example, which is very common in patients with COPD.  Osteoporosis. Heart disease.  Now a lot of these diseases are caused by smoking but some of them may be caused by the inflammation of the lungs spilling over to the rest of the body.

(Grace Anne)
When I was diagnosed with COPD, much to my surprise I had ischemic heart disease.  This is, you know, these are bed fellows.  Lung cancer.  All.  These are the natural ones that any physician should think of.

(Dr. Levy)
The lungs themselves in COPD are not the whole picture.  When you look at causes of death of patients with COPD, only about a third of it is associated with lung disease.  A third of it is tied in with heart disease, and then you move into cancer, and other co-morbidities.  So.

(Grace Anne)
Yeah.

(Dr. Levy)
It is a spectrum.  It’s a systemic disease as Barry would.

(Grace Anne)
And that’s why it’s so hard to get an adequate number.  I mean there are twelve million Americans who have this disease, have been diagnosed and are getting some form of treatment, maybe not optimal.  And twelve million who are not yet diagnosed. We must reach these people.  They are lost Americans.  And they’re suffering.

(Peter)
You’ve heard enough about Elaine.  Have you heard enough to give her a diagnosis right now, there in the emergency room with all the labs and everything else?  What are you going to say she’s got?

(Dr. Levy)
I think people would most likely agree that she probably has COPD at this phase of it, because it’s unlikely that her lung functions is entirely normal.  To get to those PCO2 levels and to be in the state she’s in. 

(Peter)
Your doctor, if I remember what you told me, told you lose weight.

(Grace Anne)
I believe that he said that because he knew the disease that I had but he believed it to be irreversible.  The definition now, according to the best medical practice, is very different from what it was then.  It is not fully reversible, but it is highly treatable. And that’s the message that has to get out to patients so they don’t lose heart and to doctors who see 90% of, family doctors, of all people who have COPD.  There’s hope.  There is hope and if you follow directions and take your medicines properly and exercise.  You must begin to get your life back.

(Peter)
The fastest rising group?  Men, Women?  It’s women right?

(Grace Anne)
Women.  They have a susceptibility.  We have a susceptibility.  And no one knows why.

(Peter)
Fourth leading cause of death in the United States.

(Grace Anne)
Yes.

(Peter)
And growing.

(Dr. Levy)
Well in fact as cardiovascular and cancer moralities have improved, COPD has doubled in the past I forget if it’s three, four, five years.  But the death rate associated with COPD has been going the wrong direction.

(Peter)
How does cigarette smoking cause COPD?

(Dr. Fisher)
Well there have been a whole host of studies that have shown a relationship between smoking and COPD, cardiovascular disease, lung cancer, etc.   The list grows almost every month. And those studies are controlled studies, epidemiological studies that have various ways of piecing together the puzzle. So I don’t think too many people have too much question at this point that COPD is largely caused by smoking.

(Peter)
We have to pause just for a moment here and sum up what we’ve covered, which is a lot.  But I think we can boil it down to this.  COPD is chronic obstruction of airflow through the airways.  It is common but it’s often incompletely diagnosed or even misdiagnosed.  And by misdiagnosed people are going to lose time.  Lose time when they might otherwise have had therapy that might have helped them.  Is that fair?

(Lisa)
That’s absolutely fair.

(Dr. Levy)
That’s fair.

(Peter)
Alright, here’s Elaine.  She has COPD.  We agree.

(Dr. Levy)
Yes.

(Peter)
Okay.  What are you going to do now?

(Dr. Make)
Let’s take the most severe consequence of any disease and that’s death. So you can talk about more or less of these treatments but we have treatments that can prevent death in patients with COPD.  We have treatments that can prevent exacerbations or periods of worsening like lead her to the hospital.  And we have medications that help patients every day be less short of breath.  Be able to do more and feel better. And so that’s the gamete of what our objectives and our goals are for these patients.  We can improve them a lot. 

(Peter)
Grace Anne, what did you do when you were told you had COPD.   What was the kind of regime that you followed?

(Grace Anne)
Well fortunately my doctors, and there were a team of doctors, recommended a very aggressive treatment plan.  And I implemented it to the best of my ability, so I went to pulmonary rehab.  I took all my medicines on schedule.  I tried to change my life.  I had stopped smoking fifteen years before but that’s another quirk of this disease.  You’ve done what the Surgeon General asked.  You’ve done what your family and friends want.  You’ve given up the cigarettes and it only strikes in your middle life, in 40s, 50s, 60s.  So there you’ve been reformed and you’re still hated for it. 

(Peter)
How did your lung capacity change on it?

(Grace Anne)
I exercise six days a week and I do everything by the book.  I have, over these last eight years, I’ve gone from 26% of predicted to between 60 and 65% of predicted and I’ve maintained it despite surgery for lung cancer in 2005.  An hour a day, six days a week and I’m lifting weights and I’m doing what I can to preserve what is left of me.

(Peter)
How on earth do you tell somebody who can’t breathe to get on a treadmill? How does that work?

(Grace Anne)
Sure you do.  You can get on with oxygen and you can start slowly.  You will be wearing a heart monitor.  You will have oxygen, if needed.  Your heart, your blood pressure, everything’s going to be checked. That’s the way you do it.

(Lisa)
Right.

(Dr. Levy)
Pacing oneself through an exercise, not to exhaustion but doing it in moderation, so you still get the benefit.   But the key thing is if you don’t want to cave into the shortness of breath and you’ve done a marvelous job, you know, on the treadmill and doing all the right things.  Because there’s a vicious cycle, shortness of breath, inactivity, more shortness of breathe because of deconditioning. 

(Peter)
I want to talk about Elaine.  Unfortunately Elaine ain’t so great. Elaine is still in the hospital.  They admitted her with an acute problem.  She has pneumonia.  She’s treated in the hospital aggressively.  She gets IV fluids, antibiotics, oxygen, more steroids, nebulizers, and she gets better and she actually gets to go home. And she’s given some inhalers.  She’s on nighttime oxygen.  They do not forget to give her the vaccine for flu and pneumonia.  Did we lose three years of this?

(Dr. Levy)
There’s no question that early diagnosis is key.  If you diagnosis this early you might achieve smoking cessations sooner, so that would preserve lung function that’s otherwise going to be lost from ongoing use of cigarettes.  And then if you’re on medications, some of these medications look like they may actually, in subtle ways, alter the natural history of COPD.  But most importantly the medications will reduce symptoms so the patients can exercise and avoid the deconditioning cycle that we were just talking about.

(Peter)
Elaine goes into a smoking cessation program.  The doctor’s quite emphatic about that.  In your case, in smoking cessation how hard was it to quit?

(Dr. Fisher)
Well it took me about twelve times before I got it down.  It takes the average individual about four or five times before they are able to quit.  So a real important thing in quitting smoking is recognizing that just because you fail this time doesn’t mean you’re not going to succeed.  It’s sort of like skinning your knees on the path to learning to ride a bicycle.  The data are that half of all people who have smoked in the United States have quit.  That’s remarkable giving the fact that smoking is addictive.  It’s the most heavily marketed consumer product in our country, and it’s relatively convenient and still fairly easy to do in spite of all the regulations against it.  So people, even Elaine, need to understand that they can quit.  More important, the medical community and their families need to understand that even though she’s in pretty dire straits with a smoking related disease, she can still accomplish some good.

(Peter)
At this point, if Elaine actually gets into a smoking cessation program and she quits, what’s her life going to be like from this point forward?

(Dr. Make)
Well the first is that the thing that lead her to see you in the first place and the second hospitalization.  She’ll have less of those periods of worsening that we call exacerbations, that’s the medical term.  But she’ll have less periods of worsening.  That’s important.  She’ll have less problems with her nose.  She’ll have less chance of having cancers.  So the longer she’s a non-smoker the better everything is, not just her COPD and related symptoms.  And she will survive longer and her lung function will not decline as rapidly as though she continued to smoke.

(Peter)
Now I can tell you that Elaine did go into a smoking cessation program and she claims she has quit.  And she claims she is doing well.  How are you doing, Grace Anne?

(Grace Anne)
I am doing well.  I am here really to give courage to people.  To say what their disease is and to learn everything they can about it.  And I mean Earnest Hemingway said, “the world breaks us all eventually. But then most of us become strong in all our broken places”. 

(Peter)
Alright, I want to stop for just a moment and sum up what we’ve been discussing to this point.  It’s been a very complicated discussion as it turns out.  Proper treatment of COPD, with medications and lifestyle changes, can stabilize the disease and it can make you less symptomatic.  But I can tell you what our viewers want to hear.  And I’m just going to ask it.  Can you cure COPD?  Is there a cure on the horizon?

(Dr. Make)
I think there is a prevention, and the prevention in addition to cigarette smoking is to figure out why some people get the disease and other people don’t get the disease. 

(Peter)
Does it matter if you have a cure if you have a pretty good treatment?

(Dr. Levy)
We don’t have that great of a treatment. We have treatments that do minimize symptoms and definitely they are a benefit.  If you don’t smoke your lifetime risk of COPD, living in the US where you have pretty clean air in general, is pretty darn small. 

(Dr. Fisher)
I just want to mention two things before we slide over them.  One is you used in your summary stabilize.  You’re.

(Grace Anne)
I’m stable.

(Dr. Fisher)
No, you’ve improved remarkably.  Your function has gone from 25%

(Grace Anne)
Yes, and no one knows why.

(Dr. Fisher)
To 68%.  You can do much more than stabilize COPD.  People can lead full lives with COPD.

(Grace Anne)
Yes.

(Dr. Fisher)
And that’s an important message.  And it’s not just stabilization and symptom reduction.  Even short of a cure, people can live good lives with COPD.

(Grace Anne)
Yes.

(Dr. Fisher)
The other thing we absolutely have to trash is the notion of blaming people with COPD.

(Grace Anne)
Yes.

(Dr. Fisher)
For the fact that they smoke. They smoke because cigarettes are addictive.  Because they’re heavily marketed.  Because they’ve been normative.  The Army used to give it to people in the Army as part of their privileges of being a soldier, for goodness sakes.  So that’s why people smoke. They don’t smoke because of character flaw. They don’t get COPD because of character flaw.  We just need to take that off the table and move on.

(Peter)
Well I want to thank all of you for being here, especially you for discussing your particular problem.  And it’s courageous of you to join us. Thank you again very, very much.  Let me sum up what we’ve been discussing.  COPD is chronic obstruction of air flow, through the airways.  It’s common but often incompletely diagnosed and often misdiagnosed.  Proper treatment of COPD with medication and lifestyle changes can stabilize the disease.  And with respect to my colleagues, perhaps do better than that.  They can make you less symptomatic.  And our final message is this.  Taking charge of your health means being informed and having quality communication with your doctor.  I’m Dr. Peter Salgo and I’ll see you next time for another second opinion. 

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