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Colin Ward (Host):  Chronic obstructive pulmonary disease or COPD affects more than 250 million people worldwide. Today on the Upper Chesapeake Hero podcast, we will learn about this life threatening lung ailment and the new methods to care for people with this chronic condition as we strive to create the healthiest community in Maryland. Good afternoon. I’m Colin Ward Vice President of Population Health. And with me as always from our palatial podcast studio is Lyle Sheldon, the CEO of Upper Chesapeake Health. Lyle, welcome.

Lyle Sheldon, FACHE (Guest):  Colin. Happy New Year. Glad to be here.

Host:  It’s great to have you and Lyle it seems like we’ve been spending – you and I have been spending a lot of time talking about lung issues. So, if you recall, we talked about vaping and then we talked about medical marijuana and as an avid cyclist, you surely know the benefits of having good fitness levels and how important your lungs are.

Lyle:  And I can tell you both vaping and medical marijuana don’t help with lung capacity. Did I ever tell you about Harford County? Any time you see a hill or excuse me, a road that has mill in the road like Whitaker Mill or Johnson Mill, you know you are going down to the river and having to come back out. So you need strong lung capacity to tackle those hills in Harford County.

Host:  And it’s that coming back up part that’s always the draw back for me. So, Lyle, COPD, it’s a common problem that’s impacting patients in our community and across the country.

Lyle:  And when you think about COPD, it’s actually lung disease is the third leading cause of death in the United States and represents a very large portion of the patients that we see in our hospitals.

Host:  And so you have to figure you’ve got patients with heart disease, or cancer, sometimes it’s easy to overlook pulmonary conditions as being a leading cause.

Lyle:  Believe it or not, there are over 24 million people in the United States right now that have COPD but what’s even scarier is that half of the people that have it don’t even know that they have the disease.

Host:  Okay so that persistent cough somebody is having might actually be something greater than just a cold.

Lyle:  And one of the reasons that we went under this whole focus of creating the healthiest community in Maryland, one of the reasons that five years ago, we adopted a policy of hiring nonsmokers was just for that reason. And we want to promote tobacco free living among our team members.

Host:  All right great. Well thank you Lyle. When we come back, we’re going to hear from MaryBeth Their, a Pulmonary Nurse Practitioner about how this condition can be diagnosed and treated and help people maintain their optimal health. Welcome back. I’m Colin Ward and I’m pleased to be joined by MaryBeth Thier a doctorly prepared Nurse Practitioner for Pulmonary and Critical Care Associates of Baltimore.  Welcome MaryBeth. Thanks for joining us.

MaryBeth Their, DNP (Guest):  Thank you for having me Colin. It’s great to share some information with our population about COPD.

Host:  Well perfect. Let’s get right into it then. So, what is COPD and how is it different than other lung ailments.

MaryBeth:  So COPD as you said is chronic obstructive pulmonary disease. It’s a disease that affects the lungs. It includes emphysema and chronic bronchitis. Emphysema is a lung disease that damages the walls of the alveoli or air sacs in the lungs. And chronic bronchitis is an inflammation of the bronchial tubes or air tubes of the lungs. Both of these diseases fall into the category of chronic obstructive pulmonary disease.

Host:  So and in laymen’s terms, what that means is it’s what for people trying to breathe?

MaryBeth:  It’s hard for people to breathe. They can have flare ups. They can have shortness of breath that affects their everyday living. They can have a decrease in quality of life depending on how bad their disease is.

Host:  Okay and who does this disease typically impact? Is this a smoker’s disease or could it be anyone?

MaryBeth:  So, in the United States 85% of COPD is caused from cigarette smoking. There are other causes of COPD. For instance, air pollution including secondhand smoke, exposures that you might have at a job, welders, or plumbers or dust, construction workers, all those types of things that may be inhaled can lead to COPD. And then another very small proportion of people with COPD it’s actually a genetic problem called alpha1 deficiency. This is a very small less than one percent of the COPD patients that have this.

Host:  Okay and is this – would this be a cousin of like lung cancer or are these two separate and distinct areas?

MaryBeth:  No, these are two separate and distinct areas.

Host:  Okay and typically is this a young person’s issue or this develops as people are aging?

MaryBeth:  So, typically we will diagnose people in their 60s but anybody over 45 usually. Chronic bronchitis tends to be diagnosed in the younger population whereas emphysema takes a little bit longer to develop and we see that in older over 60 population.

Host:  Okay so you mentioned when you diagnose, how do you diagnose somebody with COPD?

MaryBeth:  So, we diagnose COPD by using pulmonary function tests or PFTs. They can be done in the doctor’s office, sometimes some hospitals will perform PFTs. And the patient goes in and they are asked to blow into a machine with their nose plugged. Sometimes –

Host:  Well everyone loves that.

MaryBeth:  Yes, it’s difficult especially when you already have breathing problems. There is also some of the hospitals will have a box that they do pulmonary function tests in. So, you may see it either way. The doctor’s offices tend to have just an open area where they are doing pulmonary function tests. But both – they plug your nose with something, and have you breathe very deep and hard into a machine and then the computer gives us information. And the computer tells us not only do you have COPD but how bad is your COPD. Is it mild, moderate, severe or very severe depending on your results.

Host:  Okay and that’s critical because that is going to help guide you in terms of treatment options, correct?

MaryBeth:  Definitely. It definitely affects how the patient may need to be treated and then what risks they have for having increased symptoms or exacerbations or flare ups.

Host:  Okay so can you walk us through what kind of treatment modalities you currently have? What’s your arsenal for caring for people with COPD?

MaryBeth:  So, depending on where they fall and the gold standards, Global Obstructive lung Disease Initiative, they kind of guide where we go with treatment. And we have lots of inhalers and different types of nebulizers out there to treat COPD.

Host:  So, tell me really quickly what is the difference between an inhaler and a nebulizer?

MaryBeth:  So an inhaler is a device that you would – and there’s a couple of different kinds, but you would put maybe a pill in it or it’s preloaded and you would inhale the medication in. A nebulizer is a little machine that you would put your liquid medication into a little cup, and you would breathe that in over a few minutes.

Host:  And that feels more like a vaporizer that you probably had as a kid.

MaryBeth:  Yes.

Host:  Okay so you have those two as your options potentially. Are there other methods that you use to care for patients with COPD?

MaryBeth:  So, one of the key things to treat COPD is quitting smoking and encouraging the patient to quit smoking. Okay so, we should really help patients quit smoking. That’s one of the key things they can do. As I said, there’s all different kinds of inhalers and nebulizers and we really have to look at medications, what the insurance company is going to cover, what the patient is able to tolerate, what type of inhaler the patient is able to tolerate. So, all of that comes into play in deciding what their treatment should be. Other things complimentary type therapies, patients will do yoga, or massage, relaxation techniques, meditation, all these kinds of things can help with managing your COPD.

Host:  Okay so one of the interesting things about COPD based on what you told me there is you’ve got a wide spectrum of severity in terms of how it is and when the patient may potentially be diagnosed with the issue. The difference between caring for a COPD patient and someone with high blood pressure is that patient with high blood pressure takes a pill and it’s known the pill was ingested. With COPD, it’s not just that you have to pick the right medication, but you have to train the person on how to properly inhale it. so, are the treatments then more complicated? So, you get the right medication for the patient but if they’re not taking it right, you don’t seem to be making headway. Is that true?

MaryBeth:  They can absolutely be difficult for patient to learn how to use. But it’s our responsibility to make sure that patients are taught the proper use. There’s also – there’s going to be medications that are their controller medications like their blood pressure pill that they use every day no matter how they feel, they do it every day, it’s their controller medication. It helps prevent flare ups. And then they are going to have a separate medication that’s for when they get in trouble. And they take that when they are having a flare up or exacerbation or more shortness of breath and that’s called their rescue inhaler. And it’s very important for patients to know what their meds are and how they work and what they’re for. And I often see patients not using controller medications correctly or every day and I tell them this is like your blood pressure pill. If you had high blood pressure, you would take your pill every day. You have emphysema, chronic bronchitis, COPD whatever you want to call it and you have to take this every day. This is treatment to keep your disease under wraps.

Host:  Got you. Okay so if patients don’t take that every day, where do they usually come? They usually come to the Emergency Department, right?

MaryBeth:  They can end up coming into the Emergency Department because they have flare ups, they get more short of breath, they start wheezing, they have flare ups and then they end up in the Emergency Room.

Host:  So, this is where it gets a little bit challenging for patients and for providers because you may now have a primary care provider who has been working with you on maintenance of COPD, you may have a pulmonologist who is helping you and prescribing medications and now you bring in an Emergency Department provider and a hospitalist, now you potentially have four different prescribers. So, how does that – having a patient come to the hospital create challenges for the prescriber community, the caregivers in terms of managing that patient’s health?

MaryBeth:  So, communication among all those areas is very important. So, if the patient is seeing a pulmonologist, that pulmonologist should make sure that the primary care physician is getting records and what I’m doing and what the patient’s being treated for and the same with the Emergency Room. If the patient is seen in the Emergency Room; it’s helpful if those notes, make it to the patient’s primary care physician or the pulmonologist so we know what took place and what the patient may need.

Host:  Okay. So, are there any new treatments that are coming down the pike for COPD? Is there research that’s saying heh we can help people live longer with this chronic condition?

MaryBeth:  So, we have a lot of great new inhalers, again, the challenge is cost. Okay so we have to see what that particular individual’s insurance will cover. But there are a lot of nice new inhalers coming out easier to use, once a day as opposed to twice a day. We have medications that are now in combo so the patient may have all three medications in one inhaler to use once a day. So, that helps with compliance. The other options, there are surgical options and there are some new surgical options out there especially for people with bad emphysema. If you have emphysema, you have these big air sacs that are not used, and air just gets trapped in there. There’s now surgical procedures that can cut them out and decrease that called a bullectomy or lung reduction surgery. There’s also a new procedure that is fairly new to FDA approval that they can actually put valves in those areas so that they kind of block off those areas that aren’t working in the lung so that air goes to the good part of the lung.

Host:  Oh wow, that’s quite interesting. So, there are new and emerging ways to help people live longer with this condition.

MaryBeth:  Yeah, these are – these tend to be for the more severe patients. They are new. They are still being looked at but yes, those are some new modalities coming.

Host:  Okay now, for some of those patients with a more severe case or who have been living longer with this; this is a difficult question to ask, but how do you weight that decision with the patient and the patient’s family on when to keep fighting and when to migrate into palliative care?

MaryBeth:  So, Colin this is very important in lung disease. Because it can be – you can get to where it’s end stage and there’s not much more we can do. And I think that it’s very important for us as medical people to start that conversation. Even if it doesn’t mean they have to make that decision on this admission or this visit; at least get the family to start talking about it. Patients with chronic illnesses like COPD they should have advanced directives and have that conversation with their loved ones, family members whoever is going to be speaking for them. Because there is going to come a time when we don’t have any other answers and we need to start focusing on the quality of life instead of the quantity of life. And keeping that patient comfortable. And hospice may be the answer, hospice, palliative care. I always hate using the word hospice with my patients because a lot of especially our older patients connect that with, I’m going to die next week. And we have lots of our patients that we’ve put on hospice that actually get graduated off because they do better. Because they have that support.

But it’s very important that with a chronic illness, you have that conversation with your loved ones as hard as it is so that you don’t get put on machines if you don’t want to be put on machines and you don’t end up having to make those decisions when it’s critical instead of when you are stable.

Host:  Absolutely. Okay so, in order to avoid that circumstance, your advice would be stop smoking, and what else in terms of early diagnosis.

MaryBeth:  So, the major things that I would tell you that patients should do for their COPD to control it the best, in summary I would say don’t smoke, if you do, quit. Yes quitting is very difficult, but the important thing is to just keep working at it. You don’t have to quit cold turkey. You don’t have to quit in a week. You don’t have to quit in two weeks. As long as you’re working towards it, that’s the important thing. Know your medications and how to use them. Make sure you know what your controller medication is and what your rescue medication is and when and how you should use them. Know your symptoms of getting into trouble. I have a lot of patients who didn’t realize that the little cough they started with was actually the red flag they should have paid attention to and upped started using their rescue inhaler and those things.

So, you want to know your symptoms of when you start getting into trouble. And COPD is a chronic illness, so you need to make sure you are doing good follow up with your physician, with your pulmonologist that you have a close relationship with them and then again, making sure that you have advanced directives and end of life decisions made before they need to be made.

Host:  Great well MaryBeth Thier from Pulmonary and Critical Care Associates of Baltimore, thank you so much for helping us understand this chronic condition. We appreciate it.

MaryBeth:  Colin thank you so much for having me.

Host:  Great, okay, well our next podcast will be released later in January. For Lyle Sheldon, I’m Colin Ward and we hope you will join us in becoming a healthcare hero.