Scott Webb (Host): There are a lot of newer, innovative treatment options for COPD and asthma patients, and my guest today is here to share his expertise on these conditions and how Franciscan Health can help. I'm joined today by Dr. Faisal Khan. He's a board-certified interventional pulmonologist and independent provider who chooses to practice at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctors, it's nice to have you here today. We're going to talk about the evolution of COPD and asthma treatment options. So, it's great to have you here, great to have your expertise. And, you know, I know treatment options have evolved for both conditions. So, I just want to have you start off by briefly describing what are the differences and similarities between asthma and COPD.

Dr. Faisal Khan: So from both asthma and COPD standpoint, I think there is in public some confusion about whether they're similar or different. And at the fundamental level, there is similarity in the physiology of the disease, meaning that both the disease processes belong to a category of disease, what we call obstructive lung disease, which is basically there is a restriction to the air flow going through the tubes, the bronchial tubes that go into the lungs. So, it's more of a supply issue, where when we breathe, the air tubes are not as wide and open as they should be. Now, that is at the heart of it. And that's what drives the symptoms of cough, chest tightness, wheezing, and shortness of breath.

But the key differences are the reason behind this disease processes. So, majority of the time, people belong to one or the other. And sometimes there is overlap where some patients may have both processes. Now, asthma by default is usually the sensitivity of our airways to different stimuli. And majority of the time, those stimuli are environmental. So, someone is more sensitive to heat, dust, cold, perfume, strong scent. And what happens is that if someone has asthma and they're sensitive to those triggers, whenever they're exposed to those triggers, the bronchial tubes, they react and the muscles in those tubes kind of clamp down and make the airway narrow.

Now, one of the key features of the asthma is that majority of that constriction or narrowing is reversible, meaning if you avoid the trigger or you use the medicine, the airway will open back up almost to normal caliber-- or if not even back to normal. It'll show a good response to what we call bronchodilator medications.

In contrast, COPD is more of a fixed narrowing of the airway and it gets worse with time. And the major reason behind COPD is smoking. There are other causes as well, but the predominant reason is smoking. And what happens is because of smoking, over time, there is constant irritation of the airway that leads into inflammation. And then, that constant inflammation over years causes scarring of the air tubes. And, as you know, the scarring is generally not reversible. So as the airways gets scarred and narrow, that narrowing of the caliber is more of a fixed narrowing than compared to asthma where there's some reversibility.

Now, having said that, there is some reversibility in the COPD narrowing as well, but it's not as profound as you see in asthma. So, the bottom line is that the inhalers that are commonly used for both, they do impact COPD and help relieve symptoms, but the magnitude of improvement may not be as robust as what you see in asthma because the fundamental reason behind both and at the molecular level and at the pathological level, the driving forces are different and the changes in the airway walls are different.

Host: Right. Yeah. You mentioned and referenced there the inhalers and medications. So, let's talk about the medications used to treat asthma and COPD and have they changed?

Dr. Faisal Khan: Yes. I'll start by asthma first. For years, the only main philosophy I would say behind treating these diseases was to use the drugs that basically have a mechanical effect of causing relaxation of the air tubes and allow more caliber so that the air can enter easily. And those are what we call bronchodilators. The delivery mechanisms were the inhalers. So, we had short-acting and long-acting bronchodilator medications that would act directly on the airway wall and cause relaxation of the air tubes. Now, some of the inhalers would also have steroids in it that reduce the burden of inflammation in the airway wall, which is the primary driving force in both pathologies.

Now, over the years for asthma , the focus has been more on chasing the molecular pathways that drive the common form of asthma. And there are different subtypes of asthma, but the more predominant in the layman term is called allergic asthma, again, mostly as a response to sensitivity to environmental triggers. And there's a certain type of cells in our body that drive that kind of inflammation, and those cells are called eosinophils. They circulate in our blood.

So, the newer treatments, which are mostly in the form of injections, subcutaneous injections, meaning injections given under the skin, they target the pathways that drive those eosinophils. So by targeting the root cause of the main derivative of inflammation, you in turn impact the load of inflammation in the airways and also reduce the sensitivity of the airways to the trigger. So, you're not going to twitch the airway to the same amount when exposed to the same trigger as you would be if you had a higher eosinophil count.

So, those modalities, those injections that are targeting these fundamental molecular pathways have made a huge difference in people who have had severe asthma and who in the past we would only have the option of putting these folks on long-term steroid therapy. And steroids are helpful because they cut the inflammation, but they come with a whole baggage of their long-term side effects in terms of weight gain, diabetes, bone loss, blood pressure issues and so many others, that in the long-term, these people would even though feel better from asthma, but they would suffer the side effects of the long-term steroids, but unfortunately, were not able to come off those. So, there's been this evolution of different shots that are now available with some nuances of which one is better for which patient, but the fundamental is they target the underlying molecular pathways. And from that standpoint, we have seen a lot of progress.

There's also a procedure aspect to it, which is really reserved for people who have severe asthma that is just not controllable by any medication or they cannot take even these newer medication having side effects and all. And that is called bronchial thermoplasty. It was much more used before these immunologic shots scheme into the market. The use has gone down, but the option is still FDA approved. And this procedure basically, it targets the smooth muscle wall or the smooth muscle layer in the walls of the bronchial tubes. So, you can imagine if you have a bicep and you cut it in half, the arm is not going to flex with the same force. So basically, same idea that this is a heat-based therapy where you go in with a bronchoscope and apply heat to the walls of the bronchial tubes. And that heat application causes thinning of the muscle wall, where thereby when that muscle wall, that air tube is exposed to a stimulus, it doesn't constrict or twitch with the same force as it used to. Again, as I said, the use of this procedure has gone down significantly to the point that, even though the procedure is available, the newer catheters are not available because the company that makes it is probably not finding it worthwhile to manufacture more cathethers.

Host: Sure. Not profitable.

Dr. Faisal Khan: Yeah. Not profitable. But that also speaks to the impact of these immunologic drugs that we have out there. So, majority of the patients would not require immunology. But now, there are options, if there someone is not getting controlled on routine inhalers and the fundamentals that you all start from ABCs, and if those are not working, then there are many more effective and safer options.

In regard to the COPD, again, in the past, the main modality was inhalers to help with the breathing. But, lately, there was a focus on, again, the pathways that drive the inflammation. And some of the COPD patients also have an overlapping asthma diagnosis. So then, you kind of work them up as an asthmatic as well and look into those things. But even if they don't have asthma, the inflammation drivers in the COPD are variable, and some people with COPD have the same cells that drive their COPD and bronchoconstriction as the asthmatics. So, the eosinophils do play a role, not in everyone, but in some.

So, the key is to identify those individuals that have COPD and are on regular inhaler and they're adhering to it, and still not getting control, then to identify whether these immunologic or biologic options are valid for them or not. And that's where we do the blood work and kind of see. And those have been shown to be very effective, not only with the symptom control, but more in COPD, the biggest challenges that people with COPD, they end up with frequent flareups during the year and they end up either needing much more aggressive therapy or hospitalization. So, it's what we call exacerbations of their disease. So, those events of exacerbations have been significantly cut down, thereby leading to a good quality of life and not having the fear of having a flareup.

That being said, there are other changes in the treatment options that have come in COPD as well. There are other set of medications that, again, target a different pathway. Those are oral medications and inhaled medications. But they fundamentally are more useful for people who have a lot of what we call productive cough, or predominantly bronchitis compared to emphysema. Those are both different kind of nuances within the bigger picture of COPD. So, people who generate a lot of phlegm, there are medications now that help reduce that phlegm amount and also reduce the rate of flareups. So, those are both available in oral and inhaled form. And that's something that we did not have before, but they have had shown impact on reducing hospitalization and flareups and improving quality of life.

The third evolution that has happened within COPD is the procedure. So, people who have predominant emphysema, emphysema by default is where people with COPD have a lot of these empty pockets in the lung and those pockets have air trapped in them. That is wasted air, just taking the space without contributing to the oxygen exchange. And that also causes stretching of the lung because those are big pockets of air, empty air pockets in the lung. So, that stretches the surrounding muscles and structures. So, it puts people at mechanical disadvantage in terms of using their respiratory muscles for breathing. So, there's a concept called lung volume reduction, where you identify areas in the lung that had the most wasted air pockets and are just not useful areas in the lungs.

Before, it was only surgical, I mean, doing surgery in people with severe COPD, by default, it's high risk. But now, we have a bronchoscopic approach to deal with this, where there's no incision involved. It's not for everyone, but people with emphysema who have a lot of air trapping. There's a selection criteria. But should someone qualify for those, then you identify areas in the lung that have the most wasted airspace and least amount of contribution to their breathing. And then, you block those areas by putting one-way valves, which does not allow the air to go into those segments and causes a collapse of those segments. So, air can be redirected towards the healthier segments. And thereby, also, it reduces the volume of the lung, which helps bring the muscles back to the more advantaged position in the chest wall muscles, and the diaphragm comes back because you're not overstretched. And that helps in terms of sensation of breathing, quality of life. And I mean, there multiple advantages associated with that intervention.

So, that is also an option that is now available and has been practiced for almost more than five years with a lot of good outcomes. Again, not meant for everyone, but it's a kind of a good bridge for people with severe COPD emphysema who may not be a transplant candidate yet, but are still limited in their day-to-day activities. So, this is a good option for those to kind of act as a bridge, even if they're considering transplant.

Host: Yeah, a bridge. So, let's talk about surgical options, any new advancements? You know, you talked there about transplants perhaps for COPD patients down the line. But just in general, what are some of the newer surgical options for asthma and COPD?

Dr. Faisal Khan: Asthma, we talked about the bronchial thermoplasty where go in and you thin the muscle. And COPD again, like I mentioned, the valves, those are not surgery per se, they're bronchoscopic approaches. Now, these lung volume reduction surgery, which basically meant surgeon going in and cutting out the diseased portion of the lung, that had been practiced for more than 20 years. But the use is really limited because the postoperative mortality and morbidity was high. So, people shied away from that. But then, there was still a need felt that the underlying concept was still valid, that you want to get rid of those wasted portions.

So now, we have two valves in the market. One is called Spiration, one is called Zephyr valves, that are available for those patients where you can go in with a bronchoscope and block those areas off with the valves, and not worry about cutting someone open or doing a proper surgery. The transplant, again, there's a definite criteria for who gets a transplant, and that's a whole different discussion.

But most of the time, fundamentally, transplant is for people who are in the younger demographic and in the 60s range. Sometimes if you are too healthy and you're in 70s, they will take you. But generally, people above 70 don't have transplant as an option either for the most part, because there are other medical comorbidities. But with the introduction of these valves, now there's some hope that if they're struggling on day-to-day basis, then the valves can make a difference. It's not as invasive as a transplant or the surgical lung volume reduction, but it's a bronchoscopic approach.

Typically, people require coming in, getting the procedure, stay in the hospital for three days and then they go home. And then, they have to go through rehab and all that to get with the maximum benefit out of the intervention. But this is an option that is making a lot of impact in improving people's quality of life and kind of overall sense of confidence and not have that impending doom of like struggling to breathe all the time.

Host: Right. Yeah. Impending doom. Yeah. You touched on pulmonary rehab. And so, I wanted to talk about that. Like, what role does it play in helping asthma and COPD sufferers?

Dr. Faisal Khan: Yeah. So, the predominant role of pulmonary rehab is in people with COPD. COPD is not only the disease of the lung, it's a disease that primarily involves the lung, but the inflammation that it induces in the lung, which is a big organ, spills over and impacts almost every organ in the body.

So, some people with COPD do not only have lung disease, they will have muscle weakness. They have the structural changes in the lung, like I alluded to before, causes the muscles to go in a disadvantaged position, the muscles that move our rib cage. There is loss of appetite and weight loss, and all that.

Then, there are psychosocial impacts of COPD, because people do get impacted by this constant sensation of shortness of breath, and that leads into mood disorders and all that. Smoking is a big part of COPD as well. It's the main driver. So, what pulmonary rehab does, it targets all these aspects. So, it will, number one, when someone is enrolled in pulmonary rehab, they will be educated about proper use of their inhalers. They will be counseled for smoking cessation and discuss techniques of how they can wean themselves off the cigarettes. It'll focus on certain specific exercises that help improve the stamina and also strengthen the muscles that help us breathe.

It'll also educate them about clearance techniques, how to bring up the phlegm and clear their lungs. And then also, the impact of seeing other people in a rehab program going through the same thing, that also is a reassuring for patients, that they're not the only one. And they see success stories that has a impact on the mood and all that.

So, what the data objectively shows is that when someone goes through rehab, from an objective standpoint, it reduces their sensation of breathlessness. It improves their stamina, it improves their quality of life. It improves the risk of flareups or exacerbation actually reduces it. It reduces hospitalization. So, there's a lot of positive that is a result of pulmonary rehab. And it's very underutilized modality because people, the first go-to is, okay, give inhalers and then see what happens. It's a commitment both from the patient standpoint and from the provider standpoint to think about it and refer to the appropriate programs that are offering it. But I cannot overstate the importance of it. It's really important for people with symptoms who have COPD.

Host: Definitely. There's been good stuff today, Doctor. And I know we're going to speak soon about lung cancer, lung screenings, scans, all those things for today. Let's just wrap up and get whatever advice you would have, like what's your best advice you would give to a patient who's struggling with asthma or COPD?

Dr. Faisal Khan: For both in general, I think that my first message would be if you are a smoker, really think hard about quitting smoking. I know it's easier said than done, but there are options available. There are strategies available. If you have failed once, don't get discouraged. An average person who quits smoking takes multiple tries, six to seven according to some literature studies before they become successful. So, one or two failures should not be a point of discouragement. Have a conversation with your provider. There's so many options available, so many techniques available to go through that and get rid of the cigarettes.

Number two, know your other environmental triggers. If there's certain situation that triggers your asthma or COPD, then try to avoid those. Be mindful of your overall health. Stress plays a lot of role in aggravating these diseases, believe it or not. So just having a healthier lifestyle where you're not gaining weight, you're doing some sort of exercise, rehab. That is imperative, that also impacts positively the overall control of this disease process.

One of the biggest areas where we find challenge, especially in older patients, is their technique of using the inhalers. You may be using it in your mind, but you're not delivering the drug to the lungs because your technique is wrong. So, take some time with your provider, with your respiratory therapist to know what's the best way how to deliver the drug in your lung, how to use the inhaler. Some folks have dexterity issues, whereas arthritis and all that, and the inhaler may not be a good option for them. Then, a nebulizer may be a good option for that. So, think about on those lines and have that conversation. And I think there's so many options now available.

Host: Yeah, I think you're right. It sounds like there's a lot of room for optimism, obviously, if you're a smoker, try to quit. But lots of options. And as I said, reason for optimism for sufferers of asthma, COPD, as you mentioned. Some folks suffer from both, unfortunately. Like I said, we're going to speak again soon, but for today, thanks so much.

Dr. Faisal Khan: Thank you so much.

Host: And to learn more, visit franciscanhealth.org and search pulmonary and respiratory medicine. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.