Carl Maronich (Host): Welcome to the Live Greater podcast series, information for a healthier you, from the University of Maryland Medical System. I'm Carl Maronich. And with me today is Dr. Nirav Shah, a critical care pulmonologist from the University of Maryland Medical System. And we're going to be discussing COPD exacerbations. Dr. Shah, welcome to the podcast.

Nirav G. Shah, MD, FCCP, ATSF: Thank you for having me.

Host: Maybe we could start by kind of defining what a COPD exacerbation is and how it's different from day-to-day symptom changes.

Nirav G. Shah, MD, FCCP, ATSF: Yeah. Thank you very much. So, COPD or chronic obstructive pulmonary disease is a disorder that affects a lot of different people. It's characterized by obstruction to airflow, difficulty getting air out of your lungs. And an exacerbation of COPD is really a flareup, a period when symptoms suddenly get much worse than a person's usual day-to-day level. People with COPD often live with some symptoms at baseline. They have cough or shortness of breath, mucus production, et cetera. But an exacerbation is really when these symptoms get worse relatively quickly, over hours or days.

And so, the way that I think about it is kind of the daily variability is minor ups and downs in how people feel on a daily basis, but an exacerbation is really a sudden significant worsening that's going to disrupt your normal activities, whether it's going to school, going to work, doing your activities of daily living. And it usually requires medical treatment. You know, exacerbations often are going to signal increased inflammation or even infection in the lungs. And it's important that we see patients that have an exacerbation in a timely manner.

Host: Yeah. Are there common triggers for these exacerbations?

Nirav G. Shah, MD, FCCP, ATSF: So, the most common trigger is actually an infection. So, respiratory infections, whether it be viral or bacterial, are going to be the number one cause of a COPD exacerbation. But other things can cause an exacerbation too or can trigger it as well. So, things like changes in the weather or exposure to an allergen. Sometimes people get exposed to pollen or freshly cut grass, et cetera.

And I think it's also important to think about indoor irritants. Patients that have COPD often can get exacerbated by even the strong smell of a chemical. So like, bleach for cleaning, for example you think you're doing the right thing and keeping things clean, but that smell of the bleach itself can actually cause a trigger. And then, really importantly, smoking or secondhand smoke is definitely a trigger for COPD exacerbation. So, every person has their own kind of pattern of what triggers them. And so, it's important to know that. But really, infections and environmental irritants are going to account for the most.

Host: Yeah, a little bit about COPD. If someone's diagnosed with it—initially, they have a diagnosis—is it naturally something that's going to get worse or is that different from patient to patient? How does the life, if you will, of COPD run through a patient, if that makes sense.?

Nirav G. Shah, MD, FCCP, ATSF: Yeah, that's a good question. So, COPD is going to be characterized by an obstruction to airflow, as we mentioned. And people have difficulty getting air out of their lungs when people tell them to kind of blow, blow, blow as hard as you can, they have difficulty getting that air out. And all of us lose lung function after a certain age by a little bit every year.

The goal with patients with COPD is really to try and preserve as much lung function as possible. If you continue to have exacerbations or are exposed to triggers or continue to even smoke cigarettes or be exposed to secondhand smoke, for example, then lung function can decline more rapidly than we expect it to.

And exacerbations in and of themselves also can lead to worsening lung function. So, our goal is to really preserve what lung function patients have when they see us, try and reduce the amount of decline in their lung function, and improve their quality of life. Try and allow them to be able to do the things that they want to do. So, that's important to think about because as you lose lung function, you can't gain it back.

Host: You mentioned a bit ago, doctor, some triggers potentially, seasonal changes, things like that. If someone has allergies, are they going to naturally then get COPD? Or how do those two kind of live together, or do they?

Nirav G. Shah, MD, FCCP, ATSF: Yeah. So, just because you have seasonal allergies doesn't mean you're going to get COPD. But for sure, if you have COPD, seasonal allergies can be a trigger for worsening symptoms. And so, seasonal allergies are going to cause inflammation in your upper airways. And for people with COPD, that inflammation can really tighten the airways, make breathing harder, it can increase mucus production, which is already an issue. It can lead to coughing, wheezing, shortness of breath. And so, I think that's important to think about.

Further, seasonal allergies can make the lungs more vulnerable to infection. So, I think anything that irritates the airways in a patient with COPD that already has obstruction to airflow is going to be something that we're going to want to try and control as much as possible. So even though allergies and COPD are different conditions, there is overlap. And allergy season can really act like a double hit to the respiratory system.

Host: Interesting. Are there early warning signs people should be kind of on the watch for that an exacerbation could be starting?

Nirav G. Shah, MD, FCCP, ATSF: That's a great question. So, catching a flareup is really key in patients with COPD. So, the symptoms we tell them to watch for are things like increased shortness of breath or increased cough, even a change in their sputum. A lot of patients with COPD have sputum production. But if the color changes, if the consistency of it gets dark or thicker, et cetera, we want people to know about that. Things like wheezing or feeling tight in their chest, I think, are early warning signs.

And then, you know, sometimes even before you have those symptoms, you might just feel like, "Oh man, today, I'm feeling run down. I'm feeling unusually fatigued." And that can be a symptom as well. So for a lot of patients, it's this intuition of "I just don't feel right. I just don't feel as good as I normally do." And if that persists, I think it's important to recognize that that's an early warning sign that you might be having an exacerbation of your COPD.

Host: Yeah. That affects so many health issues. So therefore, I guess the takeaway from that is know your body and know when something just doesn't feel right. Even if you have a chronic condition, there are days when it just feels different than it used to, and that's a sign.

Nirav G. Shah, MD, FCCP, ATSF: Absolutely.

Host: So, how are exacerbations treated? You mentioned early treatment makes a big difference.

Nirav G. Shah, MD, FCCP, ATSF: Yeah. I think a lot of it is we have patients on medications at baseline. So when they're exacerbating or having a flareup, we really want to think about other things that we're going to need to add. So, for example, we may need to use more bronchodilators or medicines that open up the airways. We might need to use higher doses of steroids to kind of calm down the inflammation.

And oftentimes ,for patients with COPD that come in with an exacerbation, we're going to start them on antibiotics because oftentimes, as I mentioned earlier, viral and bacterial infections can cause an exacerbation. And so, we don't know if it's viral or bacterial when we first see you. But we're going to start antibiotics with the premise that this is a bacterial infection until proven otherwise. And so, that's a key treatment for patients with COPD.

Further, a lot of patients with exacerbations are going to need some supplemental oxygen to keep their oxygen level where it needs to be. And so, starting them on oxygen is important. As I think of a patient that hits the hospital emergency department or urgent care, or the doctor's office with an exacerbation, I'm going to think, "Let me get their airways open with medications that'll do that, so bronchodilators. Let me calm down the inflammation with steroids. And let me put them on an antibiotic to make sure that this is not bacterial or, if it is, that we're treating it."

In terms of early treatment, I think that that's really important. And really, the idea is that the sooner you control inflammation, the less permanent damage you're going to cause. So, we know that early treatment prevents hospitalization. We know that it reduces the risk of long-term decline in lung function and helps people recover faster. And so, really keeping people out of the hospital, feeling good, being able to work or go to school or do the things that they do on a daily basis is the goal of why we want to catch this early.

So, I think talking to your primary care physician, if you have a pulmonologist, talk to them, and get in and see them when you're not feeling right.

Host: What steps can people with COPD take right away to lower their risk as allergy season approaches?

Nirav G. Shah, MD, FCCP, ATSF: Yeah. So, the first thing I'm going to say is if your COPD was a result of a trigger that you know of, you want to minimize that trigger or eliminate that trigger. So for a lot of patients in the United States, the trigger for COPD was smoking. So, smoking cessation is going to be one, two, and three on our list of things that we want people do to do to lower their risk.

In addition, staying on your daily controller medications for COPD is important. Even when you're feeling well, you want to take your inhalers because it keeps inflammation down, it keeps your airways open, it keeps you getting the mucus that your lungs naturally produce out of your lungs as needed. And so, I think that that's important.

In addition for allergy season, if you're starting to feel the season is coming and it's hitting you, taking allergy medications can be helpful. Using your rescue inhaler early if symptoms start to arise. And then, kind of things that limit our exposure to the environment. Keeping your windows closed on high pollen or bad air pollution days. Consider using air purifiers with HEPA filters, all kind of important things.

In addition, if you're going to be outside and you're going to be doing stuff in the garden or spending long periods outdoors where you're going to be exposed to air that has a lot of allergens in it, you can even consider wearing a mask. And then, I always tell my patients that avoiding strong fragrances that can cause irritation. So, strong perfumes, colognes, air fresheners, et cetera.

And then, no talk about kind of preventing exacerbations would be complete without talking about staying up-to-date on vaccinations. Really, really important. Getting the pneumococcal vaccine, getting the COVID vaccine, getting the flu vaccine. These are things that we can prevent and can avoid causing COPD exacerbations in a lot of our patients. So, I think that's really important.

And then, lastly, we often tell our patients to have a written action plan so that when you're not feeling well, you kind of have an algorithm that you can follow to say, "This is what I'm going to do when I start to feel symptoms, then this is when I need to call my physician," or even sometimes head into the emergency department or urgent care.

Host: Doctor, at some point, you decided what area of medicine you wanted to pursue. Maybe I could ask what drew you to pulmonology?

Nirav G. Shah, MD, FCCP, ATSF: I'm fascinated by the lungs and their exposure to the environment. I've always enjoyed pulmonary physiology and, you know, kind of hand in hand with that, critical care medicine for that matter. The two kind of go hand in hand with each other. And we can make a difference. We can help people feel better.

When I often think about my patients, the idea that you can't breathe or that breathing is hard, is something that we want to have an impact on, right? We just do it naturally. But when you feel like you can't get a deep breath in, or you are struggling to breathe, that is not a good feeling. And so, really being able to impact patient's lives, how they feel, and what they can and can't do, I think, is really why pulmonary medicine was attractive to me.

Host: Very interesting stuff. Well, Doctor, as we're talking about COPD and exacerbations, what key takeaways would you like to have our listeners step away with?

Nirav G. Shah, MD, FCCP, ATSF: I think I would emphasize that COPD and COPD exacerbations are serious. And that the exacerbations can be preventable, but they definitely can be manageable. And so while allergies and triggers can often cause exacerbations, we can help how people feel when they are having one. So, kind of time and preparation matters.

I'd like my patients to really pay attention to their early warning signs, because small changes can be the first clue. And to act fast if they have a exacerbation that's starting so that we can get them the right treatment at the right time and avoid hospitalization or visits to the emergency department. And really, kind of preserve their lung function as much as possible. We know that with the right habits and planning that people with COPD can stay active, they can really enjoy all four seasons. In Maryland, we have four seasons that are wonderful, and they can enjoy all four seasons with the right care and attention to their disease. So, patients with COPD can monitor their symptoms in a lot of different ways. And I think, for this, we want to be partners with our patients to make sure that we are catching exacerbations early, that we're helping them live their best life.

Host: Dr. Nirav Shah, critical care pulmonologist, with the University of Maryland Medical System. I think folks can breathe easier now that they're armed with great information. Thanks to our chat here today.

Nirav G. Shah, MD, FCCP, ATSF: Thanks, Carl.

Host: To listen to more Live Greater podcasts, visit umms.org/podcast, YouTube or your favorite podcast platform. Thank you for listening to Live Greater, a health and wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again. And please share this on your social channels. Thanks for listening.