COPD With Dr. Brad Drummond

00:01:11:07- 00:04:04:00

FALK: So I started out with a whole series of terms and the question is what do any of them mean? Let’s start by defining what is chronic obstructive pulmonary disease. What is COPD?  

 

DRUMMOND: Yeah, it’s a great question. It’s a confusing term. So I think let’s break it down. So the C is for chronic, which means that once this disease starts, it generally doesn’t go away. Obstructive refers to the main abnormality we see on breathing test. That is that there is an obstruction of airflow. When you breathe out in the lungs, pulmonary obviously refers to the lungs and diseases that it’s a disease of the lungs. So what’s confusing about COPD is that it’s actually a spectrum of different diseases. 

So we have on one end of the spectrum this disease called chronic bronchitis. And then on the other end of the spectrum, we have this disease of emphysema. So I like to think of the lungs as a tree turned upside down in your chest. You’ve got a trunk, you’ve got branches, and then you’ve got the leaves at the end of the branches that actually are moving the oxygen and carbon dioxide out. 

 

So chronic bronchitis is a disease of the airways, the branches in the trunk, you get swelling in the airways, you get inflammation. And that can lead to things like cough and wheezing and mucus production. And then at the very end of the branches where those leaves are, that’s called the alveoli. That’s where we actually have the oxygen moving into the lungs and the carbon dioxide leaving the lungs, leaving the blood and the destruction of those leaves or the pruning of those leaves, if you will. That’s called emphysema. That’s destruction of the lung tissue. So both chronic bronchitis and emphysema can be present in the same person. And because that can happen, we sort of put them under this umbrella term of COPD. 

Falk:  So let’s go back to these leaves or alveoli or where the oxygen comes through that trunk, through those branches, and eventually into the blood and in exchange for carbon dioxide, what do those things actually look like?  

 

Drummond: So we call them alveoli, which is Latin for grapes. They look like little sacks of grapes at the end of those very small branches.  

 

FALK: You’d like the grapes to be full of things. When I eat a grape based, crunchy. But you’re saying these alveoli are really air sacs. 

 

DRUMMOND:They’re air sacs. Think of them almost like a cluster of ping pong balls. They’re actually hollow on the inside. And so these the oxygen can move in and out. The blood vessels are very thin blood vessels, and they line the edges of these ping pong balls or  alveoli. And that’s how you actually get the movement of gases in and out of the lungs. 

00:04:05:00- 00:06:43:00 

FALK: So you can imagine any number of things that you could inhale or get through the tree to those alveoli potentially would cause damage. 

DRUMMOND: Absolutely. And so what we think most commonly in the United States is cigarette smoke is the most common sort of cause of copd. As individuals inhale cigarette smoke, they’re inhaling all those toxins, those inflammatory agents and tar and other caustic chemicals and that can lead to damage to both the airways and the alveoli. But important only not everyone who has COPD has smoked in the past. In fact, worldwide it’s more commonly that we see exposures to when people are burning fuels in their house to try to, you know, heat their house. In the U.S., this is akin to having woodburning stoves that are poorly ventilated. So certainly, those types of exposures can lead to COPD. We often will see it in individuals who maybe had an occupation where they’re constantly breathing harmful fumes. Think about, for example, the bus driver who’s always breathing that exhaust fuel as their bus is idling, perhaps firefighters who are breathing in smoke. Those types of occupations can also lead to COPD  

FALK: So help me again with the word emphysema. What’s emphysema again? 

DRUMMOND:So emphysema is destruction of the lung tissue, Those alveolar sacs or those leaves at the end of the branches of the tree.  

FALK:So if somebody tells me I have emphysema, I’ve got to worry about those air sacs and something has hurt them, whether it’s smoking or occupational exposure.   

DRUMMOND: That’s right.  

 FALK:Got that. What then? Hurts the trunk and the branches of the tree? 

DRUMMOND:Yes. So it’s the same toxins. Because in order for those toxins to get to the alveoli or the leaves, they have to go through the trunk in the branches. So the same irritation causes inflammation of the airways, can cause swelling, excess mucus production, and then this can lead to a little bit different symptoms. So patients with emphysema typically feel mostly short of breath, especially when they’re exerting themselves and they put more stress on the system. But individuals with chronic bronchitis, because the airways are inflamed, they can have more wheezing, more mucus production. The other important thing is called an exacerbation or a breathing flare. This is where they, you know, are having a good day one day and suddenly the next day they can’t breathe. They’re short of breath, they’re having chest tightness. And often they have to go see their physician primary care provider, get a treatment with an antibiotic, prednisone, other therapies to treat that exacerbation. 

00:06:44:00- 00:10:10:00

FALK: How does somebody know when they’re walking along, then suddenly you’re getting short of breath or are a little bit short of breath and now it’s worse? How do they know it’s the lungs and not the heart? 

 

DRUMMOND: Well, this is one of the hard parts about COPD. And so we know that there’s probably somewhere around 16 million people in the United States who have COPD. 

But guess what? There’s about 16 million who we think have never been diagnosed. We call those the missing millions. The reason it’s not diagnosed as frequently is because people attribute these symptoms: shortness of breath, cough, wheezing to something else. Maybe they’re a little bit older, maybe they’re out of shape, Maybe they’re worried it’s their heart. It could be allergies or pollen, any of those things that can really trigger those types of symptoms. 

FALK: One of the other symptoms are that patients cough up mucus, globs of material. What’s all that?  

DRUMMOND: Yeah. So as those airways become inflamed, the way the airways respond is they start making more mucus and that mucus has to go somewhere in the response from the lungs, has to get it out of the lungs because it’s not really supposed to be there. 

So this is called that typical smoker’s cough. It’s worse in the morning. Patients will bring up a lot of mucus or phlegm, and it can happen throughout the day as well. But that’s really a response of the lungs, the airways in particular are trying to get that mucus out.  

 

FALK: And mucus can be multiple colors can be clear, yellow, red, green.Help! What does all that mean?  

DRUMMOND: Yeah, there’s actually some very interesting research that has looked at how the color of the mucus predicts whether there is an infection. So it’s common for all of us to make mucus every day. Typically, it’s clear skin. Maybe you cough it up and don’t even notice it. But when people have a change in the color where it gets grayer or yellow or darker, that can be a sign of infection. Certainly, if you see red, which would be concerning for blood, that raises other, you know, worries that we have. And you’d not want to just ignore that.  

 

FALK: If I have COPD and I’m doing well, living my life, having my morning cough along with my coughing and otherwise I’m doing okay. And then over the course of a day or two, I start feeling poorly, maybe have more of a cough, more shortness of breath. What is that?  

 

DRUMMOND:Yeah. So that would be what we call an exacerbation or a breathing flare. So the classic definition of an exacerbation is when you have a worsening of your symptoms. Cough, phlegm, wheeze, shortness of breath, chest tightness that’s beyond the normal, good, bad day variation. So COPD patients have good days and bad days. We like for them to have more good days and bad days. 

But if they start having more bad days in a row, that can be a sign that they’re having this inflammatory response in their lungs. It’s often caused by viral infections, exposure to inhaled irritants. And if that’s not recognized and treated, it can actually progress to a significant clinical event, meaning they have to go to the hospital, potentially spend time in the hospital for treatment. 

00:10:11:00– 00:15:33:00

FALK:You pointed out that a lot of these patients, or some of them at least, have had a smoking history. Does it make any difference what you smoke? 

 

DRUMMOND: It’s a great question. We have the most information about cigarette smoke and this is because quite frankly, we have generations of individuals who began smoking in the to their twenties and thirties.World war two veterans, vietnam veterans. Now we actually see COPD more commonly in women because of the targeted advertisements, the Virginia Slims, the advertisements for examples in the late seventies. What we don’t know a lot about are things like electronic cigarettes marijuana use. These are really new in our sort of epidemiology of COPD. The big word for meaning studying over many, many years. 

 

 

So I don’t know that we have enough information to understand these other inhalants and how they may lead to COPD. If at all. 

FALK: And did the menthol help or hurt? 

DRUMMOND: Yeah, so menthol cigarettes are is a very interesting chemical. So, you know, we think that menthol actually leads to more progressive COPD. What menthol does is it’s a mint flavoring that actually almost creates a cools and cooling sensation in the airways, which makes smoking more pleasurable, meaning you don’t cough as much, so you end up using it more.Unfortunately, menthol cigarettes were really targeted towards African-Americans and we see much higher rates of COPD in that population, which we believe is related to that menthol cigarette use.  

 

FALK: Let me come back to the vaping question. Electronics Cigarettes commonly known as vaping. Boy, it’s pretty common. Walking around seeing people all of a sudden puffing huge puffs of smoke into the air or some sort of vapor into the air. What do you think it’s doing to the airways?  

 

DRUMMOND:Yeah, this is something that worries us a lot, and I’ve actually been involved in research at the population level regarding the harms of vaping or electronic cigarets. Look, it took 50 years to prove that regular cigarets cause COPD and lung cancer. Vaping or electronic cigarets haven’t been around that long. We have no idea what’s going to happen to users related to their lungs. 30 years from now, the lungs change very slowly. But here’s what really keeps me up at night. Your lungs grow until you’re about 30 years old or so, and then you have this plateau phase where they just kind of hang out for ten or 15 years and then like everything else starts going downhill slowly. What we’re worried about is people who use vaping or electronic cigarettes or even regular cigarets. During that growth phase, teenagers, young adolescents, they’re stunting the growth of their lungs now, and they’re not going to have that reserve when they’re 40, 50, 60, 70, 80 that a nonsmoker/non-vaper would have.  

FALK:And then how about marijuana? You raise that question. And as marijuana becomes legalized in states or any version of THC, what do you think that’s doing?  

 

DRUMMOND:Yeah, so that’s a great question. So there’s actually a little bit of controversy in the pulmonary world about what inhaling marijuana does to the lungs. There’s some studies and there are some studies that show that it worsens lung function. There’s maybe a couple of studies that shows that it improves lung function, but that may be because of the vigorous respiratory effort involved in using some types of marijuana. 

Our recommendation is that, you know, inhaling anything beyond air is probably bad for the lungs until we have more information.  

 

FALK: You’ve said cigarettes multiple times. What about cigars? 

 

DRUMMOND: Cigars is another great question. You know that we see more risk of cancer of the mouth in the throat than we do with the lungs. I think it’s simply because of the way cigars are inhaled or not inhaled the same way as Cigarettes and generally, people may not smoke 20 cigars a day. So the overall exposure is low compared to a pack of cigarettes, but they’re certainly still harmful. They increase risk of mouth cancers, they increase risk of heart disease. I mean, we have to remember that cigarettes aren’t just affecting the lungs, right? We have the heart. We have other parts of the body that are very important that we have to worry about that can be harmed by these things. 

 

FALK: So you’ve talked about exposures. Are there genetic causes, things that families should be concerned about?  

 

DRUMMOND: Yes. So there’s one very well characterized genetic disorder called Alpha one antitrypsin deficiency. It’s kind of a mouthful. We call it alpha one for short. So the alpha one gene makes a protein that helps protect the lungs against inflammation, the same type of inflammation that we see with smoking. So in patients who have the genetic deficiency, they don’t have that protection in the lungs. So they can actually develop COPD even though they never smoked. In fact, the recommendations are that anybody who has COPD or has emphysema on a CAT scan should be tested for Alpha one because they may have an undiagnosed genetic disorder. Now, UNC is actually the only academic center in the state that’s an Alpha one Antitrypsin clinical resource center, which means we’re certified by the Alpha One Foundation to provide high quality care to patients who have Alpha one lung disease. 

00:15:34:00- 00:17:13:00

FALK: So whether you’re a young person or an older person, walk me through the patient’s journey since this is a progressive or can be a progressive problem. 

 

DRUMMOND: Absolutely. So most patients with COPD are typically diagnosed in their fifties, but the reality is they may have had symptoms for the last 5 to 10 years. Maybe those symptoms, like we talked about, were were attributable to getting older, to being out of shape, to heart issues.But usually once somebody is diagnosed, the way we make that diagnosis is with spirometry testing. So this is a test where you put a clip on the nose and you have the patient below really hard into this little machine that measures the lung function. And that’s the the classic test. I say classic test because there’s a lot of interest and understandin g.Can we get other clues of COPD from things like CAT scans? You know, many patients get CAT scans, You do a lung cancer screening, CAT scan because you’re a smoker, you get in a car accident and they get a CAT scan and the emergency room and maybe they report emphysema on that CAT scan. So we do regard emphysema as a risk factor for that umbrella term of COPD. And we want those patients to undergo spirometry testing. So once somebody’s been officially diagnosed, the good news is we do have treatments. We have very effective inhalers. Most of our therapies start with breathing medicines. They can be used once a day, twice a day. They help open up the airways to relieve the breathlessness. They help reduce course that mucus production so there’s not as much cough. And then that can lead to less shortness of breath and better quality of life and activity.  

 

00:17:14:00-00:22:12:00

FALK: So give me some examples of what kinds of medicines these are like names. What are they? 

 

DRUMMOND Yeah, so there’s a whole host there’s about 21 different approved inhalers for COPD, which is what makes my job fun. The common ones we think about are things like Trilogy or Advair or Breo or Meriva.I won’t bore you with the whole . But we can keep on going. 

FALK: And all of those do what? 

 

DRUMMOND: So most of the inhalers we use these days have two or three different medicines in one inhaler for convenience. So the general approach is that that all of these inhalers open up the airways, they relax the muscles that kind of constrict in the in the in the breathing tubes.They also lead to reduced inflammation. And then the third category helps reduce mucus production, that kind of overproduction of sputum. 

 

FALK: So there’s some kind of steroid in a lot of them.That’s what decreases the inflammation. Is there any risk to those patients for to be immunosuppressed because of using these inhaled drugs?  

 

DRUMMOND: Yeah, you’re exactly right that the steroid part of the inhaler seems to have the most side effect.So it can cause local side effects in the mouth. Patients can get thrush, which is sort of a fungal infection in the back of the throat. We know that inhaled steroids can also increase the risk of pneumonia. And that’s obviously something we want to avoid in somebody who has COPD. So we really think critically about when to use the inhaled steroid part of that regimen because we have these other medicines that are very effective at opening up the airways and reducing that mucus. 

 

FALK:So using an inhaler sounds easy, but actually it’s an art form. They come in different ways. You have to exhale than you inhale. And sometimes they’re these things that are put on the end of the inhaler. They’re spacers. What’s the best advice you can give to a patient who’s been prescribed one of these and now goes home and opens it up and gets ready to use one? What do you tell them? 

 

DRUMMOND: Yeah, so you’re exactly right. There’s probably five or six different models of inhalers, if you will. And each one has its own sort of strengths and weaknesses and challenges and in particular ways to use it. So the first thing we recommend is that if you’re seeing your your health care provider and they’re prescribing the medicine, ask if they have somebody in the clinic who can teach them how to use it. We have sort of demonstration inhalers all throughout our clinics. So that’s one option. The second option is you can go to the Internet. So if you go to the UNC COPD page at the very bottom, we have an entire link that’s just for how to use inhalers correctly. These are widely the videos are widely available on the Internet, so that’s important. You can also ask your pharmacist when they give you the inhaler, you can ask them, Hey, can you show me how to use it? Because if you’re not using it correctly, it effectively will do nothing for you.  

 

FALK: So if you breathe out and breathe all the way in and then try to breathe in more, boy, that’s not going to allow very much into your lungs. 

 

DRUMMOND:Even we’ve even shown in studies that we’ve published that standing up gets better effort and better force for these inhalers than sitting or lying down. So we tell patients, get out of bed, do it by the sink, don’t do it in your chair. So, you know, these sort of all these little tricks are important with getting this medicine.It’s much more complicated than taking a pill. 

 

 FALK:Why do I want to stand by my sink?  

 

DRUMMOND:Well, we want you to stand up. I don’t really care where you stand, but stand up rather than standing anywhere and sitting down.  

 

FALK: Okay, Sounds good. Okay, so there are lots and lots of people, as you point out, who have COPD, who should really see a lung doctor open monologist and who is best cared for by somebody close primary care doc of some kind or another. 

 

DRUMMOND:Yeah, I think there’s a pretty straightforward answer from my perspective. If you’ve had spirometry testing and it shows you have COPD and you’re put on an inhaler and you feel better and you’re not having to get antibiotics or prednisone, that’s controlled COPD. But what we see first off is we see people being told they have COPD without ever getting a breathing test.So if your primary care doctor isn’t able to help arrange that breathing test, then you probably should see a pulmonologist to confirm the diagnosis because not everything that is shortness of breath is related to COPD. Even in a smoker. Certainly if you’ve had a hospitalization for COPD, we think you need to see a lung doctor that’s a life-threatening event. We actually know that one out of four people who are hospitalized for COPD and require a lot of extra support with oxygen and a mask, almost one out of four of them will be dead in the next year without treatment.  

0:22:13:00- 00:23:32:00

FALK:That’s terrible. So the spirometry, the lung function test, breathing into a machine that tells you how well you’re breathing is really an essential step in this disease diagnosis process. 

DRUMMOND: It is akin to having somebody take your blood pressure to tell you you have high blood pressure. You have to have spirometry testing to be able to tell if somebody has COPD.  

FALK; However, most primary care docs do not have access to that technology. Does that mean at the start you’re asking all sorts of people to come see a lung doctor just for the initial diagnosis? 

DRUMMOND: So people can actually get the spirometry done at one of the pulmonary function testing labs.And then their primary care provider can often interpret that because we offer an interpretation of that test.  

FALK:So it’s really important if the doc is saying the primary care doctor say, hey, listen, I think he may have emphysema. I’m worried about chronic obstructive pulmonary disease rather than and I’m going to put you on inhaler. The first thing a patient should say is, hey, wait a minute, now, I think I need to get a lung function test, a pulmonary function test, so I can confirm the diagnosis. 

DRUMMOND:You’re speaking like a true pulmonologist.  

00:23:33:00- 00:25:44:00

FALK: I can’t wait. Okay, good. All right, so other than taking drugs or inhalers, stopping smoking, stopping inhaling, avoiding the toxins of the world, what else do you tell patients to do?  

DRUMMOND:Yeah. So we have a couple of key things we think about. First off, staying active. We know that staying active health helps improve your endurance of your heart, your lungs, and that can be any form of exercise you’re able to do. Now, the reality is that patients who have COPD may not be able to exercise. There’s a specialized pulmonary program called Pulmonary rehabilitation, or I call it physical therapy for the lungs. So this is a structured program. It’s typically monitored by a respiratory therapist, a pulmonologist, three days a week, an hour a day. It’s like going to a gym, but having a doctor look over your shoulder and they make sure you’re doing the right types of exercises in pulmonary rehabilitation has been shown to improve quality of life, functional capacity, like things that matter to patients. But sadly, only 3% of COPD patients who are eligible for pulmonary rehabilitation actually attend. Now, some of this is because, remember, you’re not feeling well. So now I’m telling you, go get in a car, drive 30 miles, go work out for an hour with somebody looking over your shoulder three days a week. And it may not be feasible, but we’re seeing a much larger increase in pulmonary rehabilitation now that we have virtual options. One of the few benefits of COVID was we had to learn how to get to someone’s home. So there are basically Zoom classes that you exercise at home and you can have a physical therapist or a respiratory therapist working with you.So exercise is important. The other thing that’s important because you’re a smoker, presumptively your risk of lung cancer is higher than the normal population. So if you’ve smoked a certain amount or a certain duration, we know that screening for lung cancer with a low dose CAT scan can help detect things before it’s too late to treat. So we think about exercise, we think about lung cancer screening in addition to the things you mentioned, such as smoking cessation. 

00:25:45:00-00:28:03:20

FALK: So looking forward to the future, what’s the fun research opportunities that you think are going to change the trajectory of this disease? Where’s the hope?  

 

DRUMMOND: Yeah, I think that really what we’re trying to understand is how can we first off, prevent progression of disease, especially those exacerbations, because exacerbations matter, they hurt the lungs. This is a lung stroke, if you will. 

And so that’s what we need to think about it. So our group is really interested in understanding how does the immune system of the nose protect the lungs from exacerbation? So if you think about it, everything that gets into the lungs comes through either the nose or the mouth. And the nose actually has its own immune system and its own bacteria that live there, much like the bacteria on our skin or in our gut that protects us. So we think that the immune system in the bacterial what we call microbiome of the nose is actually different in people with uncontrolled COPD and we long term hope to figure out how to change that immune system with nasal treatments, whether it’s nasal sprays or nasal probiotics to help try to improve the function of the immune system of the nose, to help the lungs, because it’s all one tract from the nose to the to the one  

 

FALK: might be a little harder to get patients to snort some bacteria out versus taking a pill with bacteria. But that makes a lot of sense. If you could alter the microbiome of the nose, you potentially could change the trajectory of the disease, is what you’re saying. 

 

DRUMMOND: Absolutely. And, you know, there are things we put in the nose now that we don’t know how they change the immune system or the microbiome, like think about our nasal corticosteroids, our nasal sprays. We don’t know if those are good or bad.  

 

FALK: Yeah, thank you, Dr. Drummond, for sharing your expertise on COPD with us. It has been most enlightening.  

 

DRUMMOND: Thanks again. It’s been my pleasure.  

 

FALK: Remember, you are not alone on your health journey. Stay informed, stay proactive and together as a community, we can make a positive difference in managing your health and well-being. Thanks so much for joining us. Until next time, take care.