This episode features Dr. Shannon Carson, Professor of Medicine and Chief of the Division of Pulmonary and Critical Care Medicine in an interview with Dr. Ron Falk about the field of lung disease and critical care.
“The family members are partners in the patient’s care and in helping to support the patient, but they also help us understand what the patient’s wishes might be for the goals of care. All of these advanced therapeutics are not appropriate for all patients. Helping us understand what patients might want in these situations is a very important role of the family.”
– Dr. Shannon Carson
Dr. Falk: Hello, this is Ron Falk for the Department of Medicine at the University of North Carolina. Welcome to the Chair’s Corner.Today we welcome Dr. Shannon Carson, who is a Professor of Medicine and Chief of the Division of Pulmonary Diseases and Critical Care. Welcome, Dr. Carson.
Dr. Carson: Thank you.
Falk: There are a number of things we could talk about with respect to pulmonary medicine at UNC. You’ve been here for some time-you came here in 1999. What’s happened to the field of lung disease in general during this interval of time?
Carson: What’s most notable is the sudden advance of therapeutics for lung diseases which really were not available before 1999. We joke that when we were fellows all we had at our disposal were steroids and beta-agonists for bronchodilators in terms of drugs for lung diseases.
Since then, we’ve had a number of new therapeutic options for pulmonary and arterial hypertension. We’ve had some recent developments and new therapeutic options for interstitial lung diseases, a class of disease which has frustrated us as pulmonologists and certainly frustrated patients for a number of years. Now we’ve got something besides oxygen to offer those patients.
Cystic fibrosis has had some remarkable developments for therapeutics that are targeting the underlying genetic problems in CF, such that we actually now have a cure for some patients with cystic fibrosis. In a genetic disease, that’s remarkable.
Even in asthma we will soon move on from inhaled steroids to other therapeutics that can target some of the underlying inflammatory issues in asthma and improve patient outcomes, particularly for more severe and persistent asthma.
The pulmonary medicine field has advanced and therefore gotten more complicated. Some of these therapeutics are complicated to deliver, they’re expensive, and you have to choose the right patient for the right therapeutic. In response to that, we have developed a number of subspecialty clinics within Pulmonary so that we can provide the best targeted care for patients with complex lung diseases.
You’re going to hear me flipping back and forth between pulmonary diseases and critical care. That’s the nature of our field. In critical care, it’s been the opposite. The advances in our field have not been so much related to pharmaceutical interventions but related to either mechanical interventions like the appropriate tidal volume for patients with acute lung injury or processes of care–how we organize the care of critically ill patients, and do that in such a way that optimizes their outcomes. So organization of care, implementation of good practices, and growth. Our ICU has both grown in terms of number of patients we can accommodate, but we also have been working feverishly to stay ahead of advances in care so we can deliver and organize the care of our critically ill patients in the best possible ways.
Falk: So if you take that amalgamation of really remarkable progress and incredible hope for certain types of patients with lung disease, where does UNC really lead in those areas? Where are their areas of real expertise? Certainly cystic fibrosis is what UNC has long been known for, but in fact, there is depth and breadth in literally every one of the environments that you have just described.
Carson: Cystic fibrosis is a field where we have been leaders for many years. Rick Boucher and the Cystic Fibrosis Center, (also led by Jim Yankansas and Mike Knowles) has been very instrumental in defining the biology of cystic fibrosis so that some of the new therapeutics can be developed effectively, and also in organizing care to be developed in very high quality ways through our Cystic Fibrosis Clinical Center.
That set the tone for how to develop biology and also how to develop clinical care, and we’ve been expanding our breadth of service delivery and research into other areas. We’re using that as a model for translation of research findings to patient care. For example, COPD is an important airway disease that has a chronic bronchitis component and an emphysema component. The chronic bronchitis component is a mucus related problem, like cystic fibrosis. So shifting the focus of airway biology from cystic fibrosis to chronic bronchitis allows us to affect a much larger group of patients in the United States and in the world. Taking a biological research tool refined in cystic fibrosis, and then broadening it to a much larger disease area is a way that we’re going to have a big impact on pulmonary diseases in the future.
Falk: You have led the charge with critical care expertise and investigation. That group is enlarging as well, and you have described some of the critical care changes that have occurred, primarily with ventilator support and processes of care. Where do you think that field is going?
Carson: At UNC we want to focus on two areas. One area we want to continue to focus on is processes. For example, at UNC we conducted a clinical trial that suggested that one type of sedation regimen is more effective than another for helping patients be liberated from a mechanical ventilator.
Being able to protocolize such findings such that the average clinician in an intensive care unit knows that information, the nurses know that information, the pharmacist knows that information, and they are all working together as an interprofessional team to actually make sure that that ideal drug is delivered in an ideal way (not too much, not too little; the patient’s comfortable, not over sedated), and then working with the respiratory therapist and nurses together to make sure sedatives are limited so that the patient’s awake, and then can breathe more effectively and then be liberated from the ventilator.
It’s a complex process. It’s an interprofessional team that rounds each day on each patient, and communication within that team to deliver care effectively is a science. Working to make sure that best care is being provided by the right professionals in an effective and organized way is how we bundle interventions together to make sure that patients have the best chance of getting out of the ICU sooner and better chances of survival.
Falk: The concept of being liberated from the ventilator is really an incredibly interesting descriptor. And that’s what it is-you’re being liberated from having a tube in your throat and from being mechanically ventilated. That really has become a science and one that is unbelievably important not only for the patient but also for their family.
Carson: Absolutely. So creating these processes, delivering the care in the best way and then sharing them with other centers and collaboratives is work that we’re doing. But as excited as I am about improving processes of care, I am also frustrated that we really haven’t had novel therapeutics to test in Phase 3 clinical trials involving patients in large numbers.
So I’ve been committed as division chief to build translational research in acute lung injury so that we can better understand the biology of lung injury related to pneumonia or sepsis or other inflammatory diseases in the body. We have been developing translational research with the help and leadership of Claire Doerschuk, who’s a renowned investigator in our division in acute inflammatory diseases, like pneumonia and inflammatory cell function. We have recruited other young investigators like Jason Mock, Rob Hagan, and Billy Fisher, to learn more about how the lung is injured and how injured lung recovers. We’re still recruiting in that area, so that we can eventually help develop and test novel therapeutic molecules.
Falk: One of the things that you and your group have really pioneered is the interaction and communication with family members who are watching their loved one on a machine, being intubated, and to a certain extent being sedated and paralyzed. That really terrifying visual for a family is one that really requires tremendous sensitivity and effective communication. Tell us what you’re doing in that area.
Carson: Families struggle in these situations. We as intensivists are very technically minded– you know, machines and pressors and other advanced therapeutics. But we are also physicians communicating, not always with our patient, who might be heavily sedated, but frequently and constantly with their family members. Their family members are partners in the patient’s care and in helping to support the patient, but they also help us understand what the patient’s wishes might be for the goals of care. All of these advanced therapeutics are not appropriate for all patients. Helping us understand what patients might want in these situations is very important and a very important role of the family.
We have just completed one large clinical trial of a palliative care intervention to see if we can better communicate patient outcomes and better support families in this situation. Laura Hanson and the palliative care group at UNC were helpful in structuring that intervention along with our partner centers at Mt Sinai and Duke. With the help of the SHEPS Center for Health Services Research here at UNC and Dr. Hanson, my colleague Chris Cox at Duke has developed a Decision Aid. This is an electronic aid that factors in prognostic information and walks families through the patient’s condition, their prognosis, assesses the patient’s values, and determines what the patient’s goals of care might be. We have validated that decision aid, and now we’re conducting another clinical trial using the Decision Aid, comparing it to usual care and communication to see if we can improve family outcomes such as anxiety and depression and Post Traumatic Stress Disorders at three months and also improve patient outcomes.
Falk: It would be really helpful of course if those sorts of conversations between patient and family occurred when the patient was well so that there would be a much clearer understanding of what the patient’s own wishes are, but those conversations are always difficult to have because no one ever thinks anything bad is going to happen.
Carson: In part, and it’s hard for a clinician in an outpatient clinic to help patients and their families understand what true critical illness actually can be. Unless you’ve been there, it’s hard for the lay person to understand, so it’s not uncommon at all for patients to arrive at the intensive care unit in the heat of the moment and not have had a chance to consider such things. So we as the intensivists, with the help of our palliative care colleagues and the patient’s primary physicians, have to come up with the best ways to help families understand and then anticipate the patient’s and family member’s needs.
Falk: From a trainee’s perspective, the breadth and depth of opportunity that you’ve just described is pretty remarkable. One can imagine that a fellow would have time in an intensive care unit—different kinds of intensive care units, actually, and then inpatient experiences in pulmonary medicine in general, in a variety of clinics. What would you tell an incoming fellow other than that opportunity exists?
Carson: I would encourage them to come into fellowship like ours with an open mind. Sometimes they apply to Pulmonary for critical care training, but then discover that COPD or cystic fibrosis is a fascinating disease and that the outpatient care model there might be more interesting to them. So come with a very open mind. Experience all of the clinical settings that we have to offer here, and get to know the investigators in this very wide range of airway diseases, alveolar diseases, pulmonary and vascular diseases and then acute lung injury. Then decide what area of interest is going to be most fascinating to them both on the level of patient care but also basic science research or clinical or translational research.
We also have great educators and are able to train fellows in medical education in a very effective and important way. We graduate a lot of educators also.
Falk: You have wonderful, wonderful pulmonary educators. They are remarkable people.
Falk: UNC has long been known as you point out for cystic fibrosis research, both in the adult world and the pediatric world. There has been very organized relationship with the Cystic Fibrosis Foundation. Can you tell us about that?
Carson: The adult and pediatric pulmonary divisions have functioned very well over the years. That’s important, as CF is a disease that begins at birth. As a result of the great therapeutic interventions and quality of care improvements that have occurred over time, patients are living well into adulthood. So the interaction between pediatrics and adult pulmonary medicine is very important to help those patients transition. A key aspect of support throughout all of this has been the Cystic Fibrosis Foundation.
Falk: It was in part due to the CF Foundation that a particular group of patients with cystic fibrosis now have a really remarkable drug therapy that couldn’t have been conceived of in the past.
Carson: Absolutely. So branching out beyond the halls of academia– involving patients, involving concerned family members, is an important way to lead to new therapeutics and to help us as clinicians understand what’s important to patients. That’s been a fantastic model, and CF Foundation has been a great leader.
Falk: In malls and in other free-standing radiology practices there is now this drive to do computerized tomography X-rays of people’s lungs and abdomen to screen for cancers. The question comes, is that screening for lung cancer with an X-ray service next door to Rite-Aid, is that really a good idea? What’s the role of computerized tomography in screening for lung cancer?
Carson: It has been shown, through a large clinical trial funded by the National Institutes of Health, that screening for lung cancer in older patients who have a significant smoking history, is effective in reducing deaths from lung cancer. It’s important that only the right patients be screened. Patients have to be of a certain age.
Dr. Patricia Rivera has created, with interactions between radiology and general internal medicine, a lung cancer screening clinic that will counsel patients appropriately, counsel them about smoking cessation, get the right kind of low dose computerized tomography scan, and then have appropriate pulmonologists, thoracic surgeons, interventional pulmonologists, and radiologists review the scans and determine whether a discovered lesion is a high-risk lesion and needs further review for intervention or is a low-risk lesion and nothing to worry about. The risk of false positives with lung cancer screening is high.
Falk: It’s really an important message that only those patients who are at risk need a low dose, not a regular CT, but a low dose CT of their lung, and then their CT not be read by just anybody, but by a group of people who will help exclude unnecessary interventions, which almost invariably have the potential of causing the patient discomfort and potential harm.
Carson: Patricia Rivera, in our division, is a leader in the American Thoracic Society, working with groups to help translate the findings from this clinical trial to provide the most appropriate delivery of care, and the UNC Lung Cancer Clinic is going to be a model for that.
Falk: As you look to the future of pulmonary disease in general, and UNC pulmonary disease, where are you headed?
Carson: The subspecialty clinic model has, I think, been a good one. Peadar Noone and Leigh-Anne Daniels are creating a bronchiectasis clinic. This is focusing on non-cystic fibrosis bronchiectasis, which is an increasingly recognized problem, particularly for older adults. Bronchiectasis due to conditions like atypical mycobacterial infections. New subspecialty clinics will eventually a dedicated asthma clinic as new asthma therapeutics come along. Again, they’re complicated and expensive, like some of the CF and interstitial lung disease drugs so we need to organize delivery of such care.
On the critical care side, new initiatives are going to involve training across the spectrum of critical illness, not just medical critical care, but more focused training in surgical critical care, neurocritical care, and cardiothroracic. We’re doing that by starting a new fellowship that will run in parallel to pulmonary and critical care training that will be critical care-only training. These fellows will spend a larger proportion of their time in the surgical ICU, the Neuro-ICU and the Cardiothoracic ICU so that they can be more capable of managing a larger range of critically ill patients for large hospitals in the US.
Falk: There’s a huge need for that kind of individual. Dr. Carson, thank you so much for spending time with us today.
Carson: You’re welcome.
Dr. Shannon Carson is Professor of Medicine and Division Chief for Pulmonary Diseases & Critical Care Medicine.
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