05/04/2019

Lung disease in smokers who don’t have COPD

A few years ago, I saw a lovely patient who had gained a surprising amount of weight between visits. Surprised, because usually she takes great care of herself, I said, “Wow. You’ve gained 10 pounds since I saw you last. What’s going on?” She looked at me and told me that her finances were in dire straits. She explained that she gained weight because her budget did not allow her to buy healthy food. In fact, she told me that the bagged cookies she purchased at a local dollar store were the least costly way to keep her from feeling hungry.

My heart was heavy that day, as it always is when I hear that my patients are having trouble getting their basic needs met. I am fortunate to work in a practice that has social workers, so I was able to get some urgent help for her food insecurity. And yet I knew that it was going to be hard work to take off those 10 extra pounds, and that those pounds were going to make her knees sore and mess with her blood sugars and blood pressure.

I wish this were an uncommon event, but it’s not. According to a NEJM Catalyst blog post, social, environmental, and behavioral factors account for up to 60% of people’s health needs. The things we focus on so often in medicine account for just 10%.
One organization’s story: Stepping forward and making a change

Kaiser Permanente, a health care organization based in California, recognized that nations that focus on social needs — housing, food, transportation — often spend less on health care. So they decided to act on behalf of their patients and tackled the idea of meeting a patient’s social needs to help provide better health care. They didn’t build houses or grocery stores, but they did develop a system that engaged with existing community resources to help reach their neediest patients. By partnering with an exciting social enterprise organization called Health Leads, Kaiser developed a call center to help reach out to people who use a lot of health care resources. They found three out of every four patients they reached had at least one unmet social need. The most common were food insecurity, transportation problems, and difficulty paying utility bills. Kaiser’s program then connected these people with established community organizations who could help.
Putting “health” in a broader perspective

Perhaps few of you taking the time to read this blog have the kind of dire unmet social needs I mention above. But, I bet that every one of you has had a social need or a life challenge that has impacted your ability to take care of yourself. I see it all the time in parents of young children, caregivers of seniors — and, really, almost everyone I meet.

Our ability to be healthy depends on our ability to meet our own basic social, emotional, and physical needs. Articles like this one help us think about health a little bit more broadly. As the World Health Organization says, health is not just the absence of disease, but the presence of physical, mental, and social well-being. Doctors, nurses, and all health care providers need to engage with patients around their unmet needs — big and small — to help engage their patients to enhance their health and feel able to make important physical and behavioral changes. On television, heart attacks are portrayed in rather dramatic fashion — typically, an older man clutching his chest with agonizing pain. This mental image is embedded in our culture, but it actually represents only a small fraction of heart attacks. As it turns out, a variety of different symptoms may develop with a heart attack. In addition to chest pain, some of the other symptoms that can occur with a heart attack include chest pressure, chest heaviness, arm pain, neck pain, jaw pain, shortness of breath, sweating, extreme fatigue, dizziness, and nausea. That is, in part, why it is not always so easy to diagnose a heart attack. And of course, women are also at risk for heart attacks. Whether women are more likely than men to have these symptoms other than chest pain remains a controversial point.

Now, research from the Atherosclerosis Risk in Communities (ARIC) Study has found that almost half (45%) of heart attacks appear to be clinically silent — that is, not associated with any symptoms at all, at least that the patient can recall. These sorts of silent heart attacks were picked up by use of a routine electrocardiogram (ECG). And these silent heart attacks weren’t just a meaningless abnormality picked up on a test. The silent heart attacks were associated with a similar risk of subsequent death as clinically detected heart attacks.

Older studies had more or less come up with similar findings. The present study extended these observations into a much more diverse population. The excess risk associated with silent heart attacks was found to be present in both men and women. Of note, rates of both types of heart attack were higher in men than in women. There was also an excess risk of future death associated with both clinical heart attacks and silent heart attacks in both white and African American patients. Other races were not examined in this study, and more work needs to be done in this regard, though likely the results would be similar.

What does this mean for people who are worried about heart attacks? Guidelines for physicians from professional medical societies in general no longer recommend routine ECGs in healthy people, though this used to be a common practice. Certainly, if you should have an ECG for some purpose, such as before certain types of surgery, and a silent heart attack is detected, that needs to be taken seriously — really, as though you had had a clinically apparent heart attack. Any medications and lifestyle changes prescribed as a result of detecting a silent heart attack should also be relatively similar.

Future studies will have to determine if certain populations might benefit from routine screening for silent heart attacks. Beyond any studies done within the world of conventional medical research, the increasing availability of various apps will allow people to get ECGs on themselves, so detection of silent heart attacks will probably increase. The risk of this sort of indiscriminate screening is that one test abnormality might lead to another set of more expensive and risky tests. So, hopefully we can sort our relatively quickly (i.e., in the next few years) who might be best served with routine screening with ECGs, or perhaps even more sophisticated tests to detect silent heart attacks or people at risk for them. Smoking cigarettes damages your health in a number of ways. The top three smoking-related causes of death are cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease (COPD). In addition to these “top three,” smoking is also linked to a number of other cancers, getting more colds and infections, diabetes, osteoporosis and hip fractures, problems in pregnancy, difficulty with erections, stomach ulcers, gum disease, and the list goes on.
What exactly is COPD?

Emphysema occurs when the tiny air sacs of the lungs become damaged. Chronic bronchitis occurs when the lining of the airways becomes damaged. Many people have a combination of both, so the umbrella term COPD is more accurate. Having COPD makes it harder to get air in and out. Breathing tests, known as pulmonary function tests or “spirometry,” help determine how the lungs are working and are used to make a diagnosis of COPD.

So, if you smoke, or you used to smoke, but you don’t have COPD, does that mean your lungs haven’t been affected by smoking? Not necessarily.
Smoking may damage the lungs — even if you don’t have COPD

The May 12, 2016 issue of The New England Journal of Medicine included a study of smokers or past smokers (with at least 20 pack-years) who had some respiratory symptoms but didn’t quite meet the criteria for COPD. The well-recognized COPD Assessment Test (CAT) was used to measure the presence and severity of these symptoms, such as cough, mucus, shortness of breath, and activity and energy limitations. This group with symptoms (using a cutoff CAT score ≥10) was compared with non-smokers, as well as with smokers and past smokers with no respiratory symptoms.

The results showed that, when compared to those without symptoms, the group of smokers and past-smokers with symptoms had the following:

    more episodes of respiratory illness that required antibiotics, steroids, or doctor’s office and emergency room visits
    a shorter average walking distance on a 6-minute walking test
    more bronchial airway disease (bronchiolitis) as seen on lung CT scans.

This group was also often prescribed medications typically used for COPD, such as inhalers, even though they did not meet the criteria for COPD.

Though it is hard to draw firm conclusions from this study because the participants were volunteers and not randomly selected, it is notable that in this study, a full 50% of smokers and past smokers had some degree of respiratory symptoms, even though they did not have COPD.
What does this all mean?

Many smokers may not reach the cutoff criteria on spirometry for the diagnosis of COPD, but still have symptoms related to smoking — maybe a cough, mucus production, or shortness of breath with minimal exercise and activity. This study affirms that these people can experience serious health consequences, even without COPD. This finding also brings into question how we should classify chronic respiratory disease. So far, we haven’t determined a way of classifying those who have symptoms but don’t quite meet the usual criteria for COPD, and we also don’t have much data or guidance on how best to treat them.

In the meantime, quitting smoking remains the best way to lower your chances of getting COPD — and the best way to lessen any respiratory symptoms you’re having. Most smokers who stop will feel better, with less cough and mucus, within 12 months. They will also lower their risk of getting (and dying from) smoking-related illnesses. Though the benefits of stopping smoking are greater at younger ages, there is always a benefit from stopping, even at the age of 80! If you are a smoker and you want to stop, talk to your doctor. Quitting is a challenge, but there are a number of tools and treatments available to help you through it.

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