Just Breathe: Advancing New Treatments for Lung Disease

With tens of millions of Americans suffering from cancer and other diseases to our airways, it’s essential to be aware of the causes and methods of prevention through common-sense lifestyle choices.

SSome things in life are as easy as breathing. But for those with pulmonary disease, this simple action can be a daily struggle. Lung disease is experienced by tens of millions of Americans, making it one of the most common medical conditions in the world.
The lungs are part of a complex apparatus, expanding and relaxing thousands of times each day to deliver oxygen and expel carbon dioxide. Lung disease can result from problems in any part of this system.

Lung Cancer: Public Enemy No. 1

This year, nearly 221,000 new lung cancer cases will be diagnosed, according to the American Cancer Society. Although there are many causes behind this form of cancer, the most common culprit is tobacco use. Inhaling tobacco smoke and other toxins is known to cause small cell (SCLC) and non-small cell (NSCLC) lung cancers. However, adenocarcinoma, a type of NSCLC, is being diagnosed more frequently these days in non-smokers, women and adults under age 60.
Deaths from lung cancer remain substantial; more than 158,000 Americans will die from it this year. Cancer remains the second-most common cause of death in America, but among patients aged 20 to 79, it’s the most common killer.
Part of the reason for these grim statistics is that lung cancer seldom is diagnosed in its early stages. By the time it’s found, patients are often in late Stage 3 or Stage 4.
Recently, a bright spot has emerged that may help doctors to discover lung cancer earlier: the use of low-dose CT screening. Dr. Arvind J. Ponnambalam, a pulmonary specialist at SwedishAmerican Health System, a division of UW Health in Rockford, says this innovative technology is promising.
“In the past, we rarely found lung cancer until it was in later stages,” Ponnambalam explains. “Often it was diagnosed accidentally when patients were X-rayed or scanned for pneumonia or other suspected lung conditions. Lung cancer has few early symptoms. Coughing, unexplained weight loss and especially blood in the sputum are signs that lung cancer may be present, but they can also be indicative of other lung diseases. With lung cancer, patients rarely feel any pain. About two years ago, we began using low-dose CT scans to detect possible lung cancers at an earlier stage.”
Patients who meet specific criteria may be eligible for screening, says Ponnambalam.
“We now screen at-risk patients between the ages of 55 and 74 who have a family history of cancer and who have a 30-pack history of smoking,” he explains. “They can be current smokers or those who have smoked in the past but have quit within the past 15 years. Sadly, even those who quit smoking as long as 25 years ago still have an increased risk of developing lung cancer as they age. The risk is always present.”
A landmark trial produced screening guidelines that have been accepted for coverage by Medicare and most commercial insurance agencies.
“The good news is that, with low-dose CT screening, we avoid large-scale exposure to radiation,” Ponnambalam says. “This procedure uses four times less radiation than the standard CT. With it, we can see nodules or spots on the lungs and monitor them to see if they grow. Larger tumors are biopsied.”
Generally, lung cancers diagnosed in late stages are not operable and in some cases have spread throughout the body. If caught at earlier stages, they may be operable and, in many cases, curable.
At SwedishAmerican Hospital, lung cancer patients are treated with a multidisciplinary approach. Pulmonologists, oncologists, radiation oncologists, interventional radiologists, thoracic surgeons and pathologists work together to create a cohesive diagnostic and treatment plan.
The treatments themselves have changed significantly in recent years, most notably by targeting a patient’s genetics.
“In the past five years, we’ve discovered medications that target particular genes, what we term ‘oncogenes,’” Ponnambalam explains. “Patients with the EGFR and ALK genes have been shown to respond well to certain types of medications treating certain non-small-cell lung cancers. We test for the gene in patients who’ve been diagnosed with lung cancer to see if they’re eligible for this treatment.”
Asked why lung cancer occurs, Ponnambalam emphasizes that smoking is the No. 1 reason.
“Family history also contributes, as does exposure to cancer-causing irritants such as asbestos and other occupational pollutants,” Ponnambalam says. “Radon is the suspected cause of about 10 percent of lung cancers.” Radon is a colorless, odorless radioactive gas that naturally occurs from the breakdown of uranium in rock, soil and water.

Blockages from COPD

Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases that block airflow and make breathing difficult. Emphysema and chronic bronchitis are the two most common conditions that make up COPD, according to The Mayo Clinic. Chronic bronchitis is an inflammation of the lining of the bronchial tubes, which carry air to and from the lungs. Emphysema occurs when the air sacs (alveoli) at the end of the smallest air passages (bronchioles) in the lungs are gradually destroyed. Damage to the lungs from COPD can’t be reversed, but treatment can help to control symptoms and minimize further damage.
The long-term effects of COPD are frequently visible even before the patient is diagnosed, says Natalie Winebaugh, manager of Respiratory Care Services, Pulmonary Diagnostics and the Sleep Center at OSF Saint Anthony Medical Center, in Rockford.
“Many patients are visibly short of breath and may have distinctive barrel chests caused by their lungs constantly being over-inflated,” Winebaugh says. “The lungs in COPD patients don’t have the elasticity of healthy ones, which often makes it necessary for the patient to be on oxygen. You can look at the patients and sometimes predict their diagnoses.”
The primary goal of physicians is to educate patients on how to manage their COPD symptoms and improve their overall condition. But Winebaugh explains that some patients become very ill after exposure to airborne irritants such as cigarette smoke, failure to take prescription medications as directed, and waiting too long to seek medical help. When these flare-ups occur, some COPD patients require hospitalization to be stabilized.
“When patients are feeling well, they sometimes decide they don’t have to take their medications,” Winebaugh says. “This can lead to serious illnesses. COPD patients can also lack resilience and energy due to lack of sufficient oxygen circulating through their bodies. This is especially true for end-stage COPD patients.”
At OSF Saint Anthony, COPD patients are given oxygen therapy and may even need to be ventilated.
“We really hope that doesn’t happen,” says Winebaugh. “Some patients have difficulty coming off the life support. There are other options we also use, such as BI-PAP, which assists patients by giving them pressure-supported breaths. This, along with appropriate medications, helps the patient recover to the point where he or she can go home. The length of stay depends directly on how long the patient has been out of control, the patient’s ability to heal and how serious the episode is.”
Poor diet and comorbidity, such as diabetes or congestive heart failure, can complicate COPD treatment. So, too, does an unhealthy lifestyle. But some patients develop COPD as the result of a genetic deficiency.
“COPD is an umbrella term for several lung diseases,” Winebaugh says. “We used to include asthma in that group, but that perception has changed. What hasn’t changed is that all illnesses which can affect the lungs interface and influence each other.”
While COPD is not curable, a patient’s prospects for living well have improved. “The good news is that medications have vastly improved,” Winebaugh says. “But one of our strongest tools against COPD is education and rehabilitation. OSF Saint Anthony has an accredited Pulmonary Rehabilitation program. It’s based on very high standards and has been established here for years. Now, the program is taking on even more importance because we better appreciate its value.”
Pulmonary rehab includes educating patients on their disease so that they can make better lifestyle decisions. Winebaugh says the program also teaches strategies for conserving one’s energy and exercises that can help patients to regain their strength and resilience.
“We teach them how to avoid sick people, those with influenza and other infectious diseases,” Winebaugh says. “We encourage patients to join the program so they can live better and longer at home.”
COPD patients are encouraged to discuss the possibility of pulmonary rehab with their pulmonologist or their primary care physician.

Common Childhood Conditions

While it might appear that lung diseases affect mostly middle-aged and elderly folks, this isn’t the case. Lung diseases impact people of all ages. Asthma is often diagnosed during childhood and cystic fibrosis is found in children younger than 2 years of age.
Surprisingly, asthma can be diagnosed at any age, says Dr. Sushrut P. Patel, FCCP, a pulmonary specialist at Beloit Health System.
“It’s not unusual for me to diagnose asthma in patients who are well into their 70s and 80s,” he says. “Typically, however, it is diagnosed in childhood. The current thinking is that asthma is a disease of chronic inflammation similar to rheumatoid arthritis. And likewise, it’s characterized by periods of exacerbation and progression that vary from person to person. The standard joke among experts is that ‘kids outgrow their pediatrician, but not their asthma.’”
Patel says there are a number of triggers that can vary from person to person. Nonspecific triggers include changes in temperature, humidity, exercise levels and exposure to inhaled irritants. In patients with environmental allergies, certain irritants can be a prominent trigger.
“Generally, asthma is treated on an outpatient basis,” Patel says. “Rarely is emergency treatment necessary. This typically occurs when rescue therapy is not effective, and when symptoms are severe and persistent. When emergency treatment is not effective, the patient is hospitalized mostly for observation and further therapy. Sometimes, patients are hospitalized because of coexisting problems such as pneumonia or dehydration. In general, any patient requiring oxygen or IV therapy after emergency treatment usually will be hospitalized.”
Patel adds that two categories of medication are prescribed for asthma: inhalers and, more rarely, pills to either control the disease or treat its symptoms. It’s crucial that patients understand the difference between rescue inhalers and controller medications, he points out.
“Unfortunately, there is no cure for asthma, but it can be a controllable disease, perfectly compatible with normal living,” Patel says. “The best symptom control is achieved with regular use of medications and avoidance of triggers along with disease monitoring through regular doctor visits. Most acute attacks can be avoided by adhering to an asthma action plan.”
In sharp contrast to asthma, cystic fibrosis (CF) is a rare, life-threatening genetic disease that affects the lungs and digestive systems of preschool-age children. About 70,000 cases are on record worldwide, 30,000 of them in the United States. A defective gene and its protein byproduct cause the body to produce unusually thick, sticky mucus that clogs the lungs, leading to potentially fatal infections. The sticky mucus also obstructs the pancreas, preventing its natural enzymes from helping the body to break down food and absorb important nutrients. These sick young patients also may develop diabetes.
As recently as the 1950s, few children with CF lived to attend elementary school. Now, some survive into their 40s and 50s, Patel says.
“Today, infants are routinely screened for CF risk within a few days of birth,” he adds.
Symptoms may not show up for awhile. They include salty-tasting skin, persistent cough, frequent lung infections, and poor growth along with very slow weight gain. Treatment for CF patients may start with oral medications that compensate for the loss of digestive enzymes produced by the pancreas. Medications are given with every meal, but they’re only part of a constant treatment regimen. The day begins with loosening sticky muck in the lungs, often with the use of aerosolized medications administered by nebulizers.
Then, there’s percussion therapy or Chest Physical Therapy (CPT), a technique that also helps to expel the mucus. Several times a day, parents or medical staff use their cupped hands to beat on the back and chest of the child, thus helping to loosen the accumulating mucus. The technique can also be applied with a special vest that shakes the child three or four times each day.
With CF, hospitalization is a fairly common event. In the hospital, the child is immediately given IV antibiotics to treat lung infections and inflammation. For children around the Beloit area, this usually means a trip to UW Hospital in Madison or Children’s Hospital of Wisconsin in Milwaukee. Although Beloit Hospital can and does treat emergency cases, it lacks the appropriately trained medical staff to treat hospitalized CF patients.
For children diagnosed with CF, tremendous advances are helping them to survive longer. Lung transplants are proving effective, says Patel, and a new medication is showing promise.
The mutated gene responsible for the development of CF controls the flow of salt and water in the body’s cells. According to the Cystic Fibrosis Foundation, a new drug actually targets the CFTR protein defect, allowing more chloride to move in and out of the cells, which potentially creates a better balance of salt and water in the lungs. It can only be used with specific candidates and isn’t available for all CF patients, but it provides hope that genetic engineering may offer a cure, or at least vastly improved management, of the disease. The new drug hasn’t been available long enough for researchers to know whether it can cure CF.

Looking Toward the Future

Some lung diseases are the result of genetic mutations, but the good news is that the majority of these conditions can be prevented with common-sense lifestyle choices. Smoking remains the primary cause of lung disease, a fact that must be recognized and respected. Not smoking, avoiding secondary smoke and other inhaled toxins, and maintaining a healthy lifestyle is still the most reliable strategy for evading these chronic, sometimes fatal diseases. As is the case with so many debilitating conditions, it’s in our hands to lower our odds of receiving a tragic diagnosis.