Did you know that commercial truck drivers with a neck width larger than 17 inches (for a man) or 15.5 inches (for a woman), may have to take a sleep apnea test before getting their commercial driver’s license?
Or, did you know that exposure to radon – an odorless, radioactive decay product that can be found in basements – can cause lung cancer?
Respiratory system diseases and disorders aren’t uncommon by any means, but you might be surprised at some of the ways these conditions are detected and treated these days.
Dr. Shawn Shianna, an otolaryngologist (ear-nose-throat specialist) at FHN, in Freeport, frequently diagnoses patients with sleep apnea. He says cases of obstructive sleep apnea seem to be on the rise, with roughly 15% of women and 15 to 30% of men having it.
Of this condition’s two forms, obstructive sleep apnea is the most common, and it occurs when a person’s throat collapses while they’re asleep. The other form, central sleep apnea, occurs when the brain seemingly forgets to breathe. It’s more rare and typically related to head injuries or strokes, says Shianna.
Some of the uptick in diagnoses can be attributed to a rise in obesity and other illnesses, but Sianna believes better education and better awareness have helped patients to better recognize potential cases. Often, it takes someone else’s observation to identify there’s a problem.
“If your bed partner notices that you seem to struggle and snort and gasp in your sleep, that’s often a good indicator,” Shianna says.
Fatigue, headaches and the propensity to fall asleep during inappropriate times could indicate a problem.
And remember that requirement of truck drivers? A large neck circumference and/or a high body mass index (BMI) have been correlated to sleep apnea as well.
The Epworth Sleepiness Scale, easily found online, can be a good first test if a person thinks he or she may have sleep apnea.
Medical professionals typically use a sleep test to make a diagnosis. They measure eye movement, track air flow in the mouth and nose, record an electrocardiogram (or EKG), and record muscle movements and the position a patient lies in bed, among other things.
If a patient stops breathing 5 to 15 times an hour, his or her sleep apnea is considered mild, Shianna says. Stopping 15 to 30 times is considered moderate; anything above 30 is severe.
“Some folks will only have it if they’re on their back,” Shianna says. “We’ll see that on a sleep test. They do well on their side, but when they’re on their back, their tongue slips back.”
The easiest way to combat this mildest form of sleep apnea is to take a nightshirt, create a pocket on the back and slip a tennis ball into the pocket, he says. This usually stops people from rolling over, and if they do manage to roll onto their back, the tennis ball will be too uncomfortable to remain in that position for long.
Oral appliances can help to treat mild to moderate cases.
“When you wear them at night, they pull your lower jaw forward a little bit and give you more room to breathe,” Shianna says.
Surgery is also an option, where trimming away part of the palate and removing tonsils, or moving the jawbone forward, can ease breathing.
One of the most recent innovations, approved by the FDA in 2014, is a hypoglossal nerve stimulator, commonly known as Inspire.
This device is implanted in the chest, much like a cardiac pacemaker, Shianna says. A wire running up to a nerve in the throat stimulates that nerve and keeps the tongue from slipping back.
The gold standard of sleep apnea treatment, however, is a Continuous Positive Airway Pressure, or CPAP, machine. This device uses a mask to inflate the throat enough that it doesn’t collapse during deep sleep.
Untreated sleep apnea can cause a multitude of health problems, including a higher risk of stroke, heart attack at an earlier age and even early onset dementia, Shianna says.
“It is frustrating not always being able to convince everyone they should address it,” he says. “If your spouse tells you he or she is concerned about what they hear when you’re asleep, please take it seriously.”
Prostate and breast cancer are the most common cancers in men and women, respectively, but lung cancer ranks second for both genders.
It’s also the most deadly cancer, in part because it’s often caught in advanced stages, rather than its early stages, when treatment could be more effective, says Dr. Gregory Richards, a radiation oncologist at Mercyhealth in Rockford.
The good news is that this deadly disease is on the decline.
“It’s sort of a downstream effect of the anti-smoking campaign the U.S. started in the 1980s and ’90s,” says Richards. “If you fast-forward, you’ll see the number of cases decline in men and then women.”
By far, smoking is the top risk factor, Richards says. Of the disease’s two main kinds – small-cell and non-small cell – just about everyone who develops small cell has a smoking history. That’s roughly 15% of all patients.
With non-small cell lung cancer, there are other risk factors involved.
Exposure to radon, which sometimes can be found in higher concentrations in basements, is one risk. That’s why many home inspections include a radon test.
Exposure to other chemicals, especially in workplaces where particulate matter is in the air and protective equipment is a necessary precaution, can be a risk factor, too.
In the past, patients often were admitted with the first symptoms they saw – a persistent cough or blood in a cough, or even a mass in the lower part of the neck – but by then, the cancer was already advanced, says Richards.
Today, patients between 50 and 80 years old may be eligible for a low-dose CT scan if they have a 20 pack-year history of smoking – meaning they smoked a pack of cigarettes a day for 20 years, or two packs a day for 10 years, and currently smoke or quit smoking within the past 15 years.
The three-dimensional scan helps detect spots, masses and lesions that need to be re-examined or potentially biopsied, Richards says.
“That is something that people aren’t too aware of, but certainly can be important, just because up until this low-dose screening, an old-school chest X-ray wasn’t very good at finding lung cancer,” he adds.
In addition to advancements in screening, technology is improving across the board, Richards says. Surgical techniques are becoming more modernized; drug therapies are becoming more tailored; and radiation therapy is becoming more precise.
“In the old days, non-small lung cancer patients were treated with surgery alone, or surgery and cytotoxic chemotherapy, or radiation and chemotherapy,” Richards says. “Nowadays, there are a lot of new medicines that are more specifically tailored to the individual’s cancer. Now, they’ll take a surgical specimen and do genetic testing on the tumor and look at gene profiling of the tumor, and there are many new medicines that will specifically act with the patient’s tumor or the genetic expression of the tumor.”
What’s more, it used to be that patients with early stage lung cancer who could not have a tumor removed underwent radiation therapy, or radiation with chemo, for six weeks, Richards says. Now, doctors can use stereotactic body radiation therapy (SBRT) to deliver high doses of radiation targeted at the tumor.
“Instead of treating them over the course of six weeks, we can treat them over the course of one to five treatments with a high efficacy rate,” says Richards. “For early detected lung cancers and those medically unfit for surgery, this has become a game changer in the past 10 years.”
COPD, Emphysema and Chronic Bronchitis
If Dr. Iftekhar U. Ahmad was going to give any advice to someone worried about developing chronic obstructive pulmonary disease (COPD), it would be only two words: quit smoking.
“It’s not a typical chronic disease that we see that increases in number as people get older,” says the medical director of oncology services at OSF HealthCare Saint Anthony Medical Center in Rockford. “It is very specific in terms of the causes – smoking – specifically in developed countries or western countries.”
What’s more, COPD is an irreversible disease.
“Even though we can control the symptoms and get people relief, and they’re able to function, the actual, ‘what’s happening to your body on the inside of the cells’ is not reversible,” he says. “It’s something people should hear. It’s not like my cholesterol is high and I can take a pill and it’s all better now.”
COPD isn’t usually hereditary, Ahmad notes. Only about 1% of those diagnosed with COPD can attribute it to a genetic disorder, and those are usually younger patients who do not smoke.
“If there wasn’t any smoking, we would see very, very little COPD,” Ahmad says. “It would be incredible how low the numbers would be.”
There’s no way to tell how much smoking is “too much” or how long a person can smoke before it’s too late, Ahmad adds.
“You just never know,” he says. “A lot of patients tell me, ‘I’m not a heavy smoker.’ That’s not a bad thing, but you don’t know for your body how much it’s going to take for you to have an issue breathing later on.”
So, what exactly is COPD? It’s an umbrella term for a group of lung conditions that cause difficulty breathing and decreased lung function over time, Ahmad says. More than 15 million Americans have some kind of COPD, and that includes emphysema, chronic bronchitis or both.
Emphysema is a permanent condition where long-lasting damage to the lungs decreases one’s ability to retain oxygen. Oxygen support is the main treatment.
Chronic bronchitis, meanwhile, is more of an attack, during which the lungs become inflamed and an inhaler or active medication is needed to get one’s breathing back to normal.
While still a form of COPD, chronic bronchitis can be well managed, says Ahmad.
“For chronic bronchitis, there are medications you can take, specifically inhalers,” he says. “Some inhalers relax the muscles in the airways; some inhalers release steroids that can help if you’re having an acute attack. And there are combination inhalers which involve medications to relax the muscles and attack the inflammation that’s going on.”
Typical symptoms of COPD and its related conditions include progressive shortness of breath, especially during physical activities; wheezing; chronic cough; and/or frequent respiratory infections. Often, several of these symptoms occur together.
A primary care doctor can check if these symptoms are caused by an infection, and a chest X-ray can rule out a mass in the lungs that would cause similar pulmonary issues.
Ahmad stresses again that smoking cessation is an absolute must for those with COPD.
“This is something that can continue to irritate your lungs as long as you’re smoking,” he says. “Some people think, ‘I have it now, so who cares.’ Once you have it, you can make it worse by smoking. You want to get rid of the irritant.”
For patients who have been diagnosed with chronic respiratory issues, pulmonary rehabilitation is one of the best ways to improve their quality of life, says Dr. Joseph Kittah, medical director of pulmonology at Beloit Health System.
Kittah and his team establish personalized programs that include breathing techniques, exercise training and health education to improve a patient’s quality of breathing.
“Pulmonary rehab has been in existence for years,” Kittah says. “It’s nothing new. It’s supported by data, and evidence-based medicine shows that pulmonary rehab benefits patients.”
Unfortunately, many people don’t know pulmonary rehab is an option, Kittah says.
Pulmonary rehab usually entails a three-month program, with patients attending one-hour sessions a few times a week.
Tools a patient might encounter include a Positive Airway Pressure System, or EzPAP, similar to a CPAP machine; elastic resistance bands; treadmills and incentive spirometry, which involves a ball-valve mechanism that a patient blows into to develop slow, deep breathing skills.
Combined with breathing techniques and further education, many end the program in far better shape.
“Most will notice significant improvement,” Kittah says. “Pulmonary rehab is shown to decrease hospitalization for acute respiratory issues. Most COPD patients generally are now able to have greater endurance and have improved respiratory function.”
In the past two years, Kittah also has worked with patients recovering from COVID-19. Some of them have persistent respiratory issues, and Kittah tries to get them at least one visit with a therapist, just long enough to be instructed on breathing strategies and exercises they can do at home.
That’s an important aspect of pulmonary rehab: as with any other sort of rehabilitation, the best results come to those who follow through with their exercises beyond the clinic.
“The strategies we use are long-standing techniques that have been practiced over years, and what we notice is patients who follow pulmonary rehab exercise regimens at home will benefit a lot,” Kittah says. “Pulmonary rehab is an initiation program that will teach you strategies, and we expect patients will follow these exercises and these education tips on their own. If you slack, if you do not perform, over time the benefits will erode.”
The thing about lung function, he says, is if you don’t use it, you lose it.
Of course, pulmonologists would like nothing better than to see fewer patients with acute respiratory issues.
“Once you have a scar or chronic disease on your lungs, it’s difficult to regenerate your lung function,” Kittah says. “So, prevention of lung disease is a big part of what we do as pulmonologists.”
Recognizing that the most common cause of lung disease is tobacco use, certain pulmonary rehab programs won’t even admit those who continue to actively smoke, Kittah says. Helping patients quit smoking is a goal, but that individual must be ready to change their lifestyle.
And patients should adhere to the therapies prescribed by their doctors.
“Those who need long-term oxygen therapy should understand that actually using prescribing oxygen therapy improves quality of life and has survival benefits,” Kittah says. “Some come to our office not wearing their oxygen. You would do well to use oxygen if you’ve been prescribed. It’s important to listen to your lung doctor.”