Share ThisIn our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this interview, we discuss Chronic Obstructive Pulmonary Disease (COPD) with AHN pulmonologists Dr. Sohini Ghosh and Dr. Meilin Young.
Have you noticed recently that you can’t chase your grandkids around like you did in the past? Is your weight the same, no new illnesses or disease states — yet you become short of breath easily, maybe experiencing wheezing or heaviness in the chest? Do you smoke? If you answered “yes” to these questions, it may be time for a lung function test to check for chronic obstructive pulmonary disease (COPD).
Multiple disease processes fall under the category of COPD, a leading cause of death in the U.S. Unfortunately, COPD can (and often does) progress from something you might not be worried about into something more severe, so it’s important to understand symptoms, risk factors, and treatment options. To get some insight, I talked with AHN pulmonologists Sohini Ghosh, MD, and Meilin Young, MD, about how COPD presents and progresses.
Emily Adamek: Let’s start by clarifying what COPD is — it includes more than one condition, right?
Dr. Meilin Young: Traditionally, two conditions, chronic bronchitis and emphysema, fall under the umbrella of COPD. Emphysema is a disease process involving the anatomical lung units (alveoli), whereas chronic bronchitis is a disease of the major airways with increased mucus production. That said, you can have chronic bronchitis or emphysema but not COPD. In its truest sense, the only diagnosis of COPD comes from a pulmonary function test (PFT), which measures an inability to exhale a certain amount of air over a period of time and shows a fixed obstruction.
Dr. Sohini Ghosh: The most common symptoms of COPD are breathlessness, chest tightness, chronic cough, mucus production, and wheezing. Primarily, it’s shortness of breath experienced with exertion.
COPD patients tend to be either mucus producers or hyperinflated, meaning air gets trapped in the lungs. For patients in the latter category, the lung can become too inflated for the thoracic cavity, causing compression and flattening of the diaphragm, the main muscle you use to breathe. Normally, the diaphragm is concave and can move up and down when you breathe; however, when lungs are hyperinflated, the diaphragm becomes flat and has little range of motion to move with each breath. That’s why it becomes difficult to breathe when patients exert themselves.
Emily Adamek: Is there any overlap between asthma and COPD?
Dr. Sohini Ghosh: There can be. Both conditions involve obstruction — difficulty exhaling — but what is different is the physiology of why someone experiences that difficulty. Asthma is more likely if patients start having breathing problems at a younger age and when there is no smoking history or occupational exposure. However, patients can also have both asthma and COPD.
Unfortunately, lung function peaks around the age of 25 to 30, so everyone loses lung function as they age. People who smoke or have occupational exposures or other factors lose function at a faster rate.
Emily Adamek: If everyone’s lung function starts to decline with age, what advice do you give about when to be concerned?
Dr. Sohini Ghosh: Normal decline in lung function should not cause symptoms. If you’re experiencing a significant decline in your exertional ability and you have the risk factors, you should get checked for COPD.
Emily Adamek: What are the risk factors for COPD?
Dr. Sohini Ghosh: In the U.S., the number one cause of COPD is smoking. Other common causes are environmental, primarily occupational exposures (for example, people who have worked in mines, mills, or factories). Worldwide, risk factors also include biomass smoke exposure and air pollution. Genetic disease is another rare kind of COPD. There is genetic testing for Alpha 1 antitrypsin, which is one genetic disease that can cause COPD at an early age.
Emily Adamek: How big of a risk is secondhand smoke? What about vaping?
Dr. Sohini Ghosh: The risk of developing COPD is not as high as those with primary exposure, but we certainly have patients diagnosed with COPD who had significant secondhand exposure. The risk of secondhand smoke is probably underestimated because it’s difficult to study.
Vaping’s association with COPD isn’t well known because it’s a relatively new social habit. It definitely causes acute damage, but we don’t yet fully know the long-term consequences. There is likely some type of tissue damage leading to bronchial remodeling, increasing the risk of developing cancer or COPD. But COPD takes years and years to develop, so we just don’t have the data yet.
Dr. Meilin Young: To reinforce the point about smoking as a risk factor, about 50% of smokers will develop COPD. Lung function testing and other data we’ve seen so far on people who vape does suggest a rapid decline similar to what is seen with people who smoke or have other significant exposures.
Emily Adamek: Smoking cessation could be an entire article, but it is so central to COPD, I’d like to hear a bit about how you talk with patients about it?
Dr. Sohini Ghosh: Unfortunately, there’s no therapy to cure nicotine addiction with the snap of a finger. Pharmacological therapy can help you wean down nicotine use and manage withdrawal symptoms, but there’s no easy fix — smoking cessation takes a lot of work.
I generally recommend that patients take a three-pronged approach to quitting. First is behavioral modification, especially finding your triggers and adjusting your responses to them — that’s where counseling and support groups can often help. Second, create some type of prize as positive motivation. For example, set aside money you would normally spend on cigarettes with the reward of using it on something big after a set period, like three months. The third step where I can help is pharmacological assistance. This includes nicotine replacement medication to help wean down nicotine, and an oral medication such as varenicline or bupropion. Lastly, I tell my patients that if they fail the first time, it doesn’t mean they won’t succeed. It takes, on average, five to six attempts for a person to quit. It’s also really important to have everyone else in your home quit smoking.
Dr. Meilin Young: I often bring up the things in their life that they value, like running around or playing with their grandkids, and turn it around on them as a motivator if they cannot do that anymore. In addition, an exacerbation from smoking that requires a hospitalization will also result in time away from home and not doing things that they love.
Quitting is not easy, but there are a lot of resources. Many health insurance plans and employers have smoking cessation programs. Highmark Blue Cross Blue Shield has a free program to all its members. We also work with Adagio Health, an independent program.
This isn’t just for smoking cessation, but I would add that we have chronic care pathways and a COPD care transformation team for our patients with Allegheny Health Network. Each patient gets a care navigator as a point of contact for any issues, and that person can function as a motivator for quitting smoking and other changes as well. They’re a checkpoint, and the regular contact can help patients stay on track and feel accountable.
In general, having multiple individuals involved is important. That’s why I often enlist family members. If 10 people are all telling you the same thing, it starts to stick.
Emily Adamek: For someone in the early stages of COPD, is it ever reversible?
Dr. Sohini Ghosh: The damage from COPD is irreversible, so once diagnosed, the focus is on managing symptoms and limiting additional damage.
Dr. Meilin Young: With people who smoke, for example, we often see a rapid decline of their lung function — instead of a slow trickle down, there’s a precipitous fall. Now, if they stop smoking, they can level out to where they again have a slow, steady decline of function. They’re starting at a lower level than someone who doesn’t have COPD or never smoked, and they can’t get back to the function they would have had if they never smoked, but we can work on slowing the decline and reducing the risk of flare-ups.
Emily Adamek: What are some of the actions and treatment options to help do that?
Dr. Sohini Ghosh: The first thing is removing yourself from the cause, whether that’s smoking, secondhand smoke, occupational or environmental exposure. Continued exposure to these things is the biggest predictor of a flare-up, and even one major flare-up resulting in hospitalization increases mortality rates significantly.
If someone has allergies or underlying asthma, getting that under control is important, too. Then, there is medication management, most commonly inhalers. There are essentially three drugs available in inhalers — one is a steroid and the other two work on receptors in the lungs to open up the bronchial tubes and decrease mucus production. It’s also important to stay up-to-date on vaccinations, including pneumonia, flu, and COVID boosters.
I also tell patients to contact their PCP or pulmonologist if they’re having any symptoms to make sure we treat things early so they don’t worsen. There are a few other oral medications that can be used in patients who have frequent flare-ups, for example. Lastly, a pulmonary rehab program may also be part of treatment, especially for patients with even minor functional limitations.
Emily Adamek: What advances have there been in treating patients with COPD?
Dr. Sohini Ghosh: For late-stage patients, lung transplantation may be an option, and there have been advances in that field. However, that is still a big commitment with a long and strict evaluation process. Transplant also has its own associated risks.
Another procedural option is lung volume reduction surgery, which involves going in to identify the most diseased portion of the lung and surgically remove it. This allows the healthier portion to breathe better because there is less flattening of the diaphragm.
Endobronchial valve treatment is a newer, minimally invasive procedure we are doing at AHN, using the Zephyr® Endobronchial Valve from PulmonX. This is less invasive than lung volume reduction or transplants. There is an extensive work-up to identify appropriate candidates, but for the right patients, this option can make a big difference in patient’s symptoms.
The basic way this procedure works is that we use a bronchoscope, or scope inserted into the longs via the mouth, to implant one-way valves. There’s an upper lobe and lower lobe in each lung. If, for example, we determine that the left upper lobe is the most diseased portion, we put valves into that lobe to allow air to be released from that lobe but not re-inflated with air. Eventually, this causes that left upper lobe to collapse and take up less space in the thoracic cavity. This allows the left lower lobe, which is presumably healthier, to expand and do more of the gas exchange. Additionally, this also takes pressure off the diaphragm, so instead of being flat, it’s more concave with more range of motion allowing patients to breathe easier on exertion.
Emily Adamek: Do you have any closing thoughts or takeaways for people reading this?
Dr. Meilin Young: There’s a lot of research and support and awareness building around cancer and heart disease, and I would say we want people to realize that their lungs are just as important. All organs rely on the oxygen you breathe — if you can’t breathe it in, there goes your heart, your brain, and everything else.
Dr. Sohini Ghosh: My biggest message is that quitting smoking is hard but it’s the best thing you can do for yourself. Staying active is important, too. And it’s best to seek help before you need it.
Dr. Sohini Ghosh received her medical degree from Northeast Ohio Medical University in Rootstown, OH. She completed a residency in internal medicine and pediatrics at Case Western Reserve University/University Hospitals Case Medical Center, Cleveland, OH. She furthered her training with a three-year fellowship in pulmonary and critical care and a second, one-year fellowship in interventional pulmonary, both at the University of North Carolina, Chapel Hill.
Dr. Ghosh is a member of the American Association for Bronchology and Interventional Pulmonology, the American Thoracic Society, and the American College of Chest Physicians. She has authored numerous articles, presented multiple abstracts for research, and has lectured to students and medical audiences around the country.
Watch Dr. Ghosh talk about an innovative treatment for severe emphysema in this 2023 "Eye on Health" interview segment.
Dr. Young is a pulmonary and critical care specialist who treats patients for COPD, coughs, and other breathing disorders. She is experienced in performing bronchoscopy, transbronchial biopsy, and EBUS screenings. She cares for patients as if they were her own family and works to continually improve the care she provides. She speaks English and Mandarin Chinese.
Dr. Young received a medical degree from Drexel University College of Medicine in Philadelphia, Pennsylvania. She completed a residency and fellowship in pulmonary and critical care medicine at Allegheny General Hospital in Pittsburgh, Pennsylvania. She is certified by the American Board of Internal Medicine for internal medicine and pulmonary and critical care.
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