 Hello, I'm Dr. Lewis Myers. Welcome to Health Care Today. We're going to be talking today about common lung diseases or lung diagnoses and how do we diagnose and treat those. And I'm very honored to have as our guest today Dr. Veronica Jodlowski, who is the Chief of Pulmonology at Rutland Regional Medical Center. Dr. Jodlowski will be joining us from Rutland via Zoom. Dr. Jodlowski went to medical school in her native Hungary, then came to the United States where she did her residency training at Mount Sinai in New York City and her pulmonary and critical care at Columbia Hospital in New York City. She's been with us here in Vermont for many years. She was the Director of Critical Care and Pulmonology at the North Country Hospital for a number of years and has been at Rutland, I believe, for three or four years now. So, Dr. Jodlowski, welcome and thank you for being with us. Thank you for inviting me. It's very exciting. Well, we have a lot of things to cover. We're going to talk about some of the more common things we see at the hospital and in Vermont. These include COPD or emphysema and asthma, sleep apnea, lung cancer and lung cancer screening. And then, perhaps at the end, we'll talk a little bit about COVID and the long COVID syndrome, how COVID has affected people's lungs. So, let's start with very common and smoking-related disease of COPD. Tell us also what is COPD and how does it differ from asthma? So, COPD is a lung disease that is caused by exposure to different irritants. In our country, the most common irritant that is involved is cigarette smoke. But certainly, if we look worldwide, other exposures could be wood fires or burning different materials for heat and for cooking can also cause COPD. So, COPD basically encompasses two different diseases. One is what we would call chronic bronchitis, which is an irritation from the smoke, irritating the mucus glands and the inner lining of the airways and causing permanent damage and permanent structural changes eventually. And the other form of COPD would be what people would know as emphysema, which is where the cigarette smoke eventually causes structural damage at the smallest part of the lung tissue called the alveoli and ruptures them and causes these bigger, what I usually explain to the patients, as airfield bubbles in the lung that just don't participate in the breathing so well. But those are permanent changes in damage in the lung. One of the other perhaps contributors here in Vermont in Barry and Rutland and other communities is people who have worked in the granite quarries. Do you see much of that? That usually causes the granite quarries and also up north in Eden and Lowell, the asbestos mines. They tend to cause more interstitial lung disease rather than COPD. And of course, if the person who worked in the quarries and the mines was also a smoker for many years, then their risk of developing severe lung disease is even higher than the general population. But those interstitial lung diseases would include pulmonary fibrosis where there's actual scarring occurring on the lung rather than damage to these small breathing surfaces, the alveoli. How does smoking actually damage the lungs to cause the COPD or emphysema? So it's partly the cigarette smoke and partly the actual burn products in the tobacco as it burns are the damaging factors. And as such, of course, it doesn't have to be tobacco smoking. It could be marijuana. And the damage can also occur from not just smoking but vaping or using the bomb or anything like that. We don't hear as much about marijuana, but there's perhaps some misconception that it doesn't cause harm to the lungs. You're saying that's not true? No, it does cause harm to the lung. I think that the reason why we don't hear all that much about it, perhaps, is most people don't smoke at so much marijuana, which would be maybe an equivalent to a pack of cigarettes a day every single day. There is also the perception that when people cut back on their smoking that they can undo the damage or prevent damage. Is that true? So some of the damage is permanent, but some of the damage is actually reversible. And as people cut back or quit smoking, some of the reversible damage can be mitigated and can get better. So for example, we're talking about how the mucus glands are starting to put out more mucus. And before those glands go through a permanent change, they could be just irritated and inflamed. And that can get better with the irritation seizing. How do you diagnose COPD or emphysema? So COPD is diagnosed partly by getting a good history, including exposure history, and then partly by physical exam. Most of the time, by the time the airways are involved, we hear that people have some wheezing when they exhale. There's some coughing, there is chronic mucus production. And then the actual definitive diagnosis would be made on inconjunction with the history would be made on pulmonary function testing, which is a lung function test where they measure how much air one can move with different maneuvers. And there are very specific findings for obstructive lung disease like asthma and COPD. And of course, if we get a CAT scan or any kind of imaging modality, we could also see changes that reflect that the person might have COPD or emphysema. And once you have a patient with COPD, what are some of the treatment options that you have? So number one is stopping whatever the irritation is that's causing the COPD. So the smokers do very extensive work in smoking cessation counseling and offering resources and medications to help people quit smoking. Number two is based on the severity of the disease and the patient's symptomatology. We can offer inhalers, which different medications are put into the inhalers, but some of them will relax these tightened airways in different mechanisms and help the airway open up bigger so that can help with the wheezing and the shortness of breath. And some other medications in the inhalers such as some of the inhaled steroids perhaps help with the inflammation around the mucus glands. There are other medications that are also used in the care of the patient with COPD but in more specific situations or scenarios. For example, for patients who have very frequent flare-ups, lending them in the hospital or in the emergency room, we have other medications that are proven to help slow down the frequency of these flare-ups. And then lastly, we do pulmonary exercise rehabilitation program to help the person learn how to use the remaining healthy lung in a more efficient way and exercise specifically the respiratory accessory muscles that help with some of the symptoms, especially the breathlessness. And then we also encompass kind of a more overall care such as making sure that the vaccinations are on board and if a patient needs supplemental oxygen, then prescribing the appropriate amount of oxygen. Which are the important vaccines for someone with COPD to get? So for people with COPD, age-appropriate pneumonia vaccination is very important and the guidelines changed a little while ago. So people with basically any significant COPD at any age would now qualify for pneumonia vaccines. Yearly flu shots, the COVID vaccinations and the RSV vaccination, which just came out this year, would be, I think, my top four choices. And if we could switch gears and just talk a little bit about asthma. Again, very common. Tell us, what is asthma and how is it different than COPD? So asthma, in some ways there are some similarities and that in some other ways it's a very different disease. Asthma is more of a reactive airway disease. This is more of an illness of the airways, the wind pipes, kind of the tubing system, whereas COPD a lot of the times involves the actual lung tissue. And asthma, most people have a tendency for a hyper-reactive reaction. So they are inhaling some sort of an irritant that they are basically allergic to and that causes a very abrupt change in the otherwise healthy looking normal airways where suddenly the airway tightens up. The muscle around the airway also gets tight and the mucus glands can acutely start producing mucus. The symptoms could be quite similar. Once the patient is in an asthma attack, they will have shortness of breath and coughing and wheezing and chest tightness, but it has a more transient nature and has a very strong association to exposure to the irritant. So in between times the asthma patient may feel completely fine. Has the treatment of asthma changed over the years during your practice years? So in the last few years, major changes have happened in the asthma care initially by the recognition of these very specific allergy mediating cells in the blood called eosinophil cells. That patients who have a large number of these eosinophil cells in their blood, they tend to react much more abruptly to exposure to inhaled irritants and cause severe asthma flare ups. And so now if we screen these asthma patients and find that their blood has a lot of these eosinophil cells, there are injectable asthma medications that came on the market about probably at this point eight or nine years ago. Some of them are once every two weeks. The other one is every month and there's one on the market that is once every two months. But basically the bottom line is that these medications block these allergic cells, these eosinophil cells in the blood and with that they make the patient much less prone to severe abrupt asthma attacks. They tend to work very well for the right patient. They also tend to be very expensive. Is that true? They are expensive. There is a lot of... So the insurance is pretty well recognized the value of these medications in keeping people away from having bad enough flare ups that land them in the emergency room in the intensive care unit or God forbid on a ventilator. And also these medications decrease the need for taking steroids like prednisone on a long-term basis, which have a lot of long-term side effects. So keeping people healthy enough not to have to do that overall is a major healthcare saving. So I think that insurance companies by now fairly well recognize that and they usually cover one or the other medication. They may not cover all of them. And most of the drug companies have also have some patients assistance programs. So for the right patient, if the financial constraints are an issue, our clinics are definitely well worth to help them figure out a way to get them to one of these medications. Sounds like with COPD we've made some progress, but with asthma we're probably making even more progress toward controlling the symptoms controlling the disease. I think that this is true that I think that these injectable medications were groundbreaking. There is another big new change coming in the asthma world. Also the national asthma guidelines and the GINA guidelines, which is basically the two big guidelines of our therapies are now have changed and they're kind of getting into the pulmonary and primary care communities basically starting these what they call smart asthma therapy. And it's a huge paradigm shift in the way how we think about asthma and how we think about asthma care. So I think it's going to take some time until everybody will be comfortable with that mindset. But basically what we used to have controller inhalers that the person had to take every day, no fail all the time. And then we had Albuterol which was what we called an rescue or emergency or as needed inhaler. The new guidelines are especially for mild to moderate asthma are really prioritizing using one specific maintenance inhaler that has a combination of a steroid and a long acting bronchial dilator to be used on an as needed basis, which was never before kind of the mindset. So this is going to be very interesting. So let me ask you this, if a patient whether either asthma or COPD is seeing their primary care provider and they're still experiencing some difficulties, when would be a good time for referral to pulmonologists such as yourself? So I think that if, first of all, if there is a question about whether or not we have the diagnosis right or wrong, it's always a good time to refer because we have more tools to try to really make sure that the person who's complained was coughing and shortness of breath and was labeled with asthma actually has asthma and we're not missing some other diagnosis. I think if the person has like a mild intermittent asthma, very seldom has flare ups. Generally is in good control. I think it's appropriate to stay with primary care. If there is frequent flare ups or a feeling that the current medication regimen is just not controlling the asthma well, it would be a good time to refer to pulmonology. And I think that sort of the same holds true for COPD is if the treatment regimen has to be escalated and even that's not working well, it's not a bad idea to kind of have a referral. Let us see the patient will give treatment recommendations or will co-manage with primary care, depending on a lot of the different variables, how far the patient is coming from, how comfortable they are with taking back the management or how much they want us to co-manage. I'd like to move on to talk about sleep apnea, which I know you're very involved in. You run the sleep lab at Rutland Regional Medical Center and have done some special training in sleep studies. It's a very common problem. We see it in primary care quite a bit. Certainly as the population has gained weight over the years, that has exacerbated the problem because often it's associated with overweight. Can you talk a little bit about what is sleep apnea? How do you diagnose it and how you treat it? So sleep apnea is a very common problem and it's becoming more common in a pediatric population as well. So we're seeing both adults and kids with sleep disorder breathing in our clinic. In terms of sleep apnea, there is actually two different kinds of sleep apnea, but when we say sleep apnea, we just mean what's actually called obstructive sleep apnea, which is about, I would say, 90-95% of the people with sleep apnea. But there is this minor group that is a central sleep apnea, which is a completely different disease and treated differently and has very different risk factors. But since that's a pretty small portion of the pie, I would focus on the obstructive sleep apnea just right now. So that is related to the upper airway getting actually obstructed by either the tongue pushing back or extra tissues around the neck, just the weight of the tissues as we fall asleep kind of falling on the main airway or the jaw pushing backwards and again obstructing the upper main airway. And that is what results in snoring. And when the snoring ceases and the actual obstruction happens, that's when people have the apnea, which is a pause in the breathing. And the main danger of that is that when somebody is not breathing for 30 or 40 or 50 seconds, there is no oxygen coming to the body. And from there, since there's no oxygen coming to the lungs, there's no oxygen going to the blood system and to the heart and to the brain. And overall, this could be very damaging to our vital organs. And how do you diagnose sleep apnea? The sleep apnea is diagnosed with what's called a sleep study. There is basically two ways of doing a sleep study. The gold standard being an in lab sleep study where the patient comes in, spends the night in the sleep center and we monitor 18 or so different parameters, including brain waves and breathing and oxygen and respiratory effort and heart and limb movements and all kinds of different things. Short of that, for the right patient in an appropriate setting, there is also something called a home sleep study that can be done, which is kind of a little bit more rudimentary assessment. More specific to just sleep apnea does not really assess for any other sleep disorders. But again, for the right patient, it could be a little bit more expedited way of getting a diagnosis and moving on to treatment. So that would involve the patient thinking. And let's talk about treatment. Once you know that someone has at least moderate to severe sleep apnea, what are the treatment options? So for severe sleep apnea, really the best treatment option is to use a positive pressure machine, either a CPAP machine or a BiPAP machine, which basically generates an extra force to the air, which is that goes through a mask and it basically keeps the extra tissues aside and serves like a pneumatic splint. It splints the upper airway open. That is what's approved for severe sleep apnea. Now, for mild to moderate sleep apnea, the CPAP machine will still work just as well. But for those folks, there are other treatment options. So weight loss definitely helps. But for the patients who are not overweight, who do not have too much extra tissue around the neck, there's also something called an oral appliance, which is a dental device made specifically by sleep dentists. And it's something that the person only wears at night. It fits over the teeth and it basically gently incurs the lower jaw to the upper jaw and jaw from flopping back. For kids especially, but some adults, tonsillectomy could make all the difference, especially if we see children with very large tonsils and some sleep apnea that could solve all of their problems. The uvula resection and pharyngeal aplasty is kind of falling out of favor, not great results overall for adults. But then under commercials, I'm sure your viewers are seeing all the time about the Inspire device, which is a nerve stimulating device that is almost like a pacemaker built into the right side of the chest wall. And the pacing wires are going to the nerve that innervates the muscle that holds the jaw in place. I certainly know from my experience in primary care that when people have their sleep apnea effectively treated, they feel so much better. They have more energy during the day, they can concentrate. A lot of things improve. This is one area where definitely I would think people should be seeking out a specialist so that they can get diagnosed and treated appropriately because most primary care providers are not set up to necessarily diagnose and treat sleep apnea. Let's talk briefly about lung cancer. This is lung cancer screening month, traditionally November, although it should be year round. What are our screening options now? Who do we screen for lung cancer and how do we screen it? The lung cancer screening guidelines changed just within the last few years. But the idea is that patients who are smokers, active smokers or who have quit within 15 years should be screened for lung cancer. Based on the new guidelines, this is now age 50 and above, active smokers and people who have quit within 15 years. And the smoking history also has changed, but basically the equivalent to one pack a day for 20 years is the new guideline. So if somebody either smoked in the past, one pack a day for 20 years or two packs a day for 10 years, they would qualify for the screening. The screening is done with a CT scan, which is a picture of the lung, a little bit more sophisticated than an x-ray, but doesn't take a whole lot longer than doing a chest x-ray. And in fact, the radiation dose used for this particular CAT scan is not a whole lot more than a chest x-ray, a little bit more, but not a whole lot more. This does not require contrast shot or contrast administration, so this is a non-contrast CT scan once a year. Our insurance companies, under the guidelines you just talked about, are insurance companies, most of them covering this now? Yes, so this is mandatory coverage by the Affordable Care Act, and this is part of just like our mammograms and colonoscopies that are mandatory covered for the right patient, and it cannot be counted against the person's deductible either. As we know, lung cancer remains the number one most common fatal cancer in the United States, but the numbers are improving. Certainly a lot of that has to do with far less people are smoking or smoking heavily in the United States now, but is some of the difference you think from the screening? Absolutely. So I think that the difference comes from two major improvements and major advancements in lung cancer care in the last 10 years. One is the widespread availability of lung cancer screening. We're actually finding much smaller cancerous tumors when they are surgically resectable and curable, and the other advancement is just in the surgical techniques and the radiation techniques that we use now. The survival rate for small cancers has improved a great deal. And some of the chemotherapy is becoming much more specific for the kind of cancers that people often have. In the remaining time we have, let's talk about COVID. You've taken care of people through the COVID epidemic, and it unfortunately continues, although perhaps not as severe as we saw in the first year or two of the epidemic. In terms of people's lung function and pulmonary function, how is COVID changing? And also, could you talk a little bit about long COVID and how that affects people's lungs? During the acute COVID infection, some people, as you know, get through it very quickly and without much problem with a little bit of a runny nose. And some people really, really get sick and get admitted to the hospital or to the intensive care unit. It's still difficult to tell or predict who is going to do well or who is going to do poorly. But certainly, immunization against COVID has made a big difference in how well people did overall when they got infected. The people who do end up in the intensive care unit or on the ventilator tend to have the COVID lung infection involving more deeper parenchymal tissue of the lung, causing a lot of inflammation, kind of swelling inside the lung tissue. When that heals, it can heal with scarring, and that could be a permanent damage to the lung tissue and make the lung kind of more of a stiff, rigid organ and not be able to process the oxygen so well. So that could be a long-term sequelae of having severe COVID lung infection. When you see a severe form of the COVID that's affecting the lungs, are there any, aside from the couple of the IV medications or Paxlevid, are there any specific pulmonary interventions that you think can prevent this scarring? So there's very specific, so it depends on how sick the patient is. But for very severely ill patients, especially on a ventilator, there are specific ventilation strategies that we use for COVID. One of them is using the prone positioning while the patient is ventilated and changing the positions, using some IV steroids as well as the antiviral medications. Well, it's been a learning process for everyone, obviously including the pulmonologist and critical care specialist such as yourself. We've covered a lot of topics here in a short period of time and really only scratched the surface, but I want to thank you for being here. It's been really helpful. Dr. Veronica Jodlowski is the head of pulmonary care at Rutland Regional Medical Center. Thank you so much for being here. Thank you for having me.