Just Breathe

Lung Disease in US Adults

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Don’t think about breathing…. 

Right, we almost never think about breathing until we tell ourselves not to, or we are short of breath and then it is the scariest sensation.

Ondine’s Curse

In the German fairy tale, Undine, and adapted versions by French dramatist Jean Girodoux and others, an immortal nymph marries a human knight named Huldbrand to gain a soul.  Huldbrand swears “My every waking breath shall be my pledge of love and faithfulness to you.”  Through this union, Undine becomes mortal and has a child with Huldbrand. One day Undine finds Huldbrand sleeping with another woman and curses him, “for as long you are awake, you shall breathe, but should you ever fall asleep, your breathing shall cease.”  

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In medicine, Ondine’s curse describes the uncomfortable condition where automatic control of breathing is lost, and a person is forced to think about taking each breath. 

To automatically control breathing, the brain detects levels of oxygen, carbon dioxide, and the acidity of the blood.  Luckily Ondine’s curse (congenital central hypoventilation syndrome) is rare.   

Normal Lung Function

Now close your eyes and purposefully think about your breathing.  Take 5 deep breaths nice and slow.  Feel your chest rise and fall.  Imagine air filling up to the top of your head when you breathe in, and out your toes when you breathe out.  This intentional breathing can be a form of meditation, is relaxing and will lower stress. 

When breathing is happening normally, it’s automatic and we don’t think about it.  Oxygen enters at a concentration of 21%.  It crosses the thin lung lining and binds to the iron held in hemoglobin that is in our red blood cells.  The red blood cells travel down arteries and deliver the oxygen to organs like your heart.  Oxygen disembarks, enters the organ cells for use.  At the same time, carbon dioxide is released from the organ tissues, enters the red blood cells, and travels back through your veins to the lungs.  It travels across the thin lung lining, and you breathe it out.

Lung Disease

Lung diseases disrupt oxygen coming in and carbon dioxide going out.  The result is not enough oxygen getting to the organs that need it, or not enough carbon dioxide leaving the body.  For example, a person with asthma has trouble breathing in and out because the airways restrict airflow.  The heart, brain, and all other organs may not get enough oxygen and carbon dioxide levels increase in the blood.   

With chronic lung disease the body attempts to compensate to increase the delivery of oxygen and the clearance of carbon dioxide.  The heart muscle may thicken, stress hormones increase to speed up the heart, and blood pressure may rise.  If the body can’t compensate enough, then organs begin to fail.   

Threats to health and life, therefore, can come from primary diseases of the lungs, or compensatory diseases of other organs caused by lung disease (e.g., ischemic heart disease, pulmonary hypertension).

Epidemiology

Pulmonary diseases, like chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), contribute significantly to morbidity, mortality, and healthcare expenses.  

• 16 million Americans have COPD (4th leading cause of death)
• 25 million adults in the US have OSA  

Risk Factors

Given that lung disease is the 4^th leading cause of death, we need to be aware of the risks, especially the ones we can do something about (modifiable risk factors). 

Until we can stop aging, alter our genes, or time travel some of us are at risk for COPD or lung cancer by virtue of our age, genes, or past exposure to environmental toxins.  For example, alpha-1 antitrypsin deficiency is a hereditary disorder that increases the risk of developing COPD in smokers and non-smokers.

Did you know…

“Occupational lung cancer is the most common cause of occupational mortality.”

–Steven Markowitz, MD, DrPH–

We can, however, change our future risk. 

• Don’t smoke / avoid second-hand smoke (causes 80-90% of all lung cancers)
• Protect yourself at work from asbestos (used in insulation, now mostly in other countries), silica (workers exposed in mining, stone working, brick and ceramic industries), diesel exhaust (causes 10% of all lung cancers), certain fumes (welders exposed to silica, oxides, and fluorides).
• Have your house measured for radon levels. Radon is a colorless, odorless, radioactive gas that seeps up from beneath your house and can concentrate inside your house. Radon exposure is the 2nd leading cause of lung cancer after smoking. There are ways to reduce radon in your house, but you have to know it exists first.

Now let’s look at obstructive sleep apnea (OSA).  Do you snore?  Are you tired in the daytime?  These and other factors make up the STOP-BANG score which is a quick way to evaluate if you might have OSA.  Have a look:

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STOP-BANG

This stands for:

• Snoring loudly (louder than talking)
• Tiredness during the day
• Observed apnea (stopping breathing during sleep)
• hyPertension
• BMI ≥35
• Age ≥55 years old
• Neck circumference ≥16 inches
• Gender (1 point for male)

In this calculator, you get 1 point for each item that is true of you.  A score of ≥3 puts a person at intermediate risk for moderate to severe OSA and a score of ≥5 puts a person at high risk for moderate to severe OSA.  It is important to get screened because over 80% of OSA is undiagnosed, and untreated OSA puts you at risk for many other problems like abnormal heart rhythms that can lead to stroke.

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Prevention

A Medicine 3.0 approach to health is to identify risk factors early, seek ways to reduce the risk by modifying those risk factors that you can, in order to prevent developing the disease in the first place.

Our approach at Paradigm is:

1. Screening and Early Detection:
   • Metabolic blood tests –inflammatory markers, biomarkers, and blood gas associated with specific pulmonary conditions.  Arterial blood gas analysis provides information about oxygen and carbon dioxide levels in the blood and helps assess respiratory function and acid-base balance.
   • Genetic screening may be indicated in certain cases of pulmonary disease, particularly when there is a family history or suspicion of hereditary conditions such as alpha-1 antitrypsin deficiency or rare genetic mutations associated with interstitial lung diseases (ILDs).
   • Low-dose chest CT scan.  We use this screening test in those with significant smoking history or occupational exposures.  It is an effective way to identify cancer in the earlier stages when it is most treatable.  
2. Testing:
   • We use pulmonary function tests (PFTs) to assess lung function and diagnose respiratory conditions such as COPD, asthma, and ILDs.
   • We perform cardiopulmonary exercise testing (CPET) to obtain valuable information about the performance of your lungs and heart together.
   • We use chest X-rays and CT scans when necessary to visualize lung anatomy, detect abnormalities, and assess disease severity in conditions like COPD, lung cancer, and interstitial lung disease.
3. Promoting Healthy Lifestyles:
   • Being active keeps the chest wall muscles and diaphragm strong… and strong enough to expel infections when they occur.
   • A healthy diet tunes the immune system to be capable of fighting infection.
   • A healthy weight makes it mechanically easier to breathe and helps to reduce the likelihood of developing OSA.
   • Wash your hands, brush your teeth well, and otherwise live with good hygiene to avoid contracting respiratory illness.
4. Vaccination:
   • Influenza vaccination, pneumococcal vaccination, and COVID-19 vaccination is recommended under certain conditions that are specific to you, including risks, age, and other illnesses you have.
5. Smoking Cessation: For COPD and lung cancer, smoking cessation remains the most effective preventive measure.
6. Reduce Environmental Exposures:
   • Use a home air filter, especially if you are sensitive to air particles.
   • Screen your house for radon levels. If levels are high, then radon reduction strategies should be started.
   • Wear an appropriate type of mask when there is a risk of toxic exposure at work.
7. Managing Disease well:
   • For those with OSA, weight management, positional therapy, continuous positive airway pressure (CPAP) therapy, and oral appliance therapy are among the preventive approaches recommended.
   • Pulmonary PT and toilet are critical in severe respiratory disease.

Treatment

The best defense for lung disease is a strong offense.  Prevention is key.  However, it is common to acquire lung disease which is why we are talking about it here as a leading threat to vitality and longevity.

For COPD, bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy, and in severe cases, lung volume reduction surgery or lung transplantation are medical treatments.

Lung cancer treatment options depend on factors such as the stage of the disease, histological subtype, and patient preferences. Treatment modalities may include surgery, chemotherapy, radiation therapy, targeted therapy, immunotherapy, or a combination of these approaches.

For pulmonary hypertension, treatments aim to reduce pulmonary artery pressure and improve symptoms.  Medications such as vasodilators, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclin analogs are commonly used, along with supportive measures such as oxygen therapy and diuretics.

In interstitial lung diseases, treatment depends on the specific subtype and underlying cause. Corticosteroids, immunosuppressive agents, antifibrotic medications, and supportive therapies such as oxygen supplementation may be used to manage symptoms and slow disease progression.

In OSA, continuous positive airway pressure (CPAP) therapy is the primary treatment modality for moderate to severe cases.  CPAP therapy involves wearing a mask connected to a machine that delivers a continuous flow of air to keep the airway open during sleep. Other treatment options include oral appliances, positional therapy, lifestyle modifications, and surgical interventions such as uvulopalatopharyngoplasty (UPPP) or maxillomandibular advancement (MMA).

Optimization

• Pillar 1 is prevention.

• Pillar 2 is treatment.

• Pillar 3 is optimization.

Lung disease often reflects damage that is irreversible, so to optimize your lung function, first go through all the exposures that can worsen your lungs and work to reduce those.

Maybe you enjoy smoking.  If you want to optimize your lung function, you will find something else to enjoy instead.  Trying to quit smoking is the first step.  We can help you.  Lungs begin to recover and body oxygenation improves almost immediately upon reduction or quitting tobacco smoking.  We can follow your pulmonary function tests, CPET, and labs to see your lung performance improve.

With physician guidance, learn breathing exercises to improve breathing mechanics, strength, and lung volumes.

Exercise, especially swimming, can be huge to strengthen lungs.

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If you are breathing well, be thankful.  Some organs we are lucky to have two of. 

In the words of Pearl Jam:

“Some folks just have one, yeah, others they got none.

Stay with me, oh

Let’s just breathe.”

Dr. Matt and Dr. David