• New Directions in the Treatment of Chronic Lung Disease
  • by Richard Effros, MD
  • Dr. Effros caught everyone's attention by explaining that he has had a form of obstructive lung disease since the age of 4. He had severe asthma, possibly triggered by the smoking of his mother. He discussed the differences, similarities, and overlap of symptoms between asthma and emphysema. Asthma by definition is reversible while the inflammation of COPD is not. However, sometimes asthma also can become less reversible with some fixed obstruction, and thus turn into COPD.
  • Instead of immediately discussing the latest medications and trends, Dr. Effros brought things into perspective by regaling the audience with tales of old remedies. He referred us back to Dickens, rather than medical texts, for some of the earliest descriptions of disease. Dickens, while not a physician, was a trained observer. In fact, in Pickwick Papers, his description of the obese boy with a huge belly who was always falling asleep standing up, is the textbook picture of a type of sleep apnea. Even today, naming this the 'Pickwickian syndrome' honors Dickens' observations.
  • In those days, strong coffee was the only treatment for asthma. Coffee contains a substance (caffeine) similar to theophylline , which is still used to treat asthma. Back in 1850, and for many years later, asthmatic patients relied on "asthma powders". They were created by soaking paper in a mixture of belladonna and potassium nitrate, burning them, and inhaling the smoke to open the airways. Asthmador cigarettes were smoked to relieve asthma. That's right. Medicated cigarettes were encouraged for those with respiratory distress! They contained belladonna, which is related to today's Atrovent.
  • Dr. Effros gave us many other examples, commenting that many of today's medicines are derived from much older drugs. For example, the Chinese used an herb called 'ma huang' for more than 1000 years to make a tea, which was used to treat asthma. Ephedrine is the active ingredient in ma huang, and it was very popular as a medication for asthma for many years in a tablet form called "Tedral." It is also the active ingredient in the weight loss drug called "Ephedra", which was recently taken off the market because of potentially fatal cardiovascular reactions.
  • Adrenalin injections (related to today's Albuterol) were first used in the first half of the 20th century when it was the only medication available in emergency rooms for relief of severe respiratory distress. In spite of the potential of severe side effects, adrenalin is sometimes used even today, with great caution, to save the lives of those in anaphylactic shock (a severe allergic reaction) because of the immediate response and relief of symptoms that it can provide.
  • Dr Effros, who was involved with industrial medicine, was intrigued by the fact that the damage caused by inhaling smoke from cigarettes is so different from the damage done to the lungs by other inhaled pollutants. Cigarette smoke causes COPD or obstructive disease. Inhaling pollutants from industrial products can cause scarring in the lung, which results in restrictive diseases such as pulmonary fibrosis, or pneumoconiosis, seen in coal miners. In restrictive disease, the lung gets smaller, constricted by scarring, and it is difficult to get air into the lungs.
  • Cigarette smoke destroys the elasticity of the lung and its ability to spring back, making it difficult to get air out of the lungs. The lung enlarges because of destruction and air trapping in the alveoli. We use the belly muscles to press the diaphragm up to squeeze air out, BUT, if done with too much force, this can cause additional compression of the airways and further obstruction. (Do you remember being told in rehab not to work too hard to force your breathing? Now you know why.) It is somewhat reassuring to know that we normally have two to three times as much lung as we need. This is why someone can have one whole lung removed and still remain active.
  • Lung damage can be documented with the PFT (pulmonary function test), which compares your lung function to the average for your age, height, and sex. The FEV1, which is an important part of the PFT, is the amount of air you can blow out of your lungs in one second. That is that number that Dr. Petty keeps telling everyone that they should know.
  • Did you know that the inside of your lungs is normally sterile? How is that possible when it is continually exposed to organisms inhaled from the environment and the organisms that normally live in the mouth? Amazing, isn't it? Dr. Effros explained that the lungs secrete about 1/2 quart of fluid each day, which continually washes out any organisms which land on the airway surfaces. This is referred to as the "mucociliary elevator." We swallow this fluid without being aware of it. Cilia, tiny hair-like projections inside the lining of the lungs, help this process of sweeping debris out of the lung. Cigarette smoking paralyses and damages the cilia and interferes with the flow of fluid from the lungs. Mucus accumulates in the airways, the lungs are no longer sterile, and infections can start to take place with organisms that are always present in the mouth.
  • In addition to the mucociliary elevator, about 1/2 quart of water is lost from the lungs each day by evaporation as water vapor, which keeps the surfaces of the lungs moist. This is the moisture that causes the "steam" you see when you exhale outside on a cold day.
  • In response to the irritation caused by cigarette smoke, and the presence of bacteria in the airways, inflammatory cells enter the airways. Although these cells may help prevent the spread of infections, they also release enzymes, which can destroy the elastic tissue of the lungs, thereby contributing to the development of emphysema. This is particularly serious in patients who lack alpha-1-trypsin inhibitor, a protein that normally inhibits the action of these enzymes.
  • The exact role of steroids, which are used to reduce inflammation in COPD, remains quite controversial at this time. Many pulmonologists in the United States feel that steroids are helpful only during an acute exacerbation. Studies have shown that they do not prolong life. As you know, taking prednisone tablets over a long period of time can cause many complications. Even inhaled steroids can affect the musculature of the vocal cords and sometimes cause fungal infections in the mouth, though these problems are usually mild and readily treatable.
  • In answer to questions from the audience Dr. Effros commented that bronchiectasis (an abnormal dilation of the bronchi which promotes recurrent infections) was much more common and serious before the days of antibiotics. Fewer children now get whooping cough, measles or untreated pneumonia, which were the major causes of this illness. It is also much easier to diagnose bronchiectasis now that we have CT scans, making it unnecessary to inject dyes into the lungs. He also commented on the possibility that some cases of bronchiectasis in adults may actually be a mild form of undiagnosed cystic fibrosis. A sweat salt test should be done to rule this out since so much more can now be done to help this condition.
  • He ended with a final tidbit of fascinating information. We are born without true alveoli! Alveoli start developing at birth and continue to grow until about the age of seven. Children with asthma are stimulated to grow extra alveoli and can compensate by developing "supernormal lungs" as do babies born at high altitudes with lower oxygen levels.
  • Everyone thanked Dr. Effros for a fascinating lecture that helped us get a different perspective on how the past evolves into the present and on to the future. If you live in the Torrance area and are interested in attending one of these meetings call (310) 222-8276 for information and directions. For those of you who live a bit too far to manage the drive, we promise to keep writing up some of these talks. And yes, Dr. Effros promised to come back soon. We'll look forward to it!

  • Do you have a question about respiratory disease that has been bothering you? If so, feel free to write and ask us, either through our web site or by mail. We answer all of your letters.