In the second episode of Fighting to Breathe: Lung Disease in Kentucky, we examine chronic obstructive pulmonary disease (COPD) and asthma in the commonwealth. Experts discuss risk factors and treatment of these two diseases, and we travel to eastern Kentucky to learn about a public health project to improve air quality in two counties with high COPD and asthma rates.
This series is funded in part by grants from the Foundation for a Healthy Kentucky and the Kentucky Medical Association through a grant from the Anthem Foundation.
How Asthma Affects Lung Health, and Advances in Treatment
Dr. James Sublett, MD, FACAAI, FAAAAI, has been in practice for 42 years and is the co-founder and chief medical officer of Family Allergy & Asthma, a practice with locations in Kentucky and southern Indiana. Sublett is a leading national expert on the respiratory disease.
“The lungs’ main function is to exchange gases,” Sublett says. “When we breathe, we take in air down to our bronchial tubes, and you want to think of that as an upside down tree. Your trachea is the trunk, and it goes down to airways that are smaller and smaller, just like branches on a tree, until you get down to the small air sacs which are called the alveoli. If you spread them out, there are millions of alveoli about the equivalent of a tennis court. And that’s where the air exchange takes place.”
Sublett explains that when red blood cells flow into the lungs, they pick up oxygen that suffuses through the surface of the alveoli through blood vessels called capillaries. In turn, the capillaries release carbon dioxide to the alveoli, which is transported back into the airway and then exhaled. The oxygenated blood cells then flow back to the heart and are pumped throughout the body to nourish tissue – a constant process that sustains life.
Asthma is a chronic disease that affects the airways – it constricts breathing before air gets down to the alveoli, Sublett explains. “It typically occurs in childhood and is an inherited disorder in that we’re born with a tendency to have asthma,” he says. “About one in 10 people develop some signs of asthma during their lifetime.”
A person with asthma will have three different types of airway obstruction, Sublett says. First, tissues lining the airway will swell, reducing the interior space for breathing. Second, mucus production will increase and become thick. Lastly, asthma can cause the bronchial tubes to spasm, further restricting the airflow.
Poor air quality in an indoor or outdoor setting can trigger an asthma attack for individuals who have a genetic predisposition to the disease, according to Sublett. “You have different levels of exposure – there are certain allergens, like dust mite, cockroach, mice. And this has a lot to do with early exposures in childhood, and children in poverty may have substandard housing, that exposure kicks the genetics in and leads to the asthmatic response,” he says. “And allergy plays a role: about 80 percent of individuals who have asthma have some degree of allergy that triggers it.”
Sublett says that about one-third of asthma cases are undiagnosed or under-diagnosed. His staff will perform a lung test that establishes a baseline level of function and then administers bronchodilator medication to check for improvement. Over the past decade, the introduction of what Sublett calls biologics – monoclonal antibody drugs which target pathways that lead to asthma – have improved outcomes for many patients.
“The other thing we use in treatment is allergy immunotherapy or allergy shots,” he says. “That’s been around for a long time but we understand it better, it’s been refined, and we can treat the triggers that are allergic, and that can be a dramatic effect.”
COPD: A Burden on Kentucky’s Health
According to Centers for Disease Control data from 2015, Kentucky was one of seven states with the highest rate of reported COPD cases, and the majority of the state’s counties reported doctor-diagnosed COPD rates in the highest tier of 8.5-15.6 percent.
Dr. Chaitanya Mandapakala, MD, is a pulmonologist with St. Elizabeth Healthcare serving northern Kentucky. He explains that while asthma is a condition where one’s airways become obstructed due to an external trigger, COPD is a chronic disease that builds up over time to constantly restrict airways, and it can’t be reversed.
“Smoking tobacco is the most common thing everyone talks about, and it is real, it causes issues” with COPD, Mandapakala says. “Any kind of vaping can cause COPD as well, smoking marijuana can cause it, and then when it comes to the general pollutants, when you get the message that ‘today is a bad day for air quality’ – all of those things impact our patients.”
“When we look at a patient that has problems with COPD, typically just normal things like getting up out of bed in the morning is a struggle,” says Tom Cahill, RRT, the director of respiratory and sleep medicine at St. Elizabeth. “Walking down the hall can be a struggle, steps are a huge struggle. … When you feel like you can’t catch your breath, that’s the worst feeling in the world.”
At St. Elizabeth’s hospital in Edgewood, Ky., patients receive treatment for COPD and other lung diseases at a pulmonary rehab center that offers exercise classes and monitoring checkups. The program is not covered by Medicaid, however, and reimbursement rates for Medicare and private insurers are low. But Cahill says that patients in the program have a less than 5 percent hospital readmission rate, compared with close to 30 percent of St. Elizabeth patients that don’t participate.
“Interestingly, what you do with the rest of your body impacts your lungs more than people believe,” Mandapakala says. “For example, if you’re a sedentary person or obese, your muscles are weak. Weaker muscles demand more oxygen than stronger muscles. So a patient with moderate COPD but good muscles might not feel that they’re short of breath, where someone with mild COPD but very weak muscles might feel more short of breath.
“By strengthening your muscles in a pulmonary rehab program, your shortness of breath becomes much better,” he continues. “You’ll be able to do more in your day and improve your quality of life.”
Research Study Aims to Improve Air Quality in Eastern Kentucky
In Kentucky’s Appalachian counties, rates of COPD and asthma are significantly higher than in other areas of the commonwealth. The causes of this disparity are rooted in the region’s history as a coal producer as well as the state’s overall cultural connection to tobacco.
“We have alarmingly high rates of respiratory disease here in eastern Kentucky, but we also have an alarmingly high rate of smoking – still even now, which is really disturbing” says Beverly May, RN, MSN, DrPH, project manager for the Mountain Air Project. “That’s a large part of it, but the level of asthma and COPD that you see makes you think, what else is going on?”
Researchers at the University of Kentucky’s College of Public Health coordinated with community leaders in Harlan and Letcher Counties to launch a study called the Mountain Air Project. The study attempts to identify environmental factors contributing to lung disease in the region, says Steve Browning, PhD., an associate professor in the College of Public Health’s Department of Epidemiology and a principal investigator for the Mountain Air Project.
“It was important for us to select different areas within the county so that we were picking people from outside of the towns and out in the most rural areas, some of the hollers,” he says. “And we sampled from those that had lots of (coal) mining or less mining or kind of a diversity of different environmental exposures.”
Enlisting residents as recruiters for their fellow neighbors, researchers conducted a survey that totaled 970 participants in the two counties, going into their homes and conducting a 40-minute interview. They also did lung function testing with spirometry, which measures breathing capacity. Browning says that a sub-sample of homes received full-scale air quality testing that measured air pollutants such as particulates and mold.
Browning says that one of the most unexpected findings from the study connected roadway exposure to higher asthma rates among respondents. “People that lived in geographic areas that had a lot of roads and traffic and were very near the highway has asthma risks that were two or more times higher than those that were less close,” he notes. “We typically don’t think of rural areas as having air pollution problems, but we think that (based on) the geography of the hollers and the way air moves and the measurements we took on air particulates, there’s actually some trapping of higher levels of particulates around there.”
The study also found that public housing units in the counties were high-risk locations for asthma, according to Browning. He says the increased rates may be linked to the age, condition, and maintenance of the housing structures leading to the presence of mold, mildew, animal dander, and other irritants.
Browning says that 30 percent of respondents to the Mountain Air Project study were smokers, higher than the state’s 24 percent average for adults. “The factor that best predicts particulate levels, air pollutant levels in a house, is indoor smoking,” Browning says. “Just moving to a rule of smoking outside will have a big impact.”
As a follow-up, the Mountain Air Project sent visiting nurses to provide asthma care and education to participants living in public housing. They also empowered homeowners by offering healthy home inspections and distributing green cleaning kits.
“I think I’ve always believed that the answers to the problems of a community are right there in that community, if they can just get mobilized,” Beverly May says.
