Recognizing Worsening COPD and Taking Action

[Dr. Jessica Bon] (0:00 - 0:30)
It's very common and it kind of snowballs on itself. You're short of breath, you have anxiety, you become anxious. When we're anxious, our heart starts beating faster, we start breathing faster.

And people that have COPD, it's the problems getting the air out. So you need to have enough time to get that air out. So if you start to breathe faster, you're not able to get all the air out.

And that can cause trapping of air in your lungs, which is going to make you more short of breath and more anxious. So it really, it can snowball.

[Dr. Jean Wright] (0:38 - 2:37)
Welcome to the Lung Health Champion Podcast, brought to you by the COPD Foundation. I'm your guest host today, Jean Wright. I'm the Chief Executive Officer of the Foundation.

In today's episode, we'll hear from a healthcare expert about signs that your COPD may be getting worse. And she'll explain the different types of inflammation in your lung. We'll also get to hear from Tom, who is living with COPD, about what those changes and challenges actually feel like in daily life.

So whether you're living with COPD or caring for somebody who is, or you just want to be more informed, this episode today is for you. I'm so happy today that I am joined by Dr. Jessica Bond. As we say here in the South, she lives just up the road a fur piece from me.

So she is in the Wake Forest, Winston-Salem area, and I'm in Charlotte, North Carolina. And she had the good sense to move to North Carolina, what, almost a year ago? Almost two years ago.

No way, no way. All right. Well, you have added to the brilliance of our state by being here.

We're so glad that you're in a leadership position with Atrium Health, Advocate Health, Wake School of Medicine. You've just got it covered in spades. So I'm so glad that you're with us today.

I'm also joined here by Tom, who is a patient, and Tom's going to talk to us about his viewpoint and what it's like to live with COPD. So let's start off talking with a phrase that people hear a lot, but they may not understand. I'll kind of put it in air quotes, worsening COPD.

From a clinical perspective, what does worsening COPD actually mean?

[Dr. Jessica Bon] (2:38 - 4:07)
Yeah, thanks, Jean. I think from a clinical perspective, kind of simple terms, it's a decrease in your lung function or worsening of emphysema in your lungs or destruction in the lungs. Sometimes we also, when patients are having increasing exacerbations or flare-up of their COPs, we think of that as being worsening disease as well.

So I think from a physician's perspective, that's what we're thinking of, but I think that can mean a lot of different things to our patients in terms of how this translates to what the patients are feeling and experiencing. It can mean that you're having increased shortness of breath, that you're coughing more, that you're producing more phlegm or mucus when you cough. There may be things that you were able to do before that you can no longer do.

So I will often ask my patients when I ask, you know, I'm seeing them for their six-month visit, and I ask them, is there something that you can't do now that you could do six months ago? And they may tell me, well, when I used to mow my lawn six months ago, I only had to stop twice. Now I have to stop five times.

Or there may be things they can no longer do at all. So I hear a lot of, you know, I want to do this with my grandkids, play in the yard, throw a ball. It's really hard for me to do that now.

Or even when the progression is really severe, they may tell me that there are things like showering and dressing that now make me short of breath, and it wasn't like that before.

[Dr. Jean Wright] (4:08 - 4:18)
Wow, those are things most of us get to just take for granted on a daily basis. Why is it important to identify symptoms as they worsen?

[Dr. Jessica Bon] (4:18 - 5:54)
It's an exciting time for COPD treatment because I think for years we had the same medications that we used, inhalers, nothing really changed that much. There might have been different combinations of the types of inhalers we used, but we didn't have any new therapies on the market. But that's changed.

So we have new medications that are coming out that can address things like shortness of breath or flare-ups of the disease. Many of our patients that we've been seeing for a long time now are already on all the inhalers we have. So learning that they're having worsening symptoms, there's now things that we can do to help from a medication standpoint.

Also, interventions such as pulmonary rehabilitation, which is not a pill that you take, it's not an inhaler, but it's something that can be really valuable to a patient in terms of helping them be able to do more and have less shortness of breath and less symptoms with activity. That's something that we can talk to our patient about if they let us know that their symptoms are worsening. And then I think the other thing that I always think about is patients with COPD, people with COPD, it's not always the lung disease.

So there are a lot of other diseases that can cause shortness of breath. We know that people with COPD frequently can have things like heart failure, coronary artery disease. So I think going to your doctor and telling them that you're having more shortness of breath, we can think about ways to treat the COPD, but we can also look for other causes to make sure we're not missing anything.

[Dr. Jean Wright] (5:55 - 6:36)
That's so good. Yes, I don't think the patients know that in the back of our mind, we're going through a checklist and ticking off, would you be best on this medication or this medication? And as you're indicating, some of the newer ones are really for this more advanced disease.

So they may not know it. That's why it's so good that we can get them to open up and talk about it. Okay, Tom, you don't get to just sit there on the beach looking pretty.

It's time for you to get into this conversation. So tell us, as somebody with a lived experience of COPD, how does worsening or change of your symptoms show up in your life?

[Tom Krueger] (6:37 - 7:15)
Got to go about it a different way. I've been diagnosed with COPD severe in 2009. Oh, that's been quite some time ago.

And you just slow your pace down and try to do things better. But it takes longer to get something done. I have a very hard time with manual labor now.

So I can't do a lot of that stuff. But I learned to deal with it. The big thing is follow your pride and ask for help.

[Dr. Jean Wright] (7:16 - 8:42)
That's a good message right there. You know, the symptoms are so unique to people and how they live life. You know, you might want to walk down the street with one of your grandkids and now you know, maybe I can go down the street, but I can't make it to the park.

And what you want to do with your time off or your energy is different than somebody else. So somebody else may be wanting to bring in their groceries themselves. I remember, I have to talk about my family members that have this disease.

And I had an Uncle Fred who lived in East Tennessee and Uncle Fred would call me and he'd say, I can't get the pig up into the back of the truck. And so his definition of not being able to do what he really wanted to do had to do with the fact that he had been a farmer all of his life. And so just like you were saying manual labor, and it could be something as simple as, you know, planting a flower in your garden.

But all of a sudden now the energy that it takes, you know, is so much, so much worse. Dr. Bond, what do what do people notice? I guess this gets back to that underlying theme of digging it out versus them recognizing I used to do this and now I can't do it.

[Dr. Jessica Bon] (8:44 - 9:37)
I mean, I think the shortness of breath is probably one of the common symptoms that patients notice. And it is saying, I can't do this anymore, or I can't do it as fast, or I can't, like Tom's keeping up with the grandkids and things like that comes up a lot. And I think that just there are things I want to do that I can't.

So not only that I can't do things anymore, but there are things that I want to do that I just can't do anymore. And I think Tom brought up a really good point to like things like having to wear more oxygen and carry more, you know, equipment with you when you go places and it takes longer to do things. I think all those things are kind of symptoms and, you know, results of the symptoms that really impact the quality of life and daily life of our patients with COPD.

[Dr. Jean Wright] (9:38 - 10:01)
Good point. You mentioned cough, the frequency of cough or how it changes. I think we're not too far away from that, but sometimes it's subtle and people don't realize how much their cough has changed.

Is change in cough or mucus production a sign that things may be worsening?

[Dr. Jessica Bon] (10:02 - 10:47)
Yes, it can be. So definitely an increase in cough or more mucus production, even a change in the mucus. So I just can't clear the mucus anymore.

They feel like it's stuck in their chest and that that can be a sign of those diseases worsening. It could also be a sign that they're becoming weaker from the disease and they just are having more trouble getting the mucus, clearing the mucus from their chest. So, and it's, it's a really problematic symptom because it's not that the shortness of breath is not difficult to treat as well, but we really don't have great therapies for the mucus and for the patients that have, not everyone does, but the patients that do have chronic bronchitis with daily speed on production, mucus production.

[Dr. Jean Wright] (10:48 - 11:40)
That's right. That's right. And you know, using those inhalers takes a toll on somebody's immune system as well, right?

So now you're using, or you may be using your inhaler more and if it's a corticosteroid, you may be setting yourself up for more infections. So it's kind of a catch-22, isn't it? Yeah.

Many people feel that worsening symptoms may mean that they've failed or maybe aren't doing their best at managing their COPD. Tom, do you ever feel that way when, when you feel like you're making a turn in the wrong direction? Do you think, oh, you know, what did I do wrong?

Did I, you know, not take good care of myself? Did I just forget to wear the mask in the grocery store and maybe pick something up? How hard are you on yourself, Tom?

[Tom Krueger] (11:41 - 11:52)
Well, I think I do pretty well, but there are times when you get a, I like to call it a flare up because that exacerbation is harder to say.

[Dr. Jean Wright] (11:52 - 11:54)
That's a terrible word, isn't it?

[Tom Krueger] (11:54 - 11:57)
Yeah. Get that X out of there. Yeah.

[Dr. Jean Wright] (11:58 - 12:01)
Yeah. But, oh, I, I just had a...

[Tom Krueger] (12:01 - 12:44)
Flare or setback, that's a good term. Yeah. I just had about here, May 2nd, I felt something coming on, but wasn't quite sure.

And I've had other flare-ups, but they're not always the same symptoms. Oh, I was just more agitated all day and that, and here in the evening, May 2nd, I, I couldn't get my wind, just trying to suck and breathe different, and ended up with a ride to the ER. So, I just stayed for about three hours.

They did treatments and I was able to come home again.

[Dr. Jean Wright] (12:45 - 13:30)
Oh, my goodness. Well, I'm glad that you turned around that quickly. Yep.

But that, that's not a great way to spend your evening. You know, as we were preparing these questions that we're sharing with each other, there's one that didn't show up on this list that I've recently become aware of. I was in Washington, DC with some of our patients calling on the Capitol.

And one patient said to me, Gene, since the last time I saw you, I'm more anxious, more anxious. And she was noticing that when she gets short of breath, that her ability to calm herself during that was getting more and more difficult. Dr. Brown, is that, is that common?

[Dr. Jessica Bon] (13:30 - 14:33)
Yeah, it's very common and it kind of snowballs on itself, right? So, you, you're short of breath. And if I've been short of breath before and I get anxious, you know, when I'm short of breath, so you're short of breath, you have anxiety, you become anxious.

When we're anxious, our heart starts beating faster. We start breathing faster. And people that have COPD, it's the problems getting the air out.

So you need to have enough time to get that air out. So if you start to breathe faster, you're not able to get all the air out. And that can cause trapping of air in your lungs, which is going to make you more short of breath and more anxious.

So it really, it can snowball. And this, this is a problem I see non-uncommonly in my patients I treat in clinic that are, it's, you know, it's, it's a mix of the COPD is getting worse, but they're also having anxiety associated with that and trying to work with them and work on things like pursuant breathing and slowing down your breathing and focusing when you have these episodes to try to...

[Dr. Jean Wright] (14:33 - 14:52)
So it sounds like this is his symptoms. It sounds like he doesn't beat up on himself, you know, too much like that. But if you had a patient that was in front of you, Dr. Bonn, and he or she said, I'm worried I'm not doing the right thing, or why did this happen to me?

What, what are some things you could address with that kind of patient?

[Dr. Jessica Bon] (14:53 - 16:02)
Right. Well, first of all, it's, it's not, worsening COPD is not the patient's fault. This is oftentimes the natural course of the disease.

You can do everything right. Quit smoking. You can take all your medications.

You can go to pulmonary rehab and try to exercise, but some, a lot of times the disease will progress despite the, those things. So it's, it's really not, it's not the patient's fault. And we can kind of talk about, you know, there are other things that I can do to help you to try to, to stop the progression, stop the worsening, but it's, it's just not, I mean, we know that inflammation in the lungs is something that is what triggers a lot of the progression of the disease.

And they have actually done studies where they took lungs that were decades after quitting smoking and looked at them and there was still inflammation there. So it just goes to show that just, you know, you could do everything right, but this is just unfortunately the natural progression and this is the way the disease is.

[Dr. Jean Wright] (16:03 - 17:54)
Yeah. It's like it's imprinted itself on the lung, which leads us to a natural segue here to the second half of this podcast. We want to spend a few minutes where you can unpack this idea of inflammation.

We know that there's different kinds of white blood cells, right? My kids would always ask, is this going to be on the test? Right.

So I don't know for the patients listening, this won't be on the test, but you know, for the physicians that are listening or their providers, this will be on the test because understanding inflammation really is giving us keen insight. So we know in COPD, there's two types of inflammation. One uses or involves a kind of immune cells called neutrophils.

We hear of those because they help fight infections. They respond to irritants like cigarette smoke, pollution. The other type is called type two, and this involves different immune cells.

These are called eosinophils. And type two inflammation is more often linked to asthma, allergies. I think of it even linked to parasitic conditions.

Anything that gets in your system and causes a dust up, so to speak, is often in type two. We know both types can impact the airways and both contribute to getting worse. So let's go over some real world examples.

So you're sitting in your office and you're looking at that patient across the desk from you or sitting on the table. What are those specific markers or signs that you're looking for either in them clinically or in their chart or in their lab work? What are they telling you and what do their flare-ups sound like so that your alarm goes off and go, ding, ding, ding, ding?

[Dr. Jessica Bon] (17:54 - 19:18)
I'll start with the lab work because I think that's the easier thing to tackle. So we will start there. So yeah, so the type two inflammation or the eosinophilic inflammation in gene urea, we typically think of asthma and allergies and things like this, but we know that there is a subset of patients with COPD that have type two inflammation.

So typically, we can look at their lab. So they've had a blood count drawn. It will tell us how many white cells there are and what types of white cells there are.

So we're looking for that eosinophil, that type of white blood cell to be high. And that is a marker that this is somebody who has type two inflammation. So what does this mean?

So it's hard because I think we kind of historically think, well, the person with type two inflammation has more cough and sputum and they're at higher risk for exacerbations, which some of that may be true, but there's certainly plenty of patients that don't have type two inflammation that are coughing and producing mucus and are having flare-ups of their disease. So sometimes the clinical symptoms, it's hard to just look at them clinically and say, this is somebody that has type two inflammation. So I tend to first rely on looking at the labs and seeing.

[Dr. Jean Wright] (19:18 - 19:23)
It doesn't just pop out at you. It's not so obvious. It's more subtle.

[Tom Krueger] (19:23 - 19:37)
Jessica was talking about the disease is progressive, but there's ways for us to slow down the progression. We need to not be a couch potato. We need to get up and move.

[Dr. Jean Wright] (19:37 - 20:04)
So you're saying to us, the patient needs to take responsibility or understand how important that movement is. You know, we lost a dear patient this last year, Dr. Jean Romes, and she used to even sign her emails with a note about how important exercise was and it helped her live. But as she said, it also gave her a life.

She could do the things that she wanted to do, you know, for a long, long time.

[Tom Krueger] (20:04 - 20:05)
You got to keep moving.

[Dr. Jean Wright] (20:06 - 20:07)
Yep, absolutely.

[Dr. Jessica Bon] (20:08 - 20:18)
No, I agree. It's so important. And that, you know, exercising, pulmonary rehab, things like that, we know that that does prevent flare-ups.

So that can certainly have an impact.

[Dr. Jean Wright] (20:18 - 20:36)
So Tom, when you first started hearing about this inflammation stuff, was it your doctor? Was it something from the foundation? Was it another patient?

How did you first start hearing that phrase and understanding that there might be, you know, different treatments or different things for you to do?

[Tom Krueger] (20:36 - 21:01)
I probably looked online a lot, but most of the time was probably from my doctor to begin with. You know, to begin with, you're in denial, you know, when you're saying, well, you've got chronic bronchitis, which I've had for years. And of course, I smoked for years.

And in 2004, I was told to quit smoking. Well, it took me another five years. It's tough.

[Dr. Jean Wright] (21:02 - 21:03)
It's really tough.

[Tom Krueger] (21:03 - 21:27)
I went cold turkey then, but I was on life support for 10 days too. Wow. I came out of that and I got a wonderful respiratory therapist group.

And my wife and my kids are a great support. That's awesome. There's a lot of people that don't understand what the disease is.

[Dr. Jean Wright] (21:28 - 22:29)
They see it, you know. And I'm glad you talked about your support system because I worry, you know, as we get older, our kids move away or they're not, you know, as available to us, or maybe some of our friends have passed. And here you are trying to keep yourself from getting an infection.

You don't want to get flu. You don't want to get RSV. The risk of isolation, right?

Then also making you less likely to be a couch, more likely to be a couch potato, as you said, or stay home. It all adds up, you know, on top of it. Dr. Bonn, we said there's eosinic inflammation and there's neutrophilic inflammation. How do those cases look different with patients who have those two different kinds? And where does your thinking go when you're talking to somebody like Tom? Do you try to put him in a box or could he be in two boxes at the same time?

How does that work?

[Dr. Jessica Bon] (22:29 - 23:40)
It's interesting because we don't have great markers, blood markers for neutrophilic inflammation. We kind of assume that if we look at the patient's eosinophils and they're not high, then we put them in that non-type two inflammation, which we assume is neutrophilic inflammation. So there's not really a marker that we can look at for that.

And as I said before, the patients that have neutrophilic inflammation, when we're seeing them in clinic, they still have exacerbations. They have flare-ups, they may have cough and sputum production. So the clinical symptoms can overlap oftentimes.

And it's actually a more challenging group of COP patients to treat because some of the new medications that are coming on the market that target inflammation only target the type two eosinophil inflammation. So I think it's our job as physicians and as researchers trying to find those therapies that can specifically target people with COPD that have the neutrophilic inflammation or the non-type two inflammation.

[Dr. Jean Wright] (23:40 - 23:51)
Tom, have you recently undergone a change in your medications or how you approach your disease? Do you feel like you had to step up or change therapies?

[Tom Krueger] (23:51 - 24:39)
Well, there's some that nebulizers that I've gotten in the last seven months. I got one that works pretty good. I feel it does.

And I also got some that I nebulizes that it gives me the shake so bad that I don't use. Because I already got what they call the Kruger shake. And that's for the family.

Then it gets so that I can't write decent or anything. But I've been trying it again, the one nebulizer, because I guess it does help, open airways. But I'm a little leery of it.

[Dr. Jean Wright] (24:40 - 25:03)
And I don't want to make you uncomfortable, but sometimes patients with advanced disease are asked to consider like surgery on part of their lung or medications that might be an injection. Have you ever looked at any of those other kinds of treatments or things that might help some patients who have advanced disease?

[Tom Krueger] (25:04 - 25:14)
Well, not a whole lot except a lung transplant. Oh, wow. I'm checking into that now.

Wow.

[Dr. Jean Wright] (25:14 - 25:19)
That's a big decision, isn't it? Yep. Yep.

That's a big decision.

[Tom Krueger] (25:19 - 25:29)
I'll tell you, I had other ones that I know a close friend of mine I grew up with, he had it done and he's been over a year now and he's doing wonderful.

[Dr. Jean Wright] (25:29 - 27:09)
Yeah, for the right patient at the right time. It does offer hope to some, but not long ago I was talking to somebody and they said their loved one did not get much of an extension of life because we also know there's all sorts of complications. I've never had to face a decision like that.

I don't know where I would stand in that. But there are patients, one of our favorite patients has had a double lung transplant and it's amazing the number of things that she can do. But what I've learned, especially being in this role, is some people they don't get a Dr. Bond as their doctor. Dr. Bond's going to help you make a decision, oh, your disease is escalating, it's getting worse. We need to like step up and think about different medications, maybe surgery, maybe there's a big bleb in your lung and we need to reduce that so your gas flow and air exchange is better. And I really feel for patients who don't know what those other options are down the road or at least whoever's talking to you, Tom, is saying here's the full deck of cards, right?

Here are the things you could look at and I'm sure grandkids has to factor into it a lot because so many of us aspire, like I've already told my kids, I want to be a legend to your grandkids, right? But not just a memory, I want like real lived experiences, right? Where they can go, we couldn't tell where grandma got crazy and when she just was crazy to begin with.

I just want to have so much fun with them.

[Tom Krueger] (27:09 - 27:21)
That's just what I'm doing with checking in to see if I qualify and then it's my decision after that and all my other meds that I don't think there's anything else that was going to help me.

[Dr. Jean Wright] (27:22 - 27:38)
Yeah, so if we were giving some takeaways to the people that are listening, let me ask you, Tom, what kind of advice, takeaway, what do you want to make sure that they really heard from your heart today?

[Tom Krueger] (27:40 - 28:07)
Well, exercise is a big thing. Great. If you keep that going, you keep track of what you've done to start when you do exercise.

Pulmonary rehab, that's the best way to go. Absolutely. So they keep track and you don't think you improve, but at the end of that series or whatever, they'll show you the difference.

Yes.

[Dr. Jean Wright] (28:07 - 29:13)
I know when I first got into the science of this field, I kept thinking, wait a minute, how does this improve your lungs? How does this do this? And then what I realized was it improves all the rest of your body.

So your lungs are limited into the amount of oxygen it can bring in and CO2 it can take out. But when the rest of your muscles get more efficient and they do the work better, then you benefit. And just like all conditioning, if you've ever broken your arm and you put it in a cast and when the cast came off, you're like, wow, what a shriveled up weak little arm I have.

The good news is with exercise, it comes back. So even patients who are hospitalized and they lose the progress they were making in rehab, slow, steady, attention to good nutrition, getting enough protein, getting back on the treadmill or doing whatever you can do to help you is an important thing. And Dr. Bond, what would you wrap up and put a bow on today for our patients and healthcare providers that are listening?

[Dr. Jessica Bon] (29:14 - 29:58)
Yeah. I would say if you have COPD and your symptoms are worse, you're more short of breath, you're producing more mucus, you're coughing or talk to your doctor because there are things that we can do to help. And like Tom said, it's kind of, you know, you get your options and you come up with a plan together.

So there are exciting, potentially new therapies on the horizon. And this isn't a disease where we just have a handful of medications and nothing else to offer at this point. So I think we need to recognize that, you know, be open.

And, you know, even if it's that you can't load that grass, you have to stop five times to mow that grass instead of three, let your doctor know.

[Dr. Jean Wright] (29:58 - 31:23)
That's a great point. Notice those things yourself and then don't cop out and say, I'm fine, right? You know, because those little symptoms can really make a difference in helping physicians like Dr. Bond decide how to escalate care. So if this episode resonated with you, I hope you read our companion blog post. Please use the resources of the COPD Foundation. You know, we are very careful to have physicians like Dr. Bond and a host of really smart doctors take a look at this so that you're getting really curated information that's the most recent, you know, the most accurate. And then if you need somebody to talk to, give us a call. We have patients on the line that can also, you know, listen to you and with you and talk with you. Share the episode with somebody that you think needs to hear it.

And thank you for listening to the COPD Foundation podcast. And let me close by saying, you know, thank you again to Dr. Bond, to Tom Kruger. For those of you that are listening, thank you for being a listener to the Lung Health Champion podcast.

We intend to bring you solid scientific information in a digestible way that patients, caregivers, and physicians all find value in it. And we know that you too can be a lung health champion. So join us in this fight.

Thank you.

[VO] (31:25 - 32:23)
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