Smoking remains the top cause of chronic obstructive pulmonary disease (COPD), but environmental factors and occupational risks are also important, explains Meilin Young, MD, a pulmonary and critical care specialist with Allegheny Health Network.
Traditionally, COPD was predominant in men, who were more likely to chain smoke or work in jobs that exposed them to pollutants and other caustic agents that cause airway diseases. However, women are also exposed to these risks more, and the prevalence of COPD is rising among this group, but it is often under recognized until later in the disease.
Given the role of environment and occupation, prevention of COPD can be a challenge, Young said in an interview with The American Journal of Managed Care® (AJMC®). It is not realistic to ask someone to move or to change jobs.
AJMC®: COPD prevalence in women is rising and they have worse outcomes—why do you think this is?
Young: A lot of it has to do with smoking and exposure to biomass fuel. So predominantly, it was always men who would be the chain smokers. They're the workers. So, they get exposed to a lot of the pollutants and the other caustic agents that are going to cause a lot of the airway disease—especially with chain smoking. But then over the last few decades, women have started picking up smoking a lot more. We've noticed that it’s nearly equivocal now in terms of women being diagnosed with COPD, just because they're starting to smoke a bit more.
For some reason, we do notice that when women come into the office and get seen, they have a little bit more advanced disease. But I think it's just because it was under recognized for quite a bit of time until we started noticing a trend of women are doing just as much as men are in terms of exposures and developing the disease.
AJMC®: Does COPD present in the same ways in women and in men?
Young: Relatively similar overall. You'll have them coming in with shortness of breath as the main complaint. Women, they noticed that a little bit different. Women, in terms of what their activity levels are, changes compared to men. Men in the workforce, if they're lifting heavy objects, it's a little bit harder for them to do certain tasks at work. Whereas women, if they're doing general tasks, for example, childcare or whatever occupation they're at, they might not be exerting themselves as much until they get to the point where it's so profound that it's impinging on their ability to enjoy normal things, such as lifting their kids, chasing after their grandkids, going to work out at the gym, or anything else like that. Then they start becoming more aware that, “Hey, I can't do what I used to do, there's something different.”
I feel like for women, we try to let things go a little bit longer, until finally it starts becoming unbearable, and then we start to then try to figure out what's going on.
AJMC®: What kind of racial disparities do you see with COPD and emphysema?
Young: It's going to be all dependent upon the locations, but predominantly, we always see the typical the populations that are always underrepresented in most areas. So, African American individuals are always going to be diagnosed a little bit later in life because of access to medical care. We do see a lot of urban populations being diagnosed less because of the overall access. People who live in the suburbs have more access to physicians. Potentially, they have more access to care. Finances also play into it.
A lot of the limitations with what we see in a lot of other disease entities and a lot of other issues is just a lot of our socioeconomic status. And that kind of goes along with then the racial disparities that we see, because predominately African American populations live in the urban areas, and the suburbs are going to be a more Caucasian, more affluent population. We do see the discrepancies because of the socioeconomic background.
AJMC®: What can be done to increase pulmonary rehabilitation for COPD?
Young: A lot of it is access and awareness. Most of the time, if it's a diagnosis of COPD. The recommended guideline is that all patients be engaged in pulmonary rehab. And a lot of it is the diagnosis and recognition. In order to be a candidate for pulmonary rehab for Medicare and CMS, you have to have a qualifying diagnosis. So, you have to have confirmed COPD or emphysema in order to be a candidate for pulmonary rehab. Then you also have to have the provider be aware that, “hey, patients can go to pulmonary rehab” and discuss, “it's different than just going to the gym.” It's a different program. It's a different expectation. overall. And it's different individuals. When patients are aware that this is another resource, and because it is covered by insurance by their diagnosis. it's a very low cost. It's honestly the access and awareness once again of it, too.
For us, we have providers who ordered the pulmonary rehab referral, but then after that, it's all dependent on the patient to try to go to the pulmonary rehab sessions and sometimes the hours don't work with their day-to-day schedule. But if you have a coordinator or some sort of task force in place to help bridge that gap—transportation, finances, or some sort of assistance for it—and just seeing the benefits that pulmonary rehab might provide, the patients are more willing to then participate and actually continue.
AJMC®: Given that you practice in western Pennsylvania, what kind of occupational hazards do you see that play a role in developing COPD, and is there anything that can be done to prevent the disease from developing?
Young: The number one factor that we always see is smoking, but it also depends on what parts of Pittsburgh that you live in. My practice is based down south a little bit in the Jefferson area, so the Clairton mills and coal workers. Any sort of inhalation of particles also puts you at risk for developing COPD and smoking on top of it, it's like a 2-fold increased risk. But we do have a lot of patients from the sheer fact of secondhand smoking, where are they grew up and just that environment, and the air quality plays a big factor into it.
Prevention is hard, because once again, industrialization is a big aspect. The region itself is dependent on a lot of different things like the steel mill, the coal miners, etc. We can’t just tell patients to just quit their jobs or to move somewhere else, because that's just not practical. A lot of it is just making sure that they're wearing the proper respirators. That companies and industries are using the proper equipment to just protect the patients, in general. Also making sure that they aren't doing other things that are going to accelerate the rate of their lung decline. If they are smoking, tell them to stop smoking. If there are certain chemical agents that they know are also caustic to try to avoid it or anything else like that.
But it's just it's a difficult battle, because once again, we can't tell the patients to just quit what they're doing, because that is their livelihood, or quit where they're living, because that's where they're from.
AJMC®: How does emphysema impact the quality of life for the patient?
Young: For emphysema, the best way to describe it, your lungs are literally full of air. A hot air that you're just not participating at all in gas exchange. The air becomes, essentially, trapped. If you imagine, people with COPD or just sensitive lungs, in general, it's hard to get the air in. And then once you finally get the air in or the air out, it's not participating at all with what you need for just day to day function or just for oxygenation and ventilation.
For patients with emphysema, it's a bit harder because not only are they obstructed because they can't get the air out, but the air that they get in, it just compounds and adds on to it, because those lung units are not being used at all. They're wasting lung units essentially. It just keeps contributing more so to the patient's shortness of breath, because they essentially get filled with more air that do nothing for them.