ATS_BEP_046_Erika_MeiLanHan_Second_Edit
non: [00:00:00] You are listening to the ATS Breathe Easy podcast brought to you by the American Thoracic Society.
Erika: Welcome to the ATS Breathe Easy podcast. I'm your host, Dr. Erika Moison, a pulmonary critical care medicine physician in Oregon and host of the Air Health R Health podcast. Today we are here to talk about non-smoking causes of COPD, and I'm delighted to be joined by Dr. Melon Han. Dr. Han, why don't you introduce your.
Meilan: All right. Thanks so much, Erika. So my name's Melan Han. I am a pulmonologist at the University of Michigan. I'm chief of pulmonary critical care there. And I'm also, I guess, relevant to this podcast, a member of the, gold Committee that writes a lot of the, international recommendations on diagnosis and treatment of CPD.
Erika: And thank [00:01:00] you very much for doing that. I know it's a mainstay of those of us working in clinic, so we, we often think about cigarette smoking causing COPD, but we're here today to talk about other things besides cigarettes that can do that. So what are the main environmental or behavioral causes of COPD besides cigarette smoking and how do they vary, you know, here and around the world?
Meilan: So the estimates really vary, I think depending on the literature you look at. I think one of the numbers I always remember is a roughly 25%, of CPD is not related to, personal, cigarette smoking. I think one of the challenges though, is when I think about the number and then I think about my own clinic.
Those numbers don't always match up. And then I wonder how many of those patients are just sitting out there not diagnosed. So I always wonder about that a little bit. but I think that there are many, many things that likely contribute to, non-smoking related COPD. [00:02:00] And they range from factors of prematurity thing, you know, respiratory distress and infancy, recurrent respiratory infections during childhood.
Could be maternal smoking, family, poor air quality in the home. one of the things that we talk about a lot from a global health perspective, our biomass fuel. associated sup d and I think one of the eyeopener moments I had about that a few years ago was when I was reading there's a paper from Can Cold that talks about, was looking at risk factors for Sup PD and they actually, identified biomass exposures being a risk factor for development of sup d, particularly in women in Canada.
And I remember thinking about the paper because we think associate that with. I think people cooking over in, in either, you know, poorly ventilated areas in you know, in [00:03:00] parts of the world like India or China or Africa or, you know, open flames or that sort of thing. But, so I was very confused when I read this paper from Canada and I was, and so I remember chatting with a few of the authors about it and they said, oh, it's Milan.
This is all from Woodburn. Stoves in people's homes. And I was like, oh. Which, you know, that really varies, I think depending on where you are in the country. But I grew up in Idaho and I would bring stove in our house growing up where I'm gonna put call maybe emerging threats. also include things like climate change.
Air pollution. I think we knew for a long time or that it air pollution contributes to exacerbations of COPD and asthma, but now there's data suggest it can actually be causative, for those conditions. and then I think, you know. The other question I think is sort of out there as [00:04:00] well is what is the contribution of vaping, and to what extent is that going to be a major cause for CPD in the future?
I think there's definitely concerns some of the, we don't have a lot of that long-term data yet, but, so the, the, I guess to answer your question, the list is really long.
Erika: Absolutely. You know, it's interesting. I, I see a similar thing out where I am 'cause I live in Oregon and, you know, electricity and even, you know, gas to heat homes can be very expensive.
But we got trees everywhere. So there's a lot of people lighting fires inside their house. And you know, the tagline of my other podcast is don't light things on fire and breathe them into your lungs. So basically everything that we can light on fire from biomass to cigarettes, to wood in the house. To, to the air pollution and diesel fuel outside, I think we worry about causing obstructive lung disease.
And then you touched briefly on genetic or birth factors that can cause COPD. You know, I think we think of alpha one antitrypsin and prematurity. are there other things we should be thinking about when we're interviewing a patient [00:05:00] who hasn't smoked but is seeming to have obstructive lung disease on their PTs?
Meilan: Yeah. One other thing I forgot to mention is, but is obvious is asthma. So I think that's where it gets kind of confusing when a patient starts out with asthma and then they develop more permanent or fixed airflow obstruction. And now that we're recognizing more type two inflammation, ccp, it starts to get very gray.
Um, but you know, you do, but you do raise a good point in terms of the history, so. In my own clinic, I do start every new patient, questionnaire or sort of, you know, history with birth history. There's actually some interesting data that I came across that suggests that maternal smoking. During pregnancy, and it's actually the nicotine itself.
So if they were, for instance, to replace it with e-cigarettes, that doesn't necessarily get around that problem, but that nicotine exposure [00:06:00] itself actually can, contribute to the development of long and tortuous airways in the infant. Hmm.
non: And
Meilan: then there's actually some other data to suggest that that can be mitigated with vitamin C interestingly.
So that's a little bit of a, a detour, but, but I'll start with that. I'll ask about, you know, prematurity. I'll ask about any respiratory, um. issues during childhood, frequent infections, pneumonias, asthma, and so I'll just try to kind of go throughout. And then also, you know, I think the attributal risk is somewhere between 10 and 15%, but jobs that people have in adulthood, uh.
You know, a few years ago, it's not COPD, but a few years ago there was, increased awareness over, silica exposure in, in California and how a lot there, you know, several workers actually developed respiratory failure. So, but I think that's probably a lot of other factors in the home or at work [00:07:00] that we don't, often ask about that and probably are not studied as well as they should be.
But, so I do try to. Ask about, you know, okay, what do you do for a living? And just try to get a sense for the different kinds of jobs people have had and what the kinds of exposures, as well as a little bit more about living conditions in the home. do they live in a, like a multifamily housing unit where they maybe could, you know, be.
Getting exposed to cigarette smoke that way, et cetera. So, a lot of, you know, potential places where people could be exposed to things that could be harmful for their lungs.
Erika: Absolutely. Are there common features that characterize the clinical course of COPD in non-smokers versus smokers?
Meilan: So that's a good question.
There's the data that's out there suggests that non-smoking COPD, and some of this data [00:08:00] comes from places like China and Mexico, where it's probably more, for instance, more biomass exposure related, suggest that the phenotype may be more airway centric and that there may be less emphysema. Now whether that, is associated with a difference, for instance, the next obvious question would be, does that mean you should be treating these patients differently?
We just don't have a lot of data on that because if you look at all of the clinical trials for pretty much all the drugs that we use in CPD, the FDA pretty much requires that they be done in patients with, you know, 10 pack year smoking history. That's the inclusion criteria for. Almost all of these studies, so I don't, we don't have the answer to that.
'cause nobody's, nobody's done those studies. And to be honest, I've thought about it as a 'cause. One of the other hats I wear is as a. you know, physician scientist and a clinical researcher. Trying [00:09:00] to put a group of patients like this together for a clinical trial is really challenging because I think a lot of times they don't come to clear attention in the healthcare system or they get labeled as something else.
So I think it's, it would be, it's data we, I would love to have, but I think getting it would be really hard.
Erika: Well touching on that, so you mentioned serving on the Gold Guidelines Committee, so I imagine gold doesn't distinguish in its guidelines for managing COPD and non-smokers from smokers.
Meilan: No, they don't really, because we just don't have data.
Um,
Erika: yeah. And often I, these things overlap, right? You know, you grow up in a home with a mom who smokes and then you become a smoker and also you're burning wood and it's hard to tease out what exactly caused what
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Erika: so our clinicians are often short on time, but wanna provide patients with resources.
Um, and so where do you direct patients for more information on living with COPD or where do you recommend people send folks to kind of help them stay healthy and get more information when they're not in the clinic setting?
Meilan: There's a, I think, so I think there's a, a lot of different resources both for patients and physicians.
So I'll just mention some of my favorites. the COPD foundation for one, has a lot of great, patient ed. as does the American Thoracic Society and American Lung Association all have good, I think patient, resources are all places to look. Um. Gold also has, information, although I [00:11:00] think Gold's information is probably a little bit more physician centric than it is patient centric.
Um, the other place, that I'll point both clinicians and patients to, is up to date. So I think clinicians know or and are very familiar with that as a resource. it does get updated more often than gold. We do gold once a year, but UpToDate really is up to date. and then, but people may not know that UpToDate also has some patient ed sections, which actually I know about 'cause I helped to edit some of them.
And so we try to keep those updated for patients. And that's free, right? So the physician behind the firewall, but the patient ed stuff are UpToDate's free. so those are all, some, I think various places that patients and providers can get more information about. CPD.
Erika: And then one of the things I often think about with COPD is, often these are things that are done to people just from the air they breathe.
They [00:12:00] develop these illnesses, especially in the non-smoking context. So, what steps can communities take to decrease the burden of COPD, especially, you know, non-smoking COPD, and also make living with COPD easier.
Meilan: Yeah, there's like so much in that that we could spend like the next five days on that topic.
But so, um. When it comes to tobacco, right. So a lot of, pol things have already been put in place to limit tobacco in like bars and restaurants and things like that. From just like a policy perspective. I actually went to, the city I live in Ann Arbor. I actually testified, a few years ago. It's the first and only time I've done this at a, city hearing.
They were talking about moving the age limit for purchasing tobacco. And I think one of the important things to remember that pulmonary physicians know is that lungs don't really reach maturity [00:13:00] until you're about 25. So, so. So that's something to think about as well, is trying to keep people, keep that out of people's hands as long as possible.
Okay. But that's the tobacco stuff we're here to talk about non-tobacco. So non-tobacco, that's things like clean air, right? So anything we can do, and certainly, I'm worried about the EPA currently at it from a national perspective. Right. But, a lot of the, the laws and protections that were. Put into place 20 and 30 years ago now.
Ha did really did make a big difference in cleaning up our air and it's really important that we maintain or even further improve those, those protections. I. And then there's also like smaller policy things sort of on a city level. So for instance, limiting smoking in multi-family housing units.
[00:14:00] Um, even there's even some data to, well, I can't, it's hard to maybe fully make the line to COPD, but it does impact respiratory health for children. So I, I'm gonna raise it. There's data to suggest that when, for instance, schools are near, busy, you know, busy traffic areas, those children experience worse lung function, more wheezing episodes, and when children are moved away from that environment.
That all gets better. So that kind of impacts stuff like where you build schools. You don't want them necessarily near, near, you know, high traffic zones. It impacts things like, some schools, there's actually, I think there's some in information on the EPA website. definitely I think on the American Lung Association website.
On like having schools adopt anti-idling policies. So those are a lot of different things. and they just touched the surface. but, you know, vaccinations, um. Breastfeeding, [00:15:00] promoting breastfeeding in moms, again, can promote healthier lungs, and reduce the risk of respiratory infections. You know, I think as an adult pulmonologist, I often forget that in children worldwide pneumonia is like one of the leading causes of death in, in children.
Not to mention the fact that, actually there's some super interesting data, that, VI Isha has that I just saw coming out of her beacon cohort. So. The Beacon cohort is a, young, group of individuals in the uk. Okay. Granted, they are like, I know we're talking about not smoking c today, today, but it's a little bit hard for me to separate them, but,
Erika: well, I think that's the reality of the world.
These things are hard to separate. Right. You know, I'll see someone in clinic who smoked a few pack cigarettes in Right. College and they say they're there with their COPD from that. And I'm saying, you know, I think maybe it's the long lifetime of diesel trucking that is getting you here.
Meilan: Yeah. So these individuals all have a little bit of a smoking history, but they're pretty young, so not [00:16:00] like a huge smoking history.
But what she found was that, um. Both upper and lower respiratory tract infections, like things that we might call a cold, were associated with more rac with lung function to climb.
Erika: Hmm.
Meilan: And, even in young individuals. And so it just, to me, the other kind of loop that keeps playing in my head is I keep thinking about during the pandemic when all of us were a lot more careful, a lot of people wearing masks and particular our patients with COPD were, were, um.
All being very, very careful. And, we really saw exacerbation rates plummet. And,
Erika: how many of my patients said it was their best year ever?
Meilan: My son,
Erika: you know, they were just out of not in the hospital having a great time and it really makes you think about that burden of infection.
Meilan: Yeah. My son who has, it's probably asthma, but I won't call it that, I'm gonna [00:17:00] call it Reactive Airways disease, but he gets, he gets the fall wheezing episodes with these infections and then has to go on inhalers.
And even he, he had the best two years breathing wise of his life. You know, when we think about how do we, you know, protect the lungs and try to reduce the risk of developing airflow obstruction, I think we underestimate the role of respiratory infections and particularly viruses really throughout the lifespan.
Erika: Well, and I think it's a challenge because a lot of these things influence each other, right? So we know that inhaling particulate matter and smoke and air pollution changes the immune system of the lung. Even after wildfire events go through the following flu season can be more severe. Right? So then that increases your risk of infection, and then you can kind of be off to the races with a vortex of illness, I guess, as they say.
Yeah.
Meilan: Well, you know, to me, most interesting data that came out of the pandemic was that. Study, I think it was some Harvard researchers, but they looked at COVID infections in the American, in Oregon during the summer of 2020, when there [00:18:00] were wildfires. And they found more COVID infections and more COVID deaths.
And that relationship between air pollution and infections had previously been reported. But like you, like, we'd never been tracking. The infections at the level that we were tracking them during the pandemic. And so you like could really see, okay, we have this exposure in this spot, and I can tell you exactly how many more infections and dust we had related to that exposure.
And that really kind of just hit me that were all probably walking around with these insults all the time. But we don't really know the damage that they've done unless you're sort of in this, you know, kind of situation where your, you know, lungs are getting extra stress. And then it also really kind of made me wonder, I realize we're kind of going off topic here, but it also made me, it also made me think about.
How we saw such variation in, COVID related complications during the [00:19:00] pandemic. And why some patients who we thought were pretty healthy, why did they have such a horrible course? And then this other patient who had chronic lung disease did great. and I think, I don't, it's probably not all of it. I'm sure it's differences in immune system and things like that, but I do wonder whether.
Underlying lung inflammation from, you know, that you just didn't know you had from some exposure from work or the home that you didn't know you were getting, you know, modulated the severity of illness that we saw during the pandemic.
Erika: Absolutely. Well, I think our main take homes here are, to have less things on fire in our communities, whether they're cigarette butts or forests or diesel fuel or indoor, you know, dirty air and hope we can get pregnancies to full term and then try to keep the air clean and people vaccinated to try to.
Do the best by our COPD patients. And then for treatment, we just follow the beautiful gold guidelines, which I think you have participated in making. So thank you for [00:20:00] your service.
Meilan: Well, thanks Erika and ATS for highlighting this during, COPD awareness month. So thank you. Just one of the things that this conversation reminds me of is just how.
That all the stuff that we talked about today. A, I probably don't talk to my patients about it enough. Right? And B, how little I think government policy makers, insurers, people in charge, like, you know. Probably really understand about this. So it's great that we have probably ATS members listening to the podcast about this, but this is the kind of thing that really needs to get outside of the ATS community if we're really going to.
To try to, you know, prevent COPD for the next generation. [00:21:00]
Erika: Absolutely.
non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats, breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.