Diseases and Disorders:

PULMONARY MEDICINE

Asbestos Related Lung Disease
Asbestos injures the lungs and surrounding tissues in several different ways. Just the mere exposure to asbestos causes inflammation in the lining around the lungs (pleural space) and on the surface of the diaphragm, which is the muscle that assists us to breathe. Doctors can detect evidence of prior asbestos contact by examining x-rays and CT scans of the chest. In people with prior asbestos exposure these studies reveal calcification along the diaphragm and the lining of the lungs. In itself, the calcification of the diaphragm and pleural space is not harmful; it only serves as a marker of exposure.

Exposure to asbestos increases the risk of lung cancer and mesothelioma, a malignancy of the lining around the lungs. Mesothelioma occurs almost exclusively in people with prior asbestos exposure.

Some individuals with prior exposure to asbestos suffer from a disease called asbestosis. Asbestosis describes the scarring and destruction of the lungs, which results from inhaling asbestos fibers. Asbestosis usually develops many years after the initial exposure to asbestos; in some cases the delay between exposure and the onset of asbestosis can be as long as twenty to twenty-five years. Some patients have no symptoms from asbestosis, but others suffer from severe shortness of breath, fatigue and cough.

Asthma
Asthma is the intermittent inflammation and narrowing of bronchial tubes, which provide the passageway for air movement. It may occur in almost any age group ranging from infancy to old age. The main distinction between asthma and emphysema or chronic bronchitis is reversibility. Asthma occurs episodically in the form of “attacks.” In between these attacks, many patients experience no symptoms and go about their business uninterrupted. Jackie Joyner, an Olympic athlete, suffered from asthma, took medications on a regular basis, and still competed in the Olympics in track and field. With effective management of the disease, people can live relatively normal lives.

A variety of environmental exposures and other health problems may trigger asthma attacks. Many asthmatics suffer from severe symptoms related to allergies. The various allergens capable of triggering asthma attacks include dog, cat, and other animal hair, as well as dust mites, weeds, grasses, molds, trees and even cockroaches. Upper respiratory tract infections, acid indigestion and sinus infections may also provoke asthma attacks in some people along with exercise or physical exertion.

People suffering from asthma attacks usually complain of shortness of breath, coughing and wheezing. The wheezing sounds like a high-pitched noise similar to a flute and frequently worsens at night. The classic dry cough of asthma intensifies during the night as well.

Chronic Bronchitis
Chronic bronchitis prevents the complete exhalation of old, stagnant air from the lungs through inflamed and narrowed passageways of the bronchial tubes. The air passes through the much narrower tubes at a slower rate and not enough time exists between breaths for all the old air to escape. Imagine a liquid or gas flowing through a pipe. If the force pushing the liquid through the pipe does not change and the diameter of the pipe shrinks, the liquid will flow slower and require more time to transverse the length of the pipe. Since our bodies naturally initiate a new breath every four or five seconds, people with chronic bronchitis lack sufficient time to exhale completely before starting a new breath.

The inflammation of the airways associated with chronic bronchitis also produces mucus. People who suffer from chronic bronchitis cough frequently in order to clear this mucus from their airway.

The word chronic means persistent. Chronic bronchitis does not go away easily or quickly. This “chronic” component distinguishes it from the routine bronchitis most people associate with chest congestion and transient coughing. This more common “acute bronchitis” lasts only a week or two before disappearing.

The symptoms of chronic bronchitis wax and wane. Any upper respiratory congestion, viral or bacterial infection of the bronchial tubes can worsen the symptoms. Exposure to smoke, high levels of pollution, cold air or perfumes aggravates chronic bronchitis as well.

Emphysema
Emphysema refers to the destruction of the tiny air sacks on the perimeter of the lungs. Damage of these tiny air sacks or alveoli decreases the elasticity of the lungs and prevents the lungs from recoiling naturally. Imagine a balloon. When it fills with air it expands and inflates. If one unties the knot keeping the balloon closed, the air escapes and the balloon flattens back to its previous small size.

The lungs function in a similar manner. When we exhale, the lungs deflate and shrink back to their natural size. Emphysema destroys this natural ability of the lungs to recoil to their small, natural size. Consequently, patients with emphysema cannot exhale all the old air in their lungs before initiating a new breath. A small amount of air remains in the lungs after each breath and the lungs gradually increase in size due to accumulating amounts of retained air. Doctors label this gradual expansion of the lungs “hyperinflation.” Patients with pure emphysema usually do not cough or expectorate phlegm. Their main complaints consist of persistent fatigue and shortness of breath.

COPD
Distinguishing between emphysema and chronic bronchitis is often difficult. Most patients suffer from what is referred to as overlapping symptoms. For example, people often are adversely affected from the destruction of the tiny air sacks in the lungs (alveoli) and the associated loss of elasticity characteristic of emphysema as well as the chronic inflammation of the airways common in chronic bronchitis. Sometimes patients may also experience attacks of wheezing mimicking asthma. Therefore, doctors often use the diagnosis of chronic obstructive pulmonary disease (COPD) to avoid making arbitrary distinctions, which can change from time to time.

Patients with chronic obstructive pulmonary disease (COPD) usually experience the symptoms of emphysema and chronic bronchitis. They have symptoms of a productive cough and mucus production characteristic of chronic bronchitis coupled with the shortness of breath and fatigue commonly present with emphysema.

Doctors usually confirm the presence of chronic obstructive pulmonary disease based on a variety of factors. A “history” is taken of any previous illnesses, symptoms, and other information to get a clearer picture and facilitate an accurate diagnosis. If you describe feeling short of breath, coughing up phlegm on a long term basis and fatigue, one of the first disorders to surface in your doctor’s mind will be chronic obstructive pulmonary disease. Your physician will also ask about smoking cigarettes and any possible toxic exposures in your work place.

Next, a chest x-ray is usually performed. In severe cases of COPD the results will show some abnormalities including flattening of the diaphragm (the large muscle separating the chest from the abdomen), abnormally large lungs and lucent air sacks at the top of your lungs technically called bullae. In milder cases of COPD the chest x-ray may be completely normal.

The most important tests in diagnosing and evaluating COPD are pulmonary function tests. These tests consist of three major parts: spirometry, lung volumes and diffusion capacity. The spirometry measures the amount of air a person can exhale from his or her lungs in a single breath. Patients with obstructive lung diseases cannot exhale air as quickly from their lungs as normal people. More than any other tool available in modern medicine spirometry quantifies the severity of lung disease. How much air a person can exhale in a single breath determines the severity of the obstructive lung disease.

Pulmonary function tests also measure the ability of the lungs to extract oxygen from the surrounding air (the diffusion capacity) and measure the size of the lungs (the lung volumes). For patients with obstructive lung disease the measurement of the lung size will reveal an increase in the total lung size and residual air trapped inside the lungs. Patients with emphysema will also not extract oxygen from the air normally due to the destruction of the tiny air sacks in the lungs (the alveoli).

Deep Vein Thrombosis
Thrombophlebitis or deep vein thrombosis (DVT) results from the formation of a blood clot in the veins of the leg. Any period of prolonged immobility such as surgery, a long car ride or a lengthy airplane trip decreases the blood flow in the legs and increases the risk of blood clots. Smoking, obesity, pregnancy and birth control pills also increase the risk of DVT.

Patients with this condition usually complain of swelling in one leg, but they may complain of pain and difficulty walking as well. The leg can become permanently swollen from damage to the valves if left untreated for a prolonged period of time. This phenomenon is post-phlebitic syndrome.

However, the greatest risk with deep vein thrombosis is not to the leg itself; a much larger threat is the development of an embolism. When this occurs, a portion of the clot dislodges from the leg and travels through the bloodstream to the lungs. If a blood clot (embolism) lodges in the lungs, a person can experience severe shortness of breath, chest pain and anxiety. In some cases, pulmonary emboli kill people.

Due to the risk of pulmonary embolism, all patients with a deep vein thrombosis extending above the knee require therapy with anticoagulants. The drug of choice for initial treatment is Heparin. This fast acting anticoagulant is administered intravenously for five to seven days before gradually being replaced by the oral medication Coumadin. For a period of three to six months patients take Coumadin to thin the blood and prevent new clots from forming in the legs or lungs.

Taking Coumadin increases a person’s susceptibility to bleeding. Consequently, patients on this drug are more likely to bleed from an ulcer, hemorrhoids or wounds. While on Coumadin, patients should avoid activities with a high risk of injury such as horseback riding, working on ladders or contact sports. In addition, patients on coumadin must adhere to scheduled appointments with their doctor and close monitoring through lab work. This close monitoring decreases the risk of unwanted bleeding.

Pneumonia
Pneumonia means infection of the lungs. The majority of pneumonias come from bacteria (bacterial pneumonia) and around ten percent result from other microorganisms, including viruses and fungi. Contrary to some common misperceptions, going outside with wet hair or leaving your house without a jacket does not cause pneumonia. The majority of pneumonias result from bacteria normally living in our mouth and nose, which inadvertently pass down the trachea (windpipe) into the lungs. Once the bacteria reach the lungs, they proliferate and cause fever, cough and chest pain.

Some pneumonias may be transmitted from person to person through respiratory droplets. A small percentage also comes from birds living in the house (psitacosis), sheep (Q fever), or wild animals (tularemia).

Pulmonary Emboli
Pulmonary emboli are small blood clots, which lodge in the circulation between the heart and lungs and prevent blood from flowing normally through the lungs. These emboli usually begin as clots in the veins of the legs or pelvis (deep vein thrombosis). Patients with cancer, inherited problems with blood clotting, and cigarette smoking are more likely to develop deep vein thrombi and eventual pulmonary emboli. Pregnancy, the use of birth control pills or prolonged immobilization associated with surgeries or long trips also increase a person’s risk of developing deep vein thrombosis and eventual pulmonary emboli.

Physicians generally treat pulmonary emboli with blood thinners called anti-coagulants. Treatment requires initial therapy with a short acting anticoagulant called Heparin. Doctors administer it intravenously so it begins acting immediately. Patients usually require a full week of Heparin therapy. During these seven days the physician will also initiate treatment with an oral anti-coagulant called Coumadin. This drug takes effect over several days and experts recommend continuing the Coumadin for six months. During this therapy, patients must check their clotting times every two to four weeks in order to monitor the medication.

Coumadin also increases the risk of bleeding. Consequently, patients with prior histories of internal bleeding or an intracranial hemorrhage may not be candidates for Coumadin. In these cases, we recommend the insertion of a titanium filter in the large vein in the abdomen (the vena cava). This filter catches any pieces of clot dislodging from the legs and migrating toward the lungs, thereby preventing pulmonary emboli.

Sarcoidosis
Sarcoidosis causes inflammation and scar formation in the lymph nodes at the center of the chest near the lungs. Although no one knows for certain what causes sarcoidosis, it affects women more often than men and occurs more frequently in certain racial minorities. In more severe cases, the inflammation and scarring in sarcoidosis may spread to the lungs themselves causing shortness of breath, cough and fatigue.

Tuberculosis
Tuberculosis is a slowly progressive bacterial infection of the lungs. Although public health officials have made significant headway in decreasing the incidence of tuberculosis in the United States, it remains common in inner cities, patients infected with the AIDS virus and immigrants from Latin America and Southeast Asia.

Tuberculosis often lacks symptoms and physicians frequently discover early tuberculosis on screening chest x-rays or skin tests designed to detect tuberculosis. In its later stages, this disease often causes fevers, sputum production, weight loss and shortness of breath.

With modern treatments, tuberculosis is usually curable. Most standard drug therapies require a combination of four different medications given for varying durations and in different doses over a period of six months. If patients suffer from a more resistant form of tuberculosis, longer, more intense treatment may be required.

SLEEP MEDICINE

Sleep Apnea
Millions of Americans suffer from the effects of sleep apnea. When patients with this disorder sleep, the muscles of their throat and neck relax, which allows soft tissue to block the airway. Snoring results if the airway is only partially blocked, but when the airway obstructs completely, the person temporarily stops breathing. Doctors refer to this cessation of breathing as apnea. Since this serious condition occurs at night, physicians use the term sleep apnea.

Once a person stops breathing, he or she wakes up briefly and then falls back asleep. This cycle of respiratory cessation and arousal repeats itself over and over. Some people with the most severe cases can stop breathing up to an alarming 150 times in a single night. This recurrent pattern disrupts the normal sleep cycle, and individuals with sleep apnea never feel fully rested. Consequently, patients with this illness fall asleep frequently during the day. In extreme cases, patients can doze off during the course of a conversation or even behind the wheel of a car while driving. Some sufferers also experience extreme fatigue and difficulty staying awake at work, which can result in the ultimate loss of their jobs.

Doctors screen patients for sleep apnea by observing their physical appearance and asking a few simple questions. Since the condition occurs more commonly in the obese population, heavy individuals heighten physicians’ index of suspicion. Professionals delve further by asking about the telltale signs of frequent napping during the day, excessive daytime sleepiness, and snoring at night. In addition people with sleep apnea sometimes complain of waking up with severe headaches.

If you describe symptoms typical for sleep apnea, your doctor may order an overnight sleep study. During this procedure, a technician observes the sleep of a patient in a laboratory that is equipped with a comfortable bed and surroundings similar to a hotel room. Instruments monitor the oxygen level over the course of the night along with the chest wall movements, airflow from the nose, leg movements, brain wave patterns and an electrocardiogram. With the detection of patterned breathing cessation, the laboratory will diagnose sleep apnea.

Upon the confirmation of sleep apnea, your doctor will probably recommend sleeping with a special mask called CPAP along with weight loss. The CPAP (continuous positive airway pressure) blows a small amount of air through the nose into the back of the throat. This pressure keeps the airway open and prevents the airway from occluding. A dramatic and overall improvement in well-being is usually reported by individuals with the use of CPAP. In rare cases, this mask might not help patients and physicians may recommend surgical procedures to remove the excess tissue in the throat and soft palate.

Narcolepsy
Narcolepsy is a rare disorder. Sudden and abrupt falling asleep without warning characterizes this condition. Sufferers perform their normal and usual daily tasks that may include driving, operating equipment, and talking on the phone among other activities, only to drop off to an unexpected sleep. Patients with narcolepsy also suffer from an associated cluster of symptoms including sleep paralysis and cataplexy. Cataplexy is the sudden loss of muscle tone following an emotional response such as laughing. Sleep paralysis describes the sensation of being alert associated with a complete inability to move. This usually occurs just prior to arousal in the morning.

Physicians specializing in sleep disorders, use a multiple sleep latency test to diagnose narcolepsy. Patients go to the lab for the procedure after a full nights sleep. Individuals with this disorder will fall asleep in the correct environment despite being well rested. In addition, the EEG pattern and eye movements of patients with narcolepsy demonstrate a tendency to fall immediately into the rapid eye movement (REM) phase of sleep. This distinguishes them from normal individuals who gradually progress from the early stages of sleep to REM sleep.

After diagnosis, physicians treat the disorder with medications. The two most frequently prescribed medications are Ritalin and Provigil. These medicines keep patients awake during the day and prevent the sudden, unexplained sleep attacks typical in narcolepsy.

Insomnia
Insomnia is the inability to fall asleep at night. Patients toss and turn frequently, sleep only for brief periods, and have a sense of overwhelming tiredness during the day. Doctors treat insomnia effectively using a combination of behavioral therapies and medications. Physicians usually recommend adjusting the patient’s schedule to retire at the same time each night and wake up at the same time every morning. Behavioral modifications also include using one’s bed only for sleeping and not reading or watching television in bed during daytime hours. When behavioral modifications alone fail to rectify the problem, most experts prescribe non-addicting sleeping aides such as Trazadone or Ambien.

Restless leg syndrome
Restless leg syndrome describes a poorly understood condition in which patients kick and thrash their legs repeatedly during the night. This constant movement disrupts the patient’s sleep and results in repeated awakenings during the night. These recurrent awakenings in turn lead to sleepiness during the day. Physicians diagnose this syndrome using an overnight sleep study (polysomnography). Once a diagnosis of restless leg syndrome is established, physicians prescribe medications such as Klonipin, Sinemet or Requip for treatment. These medications usually alleviate the symptoms of kicking during the night and sleepiness during the day.

Parasomnias
Parasomnias are abnormal behaviors during sleep. Sleepwalking and night terrors are the most well known parasomnias. Once again, physicians use overnight sleep studies (polysomnography) to diagnose these disorders. If an overnight sleep study demonstrates a parasomnia, physicians prescribe medications and behavioral therapies to treat the problem.