Advanced Emphysema

Today on At the Forefront, we're going to discuss COPD and advanced emphysema and the toll it takes on your lungs. We'll discuss some of the exciting treatments that are increasing lifespans and quality of life for people who are suffering. That's coming up right now on At the Forefront.

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And we want to remind our guests that today's program is not designed to take the place of a visit with your physician. We're going to start off with having each one of you introduce yourselves and tell us a little bit about what you do here at UChicago Medicine. You both have been on-- you're both veterans of the program. In fact, we were talking before the show, Dr. Hogarth you were actually on the very first program. So I appreciate you being back. Tell us a little bit about your role here at UChicago Medicine.

Sure. My name is Kyle Hogarth. I'm a Professor of Medicine and I'm a Pulmonologist. And I help run our Interventional Pulmonary Program. So I, with my colleagues, we do procedures inside people's lungs to either help them breathe better or to diagnose whatever might be wrong on the inside, whether that's lymph nodes or lung nodules.

And Ajay, we're going to go over to the corner with you. We're still doing our social distancing. So you're a little ways away from us. Tell us a little bit about your role here.

Sure. My name is Ajay Wagh. I'm an Interventional Pulmonologist. I've been here at the University of Chicago now coming up on three years working with Dr. Hogarth and Dr. Murgu. And we offer minimally invasive strategies to help people breathe and diagnose and treat lung conditions. And I'm excited to be part of the team.

Great. And you guys have had some-- you do a lot of different procedures to folk's lungs and a lot of exciting things. And one of the things we're going to talk about today are our valves. But before we get into that, I want to know if you can just tell us a little bit about why you do those procedures and what kind of a patient are you you're looking at there. And Dr. Hogarth, let's start with you if we can.

Yeah, sure. So look, there are a lot of people with bad COPD and emphysema. And majority of it an inhaler that your doctor is prescribed is typically enough to minimize the symptoms and give you back less symptoms when you want to go walk places or do things. But there are a significant amount of people whose lung disease is severe enough, that their emphysema is bad enough, that even though they've done everything their doctors ask them to do, and they're taking the inhalers, et cetera.

When you ask them to do any amount of walking or any amount of activities, they run into problems. And sometimes it's even the simple things like getting around your home or being able to run errands or the simple, hey, I want to go to the corner store. It doesn't matter. They're limited. And so they have to slow down their lifestyle. They have to adjust their lifestyle.

And when they talk to their doctor about it, unfortunately, there's no other inhalers to try. There no other drugs to try. So that's where procedures come in to offer up a chance-- that we'll talk later about the workup for this-- but to specifically help these patients breathe better.

And Dr. Wagh, exactly happens to your lungs when you are experiencing advanced emphysema or COPD? There's quite a bit of damage that's been done at that point. Is that correct?

Yes, sir. So there's definitely damage. There can be damage to the lung tissue itself. There can be damage to the airways. When we think about advanced emphysema, we really think about damage to the lung tissue. And COPD is obstructive lung disease, chronic obstructive pulmonary disease. And it's really hard for that tissue to get the air out. We call that air trapping. And that's the main problem that we focus on with our special procedure.

And so let's talk a little bit about that procedure. And first of all, if you can tell us when a patient comes to you and they're experiencing these difficulties, I imagine there's a whole slew of things you probably look at and try. Walk us through that if you will.

So on the assumption that you've already been on the correct medications, quit smoking, and done something called pulmonary rehab to get your reconditioning-- because those are the core things that everyone should be doing-- be on the appropriate, guideline based medications that you're taking daily. Finish pulmonary rehabilitation so that you can maximize your exercise. And obviously quit smoking and not be around secondhand smoke.

So then if you're still symptomatic and still limited, that's when we initiate the workup to see if you're a candidate for these valves. We'll need breathing tests to quantify and measure just how bad your lungs are, to quantify how bad that gas trapping that Dr. Wagh just talked about, how hyper inflated you are. And then a specialized CT scan of the lungs to quantify and measure the degree of emphysema, so that we just how bad it is. Because these valves we've got to know where to place them. And so the scan we do helps to pinpoint the correct spot to place these devices so we maximize the benefit.

And when you're talking about these valves, I imagine they've got to be tiny.

They are quite tiny.

Where do they go and what do they look like? How do you place something like this?

So we place it through a bronchoscope. So that's why Dr. Wagh and I are involved. It's done under anesthesia. So you are asleep for it. We go through your mouth. There is no cutting. This is the beautiful thing about it. So we go down into the airways that are the ones that we said from CAT scan is where the bad part of the lung is. And think of these things as a one way valve or a cork with an exit.

So in other words, we're going to plug up the sick part of the lung. We're going to let the air out of that part of the lung. And what's pretty unique about the University of Chicago-- so there's actually two different valve manufacturers in the market that make these devices. And they're similar and yet different, and they have their pros and cons to each of them. And we are one of the only hospitals in the country that stock both and have the ability to use both.

In some very unique scenarios, we even have patients who have both inside them. So it wasn't a pick one procedure. What matters is that you need to be able to get these valves in the correct airways. And I can't be limited based on some nuance to your anatomy or a nuance to these valves. And so I think that's, again, one of the unique things about an institution like ours is that they afford us the ability to ensure that we can take care of anyone who's remotely a candidate for this procedure.

That's an amazing fact and I think if we can touch on that just a little bit more. So when you're working with a patient, is that something before you do the procedure that they're going to need these? Or is it once you get in there--

No, it's a great question. I know Ajay will agree with me. It's the unpleasant surprise that the valves that-- if you have only one company's valves on the shelf and you sit there and go, I'm not sure how this is going to work. And I can't think of anything worse than saying, I'm going to wake you up. You got to go home and you got to come back because we ordered the other one we needed.

And it's quite literally an on the fly measurement. Because we're taking active measurements on the inside. And that's how we figure this out. And it's not a common occurrence. But if it's more than one in a million, it's common enough.

Yeah, exactly. And if you're the patient that's going through the procedure, you want that variety available.

Yeah, and you'd like to be only knocked out once, not multiple times.

Dr. Wagh, I'm kind of curious, let's bring you into the conversation. What is that process like when you're doing the work and you see, OK, I need this and this, and you start to work through the process with the patient. It's got to be gratifying, first of all, that you can offer that. And what's the-- then I think if we can, let's talk a little bit about the rehab for the patient afterwards.

Absolutely. So as part of the workup, we would generally get a referral from a lung specialist of the patient who would like for us to evaluate the patient for this procedure. And as Dr. Hogarth mentioned, we look at the breathing tests. We look at the patient's ability to walk and their functional capacity.

We want to ensure that the patient has quit smoking for about four months. And we also look at their CAT scan and send that for a special report so that we can assess certain criteria on the CAT scan. And we want to do all of this stuff before we bring the patient back for the actual procedure to ensure that they're a good candidate for the procedure.

And how long does a procedure like this take, generally?

The actual procedure is quite short, less than an hour on most occasions.

Yeah, it usually ends up averaging about 30 minutes.

Wow. OK, I would have anticipated much more significant than that.

Yeah, no it's pretty incredible.

What is it the impact to the patient? Is it immediate and how do they feel afterwards?

I'll let Ajay address that one.

So it depends, just like most things medically or many things medically. I think some patients definitely see some benefit quite early on, but it could take actually several weeks to see a full benefit. And at that point in time, around six weeks or so, we ask the patient to come back for a new breathing test and a new scan to really assess objectively whether or not they've benefited.

And I would imagine that if that portion of the lung, your lungs, you're taking that pressure off and taking the air out. Do the rest of the lungs then have to kind of build and grow?

Well, in fact, that's the whole reason these things work. You've got the sick part of your lung, not only does it not work well it's gotten very enlarged, and it's actually squishing the healthy parts. That's the easiest way to think about it. And it's shoving your diaphragm down. So when I ask you to take a deep breath, you already are at rest.

So you're breathless because you can't go deeper. So if we deflate you, then the healthier part to your lungs are able to expand and do more work. And it's not the same but it's similar to cutting off the branch of a tree that's dead. And you cut the dead branch off, and then the rest of the tree expands in. A couple of weeks later the tree looks beautiful again, and you can't even tell it had a dead branch. Very similar.

So just I would imagine a tremendous--

But without cutting.

Yeah, we're not cutting any branches off. But I would imagine it's a tremendous quality of life change for these patients.

When you can't breathe nothing else matters, right? And to restore even a little bit of lung function for people to have the freedom to be able to go grocery shopping again. One of my patients was very frustrated. She's an older lady. The younger tennis players were beating her on the tennis court. She was in great shape but still had limits. And now she's back to beating the younger tennis players.

Well, that's exciting news. Let's talk a little bit about smoking, too, because I know that's central to the issue that happens here, or oftentimes it is. Is that primarily what you see in your patients or can it be a whole slew of different reasons that they get to this stage?

Well, typically we see patients who have this problem as a result of smoking. So we want to encourage-- or we continue to encourage patients to quit smoking. And it is something that we look for prior to proceeding with such a procedure.

I've always been kind of curious if somebody is a smoker and has been a smoker for a while, they've obviously done some damage to their lungs. If they stop while they're still in a somewhat healthy stage, do the lungs regenerate at all or have you pretty much have done the damage?

No the lungs don't regenerate. So I tell people the reason to quit smoking or never to start is your lungs are the bank account that you only draw money from and you never add to. The medications make the lungs work more efficiently. This treatment, these valves help to make the lungs work more efficiently. But the damage, unfortunately, is damage done. And the only way to keep that from getting worse is to quit smoking.

That's just a great reminder to people that may be watching.

And vaping, too. And by the way, all smoke. So with legalized marijuana, smoke is smoke. Your lungs don't care. Smoke is smoke. Everything damages your lungs when you put it in there. So, don't.

You know, I'm glad you brought that up because that's another huge issue currently. I mean particularly here in Illinois, we see the legalization. And we see so many people vaping. And I think a lot of people are under the misperception that vaping isn't bad for you.

Right, that it's somehow safer.

Yeah.

I think this is a moving target. I think Ajay would agree with me. And you'll hear people say, well, it's got to be safer. Yeah, I mean I guess it's safer to get hit by a car than it is to get hit by a bus. I'm going to just not get hit by either vehicle is really the analogy I would use. Both sound like a really bad idea. I don't know, Ajay would agree?

Absolutely, we just want to breathe in clean air. So I mean that's what our recommendation would be to focus on breathing clean air and focus on our environment and emphasize clean air in our environment as well. So yeah, I mean, we don't want to encourage anybody to put anything in their lungs other than clean air.

And that's what our lungs are built for. They're not built to inhale smoke and other garbage.

Correct.

Great. So there is some hope out there for folks with COPD or significant emphysema. So that's positive. If the valves don't work, there are other options as well that you all offer.

Well there are. So I think this is where it's unique. So Ajay and I-- so Dr. Wagh and I are very involved in several different clinical trials that are also looking at ways to help people with emphysema. So that will be ways to make the valves work more effectively in some people where they aren't possible. And there are multiple other medical devices under varying levels of investigation.

So they're not available yet, but this is why large teaching hospitals and research hospitals like ours exist. Precisely because at one point valves were experimental. And yet we were doing them as part of the trial. And when they became FDA approved, we were one of the first sites-- and we're the first site in Illinois-- to offer this procedure. It should be noted, probably not surprising, Dr. Wagh and I have done more of these procedures than anyone in about a couple hundred miles-- maybe it's about 400 mile radius around Chicago.

So we have the largest experience, the largest ability to care for these patients, and how to better expedite the workup. And then you're right, if somebody you're not a candidate for these device or any of the other ones coming down the pipeline, certain patients are candidates for a surgical approach to this. And then obviously, we always have transplant as some level of availability.

They have their own rules and workup, obviously. But and I always tell all my patients, don't let your doctor assume that you're a transplant candidate or not, wait till a transplant doctor says you're not a candidate. Because the rules in transplant are changing as well. And so you may be. At least worth finding out if you have no other options.

Yeah, one of the-- and these are actually multiple benefits of an institution like UChicago Medicine, academic Medical Center, Research Hospital, you guys do clinical trials. All of this exciting things that don't happen necessarily at other institutions. Dr. Wagh?

I would like to add one more thing that the valves are not prohibitive for surgical or transplant evaluation, as well. So you can still undergo valves and still undergo those other evaluations as well.

So one of the other things that I think is pretty unique about the University of Chicago is-- look, people get CT scans of their chest for many different reasons. And the scan will get read and evaluated by the doctors and thankfully it doesn't have a lung nodule, or maybe that's why they did it. But there's a whole lot of other wealth of information hidden inside that CAT scan if only we were asking the specific questions.

So you keep hearing in the news about things like artificial intelligence and various things being auto-read and algorithms, et cetera. So we utilize a very unique software made by a company called inBio. And what it does is in the background it's reading every single CT scan done here to look for the degree of emphysema you have, and flag whether you may be a candidate for these valves.

So the flip side of it is maybe you haven't even talked to your doctor about being short of breath or having limits. But we're going to flag and say, you know what? You're potentially a candidate for this. And look, you may not need them. You may be breathing just fine. But we are going to try to capture more people who would potentially benefit and could breathe better.

I literally saw a gentleman this morning who was not doing great with his breathing but just kind of thought that's how life was. And he had a CT for another reason. We found it. And now we saw him. And he's going to get this procedure in two weeks.

Wow, that's fantastic. So, Ajay, you've been leading this project. You can talk more about it.

Yeah, absolutely Dr. Hogarth. I mean I think it's wonderful to be able to offer a specialized care for patients who may or may not even be aware of the possibility. And we're actively communicating with other physicians, ensuring that they're aware of this, and should a patient's scan get flagged, we're in conversations with those other physicians to see if potentially those patients may be a candidate.

And that they could potentially have that conversation with their doctor, or even have a visit with us. And we would certainly be happy to have that conversation with the patient as well. So we've begun to identify several patients that may be good candidates. And we're out actually now discussing with those doctors who were the ordering providers.

All right. We're going to take a quick break. When we come back, we'll have a couple of other physicians join us to talk about some of the surgical options. Stay with us. We'll be back in just a moment.

And welcome back. We have two different doctors with us for this portion of the program. Dr. Renea Jablonski and Dr. Lucia Madariaga join us to talk a little bit more about COPD and advanced emphysema. And what all of that can do to a person. And some things that you can do if you have that condition.

And I want to start off and talk a little bit more about COPD and advanced emphysema. We discussed it in the first portion of the program. But the question I have now I guess is, what is the difference between the two and how do they interact?

So I'm Renea Jablonski. I'm one of the pulmonologists. And I work with the lung transplant program here. So COPD is a condition that has-- it's an umbrella term to cover two different diseases. Emphysema, which is a term to describe a process where there's destruction of the lung tissue. And chronic bronchitis, which is a condition that's mostly involving more inflammation in the air tubes in the lungs causing a chronic cough. So we're here today to talk about procedures that can be done for that subset of patients who have that emphysema subset of COPD.

And they're both pretty significant issues though for patients and very serious, particularly from a quality of life standpoint. But even longevity, would that be accurate?

That's correct. And we know that the more advanced your lung function decline is with COPD, the likely shorter your life expectancy might be. When we meet patients with COPD, we'll also often look for other things like evidence that your lungs are putting more stress on your heart or that your lungs are not doing an adequate job, either getting oxygen into your body or CO2 out of your body. As those can also be markers that your risk of death might be higher with this condition.

Dr. Madariaga, I'm sorry, I didn't give you an opportunity to introduce yourself. I went right over that portion of it, and I apologize for that. So tell us a little bit about what you do here at UChicago Medicine.

Yes, my name is Lucia Madariaga. And I'm a General Thoracic Surgeon and Lung Transplant Surgeon here at UChicago. I take care of many patients with advanced emphysema.

So let's talk a little bit about lung volume reduction surgery. We talked about valves in the first part of the program, but lung volume reduction surgery is the, I guess, the next step in this treatment. Or next treatment option, I guess you could say. What exactly is that and what does that entail and Dr. Madariaga, I'm sorry, let's go to you on that one.

Sure. So lung volume reduction surgery, the point of the operation is to remove the unhealthy upper part of the lung, so that the lower part of the lung, which is more normal, can do its work of breathing and helping the patient feel better. And the way we do the surgery here is we do it through a minimally invasive technique, meaning we use three small incisions about 1 inch in size. And we do both sides at the same time. And after the operation, the patient stays in the hospital for a bit and is able to go home.

When you say minimally invasive, is that kind of a robotic type thing or is there another way that you do that?

We have different techniques. So we use thorascopic techniques, which is with the camera. But it can also be done robotically as well.

And when a patient-- so describe that to me. When you work on the lungs for the patient, what exactly are you doing? And what is the patient experiencing at that point that needs the-- why do they need the LVRS?

Yeah, so in advance emphysema that qualifies for lung volume reduction surgery, most of the destroyed part of the lung is in the upper part of the lung. And so the theory behind this operation is if we remove that part of the lung, the upper part, which is destroyed, then the more normal part of the lung, which is the lower part of the lung, can fill up the space and work better for the patient.

And is this something that a patient has a pretty quick reaction to afterwards?

Yes. So most patients we go through a very rigorous selection process to make sure that the patients we offer this procedure on will actually get some quality of life and breathing benefit. So that after the surgery, they can notice that their breathing feels better. Of course, there's a recovery period from surgery because we do make an incision. And after the patient works through that, keeps up with exercise, perhaps going to pulmonary rehab, I think most patients feel like they can breathe better and have better quality of life.

Dr. Jablonski, how do patients-- when it comes to you, how do they know that they're at that level that they need the help? I'm assuming they're referred to you probably by another-- maybe their primary care physician or someone else. But how do they know that they're that far along that they need this level of help?

Some patients ask their physicians or their care providers for a referral. And then you're right, some patients are also referred to us, often by their primary lung doctor or pulmonologist, less frequently by their primary care doctor. And usually they're coming to us to ask for more help because they're so limited by their lungs and their difficulty breathing that they can't do and enjoy the quality of life that they would like to be enjoying.

When you talk about how limited they are, are these folks that can't walk up a flight of stairs usually or?

Frequently, yes, yes. Have trouble walking up a flight of stairs, have trouble even doing things like cooking a meal or getting dressed because it's so difficult for them to breathe.

And I would imagine if you're to that stage that has to have an impact on your heart, as well, doesn't it? I mean, isn't your heart working harder to try to pump blood at that point too?

It can. And we see in some patients with advanced lung disease that it can put more stress on the heart. As part of the evaluation for any of these procedures that we're talking about today, we do ensure that the patient's heart is healthy enough to undergo whatever procedure we think might be right for their emphysema.

Is there a point where people think about a lung transplant maybe to take care of this problem? Or is that completely out of the norm?

Yes, sometimes we do think about a lung transplant for patients with advanced emphysema. We know that with either the valve procedure or with the lung volume reduction surgery that there are a subset of patients whose lungs are just too sick to qualify for one of these procedures. Or some patients in whom we do see that extra stress that's put on the heart by the lung disease, and those are patients with whom we start to have those difficult talks about whether transplant might be the right option for them.

And I know we have a new machine. I've seen this and this is totally off topic, but I'm just fascinated by this, for lung transplants that helps keep the lungs active and alive longer. So we actually have increased our transplant I guess halo for lungs, which is pretty good news for patients. That's pretty exciting. So how does somebody get referred to the program?

So we have a streamlined process now with our advanced emphysema program where patients can, with one referral, come and see all three of our groups to decide which procedure might be best for them. And we have a website link to the University of Chicago website that has information about who to call so that you can get an appointment with us.

Dr. Madariaga, I know you alluded to this a moment ago, but how much better does a patient feel once they have one of these procedures? And how quickly do they feel better? I just I love hearing about this.

Yeah, so in general, I would say that patients feel about 30% to 40% better in terms of their breathing. But I think it's important to qualify not in terms of numbers but in terms of what they actually want to accomplish after surgery. For example, one of my patients he wanted to garden and cut roses for his wife and take out the trash. And then with his recovery after surgery, he was able to exercise and recover to the point where he is able to do those sort of things. So for each patient we need to decide what makes up your quality of life. And what would you like to do afterwards that we can help you with.

After you have the operation, you basically stay in the hospital for about 5 to 7 days. These patients tend to be on the sicker side. So we just want to be very careful before sending you home that you're fully recovered from that standpoint. And we do do an operation, so it takes maybe one to two weeks to feel a little bit recovered from your incisions. But we expect you to be able to walk as soon as surgery is over. And walking every single day and getting back to a normal exercise routine really accelerates your recovery.

And I would imagine when people get that quality of life back, I mean that's just such a huge thing. And you probably hear from a lot of happy patients and happy families. And it's got to be very rewarding.

Yes, it's very nice to see the trajectory of patients feeling much better after surgery that they're able to do the things that they want to do.

That's great. And we said it in the first segment of the program, and I just can't hammer this home enough, don't smoke. If you are a smoker, stop smoking. That's just that's so critical. And I would imagine most of the patients you will see are probably former smokers. And it just has to resonate so much with you.

Yes. And we're here to help you quit smoking if that's something that you're interested in doing.

That's great. All right, we are out of time. We really appreciate the two of you being on the program today. That was great information. Special thanks to all of our guests for being with us today. And a big thank you to those of you who watch the program.

To make an appointment, you can go online to use your uchicagomedicine.org. You can also check out our website and find just all kinds of great information on this program and others. Or give us a call at 888-824-0200. Thanks again for being with us today. And I hope everyone has a great week.