Issue February 26, 2013

Uneasy breathing

Why respiratory health in the bluegrass ranks among the nation’s worst

Around the end of September, Calvin Miracle started to feel some familiar symptoms.

“It was getting harder and harder to breathe. It was getting harder and harder to walk to work,” Miracle says.

Finally, one Friday night, it came to a head: “I knew I had an infection going.”

Miracle knew the signs from previous experience — he started having yearly chest infections in the mid-1990s. By 2008, it was twice a year. One instance even landed him in the emergency room.

But this past fall, Miracle did something different. He didn’t wait through the weekend to see a doctor. By the time he sent an email to the pulmonary manager at the University of Louisville’s Division of Pulmonary, Critical Care and Sleep Disorders Medicine later that evening, he’d already started on antibiotics and a set of steroids; it’s what his doctor had instructed him to do.

Despite decades of respiratory problems, Miracle wasn’t diagnosed with chronic obstructive pulmonary disease, or COPD, until early 2011. COPD is a group of lung diseases, including emphysema and chronic bronchitis, in which airways or air sacs in the lungs lose their elasticity, become clogged or inflamed, or are irreversibly damaged. It is also the third-leading cause of death in the United States.

In November, the Centers for Disease Control released the first state-specific study of COPD prevalence. Kentucky was at the top of the list, with 9.3 percent of Kentuckians self-reporting that they had been diagnosed with the disease, compared to 6.3 percent of adults nationwide.

Luckily, Kentucky also is home to a number of programs seeking more effective solutions for COPD. Miracle is a part of one such program at U of L, which provides each patient with a personalized COPD Action Plan. This plan isn’t just a string of medications — it’s a regimen of education, exercise and diet improvements.

Dr. Rodney J. Folz, professor of medicine and chief of U of L’s pulmonary division, says the idea is to educate non-physicians, from respiratory therapists to patients, to handle flare-ups and monitor overall wellness.

“That kind of more comprehensive approach, at least in the program we have here at U of L, has proven very successful,” Folz says.

Where there’s smoking, there’s COPD

Far and away, the No. 1 culprit behind Kentucky’s high COPD rate is smoking. At 29 percent, Kentucky has the highest smoking rate in the country, according to a 2011 Gallup poll. An earlier CDC study placed Kentucky at No. 2 behind West Virginia, which, incidentally, is tied with Oklahoma for the fourth-highest COPD prevalence in the country. In fact, the top five states for COPD are all on the top 10 list of smoking states.

Only 60.9 percent of Kentucky homes are smoke-free, ranking it 51st among U.S. states and D.C. The commonwealth also ranks 51st for youth smoking: 15.9 percent of Kentucky’s 12-17-year-olds smoke compared to 10.1 percent nationwide — a troubling statistic considering early exposure may increase COPD risk.

That’s not all: Kentucky also has one of the highest rates of children exposed to secondhand smoke — 34.2 percent, according to a 2007 U.S. Surgeon General’s Report. Secondhand smoke is known to increase chances of lung cancer, heart disease, bronchitis and pneumonia. And that might just be what happened to Ann Zahniser.

Zahniser suffered from respiratory problems for 30 years before she was diagnosed with COPD. She had only tried one cigarette in her life.

“That was enough,” she says.

But her flare-ups are often triggered by smoke — forest fires, leaf burning. If people are smoking in a public place, Zahniser leaves — but sometimes there’s no avoiding it. She was hospitalized once after a trip to Spain, where public smoking is ubiquitous.

“I’m a person who has really benefited from the smoking regulations,” Zahniser says.

Kentucky has seen a shift toward tighter smoking restrictions in recent years. Lexington became the first community in the state to mandate smoke-free public places in 2004. A UK College of Nursing study two years later found Fayette County smoking rates had decreased 31.9 percent. Thirty-five more Kentucky communities have enacted similar regulations.

COPD’s other triggers

As a child, Calvin Miracle was around cigarette smoke, and he was a smoker himself for about a decade before the coughing became too intense.

But he also points to air pollution from the mining and tanning industries in Bell County, Ky., where he spent several years as a child.

“Some of my earliest memories were of smelling tannic acid in the air,” he says.

Air pollution is a contributing factor to COPD, acknowledges Dr. David M. Mannino, director of the Pulmonary Epidemiology Research Laboratory at the University of Kentucky College of Public Health.

“In Kentucky and large parts of the South, for example, you have a higher population of people who work at dusty jobs,” Mannino says. “In Kentucky, it would be coal mines and certain parts of agriculture and farming.”

Kentucky and the Midwest also have the highest levels of airborne particulate matter in the nation, according to data collected by NASA satellites.

Mannino is another Kentucky physician looking for better ways to diagnose and treat COPD. He is part of the Burden of Obstructive Lung Disease (BOLD) Initiative, a global effort to develop a standardized methodology of measuring COPD prevalence, causes and impacts. One BOLD study found a 14 percent prevalence of COPD in southeastern Kentucky — the second highest of any group measured. Mannino links this to higher use of wood stoves in the region. Smoking is the top cause of COPD in the United States, but worldwide, it’s wood smoke.

Other household contributors to respiratory problems include mold, particulate from hobbies like woodworking, and pet exposure for more sensitive populations.

Living with COPD

People with COPD have a higher chance of developing cardiovascular disease, bone disease and depression.

The medications available for COPD patients are designed to treat the symptoms — as of yet, there’s no known cure. Instead, doctors focus on improving overall quality of life.

Ann Zahniser changed her lifestyle dramatically when diagnosed with COPD. She went to a dietician and started an exercise regimen, but was actually taking less medicine than before.

“In general,” she says, “I just felt better.”

Most days, coughing is Zahniser’s primary symptom. But she still has flare-ups — she went to the emergency room in November for trouble breathing.

Shortage of breath is almost an everyday occurrence for Miracle.

“A little bit of exertion will get me winded… I have to kind of plan things out. So if I mow the yard, I have to take it in stages,” he says. “It can affect your mood. It can affect what you want to undertake, and you never quite get used to it.”

Miracle is part of a study at U of L that may be the first of its kind — testing COPD patients with a respiratory muscle exercise program typically used with people who are paralyzed. But Miracle believes treating people who already have COPD is only part of the solution.

“Cholera was defeated by public health. I think this is something like that. I think that people like me are being caught up in a time and place in history,” he says. “I think that what will beat this disease is public health. I think it’s smoking cessation, air quality, decisions that young people make, choices that parents make around their kids with smoking.”

After all, it was an awareness campaign that finally brought Miracle to U of L, where he was diagnosed.

“I just got this flyer on my desk at my office a couple years ago about the COPD program,” Miracle says. “It was out of thin air, and it was exactly what I needed.”