Friday’s COPD Newsletter from COPD Support, Inc.

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Volume 9, Issue 34
July 24, 2009
Joan Costello, Editor

HOW DO PARTICULATES AFFECT PEOPLE?
The human respiratory system is usually well-prepared to deal with airborne invaders: Nose hairs catch the biggest ones, tiny moving hairs called cilia trap others with mucus to be coughed or sneezed out, and specialized immune cells devour any stragglers. In fact, anyone with allergies knows the body is often too prepared to defend itself.

Snot and cilia can’t catch everything, but even as some smaller particles sneak through, healthy cilia and immune cells are usually able to ward off long-term damage at normal exposure levels. The people at greatest risk from particulate pollution are those whose natural defenses aren’t at full capacity, including children, the elderly, people with heart or lung disease, and smokers.

Urban air pollution is often more toxic than rural dust clouds in part because other pollutants — especially sulfur dioxide, nitrous dioxide and ground-level ozone — can stun or overwhelm the body’s defenses, opening the floodgates in much the same way cigarette smoke paralyzes cilia and leaves the body more vulnerable to infection.

The diverse mixture of pollutants floating through many cities makes it hard to pinpoint which one caused which illness, but scientists seem to agree that, once inside the lungs, PM2.5 is responsible for the most serious health problems related to air pollution. Particles 10 microns wide and smaller stubbornly lodge themselves into lung tissue, with the smallest ones digging down the deepest. That may cause irritation, coughing and difficulty breathing in the short term, and stirs up asthma attacks or an irregular heartbeat in many susceptible people. Over time, particulate buildup in the lungs can lead to chronic bronchitis and reduce overall lung function; one type of particulate is believed to be carcinogenic.

Where does particulate matter come from?
Particulates are released by a wide range of sources, both mobile and stationary. Road dust is by far the No. 1 source of PM10 emissions in the United States, and the second highest source of PM2.5, behind only fires. Cars and trucks kick up debris clouds even on paved roads, but off-road vehicles’ large plumes stir up much more trouble. Mold, pollen and other human allergens often plague the driver or people downwind, and the tiny dust and diesel granules threaten waterways as well as human lungs, clouding clear water and blocking sunlight from algae and plants.

Whether they’re on-road or off-road, diesel vehicles throw a little something extra into the particulate pot. Diesel exhaust contains formaldehyde, benzene, polycyclic aromatic hydrocarbons and other hazardous air pollutants, including thick soot particles. While some particulate emissions from diesel engines are almost inevitable, they can be reduced with pollution controls and by avoiding idling in diesel-powered vehicles.

Despite the popularity of fossil fuels, wood is still the main emitter of fine particulates in the United States — wildfires are the No. 1 source and home firewood consumption is No. 5. Coal, oil and gas do contribute substantially, though — electricity generation, transportation and other fossil burning is a top three source of PM2.5 and in the top five for PM10.

Coal-fired power is a smog-prone enterprise by nature, and while many utilities in developed countries have now cut back on the amount of particulates and sulfates in their emissions, softer regulations in parts of Asia and Eastern Europe have led to rampant air pollution there. Widespread use of wood- and dung-burning cookstoves has also come under fire as a source of dangerous particulates and other pollutants.

For more on particulate matter and other forms of air pollution, check out links from Uncle Sam at the following site:
http://www.mnn.com/earth-matters/translating-uncle-sam/stories/are-small-particulates-a-big-deal

ALSO IN THIS ISSUE
-MANAGING ACUTE EXACERBATIONS OF COPD
-DOES NEUROMUSCULAR ELECTRICAL STIMULATION HELP PATIENTS WITH COPD?
-PULMONARY MANIFESTATIONS OF GASTROESOPHAGEAL REFLUX DISEASE
-BASIC PREMISES AND NEW DISCOVERIES IN STEM CELLS
-MISSING ZEROES
-MISCELLANEOUS

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SOURCES: News items summarized in The COPD-NEWS are taken from secondary sources believed to be reliable. However, the COPD Family of Services does not verify their accuracy.
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MANAGING ACUTE EXACERBATIONS OF COPD
Alla Marks, PharmD, MBA: Exacerbations are an important outcome measure in COPD due to their profound effect on the patient’s quality of life and prognosis. It has been estimated that patients with COPD suffer one to four exacerbations per year, and up to 70% of the direct health care costs associated with the disease are due to severe exacerbations, particularly those requiring hospitalization. Less than one-third of exacerbations are reported, and although some may not be serious enough to warrant an emergency visit or hospitalization, they have been shown to have an important impact on the patient’s health status. Exacerbations are not
random events but cluster together in time such that there is a high-risk period for recurrence in the 8-week period after an initial exacerbation. They also become more frequent and severe as the severity of the underlying COPD increases and contribute to further impairment in lung function.

Definition and Etiology
An exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations; is acute in onset; and may warrant a change in regular medication. The most common causes of exacerbations are infection of the tracheobronchial tree and air pollution, which increase airway inflammation or directly affect expiratory flow limitation, but the cause of approximately one-third of severe exacerbations cannot be identified.

Bacterial etiology in approximately 50% of exacerbations is substantiated by bronchoscopic isolation of bacteria in the distal airways; the relationship of new strain isolation and exacerbations; the development of a specific immune response to the infecting pathogen; and association of neutrophilic airway inflammation with bacterial isolation during exacerbations.

Assessment of Severity
Assessment of the severity of an exacerbation is based on the patient’s medical history before the exacerbation, preexisting comorbidities, symptoms, physical examination, arterial blood gas measurements, and other pertinent laboratory tests. Increased breathlessness is the main symptom, but is often accompanied by wheezing, chest tightness, increased cough and sputum, change of the color and/or tenacity of sputum, and fever. In patients with very severe COPD, the most important sign of a severe exacerbation is a change in the mental status of the patient.

Spirometry measurements are not accurate during an acute exacerbation; therefore, their routine use is not recommended. Pulse oximetry can be used to evaluate a patient’s oxygen saturation and need for supplemental oxygen therapy, and arterial blood gas measurements are crucial for assessing exacerbation severity. Chest radiographs are useful in identifying alternative diagnoses, and an echocardiogram aids in the diagnosis of right-heart hypertrophy, arrhythmias, and ischemic episodes.

Management
Pharmacologic treatment of the patient with an exacerbation is based on adjusting and/or adding the same medications utilized in the management of stable COPD. The goals of therapy are prevention of hospitalization or reduction in hospital stay, prevention of acute respiratory failure…resolution of exacerbation symptoms, and a return to baseline clinical status and quality of life.

Much more information on treatment at:
http://www.uspharmacist.com/content/d/feature/i/765/c/14043/

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MEDICAL DECISIONS. Your physician should be consulted on all medical decisions. New procedures or drugs should not be started or stopped without such consultation. While we believe that our accumulated experience has value, and a unique perspective, you must accept it for what it is…the work of COPD patients. We vigorously encourage individuals with COPD to take an active part in the management of their disease. They do this through education and by sharing information and thoughts with their primary physician and pulmonologist. However, medical decisions are based on complex medical principles and should be left to the medical practitioner who has been trained to diagnose and advise.
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DOES NEUROMUSCULAR ELECTRICAL STIMULATION HELP PATIENTS WITH COPD?
In spite of optimal drug treatment, many patients with COPD continue to experience disabling symptoms - dyspnea, fatigue, poor exercise tolerance - that make rehabilitation efforts extremely difficult.

Neuromuscular electrical stimulation (NMES) is generally used in conjunction with physical therapy and works by applying electrical stimulation to a group of muscles to help stimulate nerves in the muscle with electrical impulses. Under normal circumstances, the brain and muscle systems communicate with each other via electrical impulses. Injury and/or chronic illness, however, can cause muscles to atrophy, or die. With neuromuscular electrical stimulation, these natural impulses are simulated and can help “retrain” the muscles to function again.

The July, 2009 issue of Chest published a systematic review of the literature that addresses the effects of NMES on the muscles of ambulation in patients with chronic heart failure or COPD. The study reviewed 14 clinical trials, five of those which examined COPD patients. Many of the studies reported that patients had an improvement in muscle strength, exercise capacity and/or overall health status. Chest concluded that, from a review standpoint, NMES looks promising as a method of rehabilitation for COPD patients, however, further investigation is required due to the limitations of the review.
For more information, visit http://www.chestjournal.org/content/136/1/5.citation
http://copd.about.com/b/2009/07/20/does-neuromuscular-electrical-stimulation-help-patients-with-copd.htm

PULMONARY MANIFESTATIONS OF GASTROESOPHAGEAL REFLUX DISEASE
This clinical review examines the potential pathophysiological mechanisms of pulmonary manifestations of GERD. It also reviews relevant clinical information concerning GERD–related chronic cough and asthma. Finally, a potential management strategy for GERD in pulmonary patients is discussed.

Historically, pulmonary manifestations have been recognized as a potential consequence of GERD. A major advance in the understanding of extra-esophageal manifestations comes from the recognition that a significant number of patients with asthma or chronic cough, particularly if it is nocturnal, have gastroesophageal reflux as a trigger.

Causes of GERD
No one knows the exact cause of gastro esophageal reflux. The following are several contributing factors that weaken or relax the lower esophageal sphincter, making reflux worse:

Lifestyle - Use of alcohol or cigarettes, obesity, poor posture (slouching).

Medications - calcium channel blockers, theophyllines, nitrates, antihistamines.

Diet - Fatty and fried foods, chocolate, garlic and onions, drinks with caffeine, acid foods such as citrus fruits and tomatoes, spicy foods, mint flavorings.

Eating habits - Eating large meals, eating soon before bedtime.

Other medical conditions - Hiatus hernia, pregnancy, diabetes, rapid weight gain.

Pulmonary Manifestations of GERD
GERD can cause various pulmonary manifestations: Chronic cough, bronchial asthma, bronchitis, pneumonia and interstitial fibrosis. Out of these, chronic cough and bronchial asthma are more common manifestations of GERD.
http://www.thoracicmedicine.org/article.asp?issn=1817-1737;year=2009;volume=4;issue=3;spage=115;epage=123;aulast=Gaude

BASIC PREMISES AND NEW DISCOVERIES IN STEM CELLS
14 minute long Video
http://www.wimp.com/stemcells/

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COMMERCIAL FREE: We do not accept any paid advertising. Any corporations, products, medicines (prescription or non) mentioned in this newsletter are for informational purposes only and not to be construed as an endorsement or condemnation of same.
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MISSING ZEROES
Joe writes:” Joan I think you are missing some zeroes on this one. That would not buy one pack for one day for the US population.”

COST OF SMOKING AND OTHER CALCULATORS
“Smokers in the US spend nearly $50 million annually on cigarettes. How much of that money did you kick in? Use this calculator to determine how much you spend on cigarettes every week, month, and year–and how much you would save if you quit.” Also find calculators for:
http://health.discovery.com/tools/calculators/smoke/smoke.html

You’re right Joe. I checked and found that in 2006, 20% of Americans smoked. That translated to 45.3 million Americans. So obviously the figures on the site were incorrect. Sorry about that.

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The Newsletter, like all the other endeavors of the Family of COPD Support Programs, is provided to you by COPD-Support, Inc. a non-profit member organization with IRS designation 501(c)(3). If you would like to be involved and help us provide these programs to the individuals who benefit from them, please consider joining us as a member. Further information is available at:
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MISCELLANEOUS

Clickomania next generation: Clickomania! is one of my favorite time wasters. When you start the game, the board is filled with tiles. You are supposed to eliminate all these stones by clicking on groups of stones with the same color. It offers several varied game modes, web scores and more. The game is suitable for kids and young players and a challenge for adults. It «speaks» English, German, Spanish, French, Italian, Russian and Greek. Scroll down to Download: Version 1, Freeware and click on Clk.EXE (943 KBytes)
http://www.clickomania.ch/click/

Business Idioms
match up the word with the definition.
http://iteslj.org/v/e/hl-business_idioms.html

College Board Vocabulary Test
Test your knowledge on SAT words most commonly found on college board tests.
http://iteslj.org/v/e/jb-college.html

Logic Puzzles
And many other types of games listed on the right side of the page
http://www.brain-fun.com/Logic-Puzzles/

Doggie Nightmare
http://www.wimp.com/dognightmare

Until next Friday,

Joan Costello, Editor

Web version of the News: http://copd-support.com/news.html

Archives at: http://home.ease.lsoft.com/archives/copd-news.html