Can Only Progress Downward

Another reason not to smoke

You shouldn’t smoke tobacco products. Everyone knows this, even people who have been using them since they were fourteen and have no intention of quitting. It’s been established for longer than I’ve been alive—much longer—that tobacco consumption is unhealthy. Why? If you ask anybody, they’ll tell you, “it causes cancer.” Well, yes, it does. Most lung cancer is caused by smoking, lung cancer is aggressive, and lung cancer leads to a miserable death. But it’s not the only way to die a miserable death from smoking. It might not even be the most common¹.

Chronic Obstructive Pulmonary Disease (COPD) is a peculiar condition. For starters, it’s not even one condition; it’s an umbrella diagnosis for two distinct but related diseases, emphysema and chronic bronchitis. The two diseases share the characteristics of being, well, chronic obstructive pulmonary diseases. They hit the lungs, they don’t go away, and they’re obstructive in nature—that is, they make it harder to get air out, not in. The gold standard² for diagnosis is pulmonary function testing that assesses how rapidly and forcefully you can expel air before and after using a bronchodilator³. And the diagnosis is something like, “a condition of the lungs characterized by only partially reversible obstruction.”⁴ Whichever form of COPD you get, you’re facing a situation where you’re never really 100% capable of exhaling as well as you should be able to. You will, for the rest of your life—there’s no cure—deal with periodic exacerbations or flareups that send you to the hospital. They’ll get you better, you’ll return to normal and go home, and in a little bit it will flare up again and you’ll have to come back.

Now, COPD doesn’t kill you particularly quickly, especially compared to the more aggressive forms of lung cancer. You can spend years, decades even, living with COPD, which will get worse at a faster or slower rate depending on your lifestyle. Mild COPD is generally manageable and doesn’t inconvenience you that much. It’s only when it progresses to the more severe stages that your quality of life really tanks. But it’s a progressive condition. It will get worse over time, and if it doesn’t kill you it’s because you kept it mild enough long enough for some other condition to kill you first. And the best way to keep it mild is to catch it early, take care of your health in a general way, and STOP SMOKING⁵. Cigarettes are a hell of a habit to kick, and many COPD patients will keep on puffing even after the doctor tells them they’ve puffed their way to death row.

But suppose it’s gotten to the more severe stages. What’s it look like? The specifics depend on subtype, chronic bronchitis versus emphysema versus (very frequently) a combination of the two. The former is what it says on the tin: you get lung infections, specifically involving inflammation of the bronchi and bronchioles⁶, pretty routinely—specifically, you have a cough productive of sputum for at least three months out of the year, for at least two years in a row. Your airways are continuously inflamed and tight. This is obstructive in that air can get in well enough when your lungs expand during inhalation, but the exhalation phase creates a bottleneck. And if you can inhale but not exhale, you wind up with stale used-up air trapped inside you.

Emphysema, by contrast, involves changes to the alveoli themselves. Healthy alveoli look like little clusters of grapes⁷, all crenellated and convoluted to maximize the surface area where gas exchange can occur within a limited space. Empysematous alveoli are baggy and distended, all stretched out. They hold too much air, so there simply isn’t time to blow out all their contents in a given exhalation. Severe emphysema will show up on a simple chest x-ray; your lungs will be abnormally long with flattened bottoms. Sometimes comically so—the provider will look at the CXR and giggle, because practitioners get callous and holy crap, it looks like they go down to her hip-bones!

There are somewhat dated stereotypes about the different subsets of COPD, that emphysema patients are “pink puffers” while chronic bronchitis patients are “blue bloaters.” That is, the one group tend to be skinny with barrel chests and florid complexions, always exhaling through pursed lips to generate back-pressure so their airways don’t outright collapse, while the other tend to be tubby and cyanotic from chronic oxygen deprivation. These are archaic and offensive terms, and you can have chronic bronchitis and emphysema simultaneously, but you will still hear these phrases used from time to time. Frankly, I sometimes look at a patient and say, “yeah, looks like a COPDer.” Really, though it’s the shoe-leather skin that clues me in most.

COPD is, in some ways, respiratory therapists’ bread and butter. Those endless nebs we dispense are intended for use by asthma patients and COPDers, and thanks to the Baby Boomers’ immense fondness for tobacco the latter is substantially more common⁸. Bronchodilators widen the airways, allowing more air to pass through and providing temporary relief. A mild COPD patient will typically be prescribed PRN bronchodilators in an outpatient setting; that is, the doctor will hand them a script for a rescue albuterol inhaler and tell them to use it when they get short of breath. As the disease progresses—assuming the doctor is following GOLD guidelines, which is not a given—the doctor may add scheduled short-acting bronchoilators, then scheduled long-acting bronchodilators, either as inhalers or a home nebulizer, and eventually inhaled corticosteroids like pulmicort.

In the end, even those will barely make a dent, and the patient will come into the hospital, get dive-bombed with all of the above plus injected steroids and antibiotics for opportunistic infections and aaaaaallllll the other drugs, and after a long fight they will return to their frankly crummy baseline and get discharged home, where they may be using oxygen around the clock. We will be seeing them again⁹. Cancer patients die pretty quickly; old COPDers just keep coming back and coming back until we either can’t fix them or they’re tired of fighting and settle for hospice. We get to know them by name: “Hey, it’s Mrs. So-And-So again.”

It’s a slow death. It doesn’t have the pressing, Pavlovian urgency of the C-word. It’s preceded by long years of sometimes imperceptibly slow decline, as you get less and less capable of managing your own life. Eventually, you get to the point where you become short of breath just moving around, or getting dressed in the morning¹⁰. The ratchet tightens down, crank crank crank, until the day you can’t bear the burden anymore. Then you’re gone.

Between that and cancer, it’s honestly a tough choice. Oh, and you can get both. That’s a thing too. So don’t smoke. I often focus on the negative here, so here’s something positive: smoking has become substantially less popular and socially acceptable in America during my lifetime. Now we have nicotine delivery systems that are non-carcinogenic¹¹ and can be titered down to help with quitting. I am hopeful that, by the time I retire, COPD will be a ghastly rarity.

1. I’m having a hard time finding firm statistics, but it appears maybe 15% of smokers get lung cancer while about 20% get COPD? I thought the imbalance was much more skewed in favor of the latter, honestly, but it may depend on which study you look at.

2. More literally, the GOLD standard, as the Global Initiative on Obstructive Lung Disease is the primary body making recommendations on the diagnosis and treatment of COPD.

3. Read “albuterol.” Every other bronchodilator works slowly and/or indirectly.

4. Per my old RT school textbook, where I looked it up a while ago.

5. Assuming you haven’t quit already, and that you ever smoked in the first place. It is possible to get COPD without ever smoking, just like lung cancer, but as with lung cancer smokers or former smokers comprise something like 80% of cases. If you get it without smoking or other chronic exposure to weird airborne particles, you may have a genetic condition called alpha-1 antitrypsin deficiency. That particular form of COPD actually strikes earlier than typical, possibly before you even hit forty. Most COPDers are middle-aged or elderly by the time I see them.

6. The variously-sized passageways inside the lungs leading to the alveoli where gas exchange takes place.

7. At least in those cute little medical-text illustrations. I suspect the real thing is not terribly appetizing to look at.

8. Asthma is also an obstructive lung condition. There’s a mnemonic, CBABE, used to remember that the obstructive conditions are cystic fibrosis, bronchitic, asthma, bronchiectasis, and emphysema. Cystic fibrosis is a mercifully rare genetic condition and bronchiectasis is a chronic problem you get after repeated lung infections (which in some ways behaves like cystic fibrosis). That pretty well leaves asthma, COPD, and occasional fits of non-chronic bronchitis as the bulk of obstructive cases.

It can sometimes be difficult to differentially diagnose asthma versus COPD in a hospital setting, but asthma is diagnosed at a much younger age and involves sudden bronchial constriction in response to specific triggers; mine acts up when I try to exercise, but cigarette smoke or sundry allergens can act as triggers too. Asthma can progress to COPD with age but the two are distinct conditions.

9. Diseases tend to attack in packs, and cigarettes don’t just hurt your lungs, so in practice they aren’t just COPD patients. All the conditions converge on a sort of ur-patient who has some wretched mix of COPD, CHF, CAD, CKD, and various other lethal acronyms. They smush together and overlap in a combined package such that what stands out about the individual patient is not their disease presentation so much as their individual personality quirks. I had a regular patient—now deceased—who was handsy with the pretty nurses and refused to take dry powder inhalers because he believed they created “little crystal shards” that damaged his lungs. I’m a dude, so he stood out to me as “the crystal shards guy.” He was always very polite to me, but he was a registered sex offender and not especially popular with staff. Nurses are often quite nosy, so they may well find out about the skeletons in your closet, even if they are far too professional to let it affect their standards of care. I don’t think the nurses usually neglected Crystal Shards Guy as such, they just spurned his requests for hugs (squeeze! squeeze!) and weren’t in any particular hurry to do him special favors unrelated to his personal health.

10. My first real encounter with COPD as a student at clinical was when I walked into a room to give a neb and found the patient breathing really hard. I asked if he was okay, and he said yeah, he was just winded from … putting his pants on. I assumed at the time that he was circling the drain. Nope. That was his normal life. For years on end. Panting like a dog after basic life activities.

11. So far as I know, nicotine itself is not carcinogenic. Inhaling it does appear to be the thing that causes COPD (chemicals known as proteases are involved, long story), but it’s the tar and crap that gives you cancer.