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arossm
Why is COPD a progressive disease?
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Because of inflammation
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Because they don't stop smoking
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When you get a set up of chronic inflammation in the lungs, like if you don't treat plain old fashioned asthma and let it go on and on, things just sorta get worse and more difficult to control. You get to a point where you can't really shut it down.
This is true in many conditions marked by chronic inflammation, like autoimmune dzs,
Most things with an immune component are best served by aggressive treatment ASAP.
The lungs have enormous reserve capacity So the thing about COPD is by the time the lungs are appreciably ****ed by smoking you're already pretty far down the rabbit hole and there's really no turning back with the progression of destruction and scarring by chronic inflammation. All you can do is slowdown the decline.
We all have decline in lung function with age anyway, we're all breathing in stuff all the time. In the absence of other exposures though, you or I will not lose enough reserve by the time we die at 90 to ever notice. But COPD they've lost a lot and the rate of decline is seriously accelerated.
EDIT: I may be wrong about the rate of acceleration, there's more discussion below, be sure to check out the pocketcard and discussion about talking about adherence with patients
This is true in many conditions marked by chronic inflammation, like autoimmune dzs,
Most things with an immune component are best served by aggressive treatment ASAP.
The lungs have enormous reserve capacity So the thing about COPD is by the time the lungs are appreciably ****ed by smoking you're already pretty far down the rabbit hole and there's really no turning back with the progression of destruction and scarring by chronic inflammation. All you can do is slowdown the decline.
We all have decline in lung function with age anyway, we're all breathing in stuff all the time. In the absence of other exposures though, you or I will not lose enough reserve by the time we die at 90 to ever notice. But COPD they've lost a lot and the rate of decline is seriously accelerated.
EDIT: I may be wrong about the rate of acceleration, there's more discussion below, be sure to check out the pocketcard and discussion about talking about adherence with patients
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arossm
Is it really just because they don't stop smoking? So if they stopped smoking, it wouldn't be progressive? Would they return to a normal rate of decline? What are your sources?
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seriously?? how about you do your own homework...
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arossm
Do my own homework? What are you talking about? I'm asking out of curiosity because I actually care enough to understand. Go look at my other questions asked and you'll know. Get outta here.
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Did you read what I wrote?
No, they wouldn't return to a normal rate of decline. When you've smoked yourself into enough inflammation to have enough destruction of lung to now be diagnosed with COPD, there's no turning back the clock on those macrophages that have set up shop churning out IL's and all that. Decline is accelerated compared to never smokers and those that quit before COPD set in, and will stay accelerated although you slow it down with smoking cessation and tx.
The earlier in the disease course you dx it, stop smoking, and treat aggressively (actually using inhalers properly and such) the better the prognosis. Not everyone has to end up on oxygen or be life limited by the disease, it just depends.
Be sure to tell all your COPD'ers that there is no better tx for their dz than smoking cessation, and if they're not on O2 it's their best chance to slow this to try to stay off it too.
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One of the seminal pulmonology papers, Fletcher and Peto BMJ 1977.
http://www.bmj.com/content/1/6077/1645
COPD is a very heterogeneous disease. No one knows why some people quit smoking but continue to have rapid decline, while others continue to smoke and retain lung function. Some people with "mild" disease are frequent exacerbators, others with "severe" disease rarely have exacerbations, no one knows why. These are the questions that current research is trying to answer.
A little light reading,
https://www.ncbi.nlm.nih.gov/pubmed/24552242
http://www.nejm.org/doi/full/10.1056/NEJMoa0909883#t=article
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If you're gonna be snarky to people you should at least know what you're talking about. You also should apparently read the Fletcher and Peto paper...
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I've found it essential to explain the above to COPD'ers, because they always tell me, "those darn inhalers don't work, I always still end up in the hospital and my breathing never gets better."
They need to know that this is not a matter of "getting better" but slowing worsening, less frequency of exacerbations, and giving them more years of life with less symptoms. (the above about heterogeneity is true, but since we can't tell what the future brings for any given patient they should all play it safe and quit smoking and follow tx)
I pulled out my COPD pocketcard for you like I would a patient.
Someone has FEV 100 at 25, smoker, susceptible, disability at 55 with FEV ~30, dies around 67 with decline rate.
Stops smoking at 45 with dx, FEV 75. Lives to 80.
They need to know that this is not a matter of "getting better" but slowing worsening, less frequency of exacerbations, and giving them more years of life with less symptoms. (the above about heterogeneity is true, but since we can't tell what the future brings for any given patient they should all play it safe and quit smoking and follow tx)
I pulled out my COPD pocketcard for you like I would a patient.
Someone has FEV 100 at 25, smoker, susceptible, disability at 55 with FEV ~30, dies around 67 with decline rate.
Stops smoking at 45 with dx, FEV 75. Lives to 80.
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yes..apparently you are studying for the MCATs...
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I reviewed that. I was incorrect in how I was reading the graph. Oops.
It's more fair to say that quitting smoking doesn't necessarily = turn back the clock, the lungs are gonna be OK now, but that no matter how far you are with COPD there is benefit to quitting. A lot of patients rationalize that they may as well continue smoking, so I find it's important to make that clear.
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arossm
Ok, so this is what we've established:
- COPD smokers who quit smoking reduce their rate of lung deterioration - say to a relative rate of 1.5
- COPD smokers who don't smoke stay at a relative rate of 2 for lung deterioration
- non-COPD nonsmokers have a rate of lung function decline of 1
The numbers are just conceptual. Is this the correct way to think about it?
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arossm
How? How am I "apparently" studying for the MCAT?
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arossm
Let me read this...
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hon, you have posted in 2 threads, this one and this one
Vasoconstriction in response to drop in blood pressure in the MCAT section.
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I hope the pic I put up helps. Based off the Fletcher paper.
According to that, it says it slows the rate, looks like not back to normal, but I can't tell without reading the paper again which I'm not going to do right now. You should read it.
I like using the card I posted for you in talking to my patients about why they need to quit smoking and no that won't cure you but look how much it helps. Sorry if me chiming in isn't precise on this count but I won't apologize for dissenminating what has helped me get tx compliance for smoking cessation & inhalers etc with COPD pts.
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arossm
I didn't know where else to ask that question, so I chose the MCAT section. Why would I go into that much detail if I was studying for the MCAT?
And what would be wrong with studying for the MCAT, if someone wanted to do that (which I'm not)?
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The point is is that this forum is for residents and practicing physicians, and more specifically for questions related to thae practice of IM.
Since self identify as a premed, your post should be moved there and students and physicians who have information in regards to your question can answer it there.
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arossm
My apologies, what I meant to say on the second dashed line was "COPD smokers who DON'T stop smoking".
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arossm
Cool man, if you really badly want to move this post go ahead and do it. This has turned into such a big deal. Do whatever you want. All this irrelevant stuff about what I self identified as and where I posted my previous questions at. You guys are bullies. You're detracting from the question. With that, go ahead and blow up the post...
Thank you Crayola227 and the argus for your help. I appreciate it. I have saved your resources and will read those resources tomorrow.
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I'm sorry you feel that way.
The rules about appropriate location for posts have been developed over years of formulating a strong community and seeing what works best.
Users have consistently requested stronger moderation in regards to thread placement. While this may disappoint you, it works best for the community.
Those who wish to assist you with your query, can do so there.
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arossm
Well, the ratio is off. It was one person complaining (and he wasn't even complaining about placement as you are making it seem for him) vs. many other people participating.
I just thought doctors know more about this question than students.
And how do you know that my career status is not arbitrarily chosen?
A pre-med is not going to know anything about COPD, trust me. I wouldn't be asking about COPD if I was pre-med. Pre-meds ask about biology and organic chemistry.
This thread is SOOO misplaced. Now the thread will be ignored. Congrats.
I thought your goal was to correctly place threads where they should go. How it was before was more correct and appropriate.
Unless, your decision to go down this road was in part motivated by trying to rationalize that other person who was attacking me. I hate rationalization. We humans do it a lot. We are not objective human beings.
You tried to make him appear as justified for attacking me. He was spiraling fast, so you tried to make him seem at least somewhat justified for attacking me. It's called rationalization, Dr.
I just thought doctors know more about this question than students.
And how do you know that my career status is not arbitrarily chosen?
A pre-med is not going to know anything about COPD, trust me. I wouldn't be asking about COPD if I was pre-med. Pre-meds ask about biology and organic chemistry.
This thread is SOOO misplaced. Now the thread will be ignored. Congrats.
I thought your goal was to correctly place threads where they should go. How it was before was more correct and appropriate.
Unless, your decision to go down this road was in part motivated by trying to rationalize that other person who was attacking me. I hate rationalization. We humans do it a lot. We are not objective human beings.
You tried to make him appear as justified for attacking me. He was spiraling fast, so you tried to make him seem at least somewhat justified for attacking me. It's called rationalization, Dr.
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arossm
I read the first one. So according to that, what I take from it is that COPD is not a progressive disease. It is only progressive in the sense that they don't stop smoking, meaning the "VA Hopeful Dr" wasn't joking. It says they will not recover lost function (which intuitively makes sense anyway without the need to particularly mention it since you can't fix scarring and structural damage), but the rate of loss will return to normal (in other words, like a non-smoker's rate of decline). Unless of course, normal rates of decline above the manifestation threshold are observable, unlike with healthy patients where normal rates of decline stays below the threshold and so a "manifestation of the progression is non-observable".
In other words, once I've developed COPD then normal rates of decline are manifestible because I'm already working with such a low function, whereas such normal rates of decline would otherwise not be manifestible. Is this a correct conclusion to take away? If that's the idea, then it makes sense. And the graph is really great in visualizing that.
But one thing still remains, the idea that I had coming in is that there is continuous underlying inflammation taking place even after cessation of smoking. Is that wrong? Did I pick that up incorrectly from somewhere? If not, then how come former smokers return to normal rates of decline in lung function rather than a rate that is somewhere in the middle between normal-rate and smoker-rate, not as good as normal rate but not as bad as continuous smoking either?
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If I learned anything in medical school so far, it's that when uncertain, the answer is always inflammation!
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If you're going to wilfully ignore obvious forum rules at least don't act like a petulant child towards the moderators who are just doing doing their jobs.
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arossm
How did I willfully ignore forum rules? Please don't argue with me. You won't win, trust me.
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First of all, smoking is not the only cause of COPD.
Second of all, this is stuff you learn about in physiology during medical school. Even if someone gives you the "answer," you aren't going to understand because you haven't learned the principals of pulmonary physiology.
Third of all, why don't you just read up on COPD if you are curious? Why post in a pre-medical thread about the stuff? There is plenty to learn from the google and such.
Second of all, this is stuff you learn about in physiology during medical school. Even if someone gives you the "answer," you aren't going to understand because you haven't learned the principals of pulmonary physiology.
Third of all, why don't you just read up on COPD if you are curious? Why post in a pre-medical thread about the stuff? There is plenty to learn from the google and such.
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arossm
The response quality noticeably dropped. Mistafab, the moderator put the question here, I didn't. That is what I'm arguing, is that the thread is misplaced.
Second of all, I read up on it. I am coming here to clear up some confusion. Is that hard to understand? Is that inconceivable?
And where did I say smoking is the only cause?
It looks like the supposed pre-medical student is more inquisitive than the actual medical student. Lord have mercy.
Second of all, I read up on it. I am coming here to clear up some confusion. Is that hard to understand? Is that inconceivable?
And where did I say smoking is the only cause?
It looks like the supposed pre-medical student is more inquisitive than the actual medical student. Lord have mercy.
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arossm
huh?
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A few things, but keep in mind that I have very limited knowledge here, both about COPD and the rules of SDN.
1. Not all COPD patients are smokers.
2. From what I understood from a >5 minute explanation on what you get from a spirometry from a pulmonologist, some COPD patients do have a degree of reversibility when using a bronchodilator.
3. It's pretty obvious glancing at the internal medicine forum that this thread didn't really fit.
1. Not all COPD patients are smokers.
2. From what I understood from a >5 minute explanation on what you get from a spirometry from a pulmonologist, some COPD patients do have a degree of reversibility when using a bronchodilator.
3. It's pretty obvious glancing at the internal medicine forum that this thread didn't really fit.
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Oh come on, this is another one of those situations where the people who are unhappy, whine, and thus the forum ends up the way they want it. Why are people going to contact the mods just to say "hey these posts did NOT bother me"? They aren't, usually, and complaining about modding is usually ignored. Lord knows the mods always ignore me when I tell them that the constant over-modding is just as toxic to the forum as letting a few trolls slip by.
This guy wanted an answer to a question he had on pathology, this is a population who can (and may even enjoy) having that discussion. Live and let live...not sure why SDN has to be so uptight ALL the gorram time, it's exhausting. Sure, this thread is out of place, despite that it was healthy and had some good responses to a reasonable question...but we can have 80,000 going on at any given time whining about how hard med school is.
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He's making decent points. Many of the forum rules are petty or pointless. Sure, enforce them, but don't act like it's uplifting the community to do so for some of the cases where the rules are actually getting in the way of reasonable discussion.
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The attitude would make me regret the time I invested, except even if someone is rude maybe they go on one day to be a doctor and they can get a COPD'er to use their damn inhalers, avoid one hospitalization ever, and I just saved the taxpayer $20K today and justified my existence.
You've got it now.
For the MCAT, you have to worry about it, I guess.
I don't see this coming up on my IM board, but maybe. The pocketcard helps me treat patients, the other question.... otherwise, when you're in med school, there will be tons of **** like this you'll wonder and even search for, and at some point, you gotta let it go. It doesn't always make a difference. This wouldn't affect my management of patients but it might affect my MCAT choice.
I didn't see what forum this started in. I just always throw in my 2 cents as a doc. You get pearls when docs ramble even if they don't answer your question.
As one person pointed out, not all COPD is from smoking, another pointed out that not all COPD acts the same re: progression.
The patient that stops smoking, you necessarily don't stop treating with inhalers and all that, so it's hard to say what the cessation does to reduce inflammation, what is residual and increased over normal, and how much tx is then getting under control and similar to non-smoker. I think they still have what you would call increased level of subclinical inflammation, subclinical by definition meaning that it is otherwise undetectable by typical means, but would still be present on biopsy, for example.
I'll tell you this, when they quit smoking, die 20 years later, and you look at those bronchioles, it will not look like a never smoker, or a current smoker. There will be signs of chronic inflammation. But chronic acute? I dunno, I don't know if does eventually die down.
When inflammation is from an external irritant, and you remove that, sometimes the cycle still goes on and on once started. Other times, it will just resolve even if there's more interstitium, scarring, macrophages, evidence of burnt out inflamm left behind. This is more likely to be the case where the "driver of inflammation" is external and removable, when it's autoimmune or another more ongoing exposure, even if you suppress things and calm it down, it can go into remission like (some autoimmune processes do this), other times it's always simmering.
You've got it now.
For the MCAT, you have to worry about it, I guess.
I don't see this coming up on my IM board, but maybe. The pocketcard helps me treat patients, the other question.... otherwise, when you're in med school, there will be tons of **** like this you'll wonder and even search for, and at some point, you gotta let it go. It doesn't always make a difference. This wouldn't affect my management of patients but it might affect my MCAT choice.
I didn't see what forum this started in. I just always throw in my 2 cents as a doc. You get pearls when docs ramble even if they don't answer your question.
As one person pointed out, not all COPD is from smoking, another pointed out that not all COPD acts the same re: progression.
The patient that stops smoking, you necessarily don't stop treating with inhalers and all that, so it's hard to say what the cessation does to reduce inflammation, what is residual and increased over normal, and how much tx is then getting under control and similar to non-smoker. I think they still have what you would call increased level of subclinical inflammation, subclinical by definition meaning that it is otherwise undetectable by typical means, but would still be present on biopsy, for example.
I'll tell you this, when they quit smoking, die 20 years later, and you look at those bronchioles, it will not look like a never smoker, or a current smoker. There will be signs of chronic inflammation. But chronic acute? I dunno, I don't know if does eventually die down.
When inflammation is from an external irritant, and you remove that, sometimes the cycle still goes on and on once started. Other times, it will just resolve even if there's more interstitium, scarring, macrophages, evidence of burnt out inflamm left behind. This is more likely to be the case where the "driver of inflammation" is external and removable, when it's autoimmune or another more ongoing exposure, even if you suppress things and calm it down, it can go into remission like (some autoimmune processes do this), other times it's always simmering.
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Meant to point out with this too, this shows that your 65 yo, there's still so much value in quitting. Death at 80 vs like ~70. Quitting even at 65 after smoking 40 years, could still be the difference of a decade of life!
Remember something for me: no matter how old someone is, 5-10 years, is 5-10 years. Seems like what's the big deal someone old and gimpy dies at 80 vs 85. Numbers in the chart can start to feel like that, even when it's age. Maybe especially age.
But think about the amount of life you lived in the last 5 years, say, 20-25. How would you feel if I was cavalier about that in my treatment decision making for you??
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No he's not. Plenty of physicians read the premed forum and could have answered here. They shouldn't have to have their subforum, which is for issues relevant to them, cluttered with premeds asking basic pathophysiology questions they aren't even willing to Google themselves.
His terrible attitude towards a moderator is just the icing on the cake.
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Oh, please. It's not like I haven't been on here long enough to see how the various forums are used. His post is the kind of talk I'd LIKE to see in the med forums, but instead I just don't post anymore because I don't feel like whining about med school, which seems to be all anyone will approve in them. Preallo may have physicians reading it, but they're so outnumbered it would be pointless.
And the mods could use some pushback when they get heavy handed. Sorry, but that rarely improves the forum experience.
Sent from my phone, sorry for any typos or brevity.
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So the forum rules shouldn't apply because you find allo boring, and politely enforcing standards is being heavy handed and requires user push back. Got it.
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No, I'm saying most of the forum rules are terrible and the whole set needs to be overhauled. And until they are, some discretion could go a long way in making the forums actually enjoyable. Discretion is used in rules enforcement all the time; it's what allows actual disruptions to be handled without becoming suffocating.
Sent from my phone, sorry for any typos or brevity.
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I vote that we move this thread to the high schooler forum, because judging by OP's replies that's where this belongs.
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This is an uncomfortable thread *nervous laughter*
