Dr. Schiffman received his B.S. degree with High Honors in biology from Hobart College in 1976. He then moved to Chicago where he studied biochemistry at the University of Illinois, Chicago Circle. He attended Rush Medical College where he received his M.D. degree in 1982 and was elected to the Alpha Omega Alpha Medical Honor Society. He completed his Internal Medicine internship and residency at the University of California, Irvine.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
The most important treatment for COPD is quitting
cigarette smoking. Patients who continue to smoke have a more rapid
deterioration in lung function when compared to others who quit. Aging itself can cause a very slow decline in lung
function. In susceptible individuals, cigarette smoking can result in a much
more dramatic loss of lung function. It is important to note that when one stops
smoking the decline in lung function eventually reverts to that of a non-smoker.
Unfortunately, only about one third of the patients can
abstain from smoking long-term. Reasons for difficulty in quitting include
nicotine addiction,
stress in the
workplace and at
home, depression, peer pressure, and advertising from
cigarette companies.
Nicotine in cigarettes is addictive and therefore
cessation of smoking can cause symptoms of nicotine withdrawal including
anxiety, irritability,
anger,
depression, fatigue, difficulty concentrating or sleeping, and intense craving
for cigarettes. Patients likely to develop withdrawal symptoms
typically smoke more than 20 cigarettes a day, need to smoke shortly after
waking up in the morning, and have difficulty refraining from smoking in
non-smoking areas. However, some 25% of smokers can stop smoking without
developing these symptoms. Even in those smokers who develop symptoms of
withdrawal, the symptoms will decrease after several weeks of abstinence.
To help those patients with symptoms of withdrawal during the early weeks of smoking cessation,
nicotine chewing gum (Nicorette Gum), nicotine inhalers, and
nicotine skin patches (Habitrol, Nicoderm CQ, Nicotrol) are available in the United States. Nicotine replacement therapy can deliver enough nicotine into the blood to reduce but not totally eliminate withdrawal symptoms. Nicotine replacement methods in conjunction with intense patient education and behavioral modification programs have improved the rates at which individuals quit smoking. Nicotine skin patches are easy to use. They generally are used for four to six weeks, sometimes with a tapering period of several additional weeks. The addiction potential of nicotine skin patches is low. Sometimes a combination of several nicotine replacement therapies are utilized. It is important to note, that patients that continue to smoke while on replacement therapy are at increased risk for heart complications.
Bupropion (Zyban,
Wellbutrin) is an antidepressant that has been found to decrease cravings for
cigarettes. It has been shown to be of benefit to patients who want to quit
smoking.
Varenicline (Chantix) is
a medication is to aid in smoking cessation and has been approved for use in the US.
Varenicline works in two ways; by cutting the pleasure of smoking and reducing
the withdrawal symptoms that lead smokers to light up again and again. This
medicine is taken over a 12 week course and can work in ways that bupropion does
not.
In addition to nicotine withdrawal symptoms, quitting
cigarette smoking also may lead to weight gain of about 8-10 pounds on average
though more in some patients. Quitting smoking also can lead to depression and
worsening of symptoms of chronic ulcerative colitis. Therefore
quitting smoking
should be undertaken with a doctor's supervision. Nevertheless, the benefits of
quitting smoking (decreasing the rate of lung deterioration, decreasing risks of
heart attack, lung cancer and other cancers, decreasing the chance of developing
stomach
ulcers, etc.) far outweigh these potential negative effects.
Bronchodilators
Treating airway obstruction in COPD with bronchodilators is similar but not
identical to treating bronchospasm in asthma. Bronchodilators are medications
that relax the muscles surrounding the small airways thereby opening the
airways. Bronchodilators can be inhaled, taken orally or administered
intravenously. Inhaled bronchodilators are popular because they go directly to
the airways where they work. As compared with bronchodilators given orally, less
medication reaches the rest of the body, and, therefore, there are fewer side
effects.
Metered dose inhalers (MDIs) are used to deliver
bronchodilators. An MDI is a pressurized canister containing a medication that
is released when the canister is compressed. A standard amount of medication is
released with each compression of the MDI. To maximize the delivery of the
medications to the airways, the patient has to learn to coordinate inhalation
with each compression. Incorrect use of the MDI can lead to deposition of much
of the medication on the tongue and the back of the throat instead of on the airways.
Chlorofluorocarbons (CFCs) have been removed from all MDI inhalers because of the environmental effects on the ozone layer. These have been replaced by a new propellant, hydrofluoroalkane (HFA). Patients may notice that the jet they feel in the back of their throat is less intense when compared with the CFC inhaler. They should be instructed that they are still receiving the same amount of medication though it may feel different than their older inhaler. Another very important point that patients must be aware of is that "floating" these new inhalers does not help in determining the amount of medication left in the MDI. In the past, the CFC devices could be floated in a bowl of water. With more medicine in the inhaler, the canister would sink and gradually float as it emptied. This is not the case with the HFA inhalers. The number of inhalations must be counted to determine if medication is still left in the inhaler. Shaking the inhaler is not an effective method of determining how much medication is left. Often propellant (HFA) will continue to come out of the inhaler even after the medication is used up. At the present only one
albuterol inhaler comes with a counter device and this is Ventolin-HFA.
Beta-agonists
Historically, one of the first medications used for
asthma was adrenaline (epinephrine). Adrenaline has a rapid onset of action in
opening the airways. It is still used in certain emergency situations for
attacks of asthma. Unfortunately, adrenaline has many side effects including
rapid heart rate, headache, nausea, vomiting, restlessness, and a sense of
panic. Therefore, it is
not used in the treatment of COPD.
Beta-2 agonists have the bronchodilating effects of adrenaline without many of its unwanted side effects. Beta-2 agonists can be administered by MDI inhalers or orally. They are called "agonists" because they activate the beta-2 receptor on the muscles surrounding the airways. Activation of beta-2 receptors relaxes the muscles surrounding the airways and opens the airways. Dilating airways helps to relieve the symptoms of dyspnea (shortness of breath). Beta-2 agonists have been shown to relieve dyspnea in many COPD patients, even among those without demonstrable reversibility in airway obstruction. The action of beta-2 agonists starts within minutes after inhalation and lasts for about 4 hours. Because of their quick onset of action, beta-2 agonists are especially helpful for patients who are acutely short of breath.
Because of their short duration of action, these medications should be used for symptoms as they develop rather than as maintenance. Evidence suggests that when these drugs are used routinely, their effectiveness is diminished. These are referred to as rescue inhalers.
Examples of beta-2 agonists include
albuterol (Ventolin HFA, Proventil HFA, Proair),
metaproterenol (Alupent),
pirbuterol (Maxair), terbutaline
(Brethaire), isoetharine (Bronkosol),
and levalbuterol (Xopenex). Albuterol is a chemical that comes mixed in two forms, mirror images of itself, a left and right hand. Levalbuterol is a purer form of albuterol, the left hand component. There are some theoretical advantages to this form including possibly reduced side effects.
Acetylcholine is a chemical released by nerves that attaches to receptors on
the muscles surrounding the airway causing the muscles to contract and the
airways to narrow. Anti-cholinergic drugs such as
ipratropium bromide (Atrovent)
dilate airways by blocking the receptors for acetylcholine on the muscles of the
airways and preventing them from narrowing. Ipratropium bromide (Atrovent)
usually is administered via a MDI. In patients with COPD, ipratropium has been
shown to alleviate dyspnea, improve
exercise tolerance and improve FEV1.
Ipratropium has a slower onset of action but longer duration of action than the
shorter-acting beta-2 agonists. Ipratropium usually is well tolerated with
minimal side effects even when used in higher doses. Tiotropium (Spiriva) is a
long-acting and more powerful version of Ipratropium and has been shown to be
more effective.
In comparing ipratropium with beta-2 agonists in the treatment of patients
with COPD, studies suggest that ipratropium may be more effective in dilating
airways and improving symptoms with fewer side effects. Ipratropium is
especially suitable for use by elderly patients who may have difficulty with
fast heart rate and tremor from the beta-2 agonists. In patients who respond
poorly to either beta-2 agonists or ipratropium alone, a combination of the two
drugs sometimes results in a better response than to either drug alone without
additional side effects.
Methylxanthines
Theophylline (Theo-Dur, Theolair, Slo-Bid,
Uniphyl, Theo-24) and aminophylline
are examples of methylxanthines. Methylxanthines are administered orally or
intravenously. Long acting theophylline preparations can be given orally once or
twice a day. Theophylline, like a beta agonist, relaxes the muscles surrounding
the airways but also prevents mast cells around the airways from releasing
bronchoconstricting chemicals such as histamine. Theophylline also can act as a
mild diuretic and increase
urination. Theophylline also may increase the force of contraction of the heart
and lower pressure in the pulmonary arteries. Thus, theophylline can help
patients with COPD who have heart failure and pulmonary
hypertension. Patients who have difficulty using inhaled bronchodilators but no
difficulty taking oral medications find theophylline particularly useful.
The disadvantage of methylxanthines is their side
effects. Dosage and blood levels of theophylline or
aminophylline have to be
closely monitored. Excessively high levels in the blood can lead to nausea,
vomiting, heart rhythm problems, and even
seizures. In patients with heart
failure or cirrhosis, dosages of methylxanthines are lowered to avoid high blood
levels. Interactions with other medications, such as cimetidine (Tagamet),
calcium channel blockers
(Procardia), quinolones (for example,
ciprofloxacin [Cipro, Cipro
XR, Proquin XR), and allopurinol (Zyloprim) also can alter blood
levels of methylxanthines.
Corticosteroids
When airway inflammation (which causes swelling)
contributes to airflow obstruction, antiinflammatory medications (more
specifically, corticosteroids) may be beneficial. Examples of corticosteroids
include prednisone and
prednisolone (Pediapred Oral
Liquid, Medrol). Twenty to thirty percent of patients with
COPD show improvement in lung function when given corticosteroids by mouth.
Unfortunately, high doses of oral corticosteroids over prolonged periods can
have serious side effects including:
Therefore, many doctors use oral corticosteroids as the treatment of last
resort. When oral corticosteroids are used, they are prescribed at the lowest
possible doses for the shortest period of time to minimize side effects. When it
is necessary to use long term oral steroids, medications are often prescribed to
help reduce the development of the above side effects.
Corticosteroids also can be inhaled. Inhaled corticosteroids have many fewer
side effects than long term oral corticosteroids.
Inhaled corticosteroids have been useful in treating patients with
asthma, but in patients with COPD, it is not clear whether inhaled corticosteroids have the
same benefit as oral corticosteroids. Nevertheless, doctors are less concerned
about using inhaled corticosteroids because of their safety. The side effects of
inhaled corticosteroids include hoarseness,
loss of voice, and oral yeast infections.
To decrease the deposition of medications on the throat and increase the amount reaching the airways, spacers can be helpful. Spacers are tube-like chambers attached to the outlet of the MDI canister. Spacer devices can hold the released medications long enough for patients to inhale them slowly and deeply into the lungs. A spacing device placed between the mouth and the MDI can improve medication delivery and reduce the side effects on the mouth and throat.Rinsing out the mouth after use of a steroid inhaler also can decrease these side effects. It is less clear whether spacing devices help with deposition or side effects of other inhaled medications.
Advair, a powered inhaler device, contains both salmeterol (a long acting beta-agonist) and fluticasone (an inhaled steroid). This medication has shown to be effective in COPD patients with chronic bronchitis. Its major side effects include the possible development of thrush
(oral candidiasis) and hoarseness. Another combination medication available in
an MID device is budesonide and formoterol (Symbicort).
Treatment of Alpha-1 antitrypsin deficiency
Emphysema can develop at a very young age in some
patients with severe alpha-1 antitrypsin deficiency (AAT). Replacement of the
missing or inactive AAT by injection can help prevent progression of the
associated emphysema. This therapy is of no benefit in other types of COPD.
Chronic Obstructive Pulmonary Disease - Symptoms At Onset Of DiseaseQuestion: The symptoms of chronic obstructive pulmonary disease can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
Pneumonia is inflammation of one or both lungs with consolidation. Pneumonia is frequently but not always due to infection. The infection may be bacterial, viral, fungal or parasitic. Symptoms may include fever, chills, cough with sputum production, chest pain, and shortness of breath.
Lung cancer kills more men and women than any other form of cancer. Eight out of 10 lung cancers are due
to tobacco smoke. Lung cancers are classified as either small cell or non-small
cell cancers.
Bronchitis is a disease of the respiratory system in which the bronchial passages become inflamed. There are two types of bronchitis, acute and chronic. Symptoms of acute bronchitis include frequent cough with mucus, lack of energy, wheezing, and possible fever. Treatment may require medication such as bronchial inhalers and predinsone. Supportive treatment is focused on relieving the symptoms with fever reducers, cough suppressants, and rest. Treatment may be more aggressive in patients with pre-existing conditions such as empyema, COPD, or cigarette smoking.
Chronic cough is a cough that does not go away and is generally a symptom of another disorder such as asthma, allergic rhinitis, sinus infection, cigarette smoking, GERD, postnasal drip, bronchitis, pneumonia, medications, and less frequently tumors or other lung disease. Treatment of chronic cough is dependant upon the cause.
Chest pain is a common complaint by a patient in the ER. Causes of chest pain include broken or bruised ribs, pleurisy, pneumothorax, shingles, pneumonia, pulmonary embolism, angina, heart attack, costochondritis, pericarditis, aorta or aortic dissection, and reflux esophagitis. Diagnosis and treatment of chest pain depends upon the cause and clinical presentation of the patient's chest pain.
Asthma is a common disorder in which
chronic inflammation of the bronchial tubes (bronchi) makes them swell, narrowing the airways. Signs and symptoms include shortness of breath, chest tightness,
cough and wheezing.
Emphysema is a progressive disease of the lungs. The primary cause of emphysema is smoking. Alpha 1-antitrypsin deficiency is a rare disorder that has a genetic predisposition to emphysema. Aging, IV drug use, immune deficiencies, and connect tissue illnesses are also risk factors for emphysema. Emphysema is a subtype of COPD (chronic obstructive pulmonary disease, COLD). Symptoms include shortness of breath and wheezing. Management of symptoms may be achieved with medications, quitting smoking, pulmonary rehabilitation, or surgery.
Polycythemia (elevated red blood cell count) causes are either primary (aquired or genetic mutations) or secondary (diseases, conditions, high altitude). Treatment of polycythemia depends on the cause.
Premature ventricular contractions (PVCs) are premature heartbeats originating from the ventricles of the heart. PVCs are premature because they occur before the regular heartbeat. There are many causes of premature ventricular contractions to include: heart attack, high blood pressure, congestive heart failure, mitral valve prolapse, hypokalemia, hypoxia, medications, excess caffeine, drug abuse, and myocarditis.
Pulmonary hypertension is an abnormal elevation of the pressure in the pulmonary circulation caused by the constriction of the blood vessels that supply blood to the lungs. Shortness of breath and dizziness are symptoms of pulmonary hypertension. Treatment involves diuretics, blood thinners, calcium channel blockers, and using supplemental oxygen to increase blood oxygen levels.
A pneumothorax is free air in the chest outside the lung, that causes the lung to collapse (collapsed lung). There are two types of pneumothorax, spontaneous or primary pneumothorax and secondary pneumothorax. Symptoms include sudden chest pain, shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue.
Chronic bronchitis is a cough that occurs daily with production of sputum that lasts for at least three months, two years in a row. Causes of chronic bronchitis include cigarette smoking, inhaled irritants, and underlying disease processes (such as asthma, or congestive heart failure). Symptoms include cough, shortness of breath, and wheezing. Treatments include bronchodilators and steroids. Complications of chronic bronchitis include COPD and emphysema.
Interstitial lung disease, is a term to describe a certain lung condition. Causes of interstitial lung disease include lung infection, exposure to toxins in the environment (asbestos for example), medications (chemotherapy), radiation therapy, and chronic autoimmune disorders. Common symptoms of interstitial lung disease include a dry cough and shortness of breath. Diagnosis and treatment depend upon the cause of the condition.
Coma is the inability to waken or react to the surrounding environment. The Glasgow Coma Scale is frequently used to measure the depth of coma. Causes of coma include trauma, bleeding, edema, lack of oxygen, poisoning, or hypoglycemia. Prognosis for a patient in a coma depends on the cause of the coma.
Fatigue can be described in various ways. Sometimes fatigue is described as feeling a lack of energy and motivation (both mental and physical). The causes of fatigue are generally related to a variety of conditions or diseases for example, anemia, mono, medications, sleep problems, cancer, anxiety, heart disease, drug abuse, and more. Treatment of fatigue is generally directed toward the condition or disease that is causing the fatigue.
Smoker's lung photo essay is a collection of pictures and microscopic slides of lung disease caused by cigarette smoking. Smoker's lung refers to the diseases and structural abnormalities in the lung caused by cigarette smoking.
Bronchiectasis is a condition in which the bronchial tubes of the lung become damaged. Inflammation from infection or other causes destroys the smooth muscles of the bronchial tubes. Bronchiectasis is a form of COPD (which includes emphysema and chronic bronchitis). There are three primary types of bronchiectasis: 1) cylindrical bronchiectasis; 2) saccular bronchiectasis; and 3) cystic bronchiectasis. Bronchiectasis may also be acquired or congenital. The most common symptoms of bronchiectasis are recurrent cough and sputum production. There is no cure for bronchiectasis. Treatment is often geared toward controlling the symptoms of bronchiectasis.
There are many unusual symptoms of asthma, including sighing, difficulty sleeping, anxiety, chronic cough, recurrent walking pneumonia, and rapid breathing. These symptoms may vary from individual to individual. These asthma complexities make it difficult to accurately diagnose and treat asthma.
There are two types of asthma medications: long-term control with anti-inflammatory drugs and quick relief from bronchodilators. Asthma medicines may be inhaled using a metered dose inhaler or nebulizer or they may be taken orally. People with high blood pressure, diabetes, thyroid disease, or heart disease shouldn't take OTC drugs like Primatene Mist and Bronkaid.
Acute respiratory distress syndrome (ARDS) is a lung condition in which trauma to the lungs leads to inflammation of the lungs, accumulation of fluid in the alveolar air sacs, low blood oxygen, and respiratory distress. Causes of ARDS include: pneumonia, aspiration, severe blow to the chest, sepsis, severe injury with shock, drug overdose, and/or inflamed pancreas. Treatment for ARDS include extra oxygen, and/or medication.
Alpha-1 antitrypsin deficiency is an inherited disorder that may cause liver and lung disease in adults. Signs and symptoms include shortness of breath, wheezing, weight loss, respiratory infections, fatigue, vision abnormalities. Advanced lung disease from alpha-1 antitrypsin deficiency include emphysema. Liver damage from alpha-1 antitrypsin deficiency causes a swollen abdomen, swollen legs or feet, and jaundice.
Nicotine is delivered to the brain through smoking, chewing, or sniffing tobacco. Nicotine is an addictive agent. Common names for nicotine products include smokes, cigs, butts, chew, dip, spit, or snuff. Habitual nicotine use leads to many debilitating medical conditions.
The lungs are primarily responsible for the exchange of oxygen and carbon dioxide between the air we breathe and the blood. Eliminating carbon dioxide from the blood is important, because as it builds up in the blood, headaches, drowsiness, coma, and eventually death may occur. The air we breathe in (inhalation) is warmed, humidified, and cleaned by the nose and the lungs.
If you have a COPD such as emphysema, avoiding chronic bronchitis and colds is important to avoid a more severe respiratory infection such as pneumonia. Avoiding cigarette smoking, practice good hygeine, stay away from crowds, and alerting your healthcare provider if you have a sinus infection or cold or cough that becomes worse. Treatment options depend upon the severity of the emphysema, bronchitis, or cold combination.
Secondhand smoke can cause illness and disease in nonsmokers. Some of these conditions include lung cancer, heart disease, respiratory illnesses such as asthma, SIDS, bronchitis, and pneumonia. Learn how you can protect yourself and your family from secondhand smoke exposure in the home environment and workplace.
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