Take a deep breath

There is a large variety of pulmonary diseases, most of them preventable. A Jerusalem public symposium on lungs set the record straight.

(photo credit: JUDY SIEGEL)
If lungs could talk, many of them would reprimand the people who breathe through them “Why are you killing us with your tobacco smoke? Why are you overweight, putting pressure on the heart and giving us less oxygen-rich blood and risking the health of your brain? Why are you exposed to air pollution on the street and chemicals on the job? Why don’t you use inhalers for your asthma properly? Why not relax so we don’t feel the effects of your constant emotional stress?” One can just imagine the lungs turning red and seething with anger and frustration.
But as this important organ cannot communicate verbally, it too often gets its message across when it is too late – when lung cancer, heart disease and stroke have already struck; when chronic obstructive pulmonary disease (COPD) has made it impossible to breathe normally and gives the feeling of constantly breathing underwater; and when asthma attacks scare you and those around you.
Some 350 people of all ages – some with oxygen machines attached to their nostrils – came to Jerusalem’s Shaare Zedek Medical Center earlier this month for ShishiBari (Healthy Friday) free public lectures on “Take a Deep Breath: Updates and Innovations in Pulmonary Medicine.” The fifth-floor Steinberg Auditorium was as packed as the nasal cavities of people who got the winter flu after neglecting to get an influenza vaccination.
PROF. GABRIEL Izbicki, the Swissborn pulmonologist and internal medicine specialist who heads the institute, stressed the importance of the lungs and their millions of alveoli – tiny air sacs – that allow for rapid exchange of inhaled oxygen for exhaled carbon dioxide waste.
The growing institute diagnoses and treats both outpatients in clinics and inpatients with lung diseases.
DR. ARIEL Rokach, a senior pulmonologist and director of the respiratory service, noted that shortness of breath, choking, gasping for air, difficulty inhaling and exhaling are very frightening symptoms.
“They can result from physiological, psychological, skeletal, environmental and even cultural factors and cause serious suffering. The symptoms can show up in minutes, hours or weeks. They can involve a heart attack, heart valve failure, edema of the vocal cords, infection, allergy, asthma, pulmonary embolism and kyphosis [abnormal curvature of the spine]. We talk to the patient, give him a comprehensive examination and, if necessary, check oxygen saturation in the blood, do a lung-function test, x-ray the chest and even lung mapping. We can also take a mucus culture, do biochemistry and a blood count, echocardiogram and a stress test.”
He strongly urged getting a flu vaccination for everyone over the age of six months, as complications of the viral disease can be very dangerous to the elderly, people with chronic diseases, pregnant women, babies and young children. Pneumonia, whose danger can be reduced over the age of 65 by taking a free pneumococcal vaccination, shows up on x-rays as white blotches.
A variety of small foreign objects inhaled into the lungs by children and adults require pulmonologists to fish them out using bronchoscopy; an instrument is threaded through the nose or mouth and down the throat into the lungs. Among the objects institute doctors have fished out have been dental sponges, slices of hot dogs, coins and miniature metal dental probes.
Coughing is the most common complaint among patients coming to the outpatient clinic, said Dr. Nissim Arish, another senior pulmonologist.
“It is very frustrating for both the patient and the doctor because we cannot always help immediately.
Coughing is good for expelling discharge and foreign objects, but there are receptors for coughing not only in the throat but also in the lungs, internal ear and pericardium surrounding the heart. Coughing makes it hard for people to sleep well, causes headaches, incontinence, blood in the retina, hernias and even broken ribs,” Arish said.
“We always ask patients how long they have been bothered by a cough; the complaint is acute up to three weeks; subacute up to eight weeks and chronic beyond that.” Various drugs including antibiotics, antihistamines, medications and break up phlegm and cough suppressors are available.
Although whooping cough is considered a childhood disease for which there is a protective vaccine, it can occur in adults as well. Victims can cough uncontrollably for six to eight weeks, and there is no real treatment. Those in contact with whooping cough patients have to get preventive treatment, and it can be very dangerous in young children.
In cases of chronic coughing, the doctor has to rule out infections, tumors and other problems.
If a patient coughs but has not yet been sent for an x-ray, the pulmonologist should first ask if he has been taking certain hypertension drugs – or combinations of medications – as these can trigger coughing. It can take a month after changing these drugs for the coughing to end.
More than half of patients with a cough suffer from chronic sinusitis; while some of the cases can easily be diagnosed by looking down the throat and seeing a stream of mucous, in many cases, this is totally absent, continued Arish, and more difficult to determine the cause.
As for asthma, although commonly considered a children’s disease, it can also appear in adults when they are 50, 60 or older. There are dozens of types of steroid and bronchodilators for the condition. Reflux, in which gastric juices back up from the stomach to the esophagus, can cause chronic cough as well.
THE SCOURGE of smoking, which kills 8,000 Israelis a year, was the subject of Dr. Chen Chen-Shuali, another pulmonologist in the institute.
There are 4,000 chemicals in tobacco smoke, and 50 of them are carcinogenic.
When the listed just some of the poisons in tobacco smoke – including ammonia, benzene, lead, DDT, cyanide, formaldehyde, cadmium, arsenic and carbon monoxide – there was an audible sound of gasping in the audience. The list of diseases it causes, from heart attack and stroke to cancers and sudden death, induced a joker in the audience to interrupt: “When will we have a smoking break?” Almost a third of smokers in Israel will develop COPD and 900 of them die of it in an average year. In 2020, it is expected to become the third most common cause of death. The danger of cancers, said Chen-Shuali, is 16- to 20-fold more than in those not exposed to smoke. Those who smoke live an average of a decade less than those who don’t.
Hookah smoking, which spread from the Arab to the Jewish population and from teenagers to adults, is as dangerous or more dangerous than cigarettes, she continued.
Lighting up a water pipe for an hour is the equivalent of smoking a whole pack of 20 cigarettes.
Smoking actually creates nicotine receptors in the brain. Kicking the habit can cause sleeping problems, anxiety, depression and weight gain, but it is undoubtedly worth fighting these problems to give it up.
Shaare Zedek holds ongoing smoking cessation programs for patients using nicotine alternatives and non-nicotine drugs like Zyban (buprion) and Champix (vareniclin), in groups and individual counseling.
DR. AMIR Jarjou’i noted that COPD is an umbrella term that includes emphysema, chronic bronchitis, certain types of bronchiectasis, and sometimes asthma.
He said that 8% of the population suffers from asthma, which involves a genetic inclination and exposure to allergic factors. In addition to inhalers, there are injections and pills.
“There are also new treatments for COPD, pulmonary hypertension and pulmonary fibrosis. Other patients with a susceptibility to blood clots come before going on long flights, before undergoing major operations due to general anesthesia or difficulties using inhalers,” he said.
COPD includes emphysema, in which the separation between alveoli is severely damaged.
REHABILITION OF lung diseases is a major enterprise at the hospital, said pulmonologist Dr. Hava Azulai.
“We have been offering this service for 10 years, with nearly 4,000 sessions. Our interdisciplinary team includes doctors, physiotherapists, social workers, dietitians and occupational therapists who strengthen the skeleton, improve physical ability, raise lung function and improve the quality and length of life. Patients come for rehabilitation twice a week for three months, usually using equipment found in gyms but under close supervision.
A film presented an older Jerusalem woman who had been unable to walk more than a few steps due to respiratory disease and, after treatment, now walks many kilometers to the hospital and back.
Azulai also disclosed the use of a new biopsy technique that makes it unnecessary to surgically open the chest to take large tissue samples.
Advanced bronchoscopies using ultrasound make it possible to take tissue samples outside the bronchi while observing the process directly, she said. A cryoprobe is inserted into the bronchi and bronchioles, gas under pressure freezes suspect tissue, and the biopsy is quickly removed. “We now do this on a daily basis.”
The use of metal coils – being researched in North America and Europe to reduce the volume of lungs with dead tissue caused by emphysema – has also been introduced at Shaare Zedek. “Before, we had almost nothing to offer them except for a lung transplant, which is not easy to get. The pulmonologists insert Slinky-like metal coils into damaged portions of the lungs to try to improve elasticity, allowing a patient to breathe normally.
The coils act like a spring, bringing the lungs back to a smaller size so it’s easier for the patient to breathe.
The coils are inserted through a narrow tube via a patient’s nose or mouth and threaded into the bronchi. The coil then attaches to the diseased tissue and pulls it tight, compressing the diseased part of the lung, allowing the tissue that is healthier to expand.
The institute’s research unit cooperates with various groups inside and outside the hospital.
“We are now looking into the possibility of research on new drugs that have not yet been included in the health funds’ basket of health service. They include new biological drugs and inhalers for treating asthma and COPD, fibrotic lung diseases and others. The unit makes it possible to treat serious patients who have not been helped by conventional treatments. As it is experimental, patients pay nothing.”
SURELY, THE next Share Zedej ShishiBari lecture series on pulmonary disease will discuss even newer and better treatments – but for the sake of your lungs, better protect them and don’t expose them to danger.