Dr. Kyle Hogarth Discusses Asthma at UChicago Medicine
24
August

By Adem Lewis / in , , , , , , /


[MUSIC PLAYING] Hello and welcome
to a live event with the University
of Chicago Medicine. I’m Tim Brown, and joining
me is Dr. Kyle Hogarth. Thanks for being
on our event today. I was going to say the program– we’ll call it a program. Why not? That works. Dr. Hogarth is an
expert on asthma, and one of the few doctors to
do a very specialized procedure called bronchial thermoplasty. In fact, if I’m
not mistaken, you were the first doctor in the
state of Illinois to do that. And I think you told me before
the show, the third doctor in the United States, correct? That sounds about right. Well, it’s very good. It’s interesting. And throughout
this live program, kind of the neat thing
about Facebook Live is you can actually send
your questions to us and we’ll try to get them
answered as best we can. Sure. That’ll be a lot of fun. Also, we want to
remind our viewers that you can go to
uchicagomedicine.org for appointments and
more information. You can also call Tanya, who
is Dr. Hogarth’s scheduler, at (773) 795-9933. Let’s get right into it. And we’ll start with
kind of a basic– if you can just tell us
what exactly asthma is and how do you know
that you have it? That’s a great question because
it’s probably actually a couple billion dollars
in research grants I’ve tried to answer
specifically what asthma is. But I guess probably the
simplest way to describe it– it’s a disorder where the
bronchial tubes, you know, the tubes that all the air is
moving through in your lungs will essentially tighten up. They will constrict. So instead of being big, they
will become much smaller. And as that happens– and it usually happens for
many different things– triggers of irritants in
the air, ozone pollution, et cetera, smoke, or things
that you’re allergic to– pollens, cats, dust, et cetera. That constriction obviously
makes it very hard to breathe. And so you’ll have symptoms
of wheezing and cough and shortness of breath
and chest tightness. And you might not be able to,
especially if you’re a younger child, not be able to keep
up with the other kids on the playground, et cetera. If you’re playing
sports, maybe you’ll have to sit out
for a little bit. Ultimately, though,
those symptoms can come from other things. So just because you might
have that feeling doesn’t mean you’re automatically
an asthmatic. That’s obviously where you’d
go to see your physician and get evaluated. There are a series
of tests and ways to prove that indeed
you have asthma. And I think it’s important,
though, because not everything that wheezes– just because
you make a whistling sound or tell me you have
trouble breathing doesn’t mean you have asthma. So as a parent, if you see
your child struggling, what are some of the things you
look for and triggers that trip to the doctor? Yeah, well, I’ll actually
use my relative as an example because I had a relative
who was a child, who– as I was watching him
not be able to keep up with my son on the
playground and not be able to climb the
monkey bars and run around like any other little kid ought
to be able to run around– and he would stop
and you could see that he was breathing heavy. And he wasn’t able to vocalize,
you know, chest tightness. He was a little guy. But I said, you know, we need
to go get him checked out. It obviously helps that this
is what I do for a living. And so, sure enough,
no surprise– he actually had asthma. And once properly
treated, did fantastic. I think it comes down to
watch how you’re– especially if they’re younger and
they can’t vocalize– watch the breathing. Does it look like they’re
having trouble breathing? Usually the first clue
is just that simplicity of not being able to keep up
with the other kids in general, right? Yeah. So– Interesting. So I would imagine it’s
like many other conditions. You have different
levels of severity and different levels
of treatments. Absolutely. And there are, of course,
published guidelines that help guide physicians
on how to manage the disease with the patients. And then those guidelines
offer an array of medications and there are actually plenty
of medications, thankfully, that help with this disease. It’s actually been one of the
nice advances within our field that asthma has become
a disease that we have a lot more options. That way, if some patient
is on a medication but dealing with
side effects from it, we’ve got other choices. And obviously it’s
allowed something, from a competitive perspective
with their insurance, they can potentially get some
of these drugs pretty cheap. Depending on your
level of severity– and there’s lots of
ways to measure it. We usually, of course, simple
questions of, you know, is asthma interfering
with your daily life? Are you waking up at night? Are you needing
your rescue inhaler? Have you had to be
in the emergency room or on oral steroids–
drugs like prednisone? Those are all signs of,
obviously, not enough control. And if you’re not
on enough control, then whatever drug regimen
you’re currently on– so, I mean, your taking
it is not enough. And I’m going to segue
there for one second and say probably the most
important component of asthma management is that the chronic
meds that your physician has said, you should be taking,
you need to take them. And if you’re having issues
with them, don’t just stop them, but communicate with
your health care provider because, without a doubt,
we have other options. And so, if you’re
having horrible side effects from whatever
drug, let that person know. We can try something different
to try to control your disease. The rescue inhaler, albuterol,
whether that’s nebulized or, you know, a
handheld inhaler– that actually
doesn’t treat asthma. All that does is treat
symptoms of asthma. It helps relieve the
bronchoconstriction. But the underlying disease of
the inflammation in this muscle constriction– it’s not treating it at all. And so, if you’re
taking albuterol, you’re not helping your disease. And that’s actually a measure
of poor and disease control. So you’re just helping
that immediate symptom– Yeah. –at that point. And along the same lines,
I’m kind of curious– I imagine you probably
have a lot of patients, like any other doctor, that
when their symptoms improve just a bit, they will stop
taking their medication because they figure
that they’re OK. They’re OK– Not a good idea. Well, it’s not a good
idea because obviously the underlying disease
of asthma is still there. And it’s an
inflammatory disease. And it, over time,
has the potential to do real damage to your
lungs where, you know– I did the demonstration
earlier of a big airway that constricts down– then it ought to pop back open. But over time, it has the
potential to not do that. And so, your lung can start
to stay more constricted. So as you age, there
is that potential that you will not be able
to breathe like you used to and that your best
days are not nearly as good as they used to be. Yeah. Got a question from
a Facebook viewer. Robin asks, or has a question– I have difficult to
control asthma as described by my pulmonologist. So do you see patients like me? Yeah, so that’s– I guess at the core, that’s
what a pulmonologist does. That’s what we all do. And in particular, you know,
my work here– and the one procedure we offer, which
we’ll talk about ultimately. It’s a specialized procedure
and only some, you know, so many people do it, et cetera. We built a clinic
specifically to see people whose asthma has
been difficult to control despite the medical
management they’ve been on. So, of course. So how– pollution, air quality,
things like that– how much of an impact does
that have on it? It has– it plays a role. I mean, it’s– like all
things, it’s variable. It’s going to depend
on the patient. You know, one of
the questions I ask when I first meet a patient
is, what are your triggers? What sets off your asthma? And you know, here
in Chicago, you know, there’s certain days
I look downtown– I can’t see downtown, right? You know, the ozone’s high. It’s 100 degrees out,
humid, et cetera. You already know how you’re
asthmatics are going to do. I’m actually a pretty
bad asthmatic myself. I know how I do on those days. So you know, they’re not
kidding when the newscast says, you may want to stay
indoors that day. And when your doctor says
it, we’re not kidding either. So, just curious– you
are– you have asthma? Yeah. I do. Is that what caused you
to do this for a living? Probably. I’m sure it indirectly
influenced it in some capacity. Now, I will tell–
and everybody should know– it’s unbelievably
well controlled. Not because I do
this for a living, because I actually take my
medications, believe it or not. So the inhalers that
my doctor prescribes– I don’t prescribe myself. My doctor prescribes. I take them as directed, and lo
and behold, it’s under control. And I will attest
that, you know, I didn’t time things right once. I was on a vacation
out of the country, ran out of my inhaler– my controller med– oops. And, you know, guilty. And four days later, there
I was struggling to breathe and pumping down albuterol
till I got back into the US and got my inhaler. And so, you know, it’s
a controllable disease on average. And that comes back to–
you asked about severity. There are clearly some people
that their disease is worse than others and the
level of drugs required is, you know, higher than
their neighbor, if you will. And then, in some people, we’ve
got some really good drugs, but their disease is worse
than the drugs we’ve got. They’re above that. And those people
definitely suffer a lot. And there is a work up we do
to try to help figure that out. And then, ultimately, when
the drugs aren’t enough, that’s where procedures
come in or some of these newer drugs
that are injectable have a potential to
help patients as well. Now I’ve got a
relative– and I’ve just been dying to ask
this question– who has a child with asthma. And they’ve kind
of got a little bit of a war going on within
their family about pets. Ah. The kid wants a dog. Yeah. Mom doesn’t want
the child to have a dog because of the asthma. Yeah. What do you– what are
your thoughts on that? Well, it’s partly
going to depend on– is the child essentially
allergic to dogs or not? You know, if they’re
not allergic to pets– and they’ve been tested for
allergies and they’re not allergic to a pet– there may be a reason not to
get a dog for other reasons, but it would be hard
to say that that’s the etiology of their–
worsening of their asthma. Now, that all being
said, you know, tried and true methods
of helping with asthma management– they’re
not perfect– but clearly allergen
and trigger avoidance is always a good thing. You know, someone–
and I hear people say, oh, you know, if I’m around
smoke, it doesn’t bother me. It does. You may not feel it. You may have gotten
used to the symptoms. There’s no way cigarette
smoke is not remotely, you know, harmless to
someone with asthma. It’s harmful to everybody,
especially people with asthma. And I would imagine you may
not feel it right that second, but– Right. It’ll probably– Sure. The underlying information
is still ongoing. And then, on top
of that, remember– you know, we all get
used to certain things. Like anything, you know,
if you have a certain level of shortness of breath
that you’ve just learned “learned to live with”,
well that’s also unacceptable. And that’s one of
the other reasons that when people will say
to me, oh, you know, I only use my albuterol, you
know, three times a day. And I wake up twice at
night to take my albuterol. That’s OK. Like, that’s not remotely OK. That is asthma dictating your
life, not the other way around. That’s a great, great statement. I think that’s very interesting. Amanda has a question for us. Yeah. She says, in people with
difficult to control asthma, why do some people– why do some preventative drugs
seem to work for some time, then stop working
out of nowhere? She says she’s tried various
things over the years and it seems that it’s almost
random when her asthma decides that a current medication just
isn’t good enough anymore. Yeah, it’s not– so the
short answer is, don’t know. That’s the easy, short answer. It’s an honest answer. It’s an honest answer. It can be a lot of factors. So, not specific to this person,
but you know, in general– one, is the inhaler still
being taken properly? You know, the medicine only
works if it’s appropriately getting into the lungs. There are many other
things that can influence difficulty breathing in asthma. Like you said at the
very beginning is, do you actually have asthma? I bring that up because
a lot of patients have been referred to our center
for the bronchial thermoplasty because my asthma is
so out of control. And when we actually
evaluate them, we actually discover they
don’t even have asthma. And that’s actually– it
doesn’t happen frequently, but it doesn’t
happen rarely either. And that’s why I said
at the very beginning, just because you’re having
trouble breathing or wheezing, doesn’t mean you
actually have asthma. And if the appropriate
testing hasn’t been done– it’s an easy label
to slap on a patient. Oh, you have asthma. Take an inhaler, get out. But it’s not always appropriate. Now there’s– what I guess I
would say for that person is, are there other disorders? I will say, too frequently that
when someone’s had difficult to control asthma,
they frequently get put on prednisone– oral or
Medrol oral steroids– those are notorious,
obviously, for weight gain. If you’ve had large
swings in your weight, that alone will give you
significant difficulty breathing. And so, suddenly it’s
not for your asthma, but it’s your obesity that’s
giving you difficulties with your breathing– or both. And so, there’s lots of
other potential factors. Interesting. Joyce has a question for us. She says, do you recommend
your patients use flow meters? Oh, the peak flow meter. It depends. It’s a tool. It’s a useful tool. It can be part of an
asthma action plan so that if you’re not really
clear on your symptomatology, there’s a way to
measure, essentially, your ability to blow out. And if it starts to drop, you
can initiate an asthma action plan. Some physicians really
like using flow meters. Some don’t use them. They are a useful tool. I think they’re very
valuable in a scenario where some patients don’t necessarily
know the symptoms until they’re having a real
severe exacerbation. So the advantage
being of catching it a little bit earlier, that’s
sort of the canary in the mine long before you’re
suffering– or at least feeling like you’re suffering. Interesting. So Paige has a question for us. And she says, or asks,
do all types of smoke aggravate or trigger asthma? And she’s thinking bonfire
smoke, car exhaust, cooking smoke, et cetera. I mean, so the short answer
is yes, I mean, in the sense that– I should point out,
too– so, you know, cigarette smoke obviously
is the easiest one. But you know, marijuana
smoke is the same idea. Smoke is smoke. Yeah. You know, I will ask my
patients, when they come– asking them essentially
what they’re smoking. I explain to them, look,
I’m not the police. I’m not your mom. I’m not here from some
moral perspective. I care about your health. I care about what you’re
putting in your lungs. Now, you know, when you
ask about other smoke– one of the most common causes
of emphysema in developing parts of the world, where there’s not
necessarily a lot of smoking, but it is closed
environment cooking open– cooking over an open biomass. A lot of smoke. It’s all relative though. I mean, you tell me
that once in a while you like to be outside
near a campfire. And I suppose my advice would
be, don’t be immediately down wind sucking in all
the campfire smoke. But if we have your asthma
under good control– you know, that comes back
to my earlier statement– is asthma controlling
you, or are you controlling your asthma? You know, you ought to
be able to still enjoy the things in your
life that you enjoy. It’s that dose of being,
I suppose, rational. You know, let’s try to
minimize it, but you know, if you like to cook,
you’re still going to cook. Well, we were getting a
lot of smoke questions. We’ve got another one now. What are your thoughts
to a correlation to asthma and secondhand smoke? And is vaping any better? I’m sure you’ve heard
that one a few times. Yeah. So the short answer on
vaping is, not better. Number one, there’s no
regulation or control of what you’re actually
putting into your body. So there’s this thought process
that it seems “healthier”. I suppose it’s all relative. Let me– and I got asked this
question once by a junior high student, who was really
insistent on whether or not cigarettes or vaping or
like a pipe or a cigar– which one was the safest? And I answered back, I’m
going to put in front of you four different weapons. Which one do you want
to be killed with? Because, one, it might
be safer than the other– Parents everywhere are thanking
you right now, by the way, so– You know, I mean the point being
it was, you know, they were– they kept like, what if? What if? And I, you know,
basically the answer was, they’re all harmful. Sure. I mean, I suppose– if someone wants shows me
data that says such and such is less harmful– but in the end, they’re
all harmful, right? A larger caliber weapon
or a lower caliber weapon? Both shoot me. So guess what? No good answer from
a safety perspective. You know, your lungs are
a very precious organ. It’s the one organ that’s
exposed to the outside world. And we have at
least some say over what you put into your lungs. No, you can’t control what’s
happening in the air around you when you walk outside
kind of thing. But you can definitely control
what you’re putting in. And I guess my short answer– too late, I know
I like to talk– is there’s a lot of
things in this world that are going to harm you
or kill you for free. The idea that you want to
spend your own money to do it yourself seems nuts. It’s a good answer. Yeah. It’s a good answer. So apparently we have a few
physicians watching too. Hey. And Christopher is one. And he said, when should
we, primary care docs, refer for a thermoplasty? So let’s talk about
that, and let’s also just talk about
thermoplasty, in general. Can you start off kind of
describing what exactly it is? Oh, OK. Yeah. So bronchial thermoplasty
is unique in the management of asthma because it’s
actually a procedure. So whereas every other
intervention that we do for patients– you know, take
this inhaler, take this pill– that’s that. It’s medicine. It’s an inhaler or
pill or an injection. But thermoplasty is a procedure. And it’s done bronchoscopically. So sedating a patient– at our institution, we
do ours under anesthesia, so you’re out as if you
are having an operation. We go right through your
mouth into your lungs. And through the scope– so we have a, you know, tube
with a camera on it– we go in and take a look. And the way thermoplasty
works is it uses energy and it actually heats up–
that’s the thermal part– heats up the airways. And it turns out that the muscle
that wraps around the breathing tubes that causes
that constriction is very sensitive to heat. And by the act of
heating up the airways, you are able to
hopefully minimize how much symptomatology your
patient has and they can do better with their asthma. And, of course, this has gone
under lots of different studies and trials. It was FDA approved
eight years ago based off of literature
that demonstrated that, on average, the patient
felt better, went to the ER less, and you know, had
overall less symptoms. One key thing to point out– not everybody– so you
might be the ideal patient for thermoplasty. The one area that we
haven’t yet figured out is can we tease out who will
respond and not respond? From the medical literature,
it was an 79% response rate that the patients improve. But that does mean
roughly 20% of people didn’t receive a
clinical benefit from it. Now what I always point out–
and I wish I had a 100%– if I knew how to say
you wouldn’t benefit, that would be great. But by definition, if you’re
a patient who is already not responding, you’re somebody
who isn’t responding to the drugs we have. So you know, these drugs don’t
have a 100% response rate either. None of them do,
because if they did, you wouldn’t have needed
thermoplasty to begin with. So who should be referred
for thermoplasty? If you’re on maximal
medical management– so I have you on inhaled
corticosteroids at the max dose, a long acting
beta agonist. And so there’s a lot of
drugs on the market that are a combination of those. Plus or minus I’ve done
things for your allergies and so forth. I might have you on
another inhaler that’s called a long acting
muscarinic to help open up your airways more. But despite all that, you’re
still having high symptoms that– if we use some of
the symptom scoring tools– that your symptom score is– you
know, the way the scale works, low is bad– so your
scores are low, bad. You’re having needs
for albuterol at night. You’re in the ER. You’re on prednisone yet again. Two times a year
is unacceptable. So it’s not this, you know,
healthy level of prednisone. You never should be on it. That’s somebody, at
least, thermoplasty should be considered and
be at least evaluated for. Or some other form
of intervention. Maybe it is the
injectable drugs. Maybe it’s thermoplasty. But the notion of just
putting you on prednisone again is unacceptable. Now if a person
has successful BT– Yeah. –do they continue
to take medication? Great question. So this is obviously a
supplement to your medication. I mean, the– you
know, there’s never been a study that said– you
know, we don’t cure asthma. I would love to cure asthma. There will definitely
be a way smarter scientist than myself who
will figure this out someday. This is an add on therapy. The nice thing, of
course, is that we do it, and if you get the
benefit from it– the literature
has also supported that the effect lasts. And so, if we do it, and
you feel better from it, that effect will be
maintained on average. Clearly everybody’s
response is different. I’m sure there’s people
watching who’ve had it and didn’t get a benefit. I’m sure there’s people
who got a massive benefit, and everywhere in between. But what inhalers you’ll be
taking, and pills and whatnot, you’ll still be on those. You might make changes. That will be between
you and your physician, obviously, as far as
what can be dialed down. When the literature
showed, as far as ER visits and exacerbations
and the need for prednisones and all that– nobody walked away from it. It’s an issue of– there’s one patient
of ours who’s had a fairly profound response. And he had spent many
nights in the hospital, and after thermoplasty,
went down to basically one night, which is still– I’m not happy about. But it was clearly a massive
improvement, but not a zero, I’m never going
to be sick again. And so, I think that’s the
other key component of probably any intervention, whether it’s
one of the injectable drugs or bronchial
thermoplasty is that it’s setting realistic expectations. I have another one
from the physician is kind of a broad question but
I’ll let you take a shot at it. This is Karen who wonders
what your thoughts on how we can work together with our
patients on taking their asthma medication so they’re in
control of their asthma. And again, it kind
of alludes to one of the things we
talked about earlier is getting these patients to– or any patients– to
take their medicine. Yeah, well, so you know, it’s
a chronic condition, right? If you have high
blood pressure, you need high blood pressure pills. If you have diabetes, you
need to control your diabetes. And this is always that
important education component. So the analogy I use– and
it’s a silly one, but– if my leg is broken and you
give me morphine, it won’t hurt, but I very much still have a
broken leg until you fix it. So if I give you
albuterol, yeah, you feel a little bit better. But the underlying
inflammatory disease, the disease that is
asthma, is not remotely being treated at all. And so, that’s the problem. And so, if your
doctor says, look, I want you on this inhaler,
whatever it is, you know, and it’s some form of
an inhaled steroid. I want you taking it once a
day, twice a day, whatever– please do so. And you’ll say, oh, I don’t
notice anything from it. You’re not going to
notice anything from it because it doesn’t open
up the air passages like that albuterol does. But if you pay
attention, what you are going to notice over
the next several weeks, is that you’re not reaching
for that albuterol, that you’re not having to
go to the emergency room, that you’re not on
oral steroids again. It’s– you know, it
happens once in awhile– a patient who, you know,
adherence to her meds was a problem. We had sort of a nice
heart to heart about it. She got it. I said, just do me a favor. Like, just you know, humor
me for the next month. Just take it no matter what– no matter how stupid
you think I am. Just do it. And when you come back, let’s
talk about how much albuterol you used. She came back and
lo and behold, she was like, wow, I’ve
never felt this well. I was like, yeah,
there’s no secret here. I gave you a standard, you
know, an asthma inhaler. But you took it, which
was the key difference. I think ultimately– and I
completely understand this– nobody wants to
be on medication. So they– Sure. –hope that they’re
cured and they can– but it’s just not the case. And if you want to feel better,
you need to continue to take– per your instruction. Well, that’s the thing, too,
is that if someone says, I don’t take these medicines. But they start puffing down
albuterol all the time. And I will tell you that every
time you need prednisone– and I guarantee you there’s
people watching this who have been on prednisone– I’ve been on prednisone. That stuff is poison. And look, I use it. If I need it, I want
my patients on it. It does what it’s
supposed to do. It’s a good drug
when you need it. But it’s a horrible drug, and
fraught with side effects, and especially long term. And it is not a solution. It is when you have truly
nothing else to offer– when prednisone is
considered the answer. And that– and I better have
exhausted every other thing in my toolbox before
I’m going to condemn you to chronic prednisone. A couple more BT questions. Joyce asks, what are some of the
side effects and complications from the procedure? Is it a one-time procedure? And we had another
question earlier, too, that asked about recovery time. Yeah, you bet. So it’s actually done through
three separate bronchoscopies. So three separate times
you’re put under– we, by convention, do the
lower part of the right lung first then the lower
part of the left lung and then both upper parts,
the remaining real estate. Is there a healing process? Is that why you do one– Well, so all the
original studies– the thought process was,
you should give people some time to recover. And you definitely– when we
do the first thermoplasty, what the data supports and
what I tell all my patients– look, you’re going to feel
not-so-great for a few days, probably up to
about five or six. Everybody’s different. Clearly some people fly
right through the procedure and some people have
a pretty rough time. The short end is,
I say, look, you know, if we’re going to do–
if you’re procedure is Thursday at 8:30 in the morning, that’s
when you’re having an asthma attack because I’m
going to give you one. Because I’m going to
go in and irritate your airways on purpose. So because it’s an
elective procedure, if you tell me you’ve got some
big family event that weekend, we’re not going to do your
thermoplasty that week. Now why do we wait three weeks? All the original studies,
that was the protocol. And so that’s how we
know the safety record. And so, the reason I don’t
deviate from the three weeks– I’m sure we could, but I don’t
have literature that backs up that it’s as safe if you’re
doing it more frequently, you know, like every two weeks. And what’s the hurry? I mean, I want to
know safety first. I mean, I want this to
help you, obviously, but what I really want the most
is to know that you’re safe. So in the published literature,
all the trials that were done, it probably goes without
saying, but no one died. And that, I think, you
know, seems obvious, but– boy, that’s
true– great to know. And once the final procedure was
done, and a few weeks passed, is when then the
symptom improvements were noted by everybody. So what I tell
people to expect is that for the week
after each one, you’re going to probably
not be feeling so great. You’re going to be using
your albuterol more. You’re going to feel
a little wheezy, a little kind of beat up. Some of that’s an
anesthetic effect. Some of that’s us, you know,
in there with the thermoplasty. But can they go to work and do– Yeah. No, typically what–
we do it on Thursday. I tell people, you’re
going to go back to work probably on Monday. OK. You’re just not going to
have the greatest weekend. But just take it
easy, and don’t– What ends up happening,
though, you said, people come back on Monday– you
know, the next time I see him, and say, wow, I thought you said
I was supposed to feel lousy. I’m like, sorry. I’ll do better next time. It’s a good problem to have. Yeah. Andrew has a very
interesting question. I hadn’t thought of this one,
but it’s a great question. What’s your opinion on the risk
of scuba diving with asthma? Ah. And are there any
additional safety steps that can be taken to reduce
any risk that you might have? So I am not a dive
certifier person, so I’ll give you sort
of the generic answer. The concern for bad asthma,
or any asthma, for diving is multiple. One is, of course, you start
having an asthma attack and you’re down
however many feet– not going to be able to reach
for that albuterol inhaler. And can’t ascend
rapidly, either. I don’t dive, but I
know what the bends are. So there’s your first
sort of barrier. But the other
problem, ultimately, and the whole issue, of
course, with dive medicine, if you will, or diving in
general is as you are rising, gas is expanding. And because asthmatics have such
variable degree of constricture or opening of their
air passages– it’s not– you know, every time
I do, like, hands and shrink them down, that’s
happening globally, but at differing degrees. And so the concern is, is that
an area that got closed down has a lot of gas behind it. You can’t exhale. And it’s now expanding
and then it ruptures and you develop a
pneumothorax, is what it’s called, where your
lung essentially ruptures, collapses. You can imagine that
that’s never a good thing– Yes. –but it’s especially not
a good thing under water. So a suggestion
for divers, maybe– maybe take up snorkeling. You know, my understanding is,
is that technically speaking, asthmatics are not supposed
to be certified for diving. Interesting. Now I could be wrong, so
don’t– you know, let’s not– Yeah, it makes sense. But– Yeah, so not a good
idea probably to dive. I would love to– I would love to dive. I have friends who
dive, and I have not been a diver secondary to
my underlying lung disease. But I snorkel. Yeah. There you go. So let’s talk a little
bit more about BT. One of the questions we had is
referencing the safety record for the procedure. So I mean, the safety record
is actually quite excellent. Both our institution,
and what’s been published in the medical
literature, like I said, no one has died. There’s not been
lung collapse, you know, puncturing or
popping of the lung. There’s definitely been
a worsening of asthma. There’s been– there is a
small, but real, rate of, likely having to spend the night
in the hospital, maybe even a second night in the hospital,
because of worsening asthma. We do– around the
time of the procedure– we do put you on oral
steroids– the drugs I tell you I try to avoid. But those are needed for a
flare, for an exacerbation, and I’m essentially going to
give you one so we pre-treat. Now again, that’s from
all the original research. That was the safety protocol. This is how we
know to do BT safe. That’s what we stick to. I’m not going to
deviate from what I know has been a proven
track record of safety because that’s
what matters most. Interesting. So you mentioned a
little bit– and I wanted to kind of get
some clarification on this– because
you were talking about different portions
of the lungs having different levels of, I
guess, asthma attacks or different levels of issues. So how does that work? So you may have worse symptoms
in one area than another? Well, it’s not
necessarily symptoms. And you wouldn’t feel it
from a localization process. It’s just the disease, itself,
is very heterogeneous in that– you know very– it’s
diversified throughout the lung. And so, it’s not that
necessarily one area is always worse than the other,
but that’s the problem with from the
diving perspective. And the way we do the procedure,
the application of the heat is through a catheter. And so, essentially we
go into your airways and sequentially just keep
hitting the next area. So it’s almost like we’re
painting the airways. Obviously we’re not
painting, but the idea is– move it on this area, back it
up, move it on to this area. There’s videos online. I think we’ve posted some. I’m sure all over
anywhere else, if people want to see an actual
thermoplasty procedure and the catheter– and the
manufacturer, I’m sure, has that, as well,
on their website. So if a person has
asthma and they’re seeing their family physician
and they’re having a relative– and I guess it depends
on the person– but a degree of success
with their treatment, when does it get
to the stage where you step in– where they
call you and say, hey, maybe we can do a little better? Yeah. So I’ll give you a great
example because I’m on– I’m on maximum. So I’ll use me as an example. So I’m on the highest
dose inhaled steroid. And I’m on a long
acting beta aga. So I’m on maximal
medical management. So then why have I
not had thermoplasty? Because I also have no
symptoms, no exacerbations. I haven’t been on
prednisone in years. Now, I used to be
on a lower dose. My disease worsened. I needed a higher dose. And now I’m under control. If the day comes where
this isn’t enough, there’s no way I’m going
on chronic prednisone. And so this would
then be my next step. When I have no exacerbations,
no symptoms, what would thermoplasty do for me? Nothing. There’s nothing to
fix here, if you will. So you know, what
ends up happening– and this is important
because when we first started doing bronchial thermoplasty. Once it was FDA approved and
we opened up our shop and said, OK, let’s see people, a
lot of patients were set. But these were
extremely sick patients, people who had
been on ventilators for their asthma, who were never
off of prednisone, you know, et cetera. And that’s definitely–
the word severe clearly means lots of things to
lots of different people. There’s a grade there. I guess you could use the word
very severe and then severe. But if you’ve needed
oral prednisone twice in the last year, then your
asthma is not under control. You know, you’re
allowed one, basically, because it’s a variable disease. And you know, this was
one heck of a winter. If you picked up some bad
viral thing and the flu and everything else
that went through, and you needed oral steroids,
sure, you get a pass. That’s not your
disease under control. You got hit hard with a bad bug. OK. But if– now it’s
spring, and things are– not yet, but soon spring,
at least the weather– yeah, we’re getting there. And you’re now needing
your prednisone again. And then this summer,
of course, once it’s 100 degrees out and hot, and
you’re going to need it again. How is that acceptable? It’s unbelievably
not acceptable. Are there any times of
year that are more– Depends on the patient, right? I mean, it depends on
what your triggers are. If you’re very– if you’re
really allergic to pollen, you can imagine springtime
is not your friend. You know, if cold air
is one of your triggers, then you live in
the wrong city– at least if you’re in
Chicago and watching this. So one of the things I’m
always kind of curious about– when a parent or a child– you know, a child has asthma– a parent knows your
child has asthma– I think oftentimes they
look at that like, oh gosh, this is kind of a life
sentence on this disease. And I guess to a degree,
it is, but there is hope. Well, very much so. And I probably should
point out, since we’ve been talking about
thermoplasty, it’s not indicated for anyone under 18. So unfortunately, there are– if you’re on maximum
medical management, then there are– one
of the injectable drugs is available for children,
but this procedure is not. So I guess there’s two
ways to look at that. And it’s all in how
you want to spin it. So yes, it is a lifelong disease
that has a variable course. So some people “outgrow it.” I’m not a fan of that term. But for reasons we
don’t understand– or at least, that I don’t
understand– their disease severity seems to
decline to the point where they really
are symptom free. But I suppose what
I guess I would say is it’s a manageable
disease, you know. And that unlike some other
disorders just of the lungs, let alone any other organ,
where there isn’t a therapy– that you’ve been told you have
such and such disorder and, you know, good luck. You know, at least here,
there’s definitive hope. And you know, no debate here– tons of research going on. There’s a pipeline of
medications coming down the pipeline. I used that word twice– my bad. But there is a plethora of
drugs coming down the pipeline. We’ve got lots of options. And that’s the
thing, too, you know, because no one is
satisfied, right? Until you’re under
perfect control and you’re not needing
your albuterol, and if I walk over to
my emergency department, there’s not a row of
asthmatics waiting to be seen, then our job’s not done. Yeah. Can people be too sick for BT? That’s an open debate. In the literature for the
studies that were done to evaluate the safety and
efficacy of thermoplasty– like all studies, there was a– you know, here’s what we want,
here’s what we can’t take. And the who-we-can’t-take had
groups that were “too sick.” Chronic, you know, higher
doses of oral prednisone, been on ventilators, have near
death experiences with asthma. That’s understandable. If you’re trying to study
the safety of a device, you want sick, but you don’t
want that level of sick. The problem is, is
of course, there’s a lot of those patients. So our center, and several
others, have actually– if you’re a candidate
for thermoplasty– no matter how “sick” you
are, if you’re a candidate, we’ve proceeded. And so, we have presented
our experience with that and published one
small paper on that. And others have, as well. And to date, you know, the kind
of– the brief summary of it is it looks to be safe,
even in that population. Now clearly, a sicker patient– you need an experienced
bronchoscopist who has experience in
thermoplasty and managing severe asthma. You need a good
anesthesia team that knows how to manage
these patients, as well. So, like all things, it’s
definitively a team approach. You know, it’s not a– in particular for– I guess the more
severe, if you will– it’s all relative. I think that’s, you know, one
of the things that I’m lucky/ I get to work with some
fantastic people. And so, you know, the
experience within our clinic and, you know, anesthesia
team and the recovery and so forth is excellent. I’m fortunate to work with
some ridiculously great people. That’s great. Michael has a question for us. He says, what role does
weight play in asthma control? The short answer is obesity
is horrible for asthma. I don’t want to
get too technical, but let’s just make
it real simple. Your lungs are the only
organ that really needs to do a lot of moving to work. I mean, you know, the heart
is obviously doing its thing, but the lungs have to expand. And if you’re overweight, your
lungs are being compressed. Pure and simple. And everyone has experienced
that because if someone is giving you that big type
bear hug– you know, you’re a kid and your uncle came
and gave you the big squeeze– you had trouble breathing. Well, if you are 100
pounds overweight, 50 pounds overweight,
you’re being squeezed. And even people who
are not overweight have had the experience of
what it’s like sort of acutely. And what I mean by that is let’s
pick a typical Thanksgiving meal. When you went back for thirds,
right, and your stomach is all bloated out just
because you’ve obviously put a ton of food in. You can’t breathe very well. That’s not because you’re obese,
it’s because you’re very full. But remember, diaphragm
is right here. That full stomach– pushing up. Any woman who has been
eight months pregnant will tell you how difficult
it is to breathe– Yeah. –because there’s
a baby in the way. They’re not fat. There’s a baby in the way. So to extrapolate that,
you’ve got actual obesity. So the short answer is, and
it’s easier said than done, but weight loss will
dramatically improve asthma. Louis asks, outside of
prescription medication, are there any natural remedies
that help alleviate an asthma attack? Great question. Short answer– none
that have been proven. My sort of general answer to
the over the counter, you know, natural, whatever
word you want to use– it’s an important thing for
people to remember one key thing, which is by law,
over-the-counter remedies that are not a drug– that are so-called natural or
whatever word you want to use– are not required to
have proof of efficacy and are not actually
even required to contain what the box says
it contains, which is shocking. But when you read the law,
it’s actually kind of scary. Now that doesn’t
mean, of course, if you tell me you
took some supplement and it’s helping
you– that’s awesome and I have no problem with that. And I’ve had people say,
well, maybe that’s the placebo effect. What’s wrong with that? If you feel better, I’m happy. Now where I get
concerned is what’s really in what you’re taking? Are you putting something
potentially toxic into your body? Or number two,
those things are not covered by your insurance plan. So if you can
afford them, great. But when I get worried
is when someone says, I can’t afford the inhaler
that, you know, you’ve prescribed for me, Dr. Hogarth. But here are the five
supplements I’m on. And those are, you know,
$12 here, $25 there, et cetera, et cetera. Stephanie has a question for us. She says, have you had success
with biologic injectables for severe asthma? And how would you best identify
those types of patients? Absolutely. So there’s been a
lot of advances. You know, there’s
been the classic– it’s called biologics–
and the idea is that these are antibodies
that specifically target various molecules in the
body that are thought to be involved in asthma. There’s been one on the market
for some time that targets IgE. There’s been several that
are new to the market that target interleukin-5, which
is an inflammatory mediator in asthma. And they all got approved
because they were demonstrated in their studies
to improve asthma in specific types of patients. And I use these
drugs, as well, too, and have had patients
on them with success. And of course, have had patients
get started on these meds without success because,
like all things, there’s a bell-shaped
curve response. So you know, this may be
the greatest newest drug, et cetera, et cetera. Then you start the patient on
it with the best of intention. They meet all the criteria. They would have been in
the study, et cetera. And they don’t get any benefit
or they only get side effects. And it sadly does happen. But I’ve had the opposite. I’ve had people where they
started on some of these drugs and it’s been wonderful. The patient will use
the word miraculous. Now how to determine it? Well, each of these
specific drugs have their criterias as far
as what they’re indicated for. So it’s not just
bad asthma, there’s lab work that indicates that
you’re a candidate for these. And people should consider that,
for sure, and we do as well. They are injected. You have to go to a
clinic or some facility. They’re not done at home, so
that’s maybe the downside, if you will. It’s not daily. It’s at various intervals
of weeks to months. So, you know, in the end,
it’s like all things– at least how it should be–
it’s a shared decision model. You know, if you get sent to
me for bronchial thermoplasty, we’re not doing it that day. And you can say no, you know,
and you may not be a candidate. And you know, you
might come to me and say, I really want to be on
one of these injectable drugs I just read about. But then when we do the testing,
you’re not a candidate for it because you don’t have
the marker for what these drugs attack. So we know they
won’t work for you. You won’t get approved for them. You know, and so,
I think for people who manage severe
asthma, or like I said, things are exciting. We’ve got more tools
in our tool box. And you know, when I
get asked, like, well, what if I have somebody who– I prescribe– you
know, I’m a physician. I prescribe injectables
on a lot of my patients. And I like those drugs and I’m
comfortable with those drugs. I don’t know much
about thermoplasty. You know, I don’t
know what to do there. My answer is, you know,
look, if what you’re doing is working for
your patients, then why would you change anything? However, if they’re
not a candidate for those biological drugs
because of their labs, what are you offering
those people? That’s where this– if you’re
going to put this into a niche, there it is right there. Or when you start
any intervention, we should be measuring how
well they’re responding. So if I put you on in a new
inhaler or an injectable or anything, and your
symptom scores don’t remotely improve over the next
several months to a year, why are we still
doing this, right? Why aren’t we trying
something different? Another question from Andrew. How do you keep track of
the airways that have been treated during BT procedure? Do they– do they
look different? Great question. No, they don’t look different. Actually when we’re training
people on the procedure, I think, one of the things
that expect, you know, that when we’re
in there, they’re going to grill marks
or something, you know. We’re barbecuing. No, actually what’s
striking is majority of the time when you’re
doing the procedure is the lack of change that you see. Occasionally on
people you can see the tissue, which
is usually pinkish, blanches a little–
looks a little whitish for a period of time. Honestly, it’s
meticulous documentation of where we’re at. So the very beginning
of the bronchoscopy, after you’re asleep,
we go in with the scope and essentially examine your
airways and map you out. A little roadmap. A little roadmap and
sort of a plan of attack. OK, we’re going to go here. You know, the airways all
have numbering systems. OK, we’re going to go here
first, blah, blah, blah, and down the next one, come
back, go down the next one. And we have– the
nurse in our room is helping to document where
we’ve been because obviously we don’t want to double treat. We don’t want to
miss an area either. And so, that’s how
we’re able to do it. How long does one of these take? It variable because, of course,
the number of activations is dependent on your anatomy. And airways of the lungs
that are essentially like a fingerprint– I’ve never bronched
the same set of airways twice in the sense of how they
look on two different people– but roughly 30
minutes is probably the easiest number
to throw out there, at least at our institution. We’ve gotten some patients
as low as 20, others an hour. Some of it is dependent on the
amount of airway, you know, the real estate. If you’ve got big lungs, lots
of airways, lots of branches to do, we’re going to
be in there for a while. Yeah. You know, if you’re somebody
without big lungs and not that many airways,
it’ll be kind of short. Joyce has a question. She says, do you get system
effects from steroid inhalers? And she was on long term
high dose oral steroids several years ago to
control her asthma. So for sure on oral steroids–
tons of systemic symptoms, right? Obesity, risk for
diabetes, suppression of the immune system,
thinning of the skin, bruising– all bad. Osteoporosis, of
course, cataracts– inhaled steroids. The higher the dose, obviously
the potential higher risk for systemic absorption. It does appear that high dose
inhaled steroids potentially does decrease your
bone density some. But in some pretty
good studies, it doesn’t look like an
increased risk for fractures. Maybe you might see some
systemic effects in regards to risk for cataracts
and things like that. And I say maybe, but it
also comes back to, let’s– for the sake of discussion– assume that that’s for a fact–
that an inhaled steroid, let’s assume, does over
time slightly increase your risk for, you
know, complications that are systemic. OK. I don’t know if that’s true. Let’s pretend. I know one thing for sure. Oral steroids, for sure,
will give you all of these. So it’s the maybe
versus definite. And so– and of course, if
you’re not on the inhaled corticosteroid, you’re going to
end up in that emergency room and needing that
prednisone, which is– there’s a reason it begins
with p, just like poison, so– All right. I think we’re just
about out of questions. Very interesting. Well, good. Appreciate you– Are there any other in there
that we didn’t come up with? Yeah, let me look. I think we’ve– No, not really. –we’ve covered most of these. I think the other thing– just one last thing– at
least from our perspective. You know, our– we– the idea of our severe asthma
program– and my colleagues, who run the severe
asthma program– you know, this is
one of our tools. We’ve got many. And we work with your
physician, you know. We’re not here to “steal you.” We’re not here to– let’s say you
don’t live near us. You’re happy to come down for
the procedure, but you know, you’re not coming to see
me every three months. Good lord, Dr. Hogarth,
you live too far away. Look, if you have a great
doctor that you’re working with, who is working with
you, I want to work with that person or that
nurse practitioner or that PA. And you know, this
is a procedure we do. So if you need it, come do it. We’ll do it and then we
will gladly have you go back and we’ll coordinate. I’d like to see at
least once a year to make sure you’re doing
well, blah, blah, blah. But you know, we want to
work with you and your team. And that’s probably the
easiest way to put it. Perfect. Now you have an in-person
asthma patient event coming up I understand. Yes. The Ingalls Family Care
Center in Flossmoor. And that’s from 6:00 to 7:00
PM on Thursday, May 24th. And what kind of things
will happen at that event? Well, I guess I’m going
to basically stand there and answer their questions. I mean, it’s meant to be, I
suppose, very similar to this. Sure. But less, I guess– this isn’t scripted either–
but less me standing here and people being able
to ask questions. So basically, if you haven’t had
your questions answered today and you want to meet
Dr. Hogarth in person, that’s a great time to do that. Again, that’s at the
Ingalls Family Care Center in Flossmoor, 6:00 to
7:00 PM on Thursday, May 24th. Yup. We want to thank
you, first of all, for taking time out of
your day to do this. My pleasure. It’s a great service. And we want to thank
you for watching. Also want to let
viewers know that this will be saved to Facebook
after we get rid– get done with the
Facebook Live event. Get rid of Dr. Hograth– It’ll be up there, and
you can take a peek at it. We don’t want to get rid of you. Yeah, yeah. Also, if you want
more information, go to uchicagomedicine.org
for appointments. You can also call Tanya,
who is your scheduler, at (773) 795-9933. Thanks for watching. We appreciate it. Yeah, appreciate it. Thanks so much.


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