Sampling of Articles

March 1998 - Volume 9 Number 8

The Pulmonary Coalition sent us this December 1998 Consensus Statement on Lung Volume Reduction Surgery.
Forty-four physicians from all over the country, including Dr. Joel Cooper, contributed to this summary:

As the physicians in the field with years of education and experience, we know that lung volume reduction surgery
(LVRS) provides clear benefit to a known segment of the late-stage emphysema population.

These benefits include: (1) an objectively measurable improvement in lung function, not otherwise attainable through
pulmonary rehabilitation or any other treatment, and (2) a quantifiable improvement in quality of life and, therefore, a
significant reduction of daily suffering. These outcomes are highly comparable to those achieved for the elderly who
receive Medicare-supported surgery for other diseases such as lung and esophageal cancer.

Given our experience in treating late-stage emphysema sufferers who qualify for LVRS, we believe those who are
Medicare beneficiaries should have the opportunity to receive Medicare-supported LVRS at appropriately qualified
medical centers that are more broadly and geographically accessible than at present.

There is consensus within the medical community that the available medical data regarding lung volume reduction
surgery support immediate Medicare coverage and payment for late stage emphysema sufferers who meet the
following selection criteria:

Emphysema with hyperinflation and defined target areas, e.g., areas of poorly perfused, overinflated lung, limited to the
apices of the lung

· Marked physiologic impairment

· Forced expiratory volume in one second less than 35% of predicted

· Residual volume greater than 200% of predicted and total lung capacity greater than 125% of normal resulting from
the diseased lung being hyperinflated

· Marked restriction in activity despite maximal medical therapy, including ambulatory oxygen

· Activities contemplated include daily routines such as walking up and down stairs, talking on the telephone, bathing,
and getting dressed

· Age: less than 75 years old (with exceptions based upon evaluation of other criteria)

· Body weight: between 70% and 120% of ideal

· Ability to participate in vigorous pulmonary rehabilitation program for 8 continuous weeks prior to surgery

· Vigorous pulmonary rehabilitation involves use of treadmill (or stationary bicycle where indicated) and upper body
exercises

· No coexisting major medical problems such as angina, pulmonary hypertension (mean pulmonary artery pressure
greater than 35 millimeters of mercury), stroke, and absence of malignancy with life expectancy of less than two years

· Willingness to undertake risk of morbidity and mortality of surgery

· Abstinence from cigarette smoking for 6 continuous months prior to surgery


January/February 1999 - Volume 9 Number 7

Have you kept that News Year's resolution to start, resume, or increase your exercise activities?

We thought highlights of recent lectures given by Julien Roy RRT and Dr. Steven White, both of Pulmonary
Rehabilitation at Halifax Medical Center in Daytona Beach, FL might provide motivation for you. Before you start, Julien
stressed it is important to have the proper nutrition to give your muscles the energy they need.

It normally requires up to 72 calories a day just to fuel the work of breathing; a person with chronic lung disease requires
up to 10 times as much or 720 calories per day. When you start to exercise, the calories needs increase even more!

Weight loss now occurs in approximately 70% of lung disease patients due to inadequate caloric intake from shortness
of breath and indigestion.Your body starts to break down your muscles, including respiratory muscles, when not provided
enough calories.

Malnourished people also have greater incidence of infection and decreased ability to increase the rate and depth of
breathing when needed.

For men, ideal body weight is based on 106 pounds for first 5 feet, 6 pounds for every inch afterwards; women 105
pounds for first 5 feet, 5 pounds for every inch afterwards. Add or subtract 10 pounds for very large or very small frames.
As a general rule, multiply your body weight times 12 to estimate the amount of calories you are eating to maintain your
present weight.

The foods we eat, are converted to energy. In a person without lung problems, it is recommended your daily intake
consists of 55% carbohydrates; 30% unsaturated fat and 18-20% protein.

Stop worrying about cholesterol. To get the most calories and the least amount of carbon dioxide produced, you want to
increase fat consumption (1 gram of fat = 9 calories, 1 gram of carbohydrate = 4 calories and 1 gram of protein = 4
calories) and decrease carbohydrates. For COPDers, intake should be 25-30% carbohydrates; 50-55% unsaturated fat
and 12-20% protein. Avoid excess protein intake because it might increase ventilatory drive.

Try smaller, more frequent meals with dense, high caloric foods. Be careful to watch your fluid intake if you have heart
disease.

Articles from The Pulmonary Paper  August 1998 - Volume 9 Number 4

 The Four Seasons (COPD Style)

A De-Composition by Ed Harley

Ed Harley is enrolled in the pulmonary rehabilitation program of Saints Memorial Medical Center in Lowell, Massachusetts. Thanks to Diane Alaimo RRT for sharing this special poem with us!

There is a reason for this rhyme, To save your health while there’s still time.

To ask that you do not inhale, Another harmful coffin nail.

To help you kick that chronic need, To smoke that vile, and noxious weed.

So smokers, won’t you please take heed, ... and enjoy the coming season.

Now winter brings us snow and sleet, To nip our ears and wet our feet.

With burning eyes, and runny nose, We bundle up in layers of clothes.

We hack and cough, and wonder who, Has given us this "Killer Flu"

But, no matter what we do, ... we’re freezin’!

Then spring arrives with April showers, Bringing May’s bright, cheerful flowers.

Some days are cool, and some are warm. The gnats and wasps begin to swarm.

The grass and trees begin to green, and spread their yearly pollen screen,

and we all know what that will mean ... we’re sneezin’!

Now summer comes with torrid heat, Sweat covers us from head to feet.

Humidity becomes our curse, and dew points make things even worse.

The clothes we wear are thin and scant. We gasp, we moan, and start to pant.

We want to breathe, but simply can’t; ... We’re wheezin’!

But, autumn brings us ideal days, The leaves turn red, a golden haze

Fills the air, so crisp and clear. The nicest weather of the year ...

But now old fickle-fingered-fate Smiles, as winter lies in wait,

And we must now anticipate, ... another round of seasons!

So all of you who now are clean, Of tobacco’s tars and nicotine,

Can still reflect on just how tough, It was to shake that urge to puff.

An urge you never will forget, An urge that sometimes grabs you yet:

To smoke just one more cigarette! ... It’s beyond all rhyme and reason!

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Start Preparing!

For people living with Chronic Obstructive Pulmonary Disease, the key to successful management is early recognition and treatment of exacerbations (flare-ups) and infections. Often the most difficult decision a person must make is to decide to contact the physician or wait another day. This decision is an important one. Left untreated, bacterial infections can lead to a vicious cycle of inflammation, further lung injury, infection and possible respiratory failure. Some important factors to consider include:

Mucous production

Increasing shortness of breath

Mucous purulence (color, odor, taste, volume, density, texture)

Decreased ability to perform routine activities of daily living

Weight loss/poor appetite

Previous viral illness (cold, flu, sinus)

Sleep disturbances

Deciding to treat an exacerbation with antibiotics or simply monitor viral illnesses and inflammation involves cooperation between health care members and patients. Report as soon as possible any of the above changes to your health care provider. Even with today’s sophisticated diagnostic equipment and laboratory procedures, the dialogue between patent and health care provider can be the most accurate way in providing correct treatment.

Bill Motz RRT, RN

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------------------------------------------------------- Previous issue's articles:

With support of the Health Care Finance Administration and the President, the U.S. House and Senate are each approving bills which provide radical redesign of the Medicare system. Both bills include drastic cuts to the home oxygen benefit. The proposed legislation calls for a 25% to 40% cut in reimbursement for oxygen services over the next two years, as well as a cost of living freeze for the next five years. Additionally, there are provisions to allow more cuts deemed needed by Medicare's insurance carriers. The after-tax profit level in the industry averages approximately 8%. The home oxygen services industry stands to be dismantled by these drastic rate cuts!
The legislature points to a Government Accounting Office (GAO) study comparing the VA (Veterans Administration) rates for oxygen services to those in the Medicare system. The GAO determined that Medicare was paying more than the VA for home oxygen.
An even more radical proposal being adopted is the provision to implement a competitive bidding arrangement for oxygen and all non-physician Part B services.
This means the VA system of providing home oxygen would be adopted. One company would win the bid (lowest price) to provide services to a region, let's say southern California. This would eliminate the choice of an oxygen provider. All of the Medicare beneficiaries would receive oxygen services from the bid winner.
To serve all Medicare beneficiaries would be an enormous task. In my opinion, there is no provider that has the capacity to serve the entire Medicare population. But what an unfathomable undertaking! The current largest company, Apria, has about 230 locations nationwide. All the other national and independent companies total approximately 15,000 locations. It would be like sending all the children in southern California to one high school because it had submitted the lowest bid. Impossible!
It is almost too late to influence the elected officials of the effects of these proposals. If you are a beneficiary, and enjoy the provider of your choice and access to services, I'd recommend you contact your representatives in Congress to let them know how you will be effected. Certainly, the 25% to 40% cuts will result in your having to pay more out of pocket for (or deny yourself) the service you receive. If competitive bidding is adopted, access to care will definitely be a major issue, as well as the loss of provider choice.
I hope that by the time you read this article, it is not too late for your choice to be heard.

Allan J Brassard, President/CEO
RB Home Medical Services, Oceanside, California

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LVRS Centers Awaiting Protocol We spoke to Dr. Frye of the National HeartLung and Blood Institute two months after the center listings came out.He tells us that the protocol will now take approximately two to threemonths to establish and that patients will begin to be accepted into thestudy about summer time. If you missed our last issue, here is the listof Participating Centers in the Lung Volume Reduction Surgery Study withpatient referral phone numbers:

Baylor College of Medicine, Houston, TX

Charles Miller 1-800-622-9567

Brigham & Women’s Hospital, Boston, MA

Tammy Weihrauch 888-294-5864

Cedars-Sinai Medical Center,

Los Angeles, CA

Brenda Williams 800-233-2771

Cleveland Clinic Foundation,

Cleveland, OH

Patient Referral: 1-800-822-9488

Columbia University, New York, NY

Patricia Jellen RN 212-305-1158

Duke University Medical Center,

Durham, NC

Janet Johns 919-681-2720

Mayo Clinic, Rochester, MN

Kristin A. Bradt 507-284-4619

National Jewish Center for Immunology and Respiratory Medicine,

Denver, CO

Patient Referral: 1-800-222-5864

Ohio State University, Columbus, OH

Mary Lou Coffee 614-293-4509

Saint Louis University, Saint Louis, MO

Gina Roelke 800-268-5880

Temple University, Philadelphia, PA

Anne Marie Kuzma 215-707-1334

University of San Diego Medical Center, San Diego, CA

Trina Limberg 619-294-6066

University of Maryland, Baltimore, MD

Karen King 410-328-2168

University of Michigan, Ann Arbor, MI

Patient Referral: 800-742-2300

Routing #6235

University of Pennsylvania Medical Center, Philadelphia, PA

Penn Health 800-789-7366

University of Pittsburgh, Pittsburgh, PA

Betsy George 412-648-6736

University of Washington, Seattle, WA

Doctors, Inc. 800-826-1121

Washington University, St. Louis, MO

Deen Scharff 314-362-6044

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Coordinating Center

The John Hopkins University, Baltimore, MD

Principal Investigator:

Steven Piantadosi, MD 410-955-4884

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