Traveling with COPD

For patients with chronic obstructive pulmonary disease (COPD), traveling can be challenging or problematic. Because of difficulty breathing, many COPDers may curtail traveling altogether, or limit vacations to places close to home. With advance planning and preparation, you can enjoy your travels. Sometimes COPD support groups can provide helpful advise.

Prepare:                                                                                                                                         1. Medications- Most importantly, do not pack your medication in checked baggage; keep them all with you in your carry-on. Keep any dose(s) that you need to take during your flight in a separate pill dispenser and give yourself a reminder so you won’t forget. Keep a copy of your medication list with you when you travel. Many smart phones have a health app that can be accessed without a password in case of emergencies and you should make sure to have your updated medication information entered. In addition, take a close up photo of each prescription bottle, making sure to include prescriber and the drug name, dose, and frequency. Don’t forget your inhalers!
2. Air Quality-  Poor air quality can make breathing difficult for patients with COPD. Check the air quality of the place(s) you are traveling to before you go. You can learn more here.                                                                                                                                                         3. Oxygen- See below and plan ahead. Be sure to have an adequate supply and be prepared for the unexpected. Consider bringing extra supplies in case of malfunction and speak with your DME/oxygen company before you go to get names and locations of suppliers along your route. Don’t travel without it.
4. Doctors- In addition to having a written list of your doctors and phone numbers, have a list of names and locations of doctors or hospitals at your destination(s). Your own doctor may be able to offer a referral or advise. Talk to your doctor about a COPD Action Plan.

Airplane Travel:                                                                                                                          1. Plan AheadMake sure you call your airline in advance to learn their policy and procedures for traveling with personal medical oxygen/equipment. You might consider calling airlines before purchasing your tickets, as some airline companies might more or less difficult to work with than others. Talk with your doctor because at altitude your oxygen needs are going to change and a COPDer who does not need oxygen normally at sea level may need it for air travel.                                                                                                    2. Medical Documents- Some airlines require documents from your physician or proof of current medical prescription for oxygen.                                                                                    3. Arrive Early at the Airport- Some airlines require early check-in and there may be hiccups that need extra time to fix. Personal medical oxygen and other respiratory-related equipment are permitted through TSA security but you be sure to find out more here.       4. Oxygen Arrangements- Many airlines will not let you bring your own equipment into the cabin, but instead require that you use their oxygen while in flight. Plan ahead and confirm that you will have a supply of oxygen awaiting at your destination. Your DME/oxygen supplier can often help, including arranging for a concentrator.                      5. DVT Prophylaxis- With airplane seats so cramped lately, there is a risk of developing deep venous thrombosis (DVT) otherwise known as blood clots. For someone with COPD, these can be especially serious. For long distance traveling, you can help prevent DVT by getting up occasionally and walking around, exercising your calf muscles and stretching your legs while you are seated, and selecting an aisle seat when possible. You might speak with your physician about compression stockings or preventative medications.

Bus or Train Travel:                                                                                                                      1. Plan Ahead- In most cases, patients with medical oxygen may take their own oxygen aboard but be sure to review the bus/train line’s policies and procedures well in advance of travel.                                                                                                                                                         2. Air Quality- Don’t forget to confirm that your accommodations are smoke-free.

Traveling by Cruise Line:                                                                                                        1. Plan Ahead- Most cruise lines are well-equipped to help customers with special needs, such as oxygen equipment, wheelchairs, respiratory equipment, etc but make sure you inform your cruise line well in advance of travel to advise them of your needs and to confirm procedures. More information can be found here.                                                         2. Medical Documents- Some cruise line require documents from your physician, such as medical history, medication list in case any need to be replaced, and copy of your oxygen prescription.                                                                                                                             3. Oxygen Arrangements- Most cruise lines will assist you but you may need to arrange for your oxygen tanks or concentrator to be delivered to the ship prior to departure. Your DME/oxygen supplier can often help.

Car Travel:                                                                                                                                    1. Plan Ahead- Get information on hospitals and doctors on your route, in case of emergency. Ask your doctors.                                                                                                       2. Oxygen- Position your oxygen tank upright next to you, preferably secured. If you have extra tanks, don’t leave them in the trunk.                                                                         3. No smoking- Make sure no one smokes while in the car with you.                                 4. Pace Yourself- Be prepared to rest along the way and consider making shorter driving segments each day.                                                                                                                 5. Air Quality- Check the air quality of the places along your route. Avoid exhaust fumes and allergens by keeping the windows closed and the recirculating air conditioning on.

Choosing a Place to Stay:                                                                                                         1. Smoke-Free- Select a smoke-free hotel, or at a minimum ask for a non-smoking room. If you are staying with friends or relatives who smoke, ask them for your health to do so outdoors.                                                                                                                                          2. Reduce Odors and Allergens- Ask your hotel if they have special rooms with reduced allergens and use unscented cleaning products. If you are staying with family or friends, be sure to ask them not to burn incense or scented candles.

Visiting Places:                                                                                                                            1. Zoos and Animal Parks- If you have an allergic component, best to avoid exposure.
2. Swimming Pools- Chlorine and other chemicals used to clean pools can be irritating to the lungs, especially with COPD. Be sure the area is well ventilated, and you may want to avoid indoor pools.                                                                                                                           3. Camping- Campfire smoke can be very irritating and make COPD symptoms worse. Don’t sit too close and remain upwind.                                                                                            4. Outdoors- Be aware of the air quality, including smog, fumes, particulates and pollens. Don’t get over-heated and take rests in an indoors air-conditioned location. Make sure you have your rescue inhaler medication with you.



Danger of Reliance on Placebo Effect

With asthma patients, giving an inhaled bronchodilator medication, like albuterol, can result in a rapid improvement in airflow that can be objectively measured using spirometry testing. This testing can be repeated over a short period of time, thus making asthma an excellent model for assessing a “placebo effect” (benefit resulting from simulated treatment or the experience of care).

In a randomized, double-blind, cross-over study published in the New England Journal of Medicine, Wechsler et al compared 4 intervention arms in asthmatic patients:

  1. Active medication—double-blinded albuterol inhaler
  2. Placebo #1—double-blinded inert inhaler
  3. Placebo #2—single-blinded sham acupuncture
  4. No intervention at all

Only those asthmatics with documented FEV1 bronchodilator responsiveness (of at least 12%) were enrolled and each study subject received each of the four interventions three times.

The authors looked at objective evidence of airflow improvement by measuring spirometry, as well as self-reported subjective improvement, and here is what they found:

  1. Albuterol produced a significant improvement in FEV1 (20.1%), as compared to only about 7% with each of the other three interventions (p<0.001). There was no statistical difference in airflow improvement among either placebo arm or the “nothing” arm.
  2. Patients’ subjective report of improvement did not significantly differ between the albuterol inhaler (50%), placebo inhaler (45%), or sham acupuncture (46%), but all three were significantly better than no intervention (21%)(p<0.001).
  3. In an assessment of treatment credibility (percent of subjects’ subjective belief they had received an active treatment), sham acupuncture (85%) was statistically “more credible”(p<0.005) than either albuterol inhaler (73%) or placebo inhaler (66%).

For the objective testing, there was a powerful medication effect, but no placebo effect. For the subjective outcome, the placebo effects were equivalent to the active medication effect, and all were better than no intervention. Placebos offered no objective bronchodilator effect beyond no intervention of any kind. Incredibly, subjective improvement for placebo was similar to active drug, even though active drug had 3 times the bronchodilator effect and placebo was no better than no intervention.

In this well designed study, with the inclusion of a “no intervention” arm, the authors are able to demonstrate that placebos are primarily detectable in subjective outcomes, and that studies reporting only subjective results should be interpreted with extreme caution.

Don’t trust the “snake oil” study if it relies on subjective results, rather than objective measurements.



“Liquid Biopsy” for Lung Cancer

The majority of lung cancers are non-small cell carcinomas and about 1 in 5 of those have actionable EGFR mutations that can be treated with tyrosine kinase inhibitors (TKIs), such as erlotinib or gefitinib. Detection of these genetic markers usually involves genotyping of tissue biopsy material. A new “liquid biopsy” may soon change all that. New testing reported recently, using saliva, was able to detect these actionable EGFR mutations with 100% concordance with biopsy-based genotyping. Similarly, plasma genotyping (from blood sampling) for EGFR and KRAS mutations were rapid and accurate. Not only is this testing more rapid (minutes to days versus days to weeks) but it is less significantly expensive, especially if surgical procedures can be avoided. This technology may some day eliminate the need for surgical biopsy. Research and clinical trials are ongoing.

Best way to quit smoking?

Most physicians, including yours truly, have recommended to our smoking patients to quit abruptly (“cold turkey”), rather than slowly cutting down. In a recently published study in the Annal of Internal Medicine, Lindson-Hawley et al examined the success of quitting smoking by gradual means compared to abruptly quitting. This was a study of almost images-3700 smokers in England, and included behavioral support and nicotine replacement. The primary outcome was prolonged validated abstinence from smoking at 4 weeks after quitting and the secondary outcome was validated abstinence at 6 months.

The authors found that, compared to trying to quit by slowly cutting back on your smoking, quitting smoking abruptly was more likely to lead to lasting abstinence, even in those patients who preferred to quit slowly.

Bottom line: You are better off quitting cold turkey.

Teenage vaping increases smoking cigarettes.

E-cigarette usage amongst middle- and high-school students in the US has increased from 1-3% in 2010/2011 to 10-20% in 2013/2014.images-2

In a study from Hawaii, teens who reported vaping were almost three times more likely to try smoking cigarettes over the following year than were their peers who had not used e-cigarettes.

Thomas Wills, from the University of Hawaii Cancer Center, reported in Tobacco Control, regarding a 2013/2014 survey of 2,338 ninth and tenth graders (ages 14-16, avg. 14.7) in Hawaii.

Compared to teens who had never vaped or smoked cigarettes, teens who used e-cigarettes, but not smoked tobacco cigarettes, were 2.87 times more likely to smoke cigarettes within the year.

These data, as well as data from other published studies, indicate that teens who vape are more likely to go on to smoke cigarettes, making a strong case against the sale or use of e-cigarettes to minors as a smoking prevention strategy.