Other Lung Conditions

• On the alert for deep-vein blood clots
• New Developments in Hormone Replacement Therapy
• Reducing Your Risk of Deep Vein Thrombosis During Airline Travel
• Lung Volume Reduction Surgery for Patients with Severe Emphysema

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New Developments in Hormone Replacement Therapy

In July 2002, the government halted a major study of hormone therapy three years early because of a slight but significant increase in the risk of invasive breast cancer. Researchers concluded that the long-term risks of taking hormones outweigh the benefits for a woman who still has her uterus.

More than 16,000 women took part in the study, known as the Women's Health Initiative, the largest to compare postmenopausal hormones with a placebo. The therapy was a combination of estrogen and progestin (Prempro), a treatment used by an estimated six million women to replace the declining levels of hormones at menopause.

The study sought to determine whether this combination hormone therapy could prevent such ailments as osteoporosis and heart disease. But while there were small decreases in hip fractures and colorectal cancer, the increases in breast cancer, heart attacks, strokes, and blood clots were too unsettling.

The data suggested that for every 10,000 women on the estrogen-progestin combination, an additional 8 will develop invasive breast cancer, when compared with women not taking the therapy. An additional 7 will have cardiovascular disease, 8 will have a stroke, and 8 will have blood clots in the lungs (pulmonary embolism).

In the aftermath of the trial, it seems that many doctors will be reconsidering prescribing estrogen and progestin. Some women may want to lower their doses or limit the duration of the use of these combinations, while others will elect to try other treatments to combat their hot flashes, vaginal dryness, and other menopausal symptoms.

However, it is important for women already on hormone replacement therapy (HRT) to know that there is no urgency to stop, and waiting until an annual exam to discuss it with a doctor is fine. There is also no harm in stopping immediately, if a woman is more comfortable doing so.

It's important to remember that only combination therapy appears to have these effects. Estrogen alone taken by women who have had a hysterectomy has not displayed such risks. A separate trial, with 10,000 women who have had a hysterectomy randomly assigned to either estrogen or a placebo, has not indicated an increased breast cancer risk. The trial is scheduled to go until 2005.

The full report on the Women's Health Initiative appeared in the Journal of the American Medical Association on July 17, 2002.

July 2002 Update

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Reducing Your Risk of Deep Vein Thrombosis During Airline Travel

Deep vein thrombosis (DVT), recently featured in the news as "economy class syndrome," is the formation of a blood clot in the deep veins of the legs while sitting — particularly in the cramped seats of an airplane (be it economy class or first class), car, bus, or train — for long periods. You move less in tight quarters, causing circulation to decrease and allowing blood to collect and form a clot. The blood clot may cause pain and swelling in the legs. Serious, even fatal complications can occur if the blood clot breaks loose in the blood stream and travels to the heart or lungs. Older people, and those who are obese or have a family history of DVT tend to be at the highest risk.

While a blood clot can result from a number of causes, some studies suggest an association between blood clots and airplane travel. Many doctors believe this connection is simply a result of being unable to move around, and not from sitting in economy class seats or in an airplane, per se. However, it is possible that pressurized air and dehydration may also play a role in the connection between air travel and blood clots.

Many airlines have already begun to address this health issue by preparing warning pamphlets for their passengers, including articles in their in-flight magazines, posting notices on their Websites, or creating in-flight videos offering exercises aimed at prevention. A member of the parliament in Australia has even called for treadmills to be installed in airplanes that carry passengers for six or more hours.

While treadmills may or may not appear on airplanes in the near future, you can address this issue on your next lengthy flight by taking a few simple measures to help prevent blood clotting.

• Wear loose-fitting, comfortable clothing during the flight.
  
  
• Eat a small meal and drink plenty of fluids to help increase blood circulation. Avoid alcohol and caffeine, as these contribute to dehydration.
  
  
• Do not cross your legs while seated and make sure you adjust your position every half hour.
  
  
• You may want to wear elastic support hose to increase circulation in your legs.
  
  
• Most importantly, try to walk up and down the aisle at least once an hour. Even standing in front of your seat and gently shaking out your legs or slowly rising up on your toes can help.
  
  
• If you can’t get out of your seat, you can do the following exercises in your seat to increase blood circulation. Perform each exercise for 15 seconds, once an hour.
  
  
  • Ankle rotations: Draw a circle with your toes, rotating clockwise and then counterclockwise with both feet.
    
    
  • Foot pumps: Slowly alternate between flexing and pointing your toes.
    
    
  • Leg lifts: With your knee bent, lift your leg up off the seat and hold for a few seconds. Alternate legs.
    
    
  • Head and shoulder rotations: Gently roll your head clockwise and then counterclockwise, keeping your shoulders relaxed. Then gently roll your shoulders forwards and backwards.
    
    
  • Toe reach: Slowly bend forward and extend your arms down towards your toes and then gently sit back up.
    
    
• People who are at high risk for blood clotting due to other conditions should speak with their physician for additional advice before traveling.

Studies do not agree on how long a flight needs to be to pose a risk of blood clotting. A few studies even suggest that there is no association between blood clots and air travel. Clearly, more research is necessary. However, while we wait for a definitive answer to these questions, heeding these simple instructions may help prevent problems.
March 2001 Update

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Lung Volume Reduction Surgery for Patients with Severe Emphysema

In recent years, thousands of patients with severe emphysema have undergone lung volume reduction surgery even though private insurers and governmental organizations have questioned the benefits of the treatment. Physicians believe, however, that removal of the most damaged areas of the lung allows the rest of the lung to work more efficiently. Now, the results of a clinical study confirm the benefits of the treatment.

The study, performed in the U.K., involved 48 patients with severe emphysema who received either a continuation of medical treatment or the lung volume reduction surgery. After six months, most patients in the surgical group showed improvements in the amount of air they were able to exhale in one second (called the forced expiratory volume, FEV1). In contrast, the FEV1 of patients in the standard medical treatment group dropped. Most patients in the surgical group also performed better on a walking test and scored higher on a quality-of-life questionnaire than they had prior to treatment. Patients in the medical treatment group, on the other hand, experienced declining health, as witnessed by lower scores on both the walking test and quality-of-life questionnaire.

Deaths occurred in both treatment groups, five among the group receiving the surgical treatment and three in the medical-care only group. The researchers believe this relatively high mortality was a result of inexperience of the surgical team and severity of the patients’ emphysema. In any case, because of the small number of patients in the trial, investigators could not draw any conclusions on whether surgery reduces the number of deaths from emphysema. A larger United States study, which is now underway may answer this question and might offer insight into which patients benefit most from surgery.

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