Online Health Chat with Kathrin Nicolacakis, MD

October 8, 2014


COPD stands for chronic obstructive pulmonary (lung) disease. COPD is a term applied to a family of diseases that includes emphysema, chronic bronchitis and emphysema due to alpha-1 antitrypsin deficiency. COPD usually progresses gradually, causing limited airflow in and out of the lungs.

COPD adds to the work of the heart. Diseased lungs might reduce the amount of oxygen that goes to the blood. High blood pressure in blood vessels from the heart to the lungs makes it difficult for the heart to pump. Lung disease can also cause the body to produce too many red blood cells, which might make the blood thicker and harder for the heart to pump.

Patients who have COPD with low oxygen levels might develop an enlarged heart (cor pulmonale). This condition weakens the heart and causes increased shortness of breath and swelling in the legs and feet.

The good news is that COPD is treatable, and Cleveland Clinic’s Respiratory Institute can help you manage your COPD and flare-ups, and help you to modify your risk factors.

About the Speakers

Kathrin Nicolacakis, MD, is a Staff Physician in the Department of Pulmonary and Critical Care Medicine at Cleveland Clinic. Her clinical interests include asthma, bronchitis, COPD, cough, emphysema, histoplasmosis, lung cancer and pulmonary disease.

Dr. Nicolacakis earned her medical degree at The Ohio State University College of Medicine and Public Health. After medical school, she completed her residency in internal medicine at The Ohio State University Hospitals followed by a fellowship in pulmonary and critical care medicine at the University Hospitals of Cleveland.

Let’s Chat About COPD

Moderator: Welcome to our chat about Chronic Obstructive Pulmonary Disease with Cleveland Clinic specialist Dr. Kathrin Nicolacakis. Welcome, Dr. Nicolacakis, and thank you for taking the time to be with us to share your expertise and answer our questions about COPD.

About COPD

Highpointer42: Is there a distinction between chronic bronchitis and emphysema?

Kathrin_Nicolacakis,_MD: Chronic bronchitis is a diagnosis made by history. Do you have cough and sputum most days for at least three months a year? Emphysema is a diagnosis that is made by looking at your lungs, usually with a CT scan and sometimes a chest x-ray. Both fit under the "umbrella" of COPD. You do not need to have both, however, to have COPD.

elpi63: What are causes of COPD flare-ups and how can they be managed?

Kathrin_Nicolacakis,_MD: A COPD "exacerbation" or "flare" is most often caused by an infection. The key to management of COPD is first to avoid infection if possible. Get your flu vaccine and pneumonia vaccines as recommended as a first line of defense. Wash your hands often and stay away from sick people if at all possible. If you do get an increase in cough, sputum or change in the color or quantity of sputum (phlegm), you may have the beginning of an exacerbation. You should call your physician as soon as you notice this. Treatment in the first few days may avoid a visit to the emergency room or even a hospitalization.

Luddy: What is the difference between asthma, restrictive lung disease and COPD? These terms are tossed around in conversation and I do not understand the difference.

Kathrin_Nicolacakis,_MD: The terms are sometimes confusing. Asthma and COPD are related, as they are both obstructive lung diseases. We use many of the same medications to treat them, but not always. Restrictive lung disease is something else though it may be present along with the others. There are many possible causes for restrictive lung disease that may require further investigation. You should probably start with a discussion with your PCP or a pulmonologist.

Symptoms and Diagnosis

fisher: I am scheduled to see a pulmonologist for the first time. What does a full evaluation for COPD involve?

Kathrin_Nicolacakis,_MD: Usually, it would include pulmonary function testing (at least a spirometry and maybe other tests as well). You probably will also have a chest x-ray and then see the physician for a history and physical examination. Additional testing will be determined depending on your other medical problems.

barbl708: I am a 51-year-old female and I was a smoker from 1986 to 2000. (In the later years, I had moved to one pack per day.) I was never one to take drugs or anything for work stress (just smoked). Now, I have been noticing shortness of breath over the last two years. It was hardly noticeable at first. I had an anxiety attack that grew into a panic attack one day last year. I am trying to figure out if my shortness of breath is from my earlier smoking habits or anxiety. I took Xanax for one year and weaned myself off. I never noticed a difference whether taking Xanax or not. There’s no history of this in my family, but one older brother smoked and he had asthma. I recently started using a (ProAir) inhaler to see if this helps. I had a respiratory test today at the hospital. Also, I lose my breath when running quickly or fast on the treadmill. I used to be a (pretty) active runner and I miss it. Does this sound like COPD, and if so, is it treatable where I can resume running later? Thank you so much for taking the time! This is an excellent site!

Kathrin_Nicolacakis,_MD: There are many reasons for shortness of breath as you have already noticed. Certainly anxiety can affect your breathing. The way to diagnose COPD is to have a pulmonary function test called a "spirometry." That will tell you if you have COPD. If it is normal, however, you may still have asthma and you should discuss this possibility with your physician.

Gerardd: What is spirometry? Also, what is PFT?

Kathrin_Nicolacakis,_MD: PFT is "pulmonary function testing." Spirometry is one of the many "pulmonary function tests" that can be done.

sleepydwarf: At what point do you have to go on oxygen?

Kathrin_Nicolacakis,_MD: Generally, oxygen therapy is needed when you have at least moderate or severe COPD. You have to be tested with a pulse oximeter (usually a probe on your finger) that checks the percentage of hemoglobin that is saturated with oxygen. It is best if this stays above 90 percent at all times.

Highpointer42: Should the amount of mucus coughed up decrease if you use an inhaler such as Advair®?

Kathrin_Nicolacakis,_MD: Advair may help some, but probably will not make it all go away. You may need to consider adding Mucinex® as well. For some people with COPD, they will always have mucus.

Progression Prevention

Highpointer42: I have recently been diagnosed with COPD and am on an Advair inhaler twice a day. Is there anything else I can do to prevent the progression of the disease? I do not smoke and lead a healthy lifestyle; I walk and eat healthy. How would I know if it is chronic bronchitis or emphysema?

Kathrin_Nicolacakis,_MD: Preventing disease progression can be simplified into a few basic points. Do not injure your lungs further, so don't smoke, which you already do not do. Avoid infections, if possible, as they do knock you down, so get your flu vaccine and pneumonia vaccines as recommended, and stay active. You should ask your physician if you are a candidate for a pulmonary rehabilitation program, which is an exercise program for people with lung disease. You will get in better shape and you will also learn more about your disease. If you need further clarification about what exactly your diagnosis is, you may want to see a pulmonary specialist.

SrinaP: Is there a way to “prevent” or slow down COPD symptoms from becoming worse?

Kathrin_Nicolacakis,_MD: If you are a smoker, quit. That is the best and fastest way to slow the progression of the disease. If you already quit or never smoked, you need to prevent infections and stay active. Get your flu vaccine and pneumonia vaccine as recommended and treat bronchitis quickly. Start a walking program or consider enrolling in pulmonary rehabilitation if you qualify.

SteveH: Does COPD (emphysema) ever stop progressing.

Kathrin_Nicolacakis,_MD: Yes. The actual emphysema will not progress if you stop the cause of the lung injury (usually smoking). Everyone, however, loses lung function as part of normal aging. The aging, of course, continues even after you stop injuring your lungs. This is at a much, much slower rate than when you are smoking. It is never too late to quit smoking.

COPD and Other Disorders

Linda-Lou: Are people with COPD more susceptible to NTM? What respiratory hygiene exercises do you recommend and do you recommend blowing apparati to assist with lung clearance? Thank you.

Kathrin_Nicolacakis,_MD: Patients with COPD may be more susceptible to NTM (non-tuberculosis mycobacterium). Staying active (walking briskly for 30 min at least five times a week) is the best exercise for your lungs. If you have trouble with clearance of mucus, you can start with over-the-counter Mucinex twice a day. Remember to also drink six to eight glasses of water daily to stay hydrated. If that does not work, you can be prescribed a lung clearance device such as an acapella® or flutter valve. These require a prescription and education.

SLE2014: I have SLE (systemic lupus erythematosus) and have had bacterial pneumonia twice within a year, bronchitis three times in a year. My latest problem is increased phlegm in my throat. I drink four (4) sixteen-ounce bottles of water per day. I do not smoke or use illegal drugs or drink alcohol. I have trouble sleeping at times due to this problem. I had pulmonary function testing (PFT), and the person administering the test told me I had a restrictive lung disease. The pulmonologist who ordered the test said that it is no big deal. I had been diagnosed with asthma two years ago and now this pulmonologist says I do not have asthma. After three months, this same doctor placed me on Singular®. I am currently on azelastine spray and fluticasone spray. My PCP suggested over-the-counter Mucinex, and I am using this. I have had an intermittent cough since June. My chest x-ray and chest CT are normal. I have many allergies and experience chest (found not to be cardiac related) and thoracic spine pain often. I have a second opinion scheduled for December. Should I be concerned?

Kathrin_Nicolacakis,_MD: Chronic mucus production is most often related to allergies, post nasal dripping and sinus issues. It can be frustrating, however, for patients and also physicians trying to help you. Unfortunately, you sometimes have to treat these things for two to three months in order to see any benefit. It is good to know that this is not cardiac related and that you have a normal CT of the chest. Perhaps an ENT or an allergist would be the next place to go for help.

Linda-Lou: Do COPD and bronchiectasis frequently go together and are they progressive? Also, are these precursors to MAC and if so, in what percent of patients?

Kathrin_Nicolacakis,_MD: Bronchiectasis is considered to be ONE of the chronic obstructive lung diseases, It, however, is not very common and happens after multiple previous infections. MAC, or mycobacterium avium complex, is one type of chronic infection. It may be seen in patients with bronchiectasis and may not. Most patients with bronchiectasis do not progress to having MAC.

Pulmonary Rehabilitation

Magnet: What does pulmonary rehabilitation involve? This is something my mom's pulmonologist is recommending, but she does not want to do it. How will it help?

Kathrin_Nicolacakis,_MD: It is a supervised exercise program that runs eight to 10 weeks long. It is individualized to each patient according to their lung disease severity and also what they are able to do with exercise equipment (treadmill, stationary or reclining bike, etc.). The benefits are that you improve your quality of life, your physical condition and are better able to manage your lung disease. There is also a large education portion where you learn about how to live with COPD and are given tips on nutrition, oxygen, medications, travel etc. I have never had a patient who regretted going. The hardest part is getting patients to go. Once they are there, they all love it. Hope that helps!

Highpointer42: Can you find breathing exercises online if you don't go to a pulmonary rehabilitation program?

Kathrin_Nicolacakis,_MD: Yes, you can find exercises online; however, I think it is best to have personal instruction on these exercises if at all possible. You can think of it like yoga. You can buy a video, but it is not the same as going to the class and having the instructor show you. The benefits of going to a pulmonary rehab program far outweigh anything you could do at home alone.

COPD and Smoking

pan: I have been smoking for many years without any symptoms except some noises when breathing from time to time. I have healthy eating habits and lifestyle. Does it make any difference at age 60?

Kathrin_Nicolacakis,_MD: Congratulations on the otherwise healthy lifestyle! You should quit smoking, of course, if you have not quit already. It is never too late to quit. You also could be having a decline in lung function that you have not felt yet. If you are concerned, I would suggest you ask your physician to order a spirometry, which is a pulmonary function test that we use to diagnose COPD.

Skineyboy: I am already coughing, have lots of mucus, etc. I am a long-time smoker and a truck driver. My mother had COPD. I have two questions: If I quit smoking, will I avoid COPD or at least delay it? And is COPD inherited in any way? I know I need to quit smoking, but it is hard.

Kathrin_Nicolacakis,_MD: Yes, quitting smoking will slow the progression of COPD and is a must! For many people, it is hard to quit, but in order to be a successful quitter, you have to be "ready" to quit. Also, don't feel you have to quit cold turkey. There is a lot of help out there, and you should investigate what may work for you. And, yes, COPD can run in families. If you already have cough and mucus, you may have chronic bronchitis and may also have COPD. You should have a pulmonary function test called a "spirometry," which is required to make the diagnosis. There is also a blood test that can be done to look for the inherited form of COPD. Your doctor can order this test for you.

General Information

PCOCKRILL: I have a question about a financial issue relating to COPD. I have a life insurance policy with an accelerated death benefit payable when it is reasonably expected that I have one year or less or after death. My doctors, whom I call chicken sh--, (I do appreciate them) do not talk to me as to where I have any idea where I am. They say things to me like, "It's bad, very serious," "You are being too optimistic," "Do not go to the doctor’s office anymore, just go to the emergency room because you have every treatment now that you can do from home," and my favorite, "We have things to keep you comfortable in the end." Well of course, I order the paperwork to get my life insurance and get my affairs in order.

To my surprise, neither doctor will sign. My primary care would sign if he can be released from the responsibility, and he says in Virginia you cannot tell someone they are at the end until it is six months. My pulmonologists says he cannot because I can have a lung transplant and breathing tubes. Please help.

Kathrin_Nicolacakis,_MD: These are all good questions. It is understandable that you are frustrated. I would suggest that you find a palliative medicine physician to speak to about these issues. Though it is hard to know how long any patient has to live, it certainly is something someone in your position can and should prepare for. Palliative medicine-trained physicians should be an excellent resource for you for this issue and others down the road.

LucyintheSkies: Here it is - the dreaded question. What about e-cigarettes and their impact on lungs?

Kathrin_Nicolacakis,_MD: At the present time, we cannot endorse electronic cigarettes due to the lack of FDA approval. This is a safety issue currently, as we do not know what else you may be inhaling. There are case reports of them even harming the lungs. Also, there is no standard dose for how much nicotine you are getting. There may be a role in the future, however.

Bobby: Why do people need to get a flu shot? Convince me.

Kathrin_Nicolacakis,_MD: Everyone needs a flu shot! There is virtually no reason not to get the vaccine. If you get the shot, it is absolutely not possible to get "influenza," and I mean 100 percent impossible. You may feel a bit "punk" for a day or two, but that means that it is working. Remember, the reason for the vaccine is to induce your immune system to generate antibodies against three strains of influenza. That way if you are exposed to influenza, you will be prepared and ready to fight. You may still get sick, but you will have a shorter illness and a less severe course. Also remember, another reason to get the vaccine is to protect others around you that may be at an even higher risk (such as the elderly or the very young). Remember, every year thousands of people still die of influenza.


Moderator: That is all the time we have today for questions. Thank you everyone for participating today; and thank you, Kathrin Nicolacakis, MD, for your insightful answers to our questions about COPD.

Kathrin_Nicolacakis,_MD: Thank you so much for all the questions and for joining the Chat! Please get your flu vaccines and keep moving. Have a great day!

For Appointments
To make an appointment with Dr. Nicolacakis or any of the other specialists in Cleveland Clinic’s Respiratory Institute, please call 216.445.5763 or toll-free at 800.223.2273 (extension 55763) or visit us at for more information.

If you want to learn more about Cleveland Clinic COPD treatment options or make an appointment with a Cleveland Clinic COPD specialist, call Cleveland Clinic Department of Pulmonary, Allergy and Critical Care Medicine at 216/444-6503 or toll free at 800/223-2273, ext. 46503, Monday through Friday, 8:30 a.m. to 4:30 p.m. (Eastern Standard Time).

For More Information

On Cleveland Clinic

The pulmonary program at Cleveland Clinic Respiratory Institute is ranked third in the United States by U.S. News & World Report. For nearly 20 years, we have been caring for patients with all forms of pulmonary hypertension, including idiopathic pulmonary arterial hypertension (PAH), chronic thromboembolic pulmonary hypertension, portopulmonary hypertension and pulmonary hypertension associated with connective tissue diseases.

Our physicians and nurses have special expertise and interest in pulmonary hypertension, and are dedicated to the evaluation and care of patients with pulmonary hypertension. Teams are comprised of pulmonary and critical care physicians, advanced practice nurses, research nurse coordinators and research fellows. We also find it important to collaborate closely with the departments of cardiovascular medicine, cardiovascular imaging, cardiothoracic surgery and lung transplantation, as well as specialists in hepatology, liver transplantation, sleep medicine and rheumatology. This enables us to provide the most comprehensive care for our patients’ best treatment options available for pulmonary hypertension.

On Chronic Obstructive Pulmonary Disease - Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for COPD
Chronic Obstructive Pulmonary Disease (COPD)

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