The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

The National Lung Health Education Program: A Status Report

Thomas L. Petty, MD Monday, November 4, 1996

The National Lung Health Education Program (NLHEP) is a new initiative sponsored by the National Heart, Lung, and Blood Institute. In many ways it is patterned after the National Hypertension Education Program, the National Cholesterol Education Program, and most recently the highly successful National Asthma Education Program. The foundation for NLHEP is the Lung Health Study reported in JAMA 1994;272:1497-1505. The National Lung Health Study showed that patients with early degrees of airflow obstruction as identified by simple spirometry, had a significant improvement in airflow as judged by FEV_{1} if they were successful in smoking cessation. At the end of five years they had shown essentially no decline in FEV_{1}. By contrast, tose patients who continued to smoke, had a much more rapid rate of decline of lung function but still not into the symptomatic range.

Enrolled were 63% men and 37% women. Their mean age was 48.5 years. Thus it was somewhat surprising that the most common cause of death was due to lung cancer (N=57). The second most common cause of death was from cardiovascular disease, i.e., heart attack and stroke (N=37). The remainder of deaths were from a variety of causes including other smoking-related cancers. The fact that one percent of these middle-aged individuals with only mild airflow obstruction died of lung cancer is astonishing. A late follow-up has shown that the prevalence of lung cancer in recent years has doubled. Thus many more cancers will occur from this identified population.

COPD is now the fourth most common cause of death in the USA and it continues to increase. In 1996, 106,000 people are expected to die of COPD. However, the fact of airflow obstruction is also an important surrogate marker for deaths from other causes, as the Lung Health Study indicated. Accordingly, the new initiative of the National Heart, Lung, and Blood Institute, known as NLHEP, will focus upon early identification and intervention in patients with early stages of airflow abnormalities which will include mostly smokers. All primary care physicians will be urged to participate in NLHEP. It is hoped that a combination of public announcements, the development of simpler, accurate, and reliable handheld spirometers to measure FEV_{1} and VC as well as the ratio between the two, and the widespread use of spirometry so that patients can "Know Their Numbers", just as they do in high blood pressure and cholesterol. Office and clinic spirometry for all smokers and symptomatic persons will become the standard of care in the United States.

"Test Your Lungs/Know Your Numbers" is the motto of NLHEP. It is hoped that all patients, all smokers, and any patient with cough, mucus, wheeze, or dyspnea will have simple spirometric tests done by their primary care physician as a baseline. All smokers will be advised to quit for health reasons, whether or not airflow obstruction is present. It is likely that those patients who demonstrate airflow obstruction will be more motivated to quit, as has been suggested by previous studies. The judicious use of bronchoactive drugs intended to improve airflow with reliance on anticholinergics, which are well tolerated in COPD, will be offered symptomatic patients. Emphasis on other preventive aspects of care, such as influenza virus vaccine each fall, pneumococcal vaccine at regular intervals, and the aggressive treatment of purulent chest infections with antibiotics, can be encouraged, thus offering a systematic approach to treatment of patients with both asymptomatic and symptomatic stages of disease. Patients who have dyspnea on exertion are candidates for pulmonary rehabilitation. Selected patients fulfilling the criteria established by the Nocturnal Oxygen Therapy Trial (Ann Intern Med 1980;93:391-398) and approved for reimbursement by HCFA and other sources should receive oxygen therapy as part of a comprehensive care program. It is hoped that the successful implementation of NLHEP will prevent or forestall premature morbidity and mortality even in late stages of disease.

It is finally hoped that knowledge derived from the Lung Health Study and new knowledge that heavy smokers with airflow obstruction are at high risk of occult lung cancer, i.e., 1-2% in larger series, will stimulate a search for lung cancer markers and the identification of lung cancer in its early and treatable stages. NLHEP should cause us to take a new look at health by assessing the affect of smoking, occupation, or other risk factors that may affect airflow obstruction. The correction of airflow obstruction, or the retardation of its decline, can be the foundation for enhancement of total health, and thus premature morbidity and mortality for many major diseases may be avoided through the successful implementation of NLHEP.

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