The new Women’s Lung Health Program at Brigham and Women’s Hospital (BWH) provides advanced multidisciplinary care and tailored disease management for women with respiratory disease, including asthma, chronic lung infections, chronic obstructive pulmonary disease (COPD), dyspnea, lymphangioleiomyomatosis (LAM), lung cancer, pulmonary hypertension, and vocal cord dysfunction.
“Sex differences in diseases are widespread and can influence risk, prevalence, severity, treatment response, and many other aspects related to evaluation and management of disease,” said Paula A. Johnson, MD, MPH, Executive Director of the Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital. “Gender-specific approaches to care and research to better understand the underlying biological differences in diseases in men and women are critical to improving outcomes in all patients.”
The Women’s Lung Health Program brings together clinicians and researchers with vast clinical expertise and research interests in lung disease in women, including pulmonologists, pulmonary vascular specialists, thoracic surgeons, laryngologists, infectious disease specialists, geneticists, medical oncologists, dietitians, and additional specialists as needed to address the unique aspects of lung diseases in women.
Although in childhood more boys than girls have asthma, in adulthood asthma is predominantly a disease of women. Women face unique challenges managing their asthma, whether related to peri-menstrual asthma, asthma in pregnancy, or post-menopausal changes in their disease and its management. Megan Hardin, MD, a pulmonologist, respiratory epidemiologist, and member of Partners Asthma Center, has forged a close collaboration with obstetricians in BWH’s maternal-fetal medicine group to provide expedited, coordinated care for pregnant women with asthma (see Case Study on back cover). Together with BWH pulmonologist Barbara Cockrill, MD, and Christopher H. Fanta, MD, Director of Partners Asthma Center, Dr. Hardin is providing care for asthmatic women throughout their lifespan. Care of patients with complex or refractory disease can draw on the expertise of colleagues in allergy, ENT, gastroenterology, cardiology, and endocrinology to provide multidisciplinary expertise and coordinated care. Researchers at BWH are investigating genetic, hormonal, and environmental exposure differences that may explain the differential expression of asthma in women. Dr. Hardin also is exploring the interface between asthma and COPD (Eur Respir J 2014; 44:341-50).
Chronic obstructive pulmonary disease has now become the third leading cause of death in the United States, and since 2000, more women than men have died from COPD. Women face unique challenges in the diagnosis and management of COPD. Women with COPD are more likely to be diagnosed with asthma. On average, they have different symptoms than men, including more shortness of breath, and report worse quality of life. Women appear to be more sensitive to tobacco smoke, as measured by lung function. The reasons for the differences are not well understood and may include genetics, biology, environmental factors and lifestyle. Dawn L. DeMeo, MD, MPH, and Dr. Hardin, pulmonologists within the Channing Division of Network Medicine, are currently investigating the biological underpinnings of these differences, with an aim to improve COPD detection and treatment and improve outcomes for women with COPD.
Because women are more susceptible to certain types of lung cancer, have higher rates of lung cancer as non-smokers, and carry certain tumor-specific genetic mutations, dedicated care and research for women with lung cancer is essential in improving outcomes and better understanding the underlying pathophysiology of the disease. Thoracic surgeon Yolonda L. Colson, MD, PhD, has dedicated years to investigating and treating lung cancer in women and striving to improve outcomes in all patients. As Director of the Women’s Lung Cancer Program at Dana-Farber/Brigham and Women’s Cancer Center, she is leading research evaluating ways to better stage lung cancer, including new techniques to identify lymph nodes at risk for metastases (J Thorac Cardiovasc Surg 2013; 146:562-70). She also is exploring genetic clues to susceptibility to lung cancer and severity of the disease, as well as possible ways to use that information in patient care.
Led by Elizabeth Henske, MD, Director, and Souheil Y. El-Chemaly, MD, Medical Director of the Center for LAM Research and Clinical Care at BWH, care for women with LAM at BWH emphasizes aggressive multidisciplinary approaches to diagnosis and treatment, including lung transplantation in select cases. Researchers in the Center New Program Delivers Integrated, Gender-specific Care for Women with Pulmonary Diseases… continued from front cover are investigating combination therapies designed to offer a lasting response after initial treatment. A current clinical trial (Safety Study of Sirolimus and Hydroxychloroquine in Women With Lymphangioleiomyomatosis) is evaluating the safety of sirolimus and hydroxychloroquine in patients with LAM. Researchers at BWH also are leading ongoing biomarker studies for LAM using a dedicated biorepository of blood samples from LAM patients and are investigating the role of estrogen in LAM.
Women have up to seven times the risk of developing idiopathic pulmonary hypertension (PH) than men and generally exhibit symptoms up to ten years earlier than men. They also are at higher risk for autoimmune disorders that are associated with the development of PH, such as lupus and rheumatoid arthritis. Pulmonary vascular specialists Barbara Cockrill, MD, and Aaron Waxman, MD, PhD, offer highly-specialized care for women with pulmonary hypertension and unexplained dyspnea and collaborate closely with other specialists, including vascular medicine specialists, cardiac surgeons, rheumatologists, and others, in the care of patients. Clinical trials of novel approaches to PH include new oral drugs that may serve as alternatives to intravenous medications, as well as expanded indications for FDA-approved classes of drugs. Innovative diagnostic testing includes invasive cardiopulmonary exercise testing to identify the underlying cause of unexplained symptoms and inform patient care.
Paradoxical vocal fold motion (PVFM), known to impact more women than men, is diagnosed and treated using a team approach, including laryngologist Jayme Dowdall, MD, Co-director of the Voice Program at BWH, and voice pathologist, Chandler Thompson, DMA, MS, CCC-SLP, as part of the Women’s Lung Health Program. PVFM leads to paradoxical closure of the vocal folds during breathing. Strategies to treat PVFM include decreasing sources of laryngeal irritation and the use of special breathing techniques. Because asthma often coexists or is mistaken for PVFM, these specialists collaborate closely with pulmonologists in the Program to develop treatment approaches best suited for each patient. Other voice-related conditions treated by specialists in the Voice Program include phonotraumatic lesions and idiopathic subglottic stenosis, which also are more common in women than men.
A 37-year-old female patient (G2P1), who was 12 weeks pregnant and had a history of severe persistent asthma, was referred by her obstetrician for worsening shortness of breath, chest tightness, and wheezing.
Her asthma had begun eight years ago during her first pregnancy and was difficult to control throughout that pregnancy, with multiple hospitalizations for worsened asthma and one hospitalization for pneumonia. She has been treated with fluticasone-salmeterol combination inhaler, montelukast, and an albuterol rescue inhaler used as needed. As often as twice per year she has needed oral corticosteroids for flares of her asthma. Allergy skin testing was negative. She has chronic rhinitis and post-nasal drip, worse during this second pregnancy.
Her daughter developed an upper respiratory tract infection approximately one week ago. During the week prior to her visit, the patient had been using her albuterol inhaler two-to-three times per day and found it difficult to sleep because of cough and shortness of breath. Her peak expiratory flow, normally maintained at approximately 350 L/min, was 220 L/min on the day of referral.
The patient was seen immediately by a pulmonologist at the Women’s Lung Health Program. In collaboration with her obstetrician in Maternal-Fetal Medicine, she was begun on a short course of oral corticosteroids. Her respiratory status quickly improved. She also was given a nasal steroid inhaler and nasal saline irrigation for her nasal and sinus congestion, with good effect. Influenza vaccine was administered and ongoing follow-up was provided by her BWH pulmonologist. Proper use of her inhalers was reviewed, and emphasis was placed on careful adherence to her medicines. Symptoms were closely monitored, along with home peak flow measurements and office spirometry. She had one brief hospitalization during her pregnancy, at which time she was admitted to the obstetrical service with pulmonary consultative care. She delivered a healthy baby boy, and mom and son are now doing well.
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