You're listening to Deep Breaths: Updates from CHEST on ReachMD. This series is produced in partnership with the American College of Chest Physicians and is sponsored by Insmed Incorporated. Here's your host, Megan Carreon, Assistant Professor with the Division of Respiratory Care at UT Health San Antonio, Texas.
For patients with nontuberculous mycobacterial lung disease, it is important to establish and maintain proper lung function. As healthcare providers, we play a strong role in helping our patients achieve that. But what are the specific elements that make up the comprehensive management of NTM lung disease that we need to know about?
Welcome to Deep Breaths: Update from CHEST, on ReachMD. I’m Megan Carreon, and joining me are pulmonary nurse practitioner Amy Levinger from NYU Langone Health and Dr. Tim Aksamit, Associate Professor of Pulmonary and Critical Care Medicine at Mayo Clinic.
Ms. Levinger, Dr. Aksamit, welcome to the program.
Thank you so much for having me.
Megan, it’s great to be with you and Amy addressing a very important aspect of the therapeutic plan for our patients with nontuberculous mycobacterial pulmonary disease.
Absolutely. Thank you both for joining us today. I’m really excited to go over this, so let’s get started.
Dr. Aksamit, we know that overall wellness may improve quality of life, but if we look specifically at our patients with lung disease, can you share some strategies for improving general lung wellness?
This is an important aspect and should not be neglected when we see our patients in clinic. It does translate into having a large impact on the quality of life for our patients. I would start out with a couple of general principles about an approach to wellness. This would include addressing not only the physical domains of the aspects of general lung disease but also being mindful of the emotional and spiritual domains as well. This needs to be an individualized program in that what works for one person won’t necessarily work for another and vice versa, so we have to always be mindful of reflecting and assessing whether this is the best approach for our patients. And lastly, as a general principle, I would add that we need to continue to emphasize that this is a treatable disease, and if we’re mindful and have a fidelity to the treatment program, patients will do well and have a positive response to these programs.
With respect to some of the specific ideas or parts of that program, we need to always be sure that patients avoid tobacco products, and these days we also want to emphasize that that includes vaping. We want to make sure that patients are up to date on their vaccines, including not only Pneumovax and influenza but also pertussis and zoster if patients have access to that. Some of the other aspects of general pulmonary care would include being attentive to their dental care and minimizing other types of communicable infections.
Keeping those strategies in mind and that every patient is different, Dr. Aksamit, what are some activities and exercises that can improve airway clearance in patients with NTM lung disease?
Starting out, I would always encourage patients to be active. That level of activity and the type of activity has to be really individualized to the person. Most patients will walk either inside or outside, but some will actually swim or ride a bike or do ellipticals. Some patients will do just breathing techniques with yoga or tai chi, but being active is important given that many of our patients would benefit from the regular aerobic activities. This also has a positive impact on bone health, balance, strength, cardiovascular, and stress management.
Moving on to the next item in the airway clearance, we look at the positive expiratory pressure valves, such as the Aerobika valve, the Acapella valve, the Flutter valve, which was one of the originals, and that is designed to try to mobilize mucous and have airway clearance. Often times patients can do huff cough or do positional therapy. Sometimes we will even use nebulized hypertonic saline generally given after a bronchodilator, either in 3 percent hypertonic saline or 7 percent hypertonic saline on a daily or twice-daily basis depending on response to patients.
And then lastly, there’s a vest use, the high-frequency chest wall oscillation, and there are various different types of products available for patients to try. This sometimes is met with great success in mobilizing secretions and at other times can be a bit much for patients, especially if they are a bit more frail or less tolerant of this type of activity.
Thank you for that, Dr. Aksamit. And turning to you now, Ms. Levinger, what are some other components of a comprehensive management of NTM lung disease?
One thing that’s very important to discuss is maintaining a healthy weight and a balanced diet to be able to help manage and fight the nontuberculous mycobacterium disease that patients have. This is a treatable disease, but thinking of this from a comprehensive management perspective and the patient as a whole is important to remember. One thing that is important to talk about is that weight loss could be a symptom of nontuberculous mycobacterium, so having the patient have resources and education up front about the healthy weight and lifestyle is important. If patients do realize that they are losing weight, one step that we would take in the beginning is to talk about what they are eating in a day, if they need to track what they are eating. Maybe they need to add in protein drinks, as protein is an important aspect of all of this.
As disease progresses, patients may need to meet with a dietitian or even a GI doctor. Some patients may have acid reflux, so they may find that meeting with a GI doctor and dietitian they can help get other ideas for food and meals that can help keep their calories up. In addition to that, in severe cases patients may need PEG tubes. I see this towards the end in more aggressive cases of nontuberculous mycobacterium, but this is another way for patients to meet their caloric needs in order to be able to fight the disease.
In addition to that, it’s very important to think about the environment. One way that nontuberculous mycobacterium could be caused by is the environment. With that being said, we want patients to reduce exposure to the nontuberculous mycobacterium aerosols. Some common places for this include indoor pools, saunas, or hot tubs, so, if at all possible, we do encourage patients to avoid this.. If they find themselves needing to be in hot water or anything like that, I encourage that they keep a door open, that they have a fan or open a window; that way there is proper ventilation.
In addition to that, I talk about gardening with my patients, and I want to reduce exposure to dust from the soils, so if they are able to either keep the soil moist if they do like to garden or if they want to wear a mask and gloves, they can reduce their exposure to the dust.
I know that Dr. Aksamit did touch on this—but another important piece is that my patients know that they should not smoke. NontuberculousSo my goal is to keep my patients as healthy as possible and to make them aware of possible exposures.
For those just tuning in, you’re listening to Deep Breaths: Updates from CHEST, on ReachMD. I’m Megan Carreon, and today I’m speaking with Pulmonary Nurse Practitioner Amy Levinger and Dr. Tim Aksamit about the role of lung wellness in NTM lung disease.
Ms. Levinger, earlier you discussed the importance of nutrition and environmental mitigation strategies for our patients with this lung disease. So, in addition to that, what programs or activities can also help?
Some patients may find benefit to patient support groups, education, and mind and body attentiveness. As I mentioned earlier, providing patients with information, resources, and education up front is important so that they can be educated and feel empowered to learn about the disease and how they can live a quality of life.
With that being said, a lot of patients do enjoy the support groups as they feel that it is a good way to know that they’re not in this alone and that there are other patients who are going through this with them, and it’s a good way for them to have support outside of the doctor’s office and they have another source that they can talk to.
In addition to this, mindfulness is an important aspect. It’s important for patients to know that there is an emotional, mental, and physical well-being, so I encourage patients to join a pulmonary wellness program or listen to podcasts. It’s important that these patients not just live with the pulmonary disease, but live well and still have their quality of life.
Thank you, Ms. Levinger. Those are great insights to the possibilities that these patients may have and the options that they have to better help themselves and live better.
And lastly, Dr. Aksamit, when addressing wellness in patients with NTM lung disease, why is it important to consider a multidisciplinary approach? And what strategies do you recommend to help?
With respect to the multidisciplinary approach, I think that this is a critical element as well to successful treatment. This has been something that’s been well-documented in other lung diseases with pulmonary rehabilitation, using the services and resources and talents of many other individuals, which would include respiratory therapy, nursing, pharmacy, nutritional support, physical therapy, counseling, and even spiritual directors at times. Each one of those groups brings different skillsets to the table and will help our patients addressing these needs to their wellness so that they can then have effective, treatable lung disease and still have a quality of life that is acceptable and have them fully engaged with their families, communities, and others as they see fit.
And how about from your vantage point, Ms. Levinger? Do you have any tips from your own experiences on how a multidisciplinary approach can help?
I think Dr. Aksamit did a wonderful job on touching on how a multidisciplinary approach helps with all of our patients. Just to reiterate, it’s very important to remember that every patient is individualized, so being able to have this multidisciplinary approach is very important in a way that we have different aspects and opinions coming in in order for the patient to live the quality of life that they want to.
Those are great tips for us to keep in mind as we continue to care for our patients. Keep in mind that this is a treatable disease that can be well-managed with an individualized, multidisciplinary plan, which includes good nutrition, respiratory hygiene, and modified exercise plans. Resources for both our patients and our physicians can be found at the CHEST Foundation. This does, unfortunately, bring us to the end of today’s program, so with that, I want to thank my guests for joining me to discuss the comprehensive management of NTM lung disease. Ms. Levinger, Dr. Aksamit, thank you so much for being here today.
Thank you so much.
This was Deep Breaths: Updates from CHEST produced in partnership with the American College of Chest Physicians, and sponsored by Insmed Incorporated. To access other episodes of this series, visit ReachMD.com/CHEST, where you can be part of the knowledge. Thanks for listening!