What a Pulmonologist Wants You to Know About Your Lungs
Meilan Han, MD is a Professor of Medicine and Chief of the Division of Pulmonary and Critical Care at the University of Michigan, and a spokesperson for the American Lung Association. She is the author of a recently released book, “Breathing Lessons, A Doctor’s Guide to Lung Health.” In this episode Dr. Han describes how the lungs function, what can go wrong with them, lung development and why we need to pay attention to how we treat our lungs during their development phases, what medical devices she uses, her advice for companies developing technology, and why we should be testing and monitoring a fifth vital sign.
Links from this episode:
Mastering Medical Device:
Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome! Sometimes we take something for granted for a long time. And we don't think about it until it's too late. And at that point, we ask ourselves, Geez, why didn't I know about this? And why didn't I make some very simple changes years ago? Well, we're going to discuss one of those topics today. And hopefully we're going to learn a lesson for ourselves and more importantly, I think for our families. Our guest today is Meilan Han, Professor of Medicine and chief of the Division of pulmonary and critical care at the University of Michigan. And she's also a spokesperson for the American Lung Association. Dr. Han just recently authored a book titled "Breathing Lessons: A Doctor's Guide to Lung Health." And let me tell you, it is a terrific book that provides insights into a critical organ. Yet it's an organ that's not really received the emphasis that it truly deserves. In our conversation, Dr. Han describes how the lungs function, what can go wrong lung development, and why we need to pay attention to how we treat our lungs, probably for longer than you what you may think. What medical devices she uses her advice for us as companies developing technology. And why should we why we should be testing and monitoring a fifth vital sign. Here's our conversation. Dr. Han, welcome.
Meilan Han, MD 02:18
Thank you for having me.
Patrick Kothe 02:20
So as I was thinking about this discussion, this afternoon, the movie Jaws kind of came came to mono. And the movie Jaws came out and 75. And it scared a lot of people. And it scared a lot of people but jumping in the water. And when you look at it, there's only about 10 deaths per year worldwide from Shark attacks. And when you think about automobile accidents, there's actually about 1.3 5 million automobile accidents per year worldwide, or deaths due to due to automobile accidents per year. And as I was thinking about that I was thinking about, you know, diseases of the lung and kind of how we put put that within other diseases that we hear about, and not to minimize these other diseases. But I looked up a couple of things. And we think about breast cancer, and there's been a tremendous amount of focus put on breast cancer. And the number zero is there's about 2.3 million patients who get diagnosed with breast cancer every year. And Michael J. Fox has done a fantastic thing with Parkinson's and putting emphasis on Parkinson's. And there's about 10 million people worldwide who who have Parkinson's. And then when you think about, you know, another big one heart disease and ischemic heart disease worldwide is about 126 million. But now let's focus on the lungs. And there was a study in 2020 and Lancet that looked at the incidence of chronic respiratory disease worldwide. 545 million patients worldwide 545 million, yet we don't have the same amount of emphasis on lung disease. Why?
Meilan Han, MD 04:18
It's an excellent point, Pat, and something I talk about in my book breathing lessons, which I think you know, you know, I was actually recently on a call with the American Lung Association. I'm a spokesperson for them. And I think people would also be interested to know that lung disease and lung failure was the number one cause of death in the US last year, the number one cause of death, it was already high on the list before COVID. But now we have to add the COVID deaths to that as well. And so, you are correct, that there is a huge disconnect between the burden And of disease and the public perception of the disease, and, and what's actually happening on the ground. And it's a huge problem. What you know, I've been going around talking to people and, you know, you ask someone, for instance, how many times have you had your blood pressure checked? Well, everyone's had their blood pressure checked, at some point, you can't get out of the doctor's office without it. But then you ask someone will, how often have you had your lung function checked? Nobody's had their lung function checked, even I've only had it checked once, which was is part of my medical training. So I understood how the test how the head tests work. So, you know, why is that? I think it's more the reasons are really multiple. And I think it goes back. You know, I talked about this in the book, I was kind of curious about this myself, like, how did we end up here and I looked up, for instance, the history of blood pressure, and why it is that we all get blood pressure. And there's a lot of things. But you know, when the technology was invented and refined in the early 1900s, physicians actually just thought it was a cool thing to do, they thought it would make them look cool. And it would help to distinguish their skill sets from other healthcare practitioners at the time. For whatever reason, I think it may have to do with sort of the clunkiness. And the type of equipment required to measure lung function early on, it just wasn't considered portable, or something easy to do. And just wasn't popular. But you know, the funny thing is the guy who invented the spirometer, or, sorry, the early kind of one of the early lung function tests, he was actually an actuary. He knew that lung function related to death. But, but you know, it just never caught on. And then we've over time, we've developed this evidence basis, that not just measuring blood pressure, but altering it and treating it makes a difference. But it's really hard to develop that evidence basis for lung function when nobody ever measures it. So we've gotten into a bit of a vicious cycle where it's hard to measure and apply sticks or carrots within the healthcare system to something you just don't have. Nobody ever checks. It's And so unfortunately, it's become acceptable, for instance, to give someone a diagnosis of COPD without ever getting spirometry, and we just wouldn't consider that acceptable in any other part of medicine. And because of that, we don't have treatments, as we have some, but as many as I would like. And therefore there's a lot of therapeutic nihilism on the part of primary care physicians, and well, what does it really matter? Unless the patient really complains, I'm not going to check anything or do anything. So it just has become a bit a bit of a vicious cycle. And and what I would also say is that we've been ignoring this problem for a really long time. And my hope or thought is that and part of the reason for writing the book was that I think with with what's happened with COVID, it should make us realize we can no longer afford to ignore things. We have all these people that have died from respiratory failure. And we've put tons of money into development of vaccines and antivirals, and that's all great. But when you think about why people are dying, you know, we have people dying on Mechanical ventilators, we didn't have good treatments for acute respiratory distress syndrome. Before the pandemic, there's been very little extra research has gone into how you how you treat failing lungs since then, and I fear we will be no better prepared, coming out of the pandemic, for understanding lung injury, lung repair, or lung regeneration, stopping some of the fibrosis that occurs. And so I, I really feel that this needs to be a wake up call moment for the public for for health care physicians, and it's one of my greatest fears is that this sort of moment is going to come and go, and we will have missed the message.
Patrick Kothe 09:05
So the name of the book is breathing lessons a doctor's guide to lung health. Who did you write it for?
Meilan Han, MD 09:12
It's funny, because it's written for the lay public, but I have gotten emails from people saying, you know, I was so excited when your book came out. And I was shocked that I understood it. Because I know you were you know, and people are so proud of themselves. You know, I understood it. And I kind of laughed and I actually emailed with my publisher, but I said, Do you really sit? Some people think because it says, A doctor's guide to like Healthy People think I wrote it for doctors and, and they kind of paused for a moment. And it just didn't occur to any of us that that might have been the interpretation. So but no, I wrote it for the lay public. And you know, at the beginning of the pandemic, I was getting a lot of questions from people. I I actually had the great opportunity to another podcast called Freakonomics and, and I got to explain to people how they breathe. A lot of people had no clue how we normally breathe, why mechanical milliliters work some of the pros and cons. And then I, in talking to Matt Whelan, my editor, we realized, you know, there's just there is the kind of a gap in the information that's available to provide to people just to help them understand the basics. It is really a black box for many people. And I don't think it has to be. The goal in writing the book was not was in part to explain how the lungs work. But it was also to help people understand how they can help themselves. So if you're just an average citizen, without a lung problem, what can you do to protect yourself and even be proactive? You know, we don't actually talk about the word lung health, heart health is a word, but lung health really hasn't been a term. And I think that's a problem. So I really wanted to think help people think about things proactively. And then also, just kind of outline for those people who do have a diagnosis. I wanted them to have an opportunity to get inside a doctor's head. What if that was really my goal with that chapter? What is your doctor thinking? And when they order XY and Z? And what how are they working through that that diagnostic and treatment process for you? And then at the end of the book, sort of, as you mentioned, I kind of wrap things up with why we don't have the why we haven't had the investment into lung health and lung research that I think we actually made.
Patrick Kothe 11:34
One of the things that in the foreword to your book, that was a theme that kind of ran throughout it. And it really was a big takeaway for me, and in the statement is one of the problems that the lungs face, is that they actually work too well. Can you? Can you explain a little bit about what you're thinking about there?
Meilan Han, MD 11:56
Well, the lungs actually can take quite a bit of damage, you know, I got I like gardening, I would not, I try not to garden without garden gloves, just because it's such a pain to try to get, you know, the dirt off, right. But we don't really ever think I mean, we need more so now, but traditionally, we have not thought oh, I should I'm cleaning out my basement, or it's a really high air pollution day, what can I do to protect, protect my lungs, and it turns out, you can wash your hands, and it's very difficult to wash out your lungs. And so if you were to and this is something I do, as part of my research, or at least have in the past, if you take out along healthy lungs, particularly in an older individual, even in a patient without any diagnosis of lung disease, what you will see is a lifetime of little black particles everywhere. If you look on CAT scans of patients, which we're getting more and more of you will see scarring, you will see, you know, various little nodules, and patients always ask me what is that and like? Well, you know, you scrape your skin and you still have that cut from when you were four, the lungs accumulate so much silent damage over over a lifetime, but they can actually take quite a bit of damage before you will notice. So unless you are an elite level athlete, which most of us are not myself included in that, unless you're really trying to hit that peak performance, because we're not really using our lungs at the top of their abilities most of the time, they actually can accumulate quite a bit of damage before you notice symptoms. The problem is at the point that you notice symptoms, you may have already suffered quite a bit of lung damage.
Patrick Kothe 13:42
One of the things that I also noticed in the book was in the acknowledgments section, and the acknowledgement is specifically about your dad. And what would you said is that he gave you the confidence to pursue medicine. Can you tell us a little bit about your dad and what what the word confidence meant to you at that point in your life?
Meilan Han, MD 14:07
Yeah, so I had kind of an interesting childhood. I'm biracial. So my dad's from Taiwan. I grew up in Idaho. So I was didn't really look or sound like anybody else around to me. You know, in kind of a rural area my mom I had a you know, a single mom my parents were divorced. This was a time when wasn't really you know, me pursuing a career in medicine or even in a STEM field. Wasn't really on anyone's necessarily radar for me or there weren't really I mean, there's really no one that looked like me no one that was you know, even went to school or college outside of the state. The very, you know, very few people that I knew. But my dad, you know, came came immigrated here from from Taiwan, he was a nuclear engineer, which was kind of a hard path, given the trials that, that, that that field is hard, but I remember having conversations with my dad about what to do and what kind of career to pursue. And, you know, you kind of feel like you're getting pushed and pulled in many different different directions from everybody's got some piece of advice about what they think you should do. And I, you know, I remember having conversations with him about medicine, he really wanted me to be clear and wanted me to be sure and didn't want me to feel like it was something I had to do, but also wanted me to be supported. In that, in that decision, any surprisingly, because I think Asian parents, a lot of time, particularly Asian, immigrant parents get stereotyped into this sort of, you know, a lot of times push their kids into well, you know, there's only a, b and c careers that are acceptable, and, and there was definitely, you know, some of that, but I have to give him credit for really backing off and giving me the space to for, you know, pursue what I wanted to do, but also at the same time, you know, letting me know, that, that he felt that, that no matter what I did, it was okay, it was acceptable, and he thought I would be successful doing it. So, I really do, you know, to be honest, credit both of my parents for you know, doing the best they could to give me the tools that I needed to, you know, have the privilege of being passionate about what I do.
Patrick Kothe 16:51
So how did you become passionate about the lungs? What was it about the lungs that and when when did that occur?
Meilan Han, MD 16:57
You know, people medical students always ask or residents you know, and I always tell people, no one goes into a specialty because they're so in love with the heart are so in love with with, you know, the kidneys or whatever it is, I think you fall in love with the colleagues you work with in the patients that you work with, and the type of work that you do and then sort of the organ ends up being what it is. I loved working with pulmonary and critical care physician to as a medical student, and as a resident, I think a lot of residents love in particular the ICU because there's so much going on and understanding the physiology and that can be really exciting for people. Over time though, the longer that I've been in the specialty because most people in the United States are double boarded in both pulmonary and critical care. I've spent more and more time on the pulmonary side and have come to love and appreciate it even more as well particularly since it's in lung imaging and also you know, studying lungs directly as part of my research now and I it's funny a few people a friend of mine and I have to say this is probably one of the loveliest descriptions of the book but I wouldn't have thought of it this way she said you know your book is really a love letter to the lungs don't really necessarily think about it that way but I did think it was kind of funny in yes maybe I've gotten to this place now but I think I've developed a huge level of respect for for you know, what it does for us on a daily basis and but also the damage that it can suffer and what and just the crippling impact that can have on patients when there were there when there is lung damage and so I think that's where just you know just having that respect because if you think about it, you know the heart is encased inside it's deep down right and it's in a lot of filtering happens before anything gets to the heart so so it's really protected but the lung is on the frontline So it not only has to do a huge job for us get oxygen and carbon dioxide out but in doing so it's exposing itself to everything air pollution, viruses, fungi bacteria and so it's doing it's it's playing this huge defense role for us on an on a daily basis while trying to do you know its job no other organ really except for maybe this skin kind of has to do that I guess I guess the gut also gets exposed but but really it's just incredible the the job that the lung has to constantly try to balance and that's what also makes it somewhat fragile is that it is constantly doing you know performing this filtering and defense function for us while it's trying to do everything else.
Patrick Kothe 19:55
Many of us know the functional lungs but don't know actually how they work, can you explain a little bit more about how they work and how they're supposed to work?
Meilan Han, MD 20:06
So one of the things that I like to talk about when, when people ask me about that it's just from a pure mechanics standpoint. So I think, you know, everybody knows, knows air flows into the lungs and air flows out. But I don't think most people realize that the way that happens is that the lungs are actually a little bit like a rubber band. And when the diaphragm contracts, the rubber band gets stretched, and air gets sucked into the lungs, because of the negative pressure that's created. And then when the diaphragm relaxes, that rubber band goes back to sort of its its natural state, and the air is expelled. But it's really important to understand that for a couple of reasons, in certain diseases, that rubber band becomes way too stretchy. And the lungs kind of lose their elasticity. And that can make it hard to breathe. And in other diseases, you know, that rubber band actually becomes too tight becomes fibrotic. And that makes breathing hard for another reason. When patients are put on a mechanical ventilator, which people probably you know, the funny thing is, most people probably hadn't thought about that until the pandemic, and then all of a sudden everyone's talking about ventilators. But believe it or not, you know, if you've had general surgery, you've probably been on a mechanical ventilator. That is how we support patients when we, you know, when we anesthetize them, so probably most people to be honest, who are listening this podcast have been on mechanical ventilator at some point, but the reason we have to sedate people so heavily is that, as opposed to this sort of natural negative pressure breathing, that we're used to the ventilator blows air in, and we're not used to that. And I mean, if you can just imagine, you know, having air suddenly, you know, like having a balloon let go into your mouth, and it's very uncomfortable. This is why the iron lung that was used to support polio patients many years ago, I actually really recently read an article, there's still there's a woman in the US that will not give up her iron lung, and she's been desperately looking for parts, because it actually is it's not invasive, and it's comfortable, because it actually works more negative pressure as opposed to positive pressure. So so so this kind of key mechanical issue actually has a lot of downstream consequences. But once the air gets into the lung, one way or another, the goal of the lung is to get oxygen in and to get carbon dioxide out. And in order to do that the red blood cells actually flow through by the the membranes in the lung, the alveoli, the the gas exchange services, one by one, it's practically single file. And and that's what allows, you know, you get the red blood cells so close to the air that way through just as an extra single cell of the lung, that it the oxygen can go out and the carbon dioxide gets in. When you have problems like fibrosis, then that impairs gas exchange, when you have problems of the airway, so those are those passages that get the air down to the air sacs that causes other problems. And we can see that in things like, like asthma where air gets trapped in it impacts the ability, not just of the gas exchange piece, but that air trapping can cause hyperinflation, which affects the rubberband piece, and can make it really uncomfortable. You just you aren't getting as much air, you know, just the, the airflow and exchange isn't happening at the rate it needs to be. So I think from a patient perspective, just understanding these very simple concepts, helps you to understand what's going on with your lungs, and why you might feel short of breath, but also why a doctor might be prescribing medication, and why it's important that you take that medication, I have a lot of patients that I think maybe I don't always do a good enough job explaining things. So sometimes if you don't feel it, you don't use it. And so I think it's really helpful for patients to understand what the problem is, so they can help to take ownership over over the problem and to become a true partner in their healthcare.
Patrick Kothe 24:24
I also found it interesting that you're kind of an artist every time a patient walks into your office and you have to have to draw out the lungs.
Meilan Han, MD 24:32
Well, the circulation system is really confusing. And to be honest, it confused, you know, physicians and pathologist for years, they didn't really understand the dual circulation. So for our listeners who may not be familiar with the lung anatomy, what that means is the lungs primarily job, primary job is really in service to the rest of the body. So the way we define arteries as vessels that are heading away from the heart and veins that are heading to the heart. So typically, that's oxygenated and deoxygenated blood, but it's totally opposite when you get to the lungs because of their job. So you have pulmonary arteries heading away from the heart that carry deoxygenated blood, but they drop it into the lung, and then that goes back to the heart is oxygenated through the pulmonary veins, and then out to the rest of the body. But what's confusing is that that does that does help the lung and the lung does get some blood supply that way, but, but the lung actually has a totally separate blood supply called the bronchial arteries. And, and that's also kind of important. And so I think it's, but it's just really confusing for patients, when we start talking about blood clots that lodge here or there, or the that interaction between heart and lung. And if one thing is failing or not working, well, a lot of times, I do need to draw everything out for the patient so they can understand exactly where the problem is. There's a lot
Patrick Kothe 26:05
of things that can come into the body that can cause issues. And some things are are things that exist in our body, some things are caused by something that that comes in. So let's talk a little bit about acute issues and chronic issues relative to lungs and, and how those get into our body basically.
Meilan Han, MD 26:30
All right, so like what goes wrong, essentially, there's a huge category of things that can go wrong. So I mean, a main category that's on everybody's, I guess mine right now are infections, right? So viral, bacterial, etc. So those are clearly a category. Another I guess, category I would put in there are things that cause inflammation. So that might be allergens that can cause asthma. Protein particles that come from all sorts of things in the environment can also cause other kinds of immune reactions that are not asthma within the lung. There's other diseases called things like hypersensitivity pneumonitis. And that's where you get words like bird fanciers lung and things like that. There are other other things we breathe in that can also cause problems like tobacco smoke and particulate matter then cause both inflammation in the airways and emphysema, you can get blood clots in the lung that causes a whole nother host of things. Sometimes the lungs or vice innocent bystanders have other inflammatory processes. So patients that might have a systemic inflammatory process, like rheumatoid arthritis or lupus can get inflammation in the lung just along with everything else. And unfortunately, that can be really, really devastating. And then, you know, there's also a group of patients that can get scarring conditions of lungs where we really have no idea what what the initial trigger is, there's a condition called idiopathic pulmonary fibrosis or really means we have no idea exactly what what's causing it, it's probably a combination of genetics and environment that can be really difficult to, to tease out so it's, it's, you know, it's really kind of there's the sort of the whole host of things that are, you know, either infectious or, or inflammatory, that that can impact the lung.
Patrick Kothe 28:24
Can we talk about pneumonia for a second, we often hear about pneumonia can explain pneumonia.
Meilan Han, MD 28:30
So pneumonia just means infection of the air sacs primarily, so we've got the airways. And so inflammation in the airways would go by the term bronchitis or if it's the tiny airways, bronchial itis. And then if it's an involving the air sacs, we call it pneumonia. What clinically allows us to distinguish the two usually is that when you start to get accumulation of fluid, and inflammation in the air sacs, we actually can see that on an x ray, whereas inflammation in the in the bronchioles we may not see so when we start to see shadows on the X ray, that's when the word pneumonia starts that starts coming in. But pneumonia can be caused by viruses, it can be caused by bacteria by fungi, sometimes we even get chemic what we call a chemical pneumonitis. You know, if you aspirate something, so, but usually, most of the time when we're talking about pneumonia, we're talking about either viral or, or bacterial. As a physician, it can be very difficult though, just based on an x ray to try to distinguish what the cause is. So we'll typically err on the side of treating with antibiotics. If it's virus, we may or may not be able to do anything. Obviously everyone's now familiar with COVID pneumonia and there are some specific treatments now but, but for bacterial pneumonias we typically use there's some you know, standard sets of antibiotics that we will use for The most common pathogens and then if that doesn't work, then we're left with Okay, was it one of these other things on the list that that isn't but will usually go after it is, with with antibiotics, assuming common things are common.
Patrick Kothe 30:14
How serious is pneumonia? Well, it
Meilan Han, MD 30:17
is one of the leading causes of death and children. And among older adults in immunocompromised adults it can, it can be pretty deadly to I mean, even before COVID, we had deaths from from, for instance, influenza, pneumonia, so it can be incredibly, incredibly serious. This is why in childhood, it's so important that kids receive age appropriate vaccinations. And, and in adulthood, you know, we, you know, be alert about signs and symptoms, there are some things we can do for older adults to help reduce risk there are there is a new there is a vaccine that's available for one specific type of pneumonia, for instance, streptococcus pneumonia, and so, it is, you know, it is an important cause of death into and probably this last year, probably a, you know, again, a really high cause of death, particularly just because of, of, of COVID pneumonia, what the problem is, when you have pneumonia, you're not able to get enough oxygen into the body. To fix that problem, we can give you, you know, supplemental oxygen either through a nasal cannula or we can put there's more people probably have heard of something called High Flow nasal cannula that we can also use that was instituted quite a bit during the pandemic to try to stave off the use of Mechanical ventilators. But in the end, a mechanical ventilator is sort of our go to at the point that the lungs become so overwhelmed and, and by doing that, we can help get more air and more oxygen to the lungs, both by increasing the concentration of oxygen in the air that's breathed. So that's one thing you can do. But you can also increase the amount the amount of air that's being exchanged per minute. And so there's a lot of things that we can try. But depending on how bad the damage it is, sometimes the damage is so bad, we can't actually overcome it no matter what we do.
Patrick Kothe 32:21
Many of our organ systems have growth periods, and they mature at different different ages. Can you talk to us a little bit about the lungs and the stages of growth and decline?
Meilan Han, MD 32:36
So I think this is something I really thought about a lot in writing the book because I don't think most people not only do not most people not think this way, but most doctors don't even think this way or haven't traditionally. So the traditional thinking for doctors was most people get to adulthood with healthy lungs, I would know it if they weren't healthy, right? It's should be obvious. But you know, bad things happens if you smoke, you know, you worked a dusty job or something. And then some people experience because of these Knox's exposures, they have problems that was sort of the the general monitoring for me that the study that really kind of, I think flipped that conversation for physicians, was a study that came out I think it was in 2016 in the New England Journal of Medicine that looked at patients who had the most common lung condition, COPD, so chronic obstructive pulmonary disease, many instances, but not all related to smoking. And what that study showed was that when they looked at patients later in life who had COPD, but they actually had lung function measurements dating back much earlier into younger parts of life, what they found was that about half of adults that got COPD didn't get it because they had this accelerated loss of lung function in adulthood, but rather, they never reached the peak lung function in the first place. So if we have half of people who have the most common lung disease, and probably roughly 25 to 30 million people in the West have COPD, half those people never reached normal lung function in the first place. That means we have a lot of people not meeting their potential in terms of lung function, which means something is going seriously wrong before you ever reach adulthood. To me, that's absolutely mind boggling. And so the question is, what's going on? And where is that problem? So that's where you have to start going back and thinking about, Okay, what point is the lung doing what and where are things going wrong? So, so there's the developmental period in the womb, where the lung itself is forming, it starts to branch etc. And we know that certain exposures air pollution, cigarette smoke, etc, can impact how the lung is forming during that critical period. Then there's birth, preterm birth can be associated with poor lung function, you know surfactant, which I spent a lot of time talking about surfactant in the book, but it's a chemical that the alveoli make that help them to open and close without injury and to stay open. And it turns out, it's made just around the time infant is getting close to birth. And so we've got a lot more preterm births than we used to. So we've got a lot more infants that are being born, for instance, probably don't have fully mature lungs not quite ready to be in the, in the open air. So that's probably part of it. And then things like respiratory infections, you know, secondhand smoke exposure, air pollution, etc, can further impact lung development, you know, we hit peak lung function as an adult, your lungs are considered fully formed somewhere in probably your mid 20s. And for me, I think that's really important too, because we now know that a lot of kids are starting to dabble with cigarettes and vaping. In middle school, they still have 10 to 12 more years of lung development. And, and I think it's tragic. If we are not protecting our youth, from just getting to baseline, that's what we're talking about. It's like getting to first base with your your lungs to prepare you for the rest of everything you have to do in life. So I think it's really important for people out there listening, whether you're a mom or a parent or someone that's making devices, right, to realize that it does matter what's happening in before you're born. It does matter what's happening. During childhood, we almost never routinely measure lung function and child in early childhood. It's hard because kids are Don't you know, they don't follow instructions and things like that, but, but we just don't routinely do it. And, you know, it's interesting. I see a lot of patients in the office, obviously, with lung disease. But I like to if I can always start the visit with tell me about birth. Where you preterm where you term? Did you have respiratory problems? Did you see a lung doctor when you were growing up? We ever told you how to asthma? Ever Told you had pneumonia refer hospitalized for respiratory infection? And while it certainly is not everyone, what I will tell you is it is shocking, the number of people that I've picked up that clearly had some massive trauma to their lungs at birth, it was known early on and then somehow just never got followed up like, oh, yeah, it was in the hospital for, you know, five, six times during my first two years of life. And then I look at their pulmonary function tests, and they're, say, 60% of normal. And it's clear to me that this injury occurred 20 years before but just somehow fell off the radar.
Patrick Kothe 38:03
Back to your comment, sometimes the lungs work too well, they recover too well, and we just don't don't pick it up until it's going to be too late. The other thing that I've been thinking about too, is that with COVID going on right now, and parents saying, Well, kids are going to get sick, but it's not going to be bad. We don't know what the long term effects are going to be. Maybe there's nothing there. Maybe there's something that's going to manifest later on in life. Did you do you have any thoughts on along those lines? Yeah.
Meilan Han, MD 38:34
So you know, I have a, an eight year old, you know, he's got some asthmatic tendencies. And I do think I'm actually on the COVID committee for his school. And I think about this a lot, trying to protect all of the children as best I can. You know, before vaccines, we were seeing some, you know, hugely devastating effects on people of all ages. Now, with vaccines, we're seeing, I think, less devastating effects for the average person, still more devastating effects for immunocompromised, older individuals and those who don't get vaccines. I think some people may not realize that even if you survive a hospitalization with severe COVID, you may leave the hospital with very severe lung scarring. Afterwards, there may never be a normal afterwards. And so I think you're absolutely right, that is parents, if we want to set our children up for being able to do whatever it is that they want to do as as adults, and we want them to be healthy and not and you know, just kind of get a good start in life. We have to figure out how to protect their lungs and prior to COVID that included sort of all the age, you know, measles, mumps, rubella, you know, the The list goes on and on of all the regular childhood vaccines, but now you absolutely have to add COVID-19. to that to that list, because we, you know, we do know that that children still even though maybe less likely to have severe disease than an unvaccinated individual that's, you know, at for instance, we still do see a percentage of children that are hospitalized. And, you know, I mean, we have a long history of just regular pneumonias that can cause severe problems. Now, we've just got another one to add, add to the list, the lung really does not have great regenerative to capacity. So, you know, once those airways are gone and scarred, were you probably not going to get them, get them back. So you know, as a parent, it's something I think about a lot.
Patrick Kothe 40:55
It's is as someone who spent a decade in the heart valve industry and looking, being part of hundreds of surgeries, I've seen the lungs, I've seen them, yeah, I've seen them in and out, I've seen nice pink healthy ones. And I've seen ones that aren't. And it's really shocking when you when you physically put your eyeballs on lungs that are not in good shape. Because we it's something that's mostly hidden from us. But when you're an open heart surgery, you can see it, it is shocking.
Meilan Han, MD 41:28
It's interesting, I don't think there's a lot of organs, it's not going to be so obvious, right? So even the heart, you know, it's still mostly red. And you know, it's still kind of mostly has that same shape. But but the lungs when they become scarred, you know, they become, you know, bringing in narrow, gnarled and, and just kind of grotesque looking, you know, they've got like bubble air pockets over here, where they couldn't let the air out and then scarred pockets over there. And another spot where they you know, they didn't couldn't inflate properly. So it's, it's shocking how how that damage can really actually yeah, to form the lung. So I
Patrick Kothe 42:11
want to talk to you a little bit about devices because as, as a clinician, I'm sure you use quite a few devices. And I want to take take you into my world for a second. I've been in the medical device field for about 40 years, the first company I worked for was a company called American hospital supply. And I was in a division that had pharmaceutical products, we had a joint venture on one device, and that one device kind of led me into, into falling in love with the medical device field. That device was a swan ganz catheter. Yeah. And so that was that was my introduction into devices. And that that's a product that's that I'm sure you're very familiar with, too. But can you talk to us a little bit about the types of devices that you use? So I think it's
Meilan Han, MD 43:01
really expanded over time and continues to exponentially explode. So, you know, some of the types of equipment that we've worked with for many years include things like spirometers to measure lung function and, you know, oxygen delivery devices home, you know, type non invasive ventilators in the hospital, we use more invasive ventilation, sometimes things like Swan ganz catheters to measure pulmonary artery pressures. But it is an area that's really kind of exploded. And we've seen growth, I would say in well, there's a couple of areas, much more sophisticated, kind of non invasive home ventilator equipment that can combine both diagnostics as well as therapeutics, we've seen advances in the type of bronchoscopic interventions that we can do now, kind of including endo bronchial valves that were recently approved as a treatment for severe emphysema, accomplishing essentially what we used to rely on on surgery to do lung volume reduction surgery. And then just this whole separate area of tech, including home spirometers, and kind of wearable devices, things that measure pulse oximetry things that that can you know, listen to your voice and measure your lung function or, you know, measure respiratory rate and, and I think that we're still trying to figure out if that kind of information has has value. We also have seen things like you know, for instance, patients use have used inhalers as a way to get their medication for long time but now we're seeing digital inhalers that can things like monitor compliance and that information to a cell phone, measure how well you're using your inhaler. So that I feel like the list of things that are possible is Is is almost infinite the challenge when I talk to companies that are trying to get into the market and figure out, you know where that sweet spot is what what really provides added value both for the patient and for the clinician that you can measure. And I think that's really a struggle often.
Patrick Kothe 45:21
When you say value, what what does value mean to you?
Meilan Han, MD 45:25
Well valued to me means either something that makes the patient's life truly better in a way that's actually measurable. You know, is it really going to make it so the patient's taking their medication more often? Or better? Is it really going to help me make better management decisions about a patient? If, if I knew, for instance, something was going wrong at home? What would be the intervention? What would be the step that I would take? And what proof do we have that doing that would actually make a difference? For instance, if I had closer monitoring, and, and I also am finding, there seems to be a disconnect between the excitement that a developer has for what is possible, and the enthusiasm that physicians may have for what is a practical and digestible amount of extra data that I want to actually have to interpret on a regular basis, because I have a lot of stuff on my plate already, in terms of, of, of, you know, lung function measurements and vital signs and history and all the stuff I have to do in 15 minutes. View add to that, you know, reams of extra data that I have to go through, I'm not going to be, you know, without clear benefit. I'm not super excited. So. So I think that that actually, that is a challenge.
Patrick Kothe 46:49
So that value is clinical benefit, its ease of use. It's actionable data,
Meilan Han, MD 46:57
it's actionable data that is reliable, there has to be a clear reason why getting this information in a different way from I'm usually getting it is somehow now better. For instance, is it really better for me to getting breathing tests at home versus in the office, when there might be a difference in quality? am I actually going to use that information? Or not? How much harder? Is it to get it at home? versus you know, is it you know, Is it usable? Or, you know, if you're going to be you know, monitoring my patient's respiratory rate and pulse oximeter, 24/7 and you see a drop? Does it really make a difference? If I know that if the patient knows that it is or something clearly that one can do that one can measure that would make things better?
Patrick Kothe 47:41
So what kind of advice would you have for a company that has an idea for a product,
Meilan Han, MD 47:48
they need to get input from physicians early, as opposed to getting you know, I've had people come to me at the point that they've already gotten venture capital funding and already have something going without any real science behind it. And we're like, well, we have this great idea that we're going to market to this, you know, we have this subgroup of people that we think would would love a product. And we have this, this idea of what we're gonna deliver. And we've already built an app. And, and and it's not even clear to me that that there's a problem in area X, nor is there science to actually show that there's something uniquely you would do different for group x versus everyone else. And so I think it's important to see, you know, obviously, patient feedback is good, too. But I, you know, there's got to be something that you would do with this information, that's somehow a breakthrough that would make everybody want to use it. So I think the rally the number one thing would be to solicit solicit health care provider feedback early before you get too far out of the gate, because at this point, almost everybody has had this idea already. I've had a lot of people come to me that, oh, I've got this idea. I'm like, okay, you know, I've actually been talking to companies ABCDE and F about this same idea. You're not the first person. And here are all the reasons why the shift got abandoned. You know, five years ago, I've had that same conversation about the same idea with multiple companies over the years. So it is, it is being it is becoming an increasingly crowded space from an idea perspective, but there really haven't been a lot of breakthrough ideas that have really gained traction and I think have really taken care to the next level. So I think it unfortunately it is, it is also a challenging space.
Patrick Kothe 49:41
I think there's some differences between the regulated medical device market and the consumer market, right? Correct. And that regulated medical device if you've got a new bronchoscope if you get something else that you're gonna be using in the hospital for hardcore medical use, that's one type of product, these prosumer type of type of devices, that's where I think we really have some issues because you may be able to sell it. But it may not provide any value to the clinician. But it's still a sellable product. But it's not a medical device.
Meilan Han, MD 50:18
Right? I mean, there's some things that patient, you know, apps or whatever that patients are probably going to enjoy. Great, you know, but it has them thinking about their lung health more, I think that's great. I think. I think the challenge is a lot of the a lot of people that I've talked to really envision that their product would interface with physicians or you know, somehow start entering and then it just kind of opens up this whole new can of worms of how would that integrate with Epic? Or how would that integrate with my workflow? And, and, and like we said, kind of what the, the, the added value is?
Patrick Kothe 50:55
Well, what you're you're close a book with was something that I thought was really interesting, and you call it the fifth vital sign. And I'd like you to talk a little bit about that, because it bleeds into this idea of what is a medical device, and when you should be measuring these different things. Because as you said, I mean, this, this is a progressive disease. And you can't do something you can't manage something unless you measure it. So what is the fifth vital sign? And is this something that's in your mind, physician driven, vital sign? Or is this a consumer driven, driven vital sign?
Meilan Han, MD 51:37
That's a really good question. So the fifth vital sign I'm referring to in the book is is spirometry or breathing test, we get, you know, respiratory rate, heart rate, etc, blood pressure in the office, but we almost never get spirometry, and yet we diagnose lung disease all the time without it, and we treat all the time without it. And you know, we just wouldn't tolerate that in any other area of medicine, almost. And so, because of, and because of the sort of lack of awareness and lack of use, there's been a huge under recognition of lung disease in general, there's been, you know, lack of funding, and then oh, we have a respiratory pandemic hit and guess what we weren't prepared? And, and so I think, you know, as I mentioned earlier, you know, how can I make this more clear, understanding screening for lung disease, measuring lung function has to be a national priority. There's been a lot of debate, for instance, about whether we should screen everybody with one function. And, and this is sort of like the same debate as well, should everyone get PSAs? What what age should we start mammograms and, and they're always just trying to manage risk versus benefit. But there's so little risk and downside to measuring lung function. It's easy, it's not expensive, there's no radiation, there's no pokes, there's no unnecessary additional invasive testing, the downsides are so low. And yet we've put the bar that has to be crossed to do the test so high, that I think that that has, unfortunately, gotten us to the place that that we have. So one of your questions, though, is, you know, whose problem is this? Is this a consumer problem? Is this a physician? I think unfortunately, we have physicians have been unable to solve this problem. You know, we admit, maybe it's because pulmonologists have been too quiet. Maybe it's because, you know, to be honest, we actually hold lung function to a really high standard when we do it. So if you were going to do blood pressure measurement for a clinical trial, you would make the patient sit in a quiet room for like 15 minutes, you would measure the blood pressure, say probably three times you would take the average of the best measurement. Has anybody ever had their blood pressure measured that way? I doubt it any I doubt any person on this call has actually ever had their blood pressure motion that way. But when we do lung function tests, we hold it to that standard, it's got to be reproducible. And the measure has to be done so many times the whole test, you know, while it might only take seconds to blow out, we make you do it so many times to make sure that number is absolutely perfect. And it may be that perfect has become the enemy of good. And so it may be that we as physicians have have, have played into that a bit. Now, having said that, the measurements we get her really, really good. And they're really accurate. And they're really predictive of a lot of things. And so we've come to trust that and so we don't like to give up the quality of our of our data. But maybe there's maybe there's some middle ground. Maybe there's some middle ground where you know, we get the information to the consumer, we take the information to the consumer, there's some really cheap app that everybody can get on their phone and they can blow into their iPhone or their Android and they get a measure It's maybe not perfect, but it's a hint. And you know, and if you blow that test out of the water, you're probably good. But if there's any question about that test, they go to their doctor. And they actually ask, and maybe that's the disruptive technology we need. So a lot of people have been looking at trying to investigate spirometry as a replacement for the in office test. And that's where I think we run into problems because of the standards that that pulmonologist expect, maybe we need to just throw that out the window and say, Okay, this imperfect test, but I can give it to a lot of people for free, and then at least get them to take you know, and if there's a hint, then then they take that information back to the physician, you have a conversation about, about whether getting, you know, a more, you know, kind of qualified scientific tests, makes sense, you know, maybe maybe that's the disruption that we need to finally, start making headway in this space.
Patrick Kothe 56:01
So as I read the book, I didn't, I didn't come away with the feeling of that you're in love with the lungs, I came up with, away from with the feeling that you were respectful and advocating for the lungs. So as an industry, what can we do? What should we do to help to advocate for the lungs as well,
Meilan Han, MD 56:19
I think we all honestly, right now, all of us need to band together to make our voices heard at the Federal National level that lung health has to be a priority. And it has to be a priority. on every level screening research, there have to be dedicated programs for for more funding, you know, for for research, but also, you know, it's got to be coordinated to one of the huge problems that we've had also is that some of the endpoints that the FDA now looks at for clinical trials have made it very difficult to innovate in this space, because there there really only would have been willing to look at lung function as opposed to other things like for instance, CT scan data, which would be completely acceptable in other disease states. So we really need this massive overhaul of how we fund lung disease, how we screen for lung disease, how we research lung disease, that probably in many ways impacts every single branch of the federal government in some way, at whatever point whoever out there is listening may Intersect. Intersect with that I you know, I've been working some with the American Lung Association in the COPD Foundation. But we are really trying to work to coalesce all stakeholders in raising some noise to put pressure on the powers that be at the national level that this really has to be a priority.
Patrick Kothe 57:47
I thoroughly enjoyed this conversation. And the messages that Dr. Hahn shared with us. Her book actually reads just like this conversation, very easy to understand. But it's got so many valuable lessons spread throughout. So I highly recommend that you pick up a copy of this book, and it's available wherever, wherever you get your books, a few of my takeaways from the conversation. First, the lungs do their jobs so well, that we don't recognize the damage that we're doing to them, it's till it's too late, she really spent a lot of time helping us to understand that, at that the lungs are really not good at regenerating. And, you know, once we do some damage to it, it's not going to go away. So the old adage, you know, an ounce of prevention is worth a pound of cure is certainly to be followed when it comes to our lung health and our family's lung health. Secondly, you know, kind of along those same lines, the lungs are not fully developed until our mid 20s. This was kind of a revelation to me, that it's really telling mid 20s, when we stop really developing, we're building building building, and then we're declining, you know, after the mid 20s. But parents have control of their children's environment until their teen years and need to be very protective about that. But then we also need to educate young adults because from the teen years to the mid 20s. A that's them and what they choose to do with their lungs they're going to be living with for the rest of their lives. Finally, she discussed medical devices and took us through the different devices that she use, that she uses. And also she gets a lot of companies that come to her with ideas. And if you heard what she said is talk to clinicians early need to have that conversation early because in her estimation, companies weren't really delivering value that the value that a clinician would expect. So she talked about is there real science behind it? Is there a real problem here? And more importantly, I think is when you are providing something, is it providing actionable data? Or is it just another piece of data? Is it actionable? Thank you for listening. Make sure you get episodes downloaded to your device automatically by liking or subscribing to the mastering medical device podcast wherever you get your podcasts. Also, please spread the word and tell a friend or two to listen to the mastering medical device podcast as interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
