In the first episode of KET’s series Fighting to Breathe: Lung Disease in Kentucky, we examine major threats to lung health, including COVID-19, air pollution, radon exposure, and smoking/vaping. Experts discuss impacts on vulnerable populations and explain what happens when the lungs’ defenses are overwhelmed.
This series is funded in part by grants from the Foundation for a Healthy Kentucky and the Kentucky Medical Association through a grant from the Anthem Foundation.
How COVID-19 Affects Respiratory Health
When the COVID-19 pandemic began in Kentucky during spring 2020, many of the most severely ill patients experienced respiratory failure. Especially with the initial strain and with the subsequent Delta variant in 2021, COVID-19’s impact on the lungs sent many patients to the intensive care unit and in the most serious cases required ventilation.
COVID-19 is “a viral disease and when it infects the lungs it causes a lot of inflammation,” says Dr. Srinadh Annangi, MD, a pulmonologist at Harrison Memorial Hospital in Cynthiana. “It pretty much damages the whole lung itself, and in the process of healing the lungs can be scarred.” COVID-19 also increases the chances of blood clots forming in the lungs, Annangi adds. “The point of entry is the lungs – the lungs are the most affected – but it does not stop there,” he says.
Annangi explains that in a patient with COVID-19, the millions of tiny air sacs in the lungs – called the alveoli – become filled with inflammatory fluid, and that prevents the exchange of oxygen and carbon dioxide in the body that is necessary to maintain life. Patients who have reached this critical stage are given oxygen, and intubated (placed on ventilation) if that doesn’t work. A final step is putting the patient on ECMO (extracorporeal membrane oxygenation), a machine that removes a patient’s blood, adds oxygen to it, and re-introduces it. Beyond that stage, a patient cannot be saved.
Two years after the pandemic began, many patients are still struggling with diminished respiratory function along with other maladies brought upon by infection. What’s called “long covid” is an evolving topic for research, according to Annangi.
“Usually, if somebody is having any respiratory disease when they come to the hospital, they will be sick but will eventually recover and be back to their baseline,” he says. “But that’s not the case in what we’re seeing with COVID. People are having these prolonged symptoms, such as shortness of breath, cough, a loss of taste and smell, or sometimes what’s called mind fog.” Annangi says that studies on long COVID are just beginning and there is still a lot of uncertainty as to the underlying causes of these symptoms, how directly connected they are to initially being infected, and how long they will last.
At Harrison Memorial Hospital, patients with long COVID benefit from a rehabilitation program designed to improve pulmonary function and muscle strength. Lisa Hurst, an employee at Harrison Memorial, was infected with COVID-19 in December 2020 and afterward experienced lingering effects. In summer 2021, she consulted with Dr. Annangi to determine the cause of her health problems. He found no permanent damage to Lisa’s lungs, to her relief.
“Dr. Annangi basically explained to me that COVID is a disease that affects your entire body, not just your lungs, and that fatigue was probably more to blame for the shortness of breath,” she says. “What it came down to was that my muscles were having to work harder to do what they had done before, causing me to be out of breath.”
A Mission to Improve Air Quality in Louisville’s Neighborhoods
While air quality in the U.S. has improved in the 51-plus years since the Clean Air Act was enacted by Congress, an abundance of pollutants and biologic agents still exist, says Ted Smith, PhD, director of the Center for Healthy Air, Water and Soil at the University of Louisville’s Christina Lee Brown Envirome Institute.
“We are learning about the whole spectrum of what we call polluted air,” Smith says, “and while we’ve definitely tackled the pollution you can see in many cases – though not always – we’re learning that these very small particles, ultra-fine particles, are a new entity not regulated by the Clean Air Act. We’re learning about air toxins, volatile organic compounds, and really what their health effects are.”
Furthermore, Smith says that the negative health effects caused by these toxic particles fall more heavily on low-income communities. Poor air quality can have a compounding effect on residents of these neighborhoods who may already be subject to other environmental determinants of health such as lack of open spaces, food insecurity, and the stress of living in a high-crime area.
One possible solution to improving air quality in designated communities involves increasing the number of trees and bushes in the landscape. Smith says that studies show that the presence of tree canopies and ample bushes can help improve health metrics, and he and his colleagues are currently conducting their own “clinical trial” in south Louisville.
The Green Heart Project is currently underway in several neighborhoods, divided into an intervention group and a control group. “We hope to see in a five-year-period whether the vegetation, like a drug, causes good health or not,” Smith explains.
“I’m really excited,” he adds. “I’ve found a tool that looks really useful, and if we can work with it – that is, really look at the environment and not blame people and their circumstances and not hide from things that look like they’re too hard, but essentially just commit ourselves to having healthy, equitable places – that’s awesome, right?”
Radon’s Silent Threat: Spreading Awareness About a Leading Cause of Lung Cancer
Radon – a radioactive gas undetectable by sight, taste, or smell that is produced by the erosion or uranium in rock and soil – exists in many basements and foundations of homes in Kentucky. Radon exposure is the second-leading cause of lung cancer in the U.S. behind smoking, says Kyle Hoylman, president of the American Association of Radon Scientists and CEO of Protect Environmental. Hoylman is a cancer survivor, and he believes that growing up in a rural house that tested high for radon contributed to both his disease and his father’s lung cancer that proved to be fatal.
“Right now across the country the Environmental Protection Agency would suggest that around 7 percent of our buildings contain a radon problem; here in metropolitan Louisville it’s 58 percent,” he says. “If you go to Fayette County, metro Lexington, it’s 65 percent, and if you go down to the Bowling Green area, it’s much higher. Across the entire commonwealth, it’s right at 43 percent.”
Radon exposure can be measured in several ways, one of which uses charcoal to absorb radon gas in surrounding air and then counts the particles via a laboratory test. Kentucky provides free radon testing to homeowners through public health departments and some libraries.
There are two primary mitigation methods to reduce the amount of radon in a dwelling. “By far the most prevalent is called active soil depressurization,” Hoylman says. “Just think of it being a glorified vacuum system for the sub-foundation area of your home. Radon comes into the home by preferential pathways – cracks, gaps, sewer areas – and what we do is we just suck the radon out from beneath the home before it can come into the home.” The radon is then discharged above the home where it can dilute in outdoor air.
Natalie Davenport initially declined to install a radon mitigation system when she and her family built their dream home, but after learning about a University of Kentucky study named Radon on the Radar, she decided to get her new house tested. The study enlisted homeowners in four counties with high radon levels for testing, and after finding out that the house’s radon exposure levels were considerably above normal, Davenport and her husband had a system installed and used a voucher provided by the UK study to help with the cost. Now, Davenport is contacting other members of her community and educating them about the need to get their homes tested for radon.
“We live in Kentucky, and when you think about lung cancer you think about smoking, it’s such a big thing, but radon is right there with it,” she says. “I would like to see it affordable for everyone, so everyone has the opportunity to have their home mitigated.”
Tobacco’s Devastating Toll on Kentucky’s Public Health
It’s no surprise that tobacco smoke represents the number one threat to respiratory health in Kentucky, by far. The dangers of smoking have been well known for decades, yet Kentucky still has one of the highest smoking rates in the U.S. – 24 percent of adults smoke in the commonwealth, compared with the national average of 14 percent. Kentucky leads the nation in lung cancer cases and deaths based on 2021 data.
“We kind of have the perfect storm, if you will – I always say Kentucky is in the eye of the storm,” says Ellen Hahn, PhD, RN, FAAN, professor at the University of Kentucky College of Nursing and director of BREATHE. “Only about 37 percent of our Kentuckians are covered by strong smoke-free ordinances. … We have high smoking rates, weak laws, and we have a lot of people who are exposed to secondhand smoke at work, in homes, and in public places.”
In addition to those statistics, Kentucky also has a high rate of electronic cigarette use among youth, Hahn says. About 26 percent of high school students in the state use e-cigarettes, which Hahn says is a result of aggressive marketing campaigns from tobacco companies such as Altria, the owner of the popular Juul brand. According to Hahn, recent studies have shown that using e-cigarettes is harmful to the lungs due to the presence of microscopic, ultrafine metal particles that are inhaled in the aerosol.
Hahn says that the introduction of smoke-free ordinances in several Kentucky cities and towns in recent years has produced measurable reductions in tobacco usage and improvements in health conditions caused by smoking. That is very encouraging, but much more work needs to be done to move Kentucky closer to the national average in smoking rates.
“The single most preventable cause of a lot of the chronic diseases we have is our air,” Hahn says. “We’ve got to fight for better air, and we know what to do, we just need to do it. We need the political will to do it.”
