US COPD Coalition



Editorial: The intersection of women’s health, lung health, and disease

Marrah E. Lachowicz-ScrogginsLouis J. VugaAaron D. LaposkyMarishka BrownKoyeli BanerjeeThomas L. Croxton, and James P. Kiley – Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland

We celebrate World Lung Day 2021 with a somber tone, realizing that the past year has likely seen more deaths related to lung disease than at any other point in our lifetimes. The COVID-19 pandemic has provided both an unwelcome reminder of the lung’s vulnerability to environmental microbes and toxins and a striking demonstration of how scientific research can improve care and patient outcomes. Respiratory health providers—pulmonary and critical care physicians and respiratory therapists—have shown extraordinary dedication, consummate skill, and even heroism in responding to COVID-19, and it is noteworthy that the medical community associated with this journal has never looked better. But the pandemic has also shown light on how little we understand about individual factors that determine lung susceptibility and resilience—factors such as age, race/ethnicity, and sex/gender. In particular, males have suffered more from COVID-19 than females, both by cases and by deaths (12). This is especially interesting because it is opposite to what is typical for chronic lung diseases, namely, a slight to threefold predominance of female cases. The pandemic reminds us not only of the need to address health inequities but also of the complexity of that issue, which often interweaves women and men differently among the threads of race, poverty, geography, environment, education, and health-care access (34). In this editorial, we look beyond the pandemic and highlight women’s lung health—a longstanding issue that would benefit from greater research interest and intensity.


Women’s lung health has roots in the prenatal period when sex hormones and exposures in the womb drive differences in early lung development, anatomy, and physiology (3). Sex differences in lung development and maturation can be observed as early as 16 wk of gestation, where androgens increase airway branching in males resulting in larger lungs with more bronchioles at birth (4). In adulthood, these prenatal androgen exposures result in larger airway diameters, more alveoli, and increased lung volume in men when compared with women (5). Sex, hormones, and gender continue to impact lung health across the lifespan with differences in risk, susceptibility, and resilience to lung diseases (67). Effects of sex steroids on chronic lung diseases often involve their roles in immune cell function and lung inflammation (8), but this biological difference is insufficient to explain the diverse and profound differences in morbidity and mortality that women experience throughout their lifetimes (910). Gender differences are also driven by a host of external factors (1112). Research on women’s health must consider both the biological perspective, which operates at the genetic, molecular, cellular, and physiological levels and the social/environmental perspective, which operates at the individual, community, and societal levels.


Sex and gender have key roles in disparities for chronic lung diseases. Chronic pulmonary diseases have high morbidity and are the third leading cause of death for women in the United States (13). Both epidemiology and clinical presentation for chronic lung disease can differ between women and men. Asthma prevalence is more common in boys during childhood; however, incidence rates increase for girls around puberty when rates decrease in males (14). In adulthood, asthma is more prevalent in women regardless of race, and exacerbation rates, hospitalizations, and mortality are higher among women (15). Asthma severity can also be modulated by body weight and sex hormones (16). In the United States, rates for chronic obstructive pulmonary disease (COPD) in women have been rising since 2008 and now exceed those of men. COPD is a leading cause of death among women, particularly those with comorbidities (17). A notably different example is how sex can alter disease course in cystic fibrosis (CF) with what is known as the “CF Gender Gap.” In CF, estrogen has profound impact on the virulence of Pseudomonas aeruginosa and the formation of biofilms which enable bacterial persistence (18). Similar mechanisms may contribute in other chronic lung diseases associated with bronchiectasis, where there are clear gender differences in onset, association to underlying disease, morbidity, and mortality (19). Other mechanisms are likely at play in autoimmune diseases affecting the lung, which include sarcoidosis, systemic sclerosis (SSc), rheumatoid arthritis (RA), Sjogren’s syndrome, and systemic lupus erythematosus—all of which are more common in women than men (20). The pulmonary impact of autoimmune diseases may be aggravated by co-occurring pulmonary arterial hypertension (PAH), which is often progressive leading to right heart failure and death. Women are twice as likely than men to develop PAH (21), including in the context of autoimmune disease. PAH in patients with SSc who develop interstitial lung disease is associated with increased morbidity, resistance to PAH therapy, and overall poorer health outcomes (2223). As systemic sclerosis occurs more commonly in women, they represent an at-risk group for PAH (2425). An even more prevalent autoimmune condition with increased rates of lung disease is rheumatoid arthritis. The rate of RA in women is nearly threefold greater than in men, with earlier disease onset and highest incidence around menopause. Extra-articular manifestations include several forms of interstitial lung diseases with clear sex differences in clinical presentation (2627). Another autoimmune condition that is more common among women is sarcoidosis. Although the cause of sarcoidosis remains unknown, evidence suggests that underlying genetic and other risk factors for sarcoidosis include sex, race, socioeconomic status, and gene-environment interactions (GxE) (28).


Obstructive sleep apnea (OSA) is a serious medical condition characterized by repetitive episodes of partial or complete upper airway collapse during sleep, resulting in restricted airflow, oxygen desaturation, and sleep fragmentation. Conservatively, 4%–7% of women exhibit OSA, with higher prevalence in women who are overweight/obese, postmenopausal, and pregnant (2930). Sleep apnea is associated with increased risk for many conditions impacting women, including cardiovascular disease, diabetes, depression, cancer, and dementia (31). Although OSA is treatable, the majority of women with OSA fail to receive an appropriate diagnosis (29). The classic stereotype for OSA is an obese, middle-aged male with chronic snoring and excessive daytime sleepiness; however, important sex/gender differences exist in clinical presentation. Women with OSA more frequently report fatigue, depression, anxiety, insomnia, and difficulty sleeping—symptoms that are not primarily queried in most apnea risk assessment tools. Research is needed to improve methods for apnea risk detection, reducing bias due to sex differences in symptom presentation. The diagnosis of OSA is based on the apnea-hypopnea index (AHI), which measures the number of apneas and hypopneas that occur per hour of sleep. Women tend to have lower AHI compared with men, shorter duration of apneas, and less severe oxygen desaturation, but in certain cases, the health risks they incur associated with apnea are the same or even greater than in men (e.g., elevated high-sensitivity cardiac troponin levels, increased left ventricular mass, incident heart failure, impaired endothelial function, and brain white matter loss) (10). Furthermore, recent studies have shown that women are susceptible to subtle airflow limitation (AFL), which does not meet AHI criteria but nonetheless triggers arousal from sleep, sympathetic activation, and potentially other pathophysiological effects (32). These findings suggest that assessment and diagnostic criteria may need to be redefined, considering sex/gender-specific sleep-disordered breathing symptoms and clinical phenotypes.


Sex/gender differences are apparent both during acute infection with SARS-CoV-2 and for the postacute sequelae of COVID-19 (PASC, “long-COVID”). Research in this area is perhaps a model for that on other diseases, since the norm has been to report results in a sex-disaggregated manner and to routinely consider sex as a biological variable (SABV) in COVID-related studies (3334). This rigor has quickly yielded compelling data on sex and racial disparities in COVID-19 with the level of detail that is needed for nuanced interpretations. For example, a recent publication confirmed that, although men have higher mortality rates than women overall, this sex disparity does not hold across racial groups (3536). In fact, COVID-19 mortality rates for Black women are higher than rates for both men and women of either White or Asian/Pacific Islander ancestry. In addition, women appear to be much more prone to developing PASC, as evidenced by greater morbidity and health-care utilization after COVID infection (37).


This brief overview of women’s lung health illuminates many opportunities for research. It remains critically important for all clinical researchers to include adequate numbers of women in their study populations and to report results in a sex-disaggregated manner. There is also a need for specifically designed studies to investigate the etiology origins of sex/gender differences and to develop and test approaches for reducing disparities. A crude analysis of the grant portfolio of the Division of Lung Disease, using the NIH Research, Condition, and Disease Categorization (RCDC) system, suggests that among all grants on lung diseases funded by National Heart, Lung, and Blood Institute (NHLBI) in the past 5 years (Fig. 1), only 3% are specifically directed to issues of women’s health. NIH is taking positive action to address this situation. In May 2014, NIH stated clearly that rigor and transparency in research requires researchers to account for sex as a biological variable (SABV), and NIH identified this as a requirement in most NIH-funded research. This was expanded in 2018 to include consideration of age across the lifespan. These policies have implications for preclinical research (38), and they encourage the research community to go well beyond the simple inclusion of both sexes in their studies. For example, we need clinical study/trial designs that test strategies for personalized medicine that are inspired by the distinctive risks and disease mechanisms of women (1338). Although we affirm efforts by the research community to improve transparency and rigor in the reporting of clinical research studies (39), the time has come to move beyond the use of metrics developed and validated in male-dominated studies (e.g., sleep apnea, AHI) and that test interventions that target mechanisms that are particularly relevant to diseases as experienced by women. Furthermore, future research on women’s health should not only investigate biological differences associated with sex/gender but also explore how women are affected by disease in the broad context of external factors such as social determinants of health. To address these disparities in lung health across the lifespan research in health education, early intervention and primary prevention are areas much in need of stimulation (4041). This type of interdisciplinary work may be aided by expanding the capacity of the research community, especially with regard to recruitment and advancement of women scientists. NIH provides tangible support for such efforts through the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) K12 program (42). NHLBI wholly supports the 2019–2023 Trans-NIH Strategic Plan for Women’s Health Research (43) and is further advancing research on women’s health through the Institute’s Strategic Vision and through the creation of a Women’s Health Working Group in 2015 (44). We encourage the research community to partner with us to better understand the role of sex/gender in lung health through interdisciplinary research and to work toward the elimination of disparities in lung health. World Lung Day 2021 is an opportune time to reflect not only on the seriousness of lung disease but also on the tremendous opportunities that exist today for impactful research that can improve lung health for every member of our societies.

The preceding editorial is reprinted from the American Journal of Physiology: Lung Cellular and Molecular Physiology. Click here for a PDF version with references.


Toolkit for Engaging Patients To Improve Diagnostic Safety

The following article is reprinted from the Agency for Healthcare Research and Quality (AHRQ) website.

Diagnostic errors occur in all care settings and one in three patients will experience a diagnostic error firsthand. Research suggests that communication breakdowns during the patient-provider encounter are a leading contributor to diagnostic errors.

To promote enhanced communication and information sharing within the patient-provider encounter, the AHRQ has developed a toolkit. This toolkit is designed to help patients, families, and health professionals work together as partners to improve diagnostic safety.

About the Toolkit

The toolkit contains two strategies, Be The Expert On You and 60 Seconds To Improve Diagnostic Safety. When paired together, these strategies enhance communication and information sharing within the patient-provider encounter to improve diagnostic safety. Each strategy contains practical materials to support adoption of the strategy within office-based practices.

What Is Be The Expert On You?

Be The Expert On You is a patient-facing strategy that prepares patients and their families to tell their personal health stories in a clear, concise way. Research suggests that 79 percent of diagnostic errors are related to the patient-clinician encounter and up to 56 percent of these errors are related to miscommunication during the encounter. Environmental scan findings show that inviting patients to share their entire health story, uninterrupted, and in a way that gives clinicians the information they need can reduce diagnostic errors.

What Is 60 Seconds To Improve Diagnostic Safety?

60 Seconds To Improve Diagnostic Safety prepares providers to practice deep and reflective listening for one minute at the start of a patient-encounter. Research suggests that patients are interrupted by their providers in the first 11 to 18 seconds of telling their diagnostic story. Diagnostic safety can be improved when a provider allows a patient to tell his or her health story without interruption for one minute, and then asks questions to deepen understanding.

Ready To Start?

The Toolkit Implementation Roadmap (PDF, 311 KB) is the starting point for your implementation and should help you plan your strategy for adopting each intervention.

Step 1: Prepare Your Organization

  • Toolkit Infographic (PDF, 743 KB) provides statistics about incidents of diagnostic errors that are useful to engage leadership and raise awareness of the problem.

Step 2: Make a Plan

Step 3: Train Your Team

Step 4: Implement and Evaluate



August is National Immunization Awareness Month

August is National Immunization Awareness Month (NIAM). This annual observance highlights the importance of getting recommended vaccines throughout your life. We know the COVID-19 pandemic has impacted all aspects of life, including your ability to attend important appointments and receive routine vaccinations. During NIAM, we encourage you to talk to your doctor, nurse or healthcare professional to ensure you and your family are protected against serious diseases by getting caught up on routine vaccination.

August is also a critical time for those who are eligible to get vaccinated against COVID-19. To learn more about COVID-19 vaccination, check out the following websites:


An In-depth Look at Colds and Flu

The following is excerpted from the National Institutes of Health’s National Center for Complementary & Integrative Health

What’s the Bottom Line?

What do we know about the effectiveness of complementary approaches for flu and colds?

  • No complementary health approach has been shown to be helpful for the flu.
  • For colds:
    • Complementary approaches that have shown some promise include oral zinc productsrinsing the nose and sinuses (with a neti pot or other device), honey (as a nighttime cough remedy for children), vitamin C (for people under severe physical stress), probiotics, and meditation.
    • Approaches for which the evidence is conflicting, inadequate, or mostly negative include vitamin C (for most people), echinaceagarlic, and American ginseng.

What do we know about the safety of complementary approaches for colds and flu?

  • People can get severe infections if they use neti pots or other nasal rinsing devices improperly. Tap water isn’t safe for use as a nasal rinse unless it has been filtered, treated, or processed in specific ways.
  • Zinc products used in the nose (such as nasal gels and swabs) have been linked to a long-lasting or even permanent loss of the sense of smell.
  • Using a dietary supplement to prevent colds often involves taking it for long periods of time. However, little is known about the long-term safety of some dietary supplements studied for prevention of colds, such as American ginseng and probiotics.
  • Complementary approaches that are safe for some people may not be safe for others. Your age, health, special circumstances (such as pregnancy), and medicines or supplements that you take may affect the safety of complementary approaches.

Some Basics About Flu and Colds

Each year, Americans get more than 1 billion colds, and between 5 and 20 percent of Americans get the flu. The two diseases have some symptoms in common, and both are caused by viruses. However, they are different conditions, and the flu is more severe. Unlike the flu, colds generally don’t cause serious complications, such as pneumonia, or lead to hospitalization.

No vaccine can protect you against the common cold, but vaccines can protect you against the flu. Everyone over the age of 6 months should be vaccinated against the flu each year. Vaccination is the best protection against getting the flu.

Prescription antiviral drugs may be used to treat the flu in people who are very ill or who are at high risk of flu complications. They’re not a substitute for getting vaccinated. Vaccination is the first line of defense against the flu; antivirals are the second. If you think you’ve caught the flu, you may want to check with your health care provider to see whether antiviral medicine is appropriate for you. Call promptly. The drugs work best if they’re used early in the illness.

Click here to read the full article and learn what the science says about complimentary health approaches to colds and flu.

To find out more about flu and colds, visit the National Institute of Allergy and Infectious Diseases Web site.


Post-COVID Conditions

The following is reprinted from the Centers for Disease Control & Prevention’s COVID-19 website.

Although most people with COVID-19 get better within weeks of illness, some people experience post-COVID conditions. Post-COVID conditions are a wide range of new, returning, or ongoing health problems people can experience more than four weeks after first being infected with the virus that causes COVID-19. Even people who did not have symptoms when they were infected can have post-COVID conditions. These conditions can have different types and combinations of health problems for different lengths of time.

CDC and experts around the world are working to learn more about short- and long-term health effects associated with COVID-19, who gets them, and why.

Types of Post-COVID Conditions


Long COVID is a range of symptoms that can last weeks or months after first being infected with the virus that causes COVID-19 or can appear weeks after infection. Long COVID can happen to anyone who has had COVID-19, even if the illness was mild, or they had no symptoms. People with long COVID report experiencing different combinations of the following symptoms:

  • Tiredness or fatigue
  • Difficulty thinking or concentrating (sometimes referred to as “brain fog”)
  • Headache
  • Loss of smell or taste
  • Dizziness on standing
  • Fast-beating or pounding heart (also known as heart palpitations)
  • Chest pain
  • Difficulty breathing or shortness of breath
  • Cough
  • Joint or muscle pain
  • Depression or anxiety
  • Fever
  • Symptoms that get worse after physical or mental activities

Multiorgan Effects of COVID-19

Multiorgan effects can affect most, if not all, body systems including heart, lung, kidney, skin, and brain functions. Multiorgan effects can also include conditions that occur after COVID-19, like multisystem inflammatory syndrome (MIS) and autoimmune conditions. MIS is a condition where different body parts can become swollen. Autoimmune conditions happen when your immune system attacks healthy cells in your body by mistake, causing painful swelling in the affected parts of the body.

It is unknown how long multiorgan system effects might last and whether the effects could lead to chronic health conditions.

Effects of COVID-19 Treatment or Hospitalization

Post-COVID conditions also can include the longer-term effects of COVID-19 treatment or hospitalization. Some of these longer-term effects are similar to those related to hospitalization for other respiratory infections or other conditions.

Effects of COVID-19 treatment and hospitalization can also include post-intensive care syndrome (PICS), which refers to health effects that remain after a critical illness. These effects can include severe weakness and post-traumatic stress disorder (PTSD). PTSD involves long-term reactions to a very stressful event.


There are ways to help manage post-COVID conditions, and many patients with these symptoms are getting better with time. If you think you have a post-COVID condition, talk to your healthcare provider about options for managing or treating your symptoms and resources for support. Post-COVID care clinics are opening at medical centers across the United States to address patient needs.

The best way to prevent these long-term complications is to prevent COVID-19

Important Ways to Slow the Spread of COVID-19

COVID-19 and Vaccination

CDC recommends that people be vaccinated regardless of whether they already had COVID-19. Learn more about vaccination.

Although media articles have reported that some people with long COVID say their symptoms improved after being vaccinated, studies are needed to determine the effects of vaccination on post-COVID conditions.

What CDC is Doing

CDC continues to work to identify how common these longer-term effects are, who is most likely to get them, and whether symptoms eventually resolve. Multi-year studies are underway to further investigate post-COVID conditions. These studies will help us better understand post-COVID conditions and understand how to treat patients with these longer-term effects.


Finding & Evaluating Online Health Resources

The following information is excerpted from the National Center for Complementary and Integrative Health, a division of the National Institutes of Health.

What’s the Bottom Line?

How much do we know about online resources for complementary health approaches?

The number of Web and social media sites, along with mobile apps, offering health information about complementary and integrative health approaches (often called complementary and alternative medicine) grows every day.

What do we know about the accuracy of online health information?

  • Some online sources of information on complementary health approaches are useful, but others are inaccurate or misleading.
  • Don’t rely on online resources when making decisions about your health. If you’re considering a complementary health approach, discuss it with your health care provider.

Checking Out Online Sources of Health Information: Five Quick Questions

If you’re visiting an online health site for the first time or downloading a new app, ask these five questions:

  1. Who runs or created the site or app? Can you trust them?
  2. What is the site or app promising or offering? Do its claims seem too good to be true?
  3. When was its information written or reviewed? Is it up-to-date?
  4. Where does the information come from? Is it based on scientific research?
  5. Why does the site or app exist? Is it selling something?

Finding Health Information on the Internet: How to Start

  • To find accurate health information, start with one of these organized collections of high-quality resources:
    • MedlinePlus, sponsored by the National Library of Medicine, which is part of the National Institutes of Health (NIH)
    •, sponsored by the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services.
  • If you’re looking for information about complementary and integrative health approaches:

Click here to see the full list of resources on how to find and evaluate health information.


Domestic Travel During COVID-19

The following is reprinted from the Centers for Disease Control & Prevention’s COVID-19 website.

Delay travel until you are fully vaccinated. If you are not fully vaccinated and must travel, follow CDC’s recommendations for unvaccinated people.

People who are fully vaccinated with an FDA-authorized vaccine or a vaccine authorized for emergency use by the World Health Organization can travel safely within the United States.

CDC will update these recommendations as more people are vaccinated, as rates of COVID-19 change, and as additional scientific evidence becomes available. This guidance applies to travel within the United States and U.S. territories.

Domestic Travel Recommendations for Fully Vaccinated People

  • During Travel
    • Wearing a mask over your nose and mouth is required on planes, buses, trains, and other forms of public transportation traveling into, within, or out of the United States and in U.S. transportation hubs such as airports and stations.
    • Follow all state and local recommendations and requirements, including mask wearing and social distancing.
  • After Travel
    • Self-monitor for COVID-19 symptoms; isolate and get tested if you develop symptoms.
    • Follow all state and local recommendations or requirements.

You do NOT need to get tested or self-quarantine if you are fully vaccinated or have recovered from COVID-19 in the past 3 months. You should still follow all other travel recommendations.

Domestic Travel Recommendations for Unvaccinated People

If you are not fully vaccinated and must travel, take the following steps to protect yourself and others from COVID-19:

  • Before you travel:
    • Get tested with a viral test 1-3 days before your trip.
  • While you are traveling:
    • Wear a mask over your nose and mouth. Wearing a mask is required on planes, buses, trains, and other forms of public transportation traveling into, within, or out of the United States and in U.S. transportation hubs such as airports and stations.
    • Avoid crowds and stay at least 6 feet/2 meters (about 2 arm lengths) from anyone who is not traveling with you.
    • Wash your hands often or use hand sanitizer (with at least 60% alcohol).
  • After you travel:
    • Get tested with a viral test 3-5 days after travel AND stay home and self-quarantine for a full 7 days after travel.
      • Even if you test negative, stay home and self-quarantine for the full 7 days.
      • If your test is positive, isolate yourself to protect others from getting infected.
    • If you don’t get tested, stay home and self-quarantine for 10 days after travel.
    • Avoid being around people who are at increased risk for severe illness for 14 days, whether you get tested or not.
    • Self-monitor for COVID-19 symptoms; isolate and get tested if you develop symptoms.
    • Follow all state and local recommendations or requirements.
  • Visit your state, territorial, tribal or local health department’s website to look for the latest information on where to get tested.

Do NOT travel if you were exposed to COVID-19you are sick, you test positive for COVID-19, or you are waiting for results of a COVID-19 test. Learn when it is safe for you to travel. Don’t travel with someone who is sick.


Pulmonary Rehab is Severely Underutilized – Help Spread the Word!

Over 16 million people in the US have COPD and up to 60% of COPD cases go undiagnosed. According to the World Health Organization, COPD is the third leading cause of death globally. COPD continues to be a leading cause of disabling symptoms and suffering. Pulmonary Rehabilitation (PR) is the standard of care for persons with COPD and is associated with improved physical function, symptoms, mood and quality of life. Although PR is well established as a highly effective treatment for COPD and other chronic respiratory diseases in the United States only 3–4% of Medicare beneficiaries with COPD receive pulmonary rehabilitation! Similarly low estimates exist for the rest of the world.

A recent study by Peter Lindenauer and colleagues found that, in persons hospitalized due to acute exacerbation of COPD, PR within three months of discharge vs. later or no PR, was associated with a highly significant lower risk of mortality at one year (hazard ratio, 0.63; i.e., a 37% lower risk of death over the year following discharge). The study utilized claims data of 197,376 Medicare beneficiaries discharged after hospitalization for COPD.8 The findings support PR as a high priority following hospitalization for COPD.

Patients suffering from COPD should know that PR not only has potential for helping them feel better and being more independent, but also to live longer. We are asking for your support in communicating these important findings of improved survival after PR to providers and patients.

Click on the link below to view or download an infographic that you can use to help spread the word.


Are You Caring for Someone Living with COPD?

Join the Caring for COPD Caregivers Study

Respiratory Health Association is seeking caregivers of people living with COPD to participate in a new study, Caring for COPD Caregivers!


As a project participant, caregivers wll receive a free copy of the COPD Caregiver’s Toolkit, a resource designed to ease the caregiving process. The toolkit is based on caregiver, patient, and provider input.

We ask that participants:

  • Use the Toolkit for one year.
  • Give updates every few months on how it is being used, which sections are most helpful, and if the Toolkit is helping in the caregiving role.
  • Complete a brief survey at the start and end of the project.


CONTACT THE COPD TEAM AT: 312-229-6186 or

Click on the link below to view or download a shareable PDF of the above information

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