Dr. Ray Casciari, MD, Pulmonary Specialist at Providence St. Joseph Hospital in Orange, California talks about a new 4D device that can scan lungs for long COVID effects.
Interview conducted by Ivanhoe Broadcast News in July 2022.
What are you hobbies? Can I only perceive that you’ve been working a lot with long COVID patients.
CASCIARI: I see primarily pulmonary patients in my clinic. And I’m seeing a lot of long COVID. The interesting thing is that by the time I see long COVID, they’ve been to three or four other doctors. The reason they keep going to doctors is that they don’t get an answer. They have this funny feeling in their chest. They feel fatigued. They aren’t performing up to the level they think they should be performing. The doctors tell them, “Look, I think you have long COVID”. But they tell them you’re going to get better. But they want to know more. They wanted to understand more about the disease. So they keep looking for another doctor and that’s why I see them.
So, what do you say to them? What do you do for them?
CASCIARI: Well, the first thing I do is a complete history and physical. I go back before they ever got COVID. I want to find out what their health was like before they got COVID because I want to know where they were sedentary. Did they have asthma? They have asthma as a child. And what I’m finding is a lot of these people had nothing. They were completely healthy and they had completely normal lungs before they ever got COVID. They were exercisers and they were doing everything right, and that’s the frustration that they’re experiencing because they said, “Look, I was top of my game. And then I got COVID and now I’m not top of my game. I want to know what I can do to get back.”
Is there anything that puts them together at all, in terms of this is why they’re suffering long COVID?
CASCIARI: I think the thing that I do find that it’s most common, and this is a little contrary to the popular literature. It’s not necessarily obesity, it’s a preexisting history of asthma, I think is the most common thing that I’m finding, but that’s just my personal practice. I haven’t done a series of thousands and thousands. But people who had asthma as children, I think, are suffering this a little more than folks who never did. And the good news there is that they’re the most treatable too. And they’re shocked to find out, “Oh my gosh, I need to be treated again as an adult.” But there are things that we can do for them. But the frustrating part to all of these long COVID folks, is that when we do CT scans on them when we do pulmonary functions on them, it all comes out normal and that’s frustrating to them.
So, traditionally, two years ago, you have been doing the CT scan, anything any other scans?
CASCIARI: We do pulmonary function studies. We do CT scans. I do some preliminary blood work, but usually, by the time they get to me, they’ve done all of that.
Can you see everything with those scans?
CASCIARI: Well, those scans usually come out either normal or mildly abnormal. Certainly, nothing that we would treat normally. And what I tell them is, “I can leave you alone. And I think you’ll get better, but it’s going to take a while, or we can try a new scan that is just available very recently.” But it’s been showing up abnormalities in this subset of patients, this long COVID subset.
What is that scan and how does it work?
CASCIARI: So, this new test, it’s called 4D medical XV LVAS test. It’s different than a pulmonary function test, which is a spirometry test. Spirometry test basically requires you to take a deep breath and blow it out hard and fast. Generally, we measure flow rates with that. What that test does, it measures both of your lungs because all the air has to ultimately come out your trachea. This 4D XV LVAS test, it actually can measure air coming from like your upper lung on the right, lower lung on the right, upper left, lower lung, it can measure the periphery, what air, if the air is coming from periphery or centrally. It can do all of that as you just breathe normally. It doesn’t require you to do any specific maneuvers. So, it doesn’t require any control. The interesting thing is that with this test, even though the pulmonary function tests are normal, this test is abnormal. We’re seeing that the ventilation in the periphery of the lung is not very good in long COVID. And the central ventilation is totally different than the periphery of the ventilation. So that’s interesting.
What would cause that? Like, I do long COVID but what is it scarring?
CASCIARI: Well, we don’t know. This test is so new and long COVID is fairly new, too, that as pulmonologist, we’ve got to get used to using this test and we’ve got to try to figure it out. But we do know this that we can sometimes treat these people with bronchodilators. We can treat them with steroids. We can treat them with time. And over time, these abnormalities go away and as they go away, patients feel better. So there’s some correlation between what’s going on in the lungs and this test is picking that up and then the resolution of the symptoms. So that’s good because if we can correlate the findings on this test with the symptoms, we know there’s some cause-and-effect relationship there.
Can you tell me a little bit about Amy?
CASCIARI: Amy was a very interesting patient because Amy was so frustrated. When Amy came to me, she had been to other doctors and she was just coughing day and night. Amy is a person who had experienced good health all of her life and was extremely frustrated by not having good health, and came in coughing all the time. I diagnosed Amy with long COVID. Amy had a lot of symptoms, not just cough, she had fatigue and her hair was falling out. I believe if you saw Amy she had a lot of hair. When Amy’s hair started falling out, she knew she had a big problem because she, as a woman, did not like this hair business going on. I said, “Look, Amy, your hair is going to come back. I’m not worried about your hair.” But if that’s going to come back, I’m worried about your cough, because if I can’t get a handle on that, this is going to lead to chronic lung problems. So we said, look, there’s this new test out and I don’t know if it’s going to show anything or not to be honest with you, but we have it available at St. Joseph’s Hospital in Orange. It’s the only hospital at that time on the West Coast that had it. You happen to be here, let’s do it. She did it and it was dramatically abnormal. I called her up and by that time, we had started some therapy and so on. I said, Amy look, you’ve got long COVID and it’s dramatically abnormal and you got to do that. Then we’ve got to do another test on you. Amy stopped me on tests. In any event, we did do another test on her. By the time we did another test on her, she had improved dramatically. The second test was dramatically better. Well, when I called her about her second test, she was actually in Hawaii and she was scuba-diving. She felt so good and she had no cough completely better, and I said, “Amy, your second test is better, but it’s not normal.” She said, “Doc, I’m normal. I feel great, I’m scuba-diving, life is good, you’re in the way of me having a good time.” I said, “Amy, you’ll be back.”
Did you say you’re also in a hyperbaric oxygen because you’re scuba diving, so it’s going to make you feel better?
CASCIARI: Well, she was having a good time. Anyway, when she got back from Hawaii, she called me, she said, You’re right about that. I’m coughing again.” She came back in and now, she’s been treated and she’s doing fine. But the scan is good. We’re going to do a third scan on Amy and we’re going to see that she’s doing even better.
Now, with this scan, how would you explain it? Probably not night and day with what you had before, but it’s like taking a magnifying glass?
CASCIARI: If you see on the scan, it’s all color-coded based on ventilation, and the outside of her lungs are red, and red on the scan is bad, not good ventilation. The outside of her lungs, we’re not ventilating. She was only using the inside of her lungs. Even though her pulmonary functions were good and her CT scan was good, she wasn’t using the outside of her lungs. We got her to the point where she was using those and you can see on the second scan she started using them. I’m hopeful that the third scan will be even better.
Without that early intervention that you’ve got from this scan, what could happen to Amy’s lungs?
CASCIARI: Well, again, we don’t know. I think what would have happened, either she would have developed either a longer recovery period, or Amy is one of those people who had asthma as a child. I think what may have happened is she may have developed some adult onset asthma. I think that maybe we headed some of that off. The cough was clearly a function of what we call hyper irritable airways. Those peripheral airways had become very irritable. Any stimulus caused her to spasm a little bit and that’s what was causing that cough. Even though the airways look normal, and they functioned on pulmonary function okay, they were irritable and they were spasming and that’s what was making her cough all day and all night.
Will the steroids help take that down?
CASCIARI: That’s exactly right.
Do you think this is just the first step of what the scan could be used for? Is it good for COPD and all the other?
CASCIARI: I think the scan is absolutely unlimited. We have no perception of the limits of this scan. We found it in veterans who have burned pit injuries that when they have normal CT scans and normal pointing functions, we do the scan on them and they’re dramatically abnormal. We know that in veterans with burn pit injuries, we’re finding all abnormalities that we can then treat. In people who have emphysema, that we can put valves into block, like an emphysema is bled. The scan is extremely useful because the scan can divide different areas of the lung and we can analyze where the ventilation is going to, so we need to know where to block it. In patients who if maybe cannot control their breathing like let’s say you can’t hold your breath. With this scan you don’t have to hold your breath. When you go into a normal CT scanner, you have to be able to hold your breath for a long time, with this all you have to be able to do is breathe. In addition, this scan is less than $500, whereas a CT scan is over 1,000. So we may be able to use this scan for repetitive analysis as opposed to not being able to do that, because for example, CT scan is a lot more radiation. This particular scan is just slightly more radiation than a chest X-ray. We really think this has tremendous promise.
Do people already have the equipment?
CASCIARI: Yes, the equipment for this scan is what’s called fluoroscopy, which is in all the hospitals in the country. It’s a modality that’s actually fairly underutilized right now. It’s something that we could utilize that’s already existing. A hospital won’t have to buy any additional equipment to use it.
Do you see a lot of this happening with brains and all this other hearts, and not just with the lungs?
CASCIARI: Well, this is lung ventilation. This technology could also be used for lung perfusion and we’re working on lung perfusion, too. Once we get the ventilation part down, then we’ll work on the perfusion part. Once we have the perfusion and the ventilation it’s just going to shoot right up skyrocket and this will be a fantastic advance.
What is perfusion?
CACIARI: That’s the blood goes through the lungs. The whole thing about the lung is the matching of ventilation, which is air to perfusion, which is blood. When that matching is perfect, you have a perfect lung. Well, nobody has an absolutely perfect lung. But the closer you get to perfect, the better off you are, the further away you are from perfect, the worse off you are. In various disease processes, that ratio gets worse. The more knowledge we have about that ratio, the more knowledge we have about how the lungs work. As we learn more and more and more about the ventilation perfusion ratio, the more we’re going to know about disease.
Just like Amy, you’re going to be on the scanning prior for, why is that important?
CASCIARI: One of the major advantages of a 4D Medical V-fital low scan is that its cost is low and the amount of radiation is low. We can actually do serial scans and the advantage of that is that we can give a therapy and we can check on that therapy. Let’s take asthma for example. There’s all these different therapies for asthma. But a given individual may react much better to one therapy than another. Well, we can give a therapy and then we can actually do the scan and we can see, well, gee, the right lung seems to do fine with that therapy, but the left one is not reacting very well to that therapy, let’s try a different therapy. We can actually see what parts of the lung are reacting well and what parts of the lung are not reacting well to a given therapy. It’s a huge advance for us. Take children. Right now we can’t do pulmonary function studies on children because they have to be able to cooperate to do the pulmonary functions. But with this study, all they have to be able to do is breathe. We can treat children’s with bronchiectasis or with asthma and we can then see what the therapy is doing, because all they have to be able to do is breath and we can monitor their function. So, it’s a great advance.
END OF INTERVIEW
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