Talking to… Dr. Aaron Milstone

Aaron Milstone

Dr. Aaron Milstone is a pulmonologist in Franklin, Tennessee and has been in practice for more than 20 years, 15 of them as an Associate Professor in Medicine at the Vanderbilt University Medical Center. In this interview to the M3 blog, the doctor shares the novelties in the treatment of COPD and asthma, his main areas of interest, and his opinions on e-cigarettes and home-test for sleep disorders.

Data from the United Network for Organ Sharing shows a 3% increase in organ donation in the US since 2016, and a 27% increase over the last ten years. What’s your opinion on new techniques which are helping to facilitate that?

I was at Vanderbilt University Medical Center in Nashville, Tennessee, where I directed a lung transplant program for 15 years, so obviously was involved in a great deal of critical research into transplantation. In terms of lung transplants, there are many aspects contributing to the increase in organ donation, including educating the public, and expanding the donor pool to include older patients, and the preservative solution used has improved so an organ can last longer outside the donor body than ever before.

Another one of your areas of expertise is the management of COPD. What are the hottest news in this field?

Yes, my main areas of interest are COPD and asthma. I have a large clinical research program conducting phase 3 and 4 studies in both asthma and COPD. COPD is a real hot topic now as we get ready to have biologic options for patients with the condition. COPD is an enormous problem in the US, especially in the South-East of the US where smoking rates are particularly high – the highest in the US. Just in my own state of Tennessee, the incidence is very high compared to the US in general. In turn COPD rates are very high here as well. My opinion is that we are in the era of Columbus in terms of COPD treatment.

By that I mean that historically we’ve used inhalers, but now we have drugs with new mechanisms of action and new delivery systems. Now a fixed dose, triple drug therapy has come to the US market, within the last year, and there are also multiple LABA/LAMA combinations and many more therapies to come. Triple drug therapy is going to have a significant impact – patients can now use a single device rather than three inhalers, so adherence improves.

Historically we’ve relied on patients to tell us whether they’re taking their medications, but now we’re doing a lot of research looking at new ways to improve compliance, and many of those involve smart electronic devices and smart phones. In the future, your inhaler will be able to report how frequently it’s been utilized, whether the correct dose has been administered and, most importantly, give feedback to the HCP. There’s lots and lots of knowledge on the horizon that will revolutionize the use of inhalers at minimal cost to the patient and HCP.

We’re also doing a lot of work with biologic therapy. Recently one of the larger drug companies published data on biologics and exacerbations of COPD. The impressive feature of biologics is that they have the ability to improve lung function but also may have the potential to reduce flare ups. So, I think there’s going to be a change worldwide in how we treat COPD and asthma in the near future. There are currently four different biologics treatments already on the market for asthma, and many more in the pipeline, and I’d expect to see biologics treatments for COPD coming soon. It’s an exciting and unique time to be in pulmonary medicine. I believe that soon there are going to have to be niche sub-specialists who are very familiar with immunology and biologic drug classes.

Data on smoking in the US shows that the percentage of people smoking has declined from almost 21% in 2005 to 15.5% in 2015, but cigarette smoking is still the leading cause of preventable deaths in the country. In other countries there have been initiatives to reduce smoking via taxation etc, how do you think the US should approach this?

The data in the US is very similar – there is a linear correlation between smoking tobacco and higher taxation. The states that have the highest taxation on tobacco tend to be in the east. The states that have the lowest taxation tend to be in the south-east, and there is a very clear correlation between taxation and prevalence. Taxation on tobacco products can be very effective at keeping prevalence down.

Another strong approach that I’m an advocate for is improved pharmacologic coverage by insurers. Unfortunately, most insurance companies do not cover the cost of smoking cessation products such as nicotine replacement patches. I think that insurance companies should be lobbied to cover the cost of treatments for smoking cessation. At the moment if a patient can’t afford nicotine replacement patches or other treatments they have a much lower likelihood of stopping smoking. Some insurance companies now are giving discounts on premiums to patients enrolled in tobacco cessation courses or if the patient makes a ‘valiant attempt’ at cessation, and I think that’s a really good way to increase quit-rates. I think that counselling combined with pharmacologies is the best approach.

I do agree that the Australian approach to taxation is helpful, but I also think that you need to look at secondary intervention in terms of helping people to quit and giving them affordable ways to quit. This has been a real focus for me as I live in the South, and Tennessee has one of the lowest rates of taxation, and hence is a state with very high tobacco use prevalence. The reality is that I see so many complications of tobacco in terms of stroke, myocardial infarction, and lung cancer, that this area of medicine is very important to me.

The UK has reached a record low in terms of smoking rate, with over a million people reporting using e-cigarettes, which can be somewhat controversial. What are you take on them?

I think the main problem with e-cigarettes is that the long-term health effects of these cigarettes remain unknown. There’s a multi-center study looking at the long-term impact of their consumption, and until the effects are known I strongly advocate against using them to quit smoking. Yes, there are less carcinogens, but many still include high levels of nicotine. The way I see it, is that you’re just switching out one addiction (ie. cigarettes), for another (ie. e-cigarette). I believe that when we see long term data we may find that e-cigarettes are no safer than regular cigarettes, but we don’t know that at this time.

Regarding sleep disorders, another area of concern in Pulmonology, what’s your evaluation on the recent practice of home tests for the diagnosis of sleep disorders?

Definitely a hot topic. Any physician, such as a primary care physician, for example, can now order a home sleep test for a patient. However, I think the patient really loses out on some of the analysis and expertise when they’re not seeing someone who is board-certified in sleep medicine. The reason I say that is that many of the home sleep tests lack data on aspects like leg movement, so you may not be able to make a diagnosis of periodic limb movement disorder with a home sleep test.

In addition, there’s a very crude analysis of REM and non-REM.  So, many times the home sleep study may not be adequate for a diagnosis of, for instance, narcolepsy or idiopathic hypersomnia. At the end of the day, home sleep tests are best when the health care provider is looking specifically for sleep apnoea. However, a home study can lack sensitivity for patients with mild sleep apnoea. Unfortunately, if you haven’t seen a board-certified physician for the analysis you may not have been fully assessed for other diagnoses like idiopathic hypersomnia, and most importantly, may not get the degree of follow-up after starting CPAP if you have been diagnosed using a home sleep study.

That being said, home studies are a trend that’s not going away. Physicians have to be very selective about who gets a home sleep study. The health care provider has to be purely thinking about sleep apnoea and ensure that the patient is safe to be assessed in the home environment. If someone has significant heart or lung disease or underlying seizure disorder, those patients should all be assessed in a monitored sleep lab setting. Also, if you do a home study you want to make sure adequate follow-up is in place when the patient initiates therapy with positive pressure (ie CPAP or BPAP).

Talking to… Dr. An Pham

Dr. An Pham, a pulmonologist from Pennsylvania, USA, shares his opinion on stress and quality of sleep, tobacco taxation, and advancements in procedures and drugs in the treatment of pulmonary conditions.

M3 Global Research is currently conducting studies on various pulmonology-related topics. If you are a pulmonologist or internal medicine physician specialising in pulmonology and practising in the US, please contact If you are not a member of our panel already and are interested in participating in healthcare market research, you can register here.

What inspired you to specialise in pulmonology and what is the most interesting aspect of working in this area?

I did a rotation with a wonderful pulmonologist who became my mentor and made me want to follow in his footsteps.

You are certified in sleep medicine. What are your thoughts on new trends like home sleep tests, for example? Currently, the American Academy of Sleep Medicine recommends home sleep tests should be used in conjunction with a comprehensive sleep evaluation to diagnose obstructive sleep apnoea (OSA).

Mixed feelings. Most of the time this works out, but a lot of times the results come back inconclusive and have to be repeated. Additionally, the Apnoea Hypopnea Index (AHI) is frequently underestimated, which impacts treatment decisions, especially for borderline cases.

Short sleep duration has been associated with a variety of adverse cardiovascular outcomes in cross-sectional and small prospective studies. As someone with more than 20 years of medical practice, during your career have you noticed much indication of lifestyle directly influencing quality of sleep and resulting in other health issues? 

That varies from individual to individual. In general, yes, to some degree, but many patients don’t even realise that.

The percentage of the population in the United States that smoke has declined from 20.9% in 2005 to 15.5% in 2016. However, cigarette smoking remains the leading cause of preventable disease and death in the country. Do you agree with measures trying to address this? The Australian government, for example, has announced it will raise tax on tobacco by 12.5% every year from 2017-2020. Would you agree with something similar being put in place in the US?

Mixed feelings. The effect of cigarettes on health is no longer a secret, so if someone chooses to smoke he or she is willing to take that risk. It’s the same with alcohol. I’m not sure where to draw the line as far as controlling what people do with their lives.

In your opinion, how has technology improved the treatment of pulmonary diseases in the last decade?

 Lung transplants and interventional pulmonology have advanced significantly. Older patients can now be candidates for lung transplants. Many patients can now avoid surgery given new intervention bronchoscopy procedures. Also, new drugs, especially the biologic agents, have improved patient outcomes significantly.


Join M3 Global Research at ESMO and ERS

September will be a very busy month for M3 Global Research! We will be attending two large European medical congresses where we will be spreading the word about our paid studies and the work we do towards improving health and patient care.

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ESMO 2017 Congress


From the 8th to 12th of September we will be in Madrid for the ESMO 2017 Congress. The annual meeting for oncology professionals in Europe, in partnership with the European Association for Cancer Research, promises to provide important clinical updates where researchers and clinicians can exchange knowledge and ideas with the final goal of improving the lives of cancer patients. Come find us at STAND 214, hall 7.

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ERS International Congress


From the 9th to 13th of September we will be in Milan for the ERS International Congress. This is the largest respiratory meeting in the world, with an outstanding scientific and educational programme that addresses researchers, clinicians, general practitioners and health professionals.

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The M3 Global Research Team.