It’s early on a Thursday morning, the day of the Great American Smokeout.

At the Eastern Maine Healthcare pulmonary rehab center in Bangor, former pack-and-a-half-a-day smoker Rosemarie Hallsey, 75, already is hard at work – a brisk turn on the stationary bike, 80 repetitions on the lateral pull-down machine, 60 leg curls.

She moves from one piece of equipment to the next with the ease of an athlete in training, adjusting each to fit her small physique and adding the right combination of weights to challenge her growing strength and stamina.

Retired from a career of teaching foreign languages in high schools, Hallsey enjoys verbal banter and an active social life.

With an audience, she finds it hard to hold her tongue and concentrate on her breathing as she’s been taught.

“All of this was very intimidating at first,” she confides in a rush, beginning to gasp just a little as she positions herself in the imposing leg press machine.

“I can teach you how to conjugate verbs in French and Spanish, but all these instruments of torture! I didn’t understand how they worked,” she said. “I didn’t think I’d ever remember how to adjust them. I didn’t even know how to set the timer.”

Hallsey shuts her eyes – and her mouth – and gets the rhythm of her breathing under control before beginning the steady push (breathe in through your nose) and release (breathe out through your mouth), push (breathe in) and release (breathe out) of the leg press.

A costly problem

Along with about 60,000 other Mainers, Hallsey is diagnosed with chronic obstructive pulmonary disease, a common condition that claims the lives of 117,000 Americans each year and debilitates millions more.

The Bangor resident’s gumption and stick-to-itiveness qualify her for poster-girl status in a growing campaign to improve the management of chronic illnesses such as COPD, heart disease and diabetes – major cost drivers in Maine’s overburdened, underfunded health care system.

COPD is characterized by a debilitating shortness of breath, a persistent cough, a lack of circulating oxygen, and in severe cases a toxic buildup of carbon dioxide in the blood. It is the fourth-leading cause of death nationally and in Maine.

As a primary diagnosis, it’s responsible for 4,000 to 5,000 hospital admissions in Maine each year and about $40 million in hospital charges. As a secondary diagnosis, it is included in about 24,000 hospital cases annually.

Most often a combination of emphysema and chronic bronchitis, the vast majority of the 13 million cases of COPD nationally are caused by smoking or by prolonged exposure to secondhand smoke or other respiratory irritants.

The disease is a direct result of irreversible damage to the alveoli, delicate structures clustered like grapes at the ends of the respiratory tract.

It is primarily in the alveoli that life-sustaining oxygen is absorbed into the bloodstream and waste gasses are excreted by exhalation. Once ruined, tissue-thin alveoli cannot regenerate, although carefully managed interventions can make a big difference.

COPD is a progressive disease, meaning that it gets worse with time, even when it’s well-managed. Poorly managed, it can get worse fast. Patients’ ability to perform even the most basic activities of life becomes severely limited, leading to the complications of inactivity and social isolation.

The disease’s “ripple effect” is profound, straining families and caregivers as the stricken person becomes more dependent on others for physical, emotional and financial support.

End-stage COPD is accompanied by dementia, heart disease, fluid retention and, often, dependence on mechanical ventilation for breathing.

Improving care

In northern Maine, COPD diagnoses are about 40 percent higher than in the rest of the state, and repeat hospitalization rates are even higher.

That’s why the recently created Institute for Medical Improvement at Eastern Maine Healthcare is supporting a clinical trial in Aroostook County, with statewide implications for the way the disease is managed.

The institute’s study – the first of several it has planned – dovetails with similar efforts in other parts of the state, and with the Baldacci administration’s determination to reduce health care costs statewide by providing more effective treatment for all chronic diseases. The need to implement “best practices” and “evidence-based medicine” also has been identified.

Doctors everywhere are so pressured in their practices there’s little time to read up on the latest medical practices and even less to undertake the strategic interventions that make for good management of chronic conditions, said Jerry Whalen, vice president for development at EMH.

With just 10 or 15 minutes per scheduled patient encounter, he said, a physician barely has enough time to address acute complaints, let alone to delve into the complicated assessment of a chronic disease.

The result is that COPD patients get into serious trouble before they get the attention they need. Too often, they end up hospitalized.

And while patients usually improve enough to return home, each flare-up worsens the underlying disease, making the next episode harder to avoid.

For the next year or so, with funding from a federal grant, the Institute for Medical Improvement will provide additional support for COPD treatment in the Presque Isle practices of primary physician Fareed Saddiqui and pulmonary specialist Alhassan Badahman, both affiliated with The Aroostook Medical Center.

The goal is to keep patients out of the hospital and well enough to carry on the activities of their lives, including working, running errands, enjoying family life and socializing.

Siddiqui said Maine’s high number of smokers, aging population and exposure to environmental irritants such as wood smoke make COPD a special challenge to rural practitioners like him.

Additionally, implementing recommendations like the aggressive program of exercise adopted by Rosemarie Hallsey can be challenging for people in rural areas, miles from any kind of supervised exercise center.

In its initial stages, evaluators will assess the effectiveness of current interventions by analyzing a random sampling of Siddiqui and Badahman’s patient charts. “The whole idea is to see what our deficiencies are, what we are missing here in northern Maine,” said Siddiqui. “We need to see what it is we are not doing compared to national guidelines.”

National guidelines, according to the American Lung Association, call for early diagnosis, immediate smoking cessation, stress reduction, intensive and continuing education, annual flu vaccines, a pneumonia vaccine every five years, frequent evaluation of medication effectiveness and a consistent program of exercise and strengthening.

Once the “gap analysis” has been performed, the practices will be supplied with what’s needed – additional support staff, more equipment to test lung capacity, training for existing workers – to optimize care for the disease. In a year, results will be evaluated and shared with Maine’s medical community.

“If we see even a 2 to 5 percent improvement in our study, and we extrapolate our results to other offices in Aroostook County, we’d have significant improvement in COPD care in northern Maine,” Siddiqui said. “The whole idea is, if we find something that works, we have to share it with everybody.”

After the evaluation, the trick will be to find funding to continue the “best practices” treatment of COPD, keeping people like Rosemarie Hallsey out and about in the community.

Learning to cope

The independent Hallsey seems deeply chagrined by her disease but is determined not to let it get the best of her.

She kicked her 40-year cigarette habit several years ago when her cholesterol and blood pressure started to rise and she realized she couldn’t walk from her car to a restaurant without struggling for breath.

It wasn’t easy to quit, and she misses smoking. Reaching for a cigarette was the first thing she used to do every morning and the last thing she did before bed.

“I think a person just misses the habit itself,” she said. “I really enjoyed smoking. If I could do it and not have this disease get worse, I would.”

Since being diagnosed with COPD early this year, she adheres zealously to a simple regiment of medications and breathing exercises designed to keep her airways open.

She stays in close contact with her regular doctor and sees a lung specialist from time to time. She keeps a meticulous daily record of her activities – four notebooks so far, full of detailed, dated information that shows her steady progress.

Perhaps most impressively, Hallsey works out three times a week at the Eastern Maine Healthcare rehab center, spending about an hour and a half each time, strengthening her muscles, learning to control her breathing, losing some weight and building her overall wellness.

Because it’s part of her physician’s recommendations for managing her COPD, her use of the exercise center is free.

Never athletic, Hallsey feels stronger now than she ever has. “In this short period of time, I’ve done more exercise than I have ever done in my life,” she boasted. “I’m learning to cope with what I have.”

Are you at risk?

The American Lung Association says even though Maine?s COPD rates are high, many cases go undiagnosed until it?s too late to treat effectively. Many people assume shortness of breath and a cough are a normal part of aging and fail to seek medical advice, and some physicians don?t pick up the early signs of the disease.

ALA-Maine suggests current and former smokers over the age of 45 talk with their physician if they:

? Experience breathlessness with routine activities such as climbing stairs.

? Experience a persistent, wet cough.

? Live or work in areas where smog, ozone and air pollution are high.

? Experience tightness in the chest or trouble breathing in cold weather.

More information on COPD can be found on the lung association?s Web site: www.mainelung.org.