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Chronic Obstructive Pulmonary Disease (COPD)

Overview

Chronic obstructive pulmonary disease (COPD) is the chronic inflammation of lung tissues that obstructs airflow leading to compromised lung functions. It is characterized by persistent cough with mucus production, wheeze, and difficult breathing. Smoking is a major cause of COPD, but prolonged exposure to irritant gases, fumes, and dust also increases the risk of developing COPD over time. Long-term complications include heart disease, lung cancer, and other cerebrovascular conditions.
COPD is a slowly progressive and poorly reversible disease that badly affects the patient's life quality if not treated timely and promptly. The good news is it is treatable! Proper management can slow down its progression, and life quality can be improved.

Types

The American Thoracic Society defines COPD in terms of Chronic Bronchitis and Emphysema. These two conditions may occur simultaneously or separately and vary in severity.
Chronic Bronchitis:
Chronic bronchitis is defined as a chronic cough with sputum production for a minimum of 3 months a year for two consecutive years.
The air enters our body through the nose. It flows down the trachea (windpipe), bronchi (main branches), and bronchioles (smaller branches), finally reaching alveoli (air sacs) where the exchange of oxygen and carbon dioxide takes place.
Chronic bronchitis is long-term inflammation of the bronchi. There are hair-like structures called cilia in bronchi, which help airflow and keep the tracts clean and open. Due to inflammation, increased mucus production and destruction of these cilia further aggregate the disease. Thus due to loss of cilia, the air tubes are not cleaned, air can not flow properly, and the patient feels breathless with cough and sputum production.
Emphysema:
The prolonged exposure to irritating stimuli destroys the thin lining of the alveoli (air sacs). Alveoli are grape-like structures. They are very elastic, and oxygen transfer occurs in these sacs. Due to the loss of their elasticity, they become rigid, unable to expand, and tend to rupture easily. Air is trapped in these bags, and the patient feels breathless.

Causes

Globally tobacco smoking is the major cause of COPD, but in developing countries, smoke from burning coal or dung used for cooking and heating in poorly ventilated homes is also a contributing factor.

Epidemiology

COPD is a very common disease. It is more prevalent in males than in females, although many cases are now increasingly seen in females. The peak age is 40 years. 

Risk Factors

  • Smoking: whether it’s cigarette smoking, pipe, cigar, marijuana, firsthand smoke, or secondhand smoke, all increase your chances of having COPD. The longer you smoke in years and packs per day, the higher your risk!
  • Occupational exposure: People exposed to toxic gases, fumes, chemical dust in their workplaces are at high risk of developing COPD.
  • Domestic exposure: In underdeveloped countries where coal and cow dung are still used for cooking and heating purposes, the prevalence of COPD is higher.
  • Genetics: Alpha_1 antitrypsin deficiency is a rare cause of COPD in some patients. If a patient develops Emphysema before the age of 40 years and other common risk factors are not present, deficiency of this protein should be ruled out.
  • Asthma: Asthmatic patients are at increased risk of developing COPD as they age, and in the presence of other risk factors especially smoking, their chances are significantly high.

Diagnosis

  • Physical exam and history: Although COPD is a common and chronic condition, it can also go undiagnosed if keen history and physical examination are not made. The physician should pay utmost attention to personal, family, and medical history. Ruling out exposure to stimuli is crucial.
  • Lung function tests: These include several tests, the most common is spirometry. Others include pulse oximetry, a six-minute walk test, diffusing capacity, and measurement of lung volumes.
  • Chest X-ray: It can detect emphysema and helps in ruling out other lung conditions or heart failure.
  • CT Scan: A CT scan of a COPD patient helps in detecting emphysema and determining if surgery will be helpful or not. It is also beneficial in the early detection of lung cancer.
  • Arterial blood gases: This test measures the level of oxygen and carbon dioxide in your blood, which determines the function of the lungs.
  • Blood test for AATD: In patients with alpha-1 antitrypsin deficiency, specific blood tests are done to confirm the cause.

Differential Diagnosis

  • Congestive cardiac failure
  • Chronic Cough
  • Chronic asthma
  • Pulmonary Embolism (PE)
  • Emphysema
  • Nicotine Addiction

Treatment

Early detection of disease and prompt treatment are essential in managing COPD. It can help slow down the progression of the disease, thus improving the quality of life.
There are several treatment options available:

  • Smoking Cessation: This is the first and the most important step in treating COPD. Smoking is easy said than done. It needs a lot of motivation, guidance, and support. Several products and programs are available to help smokers quit and stay smoke-free. Your doctor can advise you nicotine replacement products or medicines which help smokers stay away from smoking. You can also look for support groups for smoking cessation. Staying away from secondhand smoke is also of utmost importance.
  • Medical treatment

This includes several medications given according to the patient's condition. Some medicines need to be taken regularly, while others are provided as required.

Bronchodilators: These medicines are available in the form of inhalers. They relax the muscles of the airways, making them more expansive and open so air can easily flow. They help in relieving cough and shortness of breath.
There are two types of bronchodilators, short-acting (albuterol, ipratropium) and long-acting (salmeterol, tiotropium). Short-acting is given when required or before activities, and long-acting is provided daily.
Steroids: Steroids help in reducing the inflammation of airways and prevent exacerbations. They are available in two forms, inhalers, and oral medication.
Inhaled steroids which include fluticasone, budesonide, are given to patients who experience frequent exacerbations. In contrast, oral steroids are given to those who don’t get frequent attacks, but it's more severe whenever they have an attack. Because of the serious side effects of steroids, it’s not recommended to use them for a longer duration.
Combination Inhalers: These inhalers contain a combination of bronchodilators and steroids. These include Formoterol and budesonide.
Antibiotics: This is not the first-line treatment of COPD to help treat bacterial infections since patients with COPD are more susceptible to lung infections.
Oxygen: Oxygen therapy is used when the oxygen level in the blood is low. It improves the quality of life and is proved to prolong life too. Nowadays, portable oxygen devices are also available, easier to carry around.
Prevention and Rehabilitation: Prevention and making conscious decisions are crucial in treating COPD. Treatment will only be effective if you actively seek to avoid exposure to irritating stimuli. To help you keep on track, several rehabilitation programs and centers are operating that focus on educating patients on maintaining a healthy lifestyle. These programs are based on counseling, education, fitness training, and nutrition advice.
Pulmonary rehabilitation decreases the number of readmissions and improves your quality of life.

Surgical Treatment

Surgery is advised to patients with more severe diseases and whose medical treatment has not responded well. Options are:

  • Lung volume reduction surgery involves removing the damaged lung tissue to allow the healthy lung to expand and work properly.
  • Bullectomy¸ in emphysema, when the alveoli (air sacs) are destroyed, extra air spaces are formed, called bullae. These bullae impair lung expansion. In Bullectomy, these large air spaces are removed to improve lung function.                                         
  •  Lung transplant: this is the last resort in the treatment of COPD. Though it has its pros and cons, it can drastically improve your life if successful. It can be a game-changer. Not every patient is suitable for a lung transplant. It is a long and complicated process with a higher risk of organ rejection and taking immune-suppressing drugs all your life.

Prognosis

COPD is a chronic debilitating disease. If not diagnosed and treated early can lead to severe morbidity and mortality. However, with the use of current medicines, the course of the disease can be slowed down.

Lifestyle Changes

Adoption of a few lifestyle changes will help you cope with the disease;

  • Avoid smoking
  • Eating healthy foods
  • Taking care of your oxygen and lung exercises
  • Sticking to regular exercise
  • Especially careful in your appointments and adherent to the treatments given.

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