COPD is a medical condition that is characterized by alteration in lung parenchyma, bronchitis, emphysema and narrowing of the respiratory passages. It occurs as a consequence to chronic inflammation reaction involving the respiratory tract. The mucous secretion and fibrosis associated with chronic inflammation, can cause blockage and narrowing of the airway. Bronchitis refers to inflammation of the inner lining of the lung, while, emphysema is a clinical condition that occurs following the long term destruction of lung parenchyma. Bronchitis and emphysema are both characteristic features of COPD. Destruction of lung parenchyma causes loss of alveolar attachment and decreases the elasticity of alveolar tissues. (Chandrasekhar)
Etiology: COPD can occur for a number of reasons. Smoking behavior, inhalation, occupational irritants and air pollutions, are common risk factors of COPD. There is still a lack of clear understanding on genetic susceptibility in COPD. Chronic infection of the respiratory tract and poor immune status, can also predispose individual to COPD. The disease is common in later stages of life and the aging process increases susceptibility of the person. Low socioeconomic status and poor living conditions can also increase risk to COPD. (Friedlander et al. 355-384)
Epidemiology: COPD is a non-communicable disease and accounts for a significant number of deaths globally. More than 24 million Americans are affected with COPD ("COPD Statistics Across America | COPD Foundation"). WHO reported 3 million deaths associated with COPD in 2012 ("Chronic Obstructive Pulmonary Disease (COPD)"). COPD is identified as a leading cause of morbidity and mortality, worldwide. Exposure to environmental pollution and increase in the population of aging individuals, is likely to increase the burden of disease in the future.
Symptoms: Chronic cough with or without mucus, fatigue, respiratory infection, shortness of breath and wheezing, are some of the common symptoms seen in patients with COPD. COPD can be suspected in the patient with a chronic history of respiratory difficulties. (Friedlander et al. 355-384)
Diagnosis: The initial diagnosis of COPD is made based on the symptoms and the presence of risk factors. Chronic cough, sputum production, shortness of breath, accompanied by risk factors like history of smoking, occupational pollutants and age factor, are considered while making a diagnosis. Laboratory tests can be used to confirm a diagnosis. (Mosenifar)
Assessing the severity of COPD will help to predict prognosis and to decide the line of treatment. Symptoms, limitation in the airway, risk of future exacerbation of symptoms and other comorbidities in the patient, are used to identify severity. The modified British Medical Research Council (mMRC) questionnaire test, grades the disease on a scale of 0 to 4. While grade 0 refers to breathlessness with strenuous exercise, grade 4 refers to breathlessness with minimal exertion. (Mosenifar)
Treatment: COPD is treated using inhalers, anti-inflammatory medications, and bronchodilators. Bronchodilators help in the symptomatic management of the disease. Beta 2 agonist and anti-cholinergic are used as bronchodilators. Long acting inhalant bronchodilators were beneficial in reducing future exacerbation and hospitalization. Though corticosteroids are beneficial for managing severe symptoms, they increase the risk for infection and pneumonia. Antibiotics are prescribed when infection is noticed. Mucolytic may be beneficial in a person who has trouble breathing due to excessive mucus blocking the airway. Antitussives are not recommended in COPD. In COPD caused by genetic deficiencies of alpha -1 antitrypsin, the enzyme is administered to the patient. It is not recommended in non-genetic causes of disease. (Berry and Yawn 491-497)
Oxygen therapy is provided in very severe cases or in later stages. The objective of treating COPD is to slow the destruction of lung parenchyma, to relieve symptoms and to prevent exacerbations. Efforts are also directed to help the patient regain activity and improve the quality of life. Smoking can be deleterious for individuals with COPD. It worsens the damage done to the lung and deteriorates lung function. COPD is a long term disease and can cause complications like arrhythmia, pneumonia, osteoporosis and is life threatening. Regular physical activity can offer health benefits and reduce the progress. Influenza and Pneumococcal vaccines are provided to patients who are at risk of these infections. (Berry and Yawn 491-497)
Spirometry is performed to identify limitation in airflow. The FVC value is recorded before administration of adequate bronchodilator and the FEV1 value is recorded after the administration. The ratio of FEV1/FVC provides the spirometry reading. While a normal spirometry reading is 0.8, in obstructive respiratory diseases it is less than 0.6 (figure 1).
Routine blood test that involves the blood chemical profile and the total blood count are also prescribed to the patient. These tests will help identify the effect of COPD on the body’s physiology and also in differential diagnosis.
In order to access lung function, the physician also prescribes arterial blood gases (ABG) test. Impaired lung function will result in impaired gases exchanges and thus the degree of oxygen deficiency or CO2 excess can be identified using ABG test. These test are also done to plan the appropriate line of treatment.
Figure 1: Spirometry in normal and obstructive disease
Figure 2: Chest x-ray of an individual with COPD. Areas of fibrosis are evident in the X-ray
Taken from www.stritch.luc.edu, 2016
Differential diagnosis: The symptoms that are seen in COPD, overlaps with many other medical conditions. Thus, making a correct diagnosis is very important to ensure that the patient receives the correct treatment. Chronic cough and shortness of breath can exist in the absence of COPD. For example, asthma is one condition where the patient may show signs similar to COPD. Unlike COPD, asthma has an early age of onset and family history of the disease is common in asthma. Allergies, rhinitis, and eczema may accompany asthma symptoms. The airway obstruction seen in asthma is reversible. Further, COPD is characterized by elevated neutrophil, CD8+ T cells, and macrophages in the blood. On the hand, mast cell, eosinophils, CD4+ T cells are elevated in asthma. The blood macrophage count in COPD is significantly higher than asthma. Asthma responds favorably to steroid, while COPD does not respond favorably to steroid treatment. Other diseases that are included in differential diagnosis include congestive heart failure, bronchiectasis, tuberculosis, diffuse pan bronchiolitis and obliterative bronchiolitis. (Mosenifar)
Prognosis: COPD is a slowly progressing diseases that worsens with time. Currently, there is no cure for this condition. Nevertheless, treatment can delay progress and help to improve the patient’s quality of life. Death due to COPD occurs following lung and heart failure. As a result of this failure, the cells in the body fail to receive sufficient oxygen required for survival and the individuals die. (Berry and Yawn 491-497)
Ethical consideration: COPD is marked by recurrent episodes of respiratory failure. The time to initiate ventilation is a common dilemma in the care of COPD. A few studies show that a significant number of patients survive for 1 to 2 years, following revival from respiratory failure (Pasquale et al. 757). However, the existing tests cannot accurately predict survival rate and thus the decision to withhold support to the patient in the event of respiratory failure is a cause of ethical dilemma. As it is a slowly progressing disease, there is sufficient time to explain the prognosis and identify the patient’s personal will for the end of life therapies.
Conclusion: Most cases of COPD are preventable and adopting a healthy lifestyle can help to prevent the condition. Policies to control smoking and air pollution can reduce the incidence of disease. COPD is a slowly progressing disease. Early diagnosis and treatment can result in a favorable prognosis. Future research is required to understand the underlying etiology and disease mechanism. This can help to provide a cure for COPD.
Work cited
Berry, Cristine E. and Barbara P. Yawn. "COPD Overdiagnosis, Underdiagnosis, And Treatment". J COPD F 3.1 (2016): 491-497. Web.
Chandrasekhar, Arcot. "Chronic Obstructive Lung Disease (COPD) / Emphysema". Stritch.luc.edu. N.p., 2016. Web. 4 Aug. 2016.
"Chronic Obstructive Pulmonary Disease (COPD)". World Health Organization. N.p., 2016. Web. 4 Aug. 2016.
"COPD Statistics Across America | COPD Foundation". Copdfoundation.org. N.p., 2016. Web. 4 Aug. 2016.
Friedlander, Adam L. et al. "Phenotypes Of Chronic Obstructive Pulmonary Disease". COPD: Journal of Chronic Obstructive Pulmonary Disease 4.4 (2007): 355-384. Web.
Mosenifar, Zab. "Chronic Obstructive Pulmonary Disease (COPD) Differential Diagnoses".Emedicine.medscape.com. N.p., 2016. Web. 4 Aug. 2016.
Pasquale, Margaret et al. "Impact Of Exacerbations On Health Care Cost And Resource Utilization In Chronic Obstructive Pulmonary Disease Patients With Chronic Bronchitis From A Predominantly Medicare Population". International Journal of Chronic Obstructive Pulmonary Disease (2012): 757. Web.
