COPD; Types, Causes, Symptoms, Diagnosis, Treatment

COPD (Chronic obstructive pulmonary disease) is a type of obstructive lung disease characterized by long-term breathing problems and poor airflow.It is an umbrella term used to describe progressive lung diseases including emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchio ectasis.The main symptoms include shortness of breath and cough with sputum production.COPD is a progressive disease, meaning it typically worsens over time. Eventually everyday activities, such as walking or getting dressed, become difficult. Chronic bronchitis and emphysema are older terms used for different types of COPD.The term “chronic bronchitis” is still used to define a productive cough that is present for at least three months each year for two years.

Causes of COPD

• COPD is most commonly caused by tobacco abuse mainly in the form of primary cigarette smoking. Secondary smoke also may be a contributor.
• Indoor air pollution, particularly from the burning of wood and other biomass in fireplaces and stoves
• Industrial dust and chemical fumes in the workplace
• Second hand smoke and other pollutants
• Asthma
• Frequent respiratory infections during childhood
• Genetic conditions that can result in COPD such as alpha-one antitrypsin deficiency (a genetic condition that can result in COPD)
• In rare cases, emphysema can also be caused by an inherited disorder called alpha-1 antitrypsin (A1AT) deficiency, in which a normally beneficial enzyme called neutrophil elastase damages alveoli tissue.

Other causes of COPD include

• Occupational exposures (for example, coal workers, welders, sensitized cotton and flour workers)
• Untreated diseases that cause inflammation of the airways, for example, asthma
• Environmental exposures, especially in the non- industrialized parts of the world where people cook over wood or coal burning stoves

Symptoms of COPD

Symptoms of chronic obstructive pulmonary disease include

• Cough, usually worse in the mornings and productive of a small amount of colorless sputum
• Breathlessness is the most significant symptom, but usually does not occur until the sixth decade of life
• Wheezing May occur in some patients, particularly during exertion and exacerbations
• Tachypnea and respiratory distress with simple activities
• Use of accessory respiratory muscles and paradoxical indrawing of lower intercostal spaces (Hoover sign)
• Cyanosis
• Elevated jugular venous pulse (JVP)
• chest discomfort,
• shortness of breath, and
• wheezing
• respiratory distress,
• tachypnea,
• use of accessory respiratory muscles,
• peripheral edema,
• hyperinflation,
• chronic wheezing,
• abnormal lung sounds,
• prolonged expiration,
• elevated jugular venous pulse, and
• cyanosis.

Chronic bronchitis characteristics include the following

• Patients may be obese
• Frequent cough and expectoration are typical
• Use of accessory muscles of respiration is common
• Coarse rhonchi and wheezing may be heard on auscultation
• Patients may have signs of right heart failure (ie, cor pulmonale), such as edema and cyanosis
• Cough, with usually colorless sputum in small amounts
• Acute chest discomfort
• Shortness of breath (usually occurs in patients aged 60 and over)
• Wheezing (especially during exertion)

As the disease progresses from mild to moderate, symptoms often increase in severity

• Respiratory distress with simple activities like walking up a few stairs
• Rapid breathing (tachypnea)
• Bluish discoloration of the skin (cyanosis)
• Use of accessory respiratory muscles
• Swelling of extremities (peripheral edema)
• Over-inflated lungs (hyperinflation)
• Wheezing with minimal exertion
• Course crackles (lung sounds usually with inspiration)
• Prolonged exhalations (expiration)
• Diffuse breath sounds
• Elevated jugular venous pulse

Emphysema characteristics include the following

• Patients may be very thin with a barrel chest
• Patients typically have little or no cough or expectoration
• Breathing may be assisted by pursed lips and use of accessory respiratory muscles; patients may adopt the tripod sitting position
• The chest may be hyper resonant, and wheezing may be heard
• Having trouble catching your breath or talking
• Blue or gray lips and/or fingernails (a sign of low oxygen levels in your blood)
• Trouble with mental alertness
• A very fast heartbeat
• Swelling in the feet and ankles
• Weight loss
• Heart sounds are very distant
• Overall appearance is more like classic COPD exacerbation

Diagnosis of COPD

Other tests that may also be carried out include

• physical examination
• medical history
• barrel chest
• hyperresonance on percussion
• distant breath sounds on auscultation
• poor air movement on auscultation
• gas transfer and lung volume tests
• blood tests
• sputum analysis
• chest x-ray
• computed tomography (CT) scan.
• spirometry
• pulse oximetry
• ABG
• CXR
• sputum culture
• PFTs
• chest CT scan
• alpha-1 antitrypsin level

Stages of COPD

The treatments are often based on the stage of chronic obstructive pulmonary disease, for example

Stage 0 – At risk: Symptoms include coughing and noticeable mucus. You don’t actually have COPD, so treatment isn’t necessarily needed. But do heed the warning. If you smoke, stop now. It would be wise to reassess your diet and exercise routines to improve overall health. Once you have COPD, it’s not reversible or curable.

Stage 1 – Mild: At this stage, some people still don’t notice symptoms, which may include chronic cough and increased mucus production. If you visit a doctor at this point, chances are you’ll start using a bronchodilator as needed.

Stage 2 – Moderate: Symptoms are becoming more noticeable. In addition to the cough and mucus, you may start to experience shortness of breath. You may need a long-acting bronchodilator.

Stage 3 – Severe: short-acting bronchodilator as needed long-acting bronchodilators cardiopulmonary rehabilitation and inhaled glucocorticoids for repeated exacerbations . Symptoms become more frequent and you may have occasional flare-ups of severe symptoms. You might find that it’s difficult to function normally. Your doctor may recommend corticosteroids, other medications, or oxygen therapy.

Stage 4 – Very severe: Symptoms are progressing and it’s harder to complete everyday tasks. Flare-ups can be life-threatening.It needed, long-acting bronchodilators, cardiopulmonary rehabilitation, inhaled glucocorticoids, long-term oxygen therapy, possible lung volume reduction surgery and possible lung transplantation (stage IV has been termed “end-stage” chronic obstructive pulmonary disease)

Treatment of COPD

Nicotine Replacement Therapy

The first line of therapy that involves medication is related to smoking cessation with nicotine replacement therapy. Nicotine replacement therapy can help patients quit smoking tobacco because it can help reduce the withdrawal symptoms due to nicotine. Replacement therapies include nicotine-containing chewing gum and patches that allow nicotine to be absorbed through the skin. In these types of therapy, nicotine is gradually reduced. This medication can work well for those patients who are seriously attempting to quit tobacco.

Bronchodilators

Bronchodilators are used for COPD treatment because they open up the airway tubes and allow air to more freely pass in and out of the lung tissue. There are both short-term (several hours) and long-term (12 or more hours) types of bronchodilators.

• albuterol
• metaproterenol
• levalbuterol
• pirbuterol

• ipratropium
• tiotropium
• aclidinium

Other bronchodilators such as theophylline are occasionally used, but are not favored because of unwanted side effects including anxiety, tremors, seizures, and arrhythmias.

• Beta-agonist inhalers – Examples are formoterol, salmeterol and Indacaterol. You can continue your short-acting bronchodilator inhalers with these medicines.
• Antimuscarinic inhalers – The only long-acting antimuscarinic inhaler is called tiotropium. The inhaler device is green-coloured. If you start this medication, you should stop ipratropium if you were taking this beforehand. There is no need to stop any other inhalers.

Quit Smoking (Smoking Cessation)

• Varenicline – is an oral medication that is prescribed to promote cessation of smoking. This is also an alternative to try to quit smoking.
• Bupropion – is an antidepressant that helps reduce symptoms of nicotine withdrawal.
• Some medications  – are used “off label” (that is, they are normally prescribed for another condition) to help people quit smoking.These medications include nortriptyline , an older type of antidepressant. It’s been found to help smokers double their chances of quitting compared to taking no medicine. Another drug used off label is clonidine .

• Corticosteroids

  Corticosteroids are usually used in inhaled form, but may also be used as tablets to treat and prevent acute exacerbations. While inhaled corticosteroids (ICSs) have not shown benefit for people with mild COPD, they decrease acute exacerbations in those with either moderate or severe disease.When used in combination with a LABA, they may decrease mortality compared to either ICSs or LABA alone.Inhaled steroids are associated with increased rates of pneumonia.Long-term treatment with steroid tablets is associated with significant side effects.

• Beta-agonist inhalers Examples are salbutamol and terbutaline. These inhalers are often (but not always) blue in colour. Other inhalers containing different medicines can be blue too.
• Antimuscarinic inhalers – For example, ipratropium. These inhalers work well for some people, but not so well in others. Typically, symptoms of wheeze and breathlessness improve within 5-15 minutes with a beta-agonist inhaler, and within 30-40 minutes with an antimuscarinic inhaler. The effect from both types typically lasts for 3-6 hours.
• Other medication -Long-term antibiotics, specifically those from the macrolide class such as erythromycin, reduce the frequency of exacerbations in those who have two or more a year. Concerns include that of antibiotic resistance and hearing problems with azithromycin. Methylxanthines such as theophylline generally cause more harm than benefit and thus are usually not recommended,but may be used as a second-line agent in those not controlled by other measures. Mucolytics may help to reduce exacerbations in some people with chronic bronchitis.Cough medicines are not recommended.
• Phosphodiesterase-4 inhibitors – This newer medication in pill form reduces inflammation and changes mucus production. It’s generally prescribed for severe COPD.
• Theophylline – medicine eases chest tightness and shortness of breath. It may help prevent flare-ups. It’s available in pill form.

• Expectorants – medication to loosen the phlegm and make it easier to cough up
• Antibiotics and antivirals – Antibiotics or antivirals may be prescribed when you develop respiratory infections.
• Vaccines – COPD increases your risk of other respiratory problems. For that reason, your doctor might recommend that you get a yearly flu shot, the pneumococcal vaccine, or the whooping cough vaccine.
• Treatment for chest infections – such as antibiotics to treat existing infections, and pneumonia and flu vaccinations to reduce the risk of infections in the future
• Pulmonary rehabilitation – these programs consist of an individual assessment followed by exercise training and education. Programs usually run for about eight weeks and at the end of the program, there is normally re-assessment and referral to an ongoing maintenance exercise program such as Lungs in Action (where available).

Having COPD makes it harder to breath, which can lead to avoiding activities that leave you breathless. Here are some breathing exercises for people living with COPD:

1. Pursed-Lips Breathing

   This exercise involves breathing in through the nose (as if smelling something) for about two seconds. Then, purse the lips (like you are whistling or kissing) for two to three times longer than when you inhaled. Repeat as needed. This exercise makes exhaling easier for the person, and they also are able to extend exhalation, which provides improved oxygen and carbon dioxide gas exchange.Pursed-lips breathing offers the following benefits:

   • Slows down breathing
   • Keeps airways open longer so your lungs can get rid of more stale, trapped air
   • Reduces the work of breathing
   • Increases the amount of time you can exercise of perform an activity
   • Improves the exchange of oxygen and carbon dioxide

2. Diaphragmatic (Abdominal/Belly) Breathing

   The diaphragm is supposed to do most of the work when breathing, but COPD prevents the diaphragm from working properly. Instead the neck, shoulders, and back are used while breathing. Diaphragmatic breathing may seem more difficult than pursed-lip breathing and seeking help from a health care professional is recommended.Inhale through the nose for two seconds. During inhalation, your belly should move outward and more than your chest. Exhale slowly through pursed-lips and gently press on your belly. This helps get the air out by pushing on the diaphragm. Repeat as needed.

   Diaphragmatic breathing offers the following benefits

   • Increases total air volume exchange
   • Trains the diaphragm
   • Easier breathing

3. Coordinated Breathing

   Shortness of breath may cause you anxiety and you might hold your breath. Coordinated breathing helps to prevent this from happening. Before you are able to begin an exercise, inhale through the nose. Exhale, through pursed-lips, during the most strenuous part of the exercise. Coordinated breathing can be practiced during exercise or when feeling anxious.

4. Deep Breathing

   Shortness of breath can be caused by air getting trapped in your lungs and deep breathing can prevent this from happening. This exercise will also allow you to breathe in more fresh air. Begin by sitting or standing with your elbows slightly back, allowing your chest to expand more. Inhale deeply and hold your breath for a count of five. Exhale slowly and deeply until all the air has been released. Repeat as needed.

5. Huff Cough

   The huff cough helps you cough up mucus that had built up in your lungs. COPD can make it difficult to cough without getting tired, but the huff cough makes it easier to cough up mucus. Begin by sitting in a comfortable position and inhale slightly deeper than normal. Exhale while making a “ha, ha, ha” sound, as if you are trying to steam up a mirror. This allows you to become less tired when coughing up mucus. Repeat as needed.

Dietary Supplements of COPD

A number of over-the-counter (OTC) supplements and foods are reportedly helpful in reducing symptoms of chronic obstructive pulmonary disease. Home remedies for COPD include:

• Vitamin E to improve lung function
• Omega-3 fatty acids to decrease inflammation (found in supplements or foods such as salmon, herring, mackerel, sardines, soybeans, canola oil)
• Antioxidants to reduce inflammation (found in kale, tomatoes, broccoli, green tea, red grapes)
• Breathing techniques relaxation therapy, meditation
• Acupuncture COPD symptom reduction by needle placement

Complications of COPD

A person with COPD is at increased risk of a number of complications, including:

• Chest infections – a common cold can easily lead to a severe infection
• Pneumonia – a lung infection that targets the alveoli and bronchioles
• Collapsed lung – the lung may develop an air pocket. If the air pocket bursts during a coughing fit, the lung will deflate
• Heart problems – the heart has to work extremely hard to pump blood through the lungs
• Osteoporosis – where bones become thin and break more easily. Steroid use in people with COPD is thought to contribute to osteoporosis
• Anxiety and depression – breathlessness or the fear of breathlessness can often lead to feelings of anxiety and depression
• Oedema (fluid retention) – problems with blood circulation can cause fluid to pool, particularly in the feet and ankles
• Hypoxaemia – caused by lack of oxygen to the brain. Symptoms include cognitive difficulties such as confusion, memory lapses and depression
• Need special equipment such as portable oxygen tanks.
• Not engage in social activities such as eating out, going to places of worship, going to group events, or getting together with friends or neighbors.
• Have increased confusion or memory loss.
• Have more emergency room visits or overnight hospital stays
• Have other chronic diseases such as arthritis, congestive heart failure, diabetes, coronary heart disease, stroke, or asthma.
• Have depression or other mental or emotional conditions.
• Report a fair or poor health status.

Referances

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