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Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD)

Overview/Pathophysiology
Chronic obstructive pulmonary disease, or COPD, refers to a spectrum of diseases where there is pro-gressive lung damage and limitation of airflow, making it difficult to breathe. COPD is almost always related to smoking. Over time, cigarette smoke causes chronic inflammation and damages the lungs, leading to resistance to airflow and difficulty breathing.

There are two main categories of COPD: emphysema and chronic bronchitis. In emphysema, there is damage to the elastic tissues within the lung, leading to permanently enlarged air-spaces which change lung mechanics, making it harder to breathe. In chronic bronchitis, there is inflammation in the airways and enlargement of the mucous glands that line these airways, resulting in narrowed airways and increased mucus production. In order to be diagnosed with chronic bronchitis, you must have a chronic productive cough for more than three months out of the year, occurring for at least 2 years.
A COPD exacerbation occurs when someone with COPD develops a rapid worsening of their symptoms, usually meaning more difficulty breathing and coughing up lots of sputum. This is usually treated with steroids and antibiotics, and may require hospitalization if it is severe.

Key points:
1. COPD is a disease of progressive lung damage and resistance to airflow.
2. There are 2 types of COPD: emphysema and chronic bronchitis.

Symptoms
The initial phases of the disease often go unnoticed, so once a person experiences symptoms it means there has been substantial lung damage already. Common symptoms include shortness of breath, decreased ability to exercise, coughing, and increased sputum production. One may notice getting respiratory infections more often. Some people also experience fatigue, wheezing, chest discomfort, weight loss, and coughing up blood.
Key points:
1. Early stages of the disease are often asymptomatic.
2. Shortness of breath and coughing are the most common symptoms of COPD.

Risk Factors
Almost everyone who develops COPD has smoked at some point in his or her life. Why some people who smoke develop COPD and others do not, however, is not clear. Other less common causes of COPD include air pollution and a congenital deficiency of a lung-protective protein, known as alpha-1-antitrypsin deficiency.
Key Points:
1. Most with COPD are smokers, past or current.
2. Other causes include pollution and congenital defects.

Diagnosis
COPD is diagnosed by spi-rometry, a type of pulmonary function test in which you exhale rapidly and forcefully into a tube. The forced expiratory volume, or FEV1, is the amount of air you can exhale in 1 second. COPD is diagnosed when the FEV1 is less that 80% of the normal value and the ratio of the FEV1 to the forced vital capacity (the total amount of air you can expire) is less than 0.7.
Your doctor may do other testing as well, such as a chest x-ray and blood test for alpha-1-antitrypsin deficiency. COPD can affect the heart, so your doctor may also want to order tests to evaluate your heart.

Key points:
1. Diagnosis made by spirometry.
2. Additional testing may be done, as recommended by your doctor.

Treatment:
If you have been diagnosed with COPD, the most important thing you can do is stop smoking. Smoking cessation is the only way to slow the rate of decline of lung functioning. Nicotine replacement options such as nicotine gum, inhaler, spray and patch can be helpful, as are medications to reduce the craving for cigarettes.
Other medical treatments are aimed at relieving symptoms, reducing complications, and improving functioning.

Depending on the severity of symptoms, your doctor may prescribe inhaled bronchodilators which help to relax the muscles in the airways so that they widen, facilitating breathing. Al-buterol and ipratroprium are bronchodilators which act over a short period of time, while others such as formoterol and salmeterol have longer-lasting effects. For more advanced disease, inhaled steroids like fluticasone and budesonide, which are aimed at limiting airway inflammation, have been shown to reduce the number of exacerbations and improve quality of life. Very advanced COPD can cause low levels of oxygen in the blood, and in this situation, using inhaled oxygen has been shown to improve survival. For disease that does not respond to any of the above treatments, a few surgical options exist, including surgery to remove part of the lung, and lung transplants.

For acute exacerbations, your doctor will probably prescribe a short course of antibiotics and oral steroids.

Finally, everyone with COPD should receive a yearly influenza vaccine and the pneumococcal vaccine (a one-time dose).

Key points:
1. Stopping smoking is the most important thing you can do to slow the progression of disease.
2. While COPD cannot be cured at this time, a variety of medications can be prescribed to improve symptoms and reduce complications.
3. Everyone with COPD should receive pneumococcal vaccine (Pneumovax) and an annual influenza vaccine.

Complications
COPD is a progressive disease, leading to gradual worsening of lung function over time. COPD can also affect the heart, leading to a type of heart failure called cor pulmonale. People with COPD are more likely to develop respiratory infections such as pneumonia.

Tips for patients
In summary, COPD is a disease related to smoking where the lungs have been damaged over time, leading to limitation of airflow and difficulty breathing. If you have COPD, the most important thing you can do is to stop smoking. Ask your doctor for help, and remember that most people who quit do so after several attempts. It is also important that you work closely with your doctor to find a treatment plan and stick to it. While COPD cannot be cured at this time, there are beneficial medications that help to reduce symptoms, improve functioning and lower the chance of complications. You should get the pneumococcal vaccine to prevent pneumonia and get a yearly influenza vaccine, since COPD can make you more susceptible to getting sick. Finally, if you do notice that you are having more trouble breathing than normal, and/or you are coughing up more phlegm, contact your doctor immediately, as you may have developed an infection that requires antibiotics.

Key points:
1. COPD is related to smoking. The best thing you can do if you have COPD is to quit smoking.
2. Work closely with your doctor to manage your symptoms. COPD cannot be cured, but many people breathe more easily when they use medications as part of a treatment plan.
3. Make sure you get the pneumococcal vaccine and a yearly influenza vaccine.
4. Contact your doctor if your symptoms worsen. You may need additional treatment to treat an in-fection that is making your symptoms worse.

References:
1. Stoller J. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. New Engl J Med 2002;346(13): 988-994.
2. Sutherland E and Cherniack R. Management of Chronic Obstructive Pulmonary Disease. New Engl J Med 2004;350(26): 2689-2697.
3. The Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. May 22, 2001, last updated July 3, 2006. National Guideline Clearinghouse. www.guideline.gov
4. Sharma S. Chronic Ob-structive Pulmonary Disease. June 14, 2006. www.emedicine.com