Patients with earlier COPD: appropriate attention?

Patients less severe?

According to the Global Initiative for Obstructive Lung Disease (GOLD), there are patients con COPD with minimal changes in the standard method for diagnosis: spirometry.

Spirometry is the only way a doctor can tell a patient if they have COPD and how severe it is. The Forced Expiratory Volume in the first second (FEV₁) helps in the classification of severity. The maximal amount of air exhaled after 6 seconds in a forced maneuver in called Forced Vital Capacity (FVC) and when the FEV₁ is less than 70% of FVC the obstruction in the airway is considered to be present.

Relevance of even early Spirometry 

Obtaining these values is really helpful. The goal to get the factual numbers i to be in the best status of open airways. That’s the reason why patients are asked to inhale a bronchodilator (rescue inhaler) and then they perform the spirometry. The numbers obtained are called post-bronchodilator FEV₁ and FVC.

Interestingly, FEV₁ needs to be compared to the predicted value according to other demographic variables like gender, height, weight, etc. If the FEV₁ is more than 70% of the predicted value, patients are considered to have mild COPD even with an FEV₁/FVC ratio less than 70%.

Guidelines and Early COPD

GOLD guidelines recommend rescue inhalers for these cases. Some doctors wonder if we could do the same with mild hypertension (management of crisis only) knowing that the disease is there anyway. There are some other measures to be taken for mild COPD patients like avoiding risk factors (smoking), annual vaccinations, changes in lifestyle and, I would say, continuous education.

Anything to do for less advanced COPD?

COPD is a progressive disease that need to be treated anyway. If we all know that it leads to an accelerated loss of lung function, which means a more rapid decrease of FEV₁ each year, it may be advisable to start looking at the disease seriously since its diagnosis.

Symptoms vs. Spirometry

Spirometry is a key indicator for the presence and severity of the disease but some symptoms may remind patients and physicians that something is not working appropriately in the lungs earlier. The presence of cough and some sputum production, breathlessness with some activities in the frame of fumes, dust, or any continuous noxious gas exposure should alert about COPD.

Looking for Patients’ Health Benefits

The good news is that we know more and more about the disease each year. There are more patients in earlier stages of the disease who are not receiving any medical intervention (including education). An engagement into the reality of the progressive nature of the disease may help to have a better quality of life when we all know that something can be done. Think about the quality of care all patients need and how they could get more benefits of life and health just understanding a little bit more of their disease.

Pucker for a better breathing: Pursed Lip Breathing

Natural Adoptions

Patients with advanced COPD look for a more complete exhalation leading to more room for breathing. That’s the reason why they breath out slowly and their lips pursed. This technique, naturally adopted by advanced COPD patients, can also be adopted by less severe COPD patients to take more of the benefits of better breathing.

The cause for Pursed Lip Breathing

When the lung airways are obstructed due to brochoconstriction (contraction of smooth muscles bands wrapping the airway), the air is trapped inside the lungs and leads to less area for exchange of oxygen to the blood. As a result patients require more time to exhale that trapped air; making lung areas available for gas exchange.

Extending the airway and keeping it open

What represents the patient’s intention to pucker their lips is the extension of the airway at the mouth level. Now the air has more way to run and this requires time, prolonging the exhalation. It also maintain the airways open during more time. The sensation for the patient is more comfortable than shortening the airway.

Pursed Lip Breathing in the Healthy

The interesting issue of this natural defense against air trapping is that healthy people do it when exhausted or during exercise workouts. It allows a better timing for using the benefit of breathing.

It has been recommended to practice the technique at least 5 minutes every day to become familiar with it. It doesn’t have to be preceded by a deep-deep breath in but by a normal inspiration. It may be practiced early morning or before going to bed (also making of it a moment of relaxation and/or meditation).

What to do?

Seated or in standing position, the patient should look ahead and relax the neck. This is followed by a normal inspiration (breath in) through the nose (closed mouth). Pucker the lips and start the breath out (through the mouth) as if the intention was to whistle. Take your time until you feel you don’t need to exhale more room. Start again. Remember: no deep breath or it may lead to dizziness.

The benefit

COPD patients have the feeling of wellness after practicing the “pursed lip breathing” technique. That’s what we all are looking for. Our patients require some time to be instructed about the benefits of this breathing technique (it’s not a pure breathing exercise). It helps patient and put into practice principles of physics and physiology in the lung ventilation. Talking to patients about it may make a huge difference in the office conversation also.

Airflow Obstruction vs. Air Trapping in COPD

Only obstructive?

Since long time ago, COPD has been considered an obstructive disease (its name says it clearly). Of course, there is obstruction in the lung airways as a result of persistent bronchospasm. However, an effect of the obstruction has been studied recently and has been associated to the symptoms more than the obstructive component itself.

More than obstruction: air trapping

The obstruction of lung airways leads to air trapping in the distant units. These units, called alveoli, are the areas where gas exchange occurs as well as the pulmonary blood circulation has place. When the air gets trapped inside them both processes occur slower than expected and symptoms appear.

Dyspnea, the most bothering symptom for patients, has been associated to the levels of air trapped more than obstruction. Airflow obstruction has been found to represent the severity of the disease but air trapping is a consequence that leads to increased local pressure and physiological changes reflected in exercise intolerance.

A recent article

In his recent “Update in the Management of COPD” (Chest 2008;133:1451-1462), Dr. Bartolome R. Celli points out the relevance of air trapping in the manifestations of symptoms independent of airflow obstruction. The fact that COPD is a multicomponent disease help us understand that management should be addressed to relieve all the manifestations possible and the management of dyspnea should be kept in mind when considering decisions.

Although Dr. Celli says that lung excess inflation is key in the genesis of symptoms in advanced disease, the importance of this physiologic hallmark has not been assessed in early stages. Two main factor may be defining this issue: the lungs’ elasticity and the symptoms minimization by patients.

Air trapping during physical activities

The concept of air trapping in COPD is more impacting during exercise or any other physical activity. When oxygen demand increase, the exhalation can not happen smoothly and air gets trapped in lungs. Unless the patient stop the activity, the excess inflation will limit normal breathing (particularly gas exchange and blood circulation in the lungs).

Not under the microscopy

Severe patients with emphysema may have their symptoms more severe due to those facts. These patients have the trend to develop considerable bubbles called bullae that take out space from the functional lung. This may be the macroscopical evidence of air trapping relevance, but it’s not necessary to wait until there.

How to find out if there’s air trapping

The true of the matter is asking for breathlessness to patients when they are smokers, when they already have cough and sputum production, when they say “I have smoker’s cough only“, is paramount to help them and take decisions. How much the activity is limited because of some “Tiredness” or “Fatigue” needs to be carefully assessed to find the results of air trapping in the elastic lungs. Masking symptoms is not good, in any case. Let’s assume the importance of the underlying air trapping (and lung excess inflation or hyperinflation).