Some facts about COPD you should know

What you should be aware of

What is fact and what is fantasy in the world of CODP? There are several things patients need to be aware of when having discussions about their disease with their doctors. The chronicity, the obstruction, the treatable feature, the progression, and the prevention, has been outstanding topics in the literature for physicians. That without talking about the complications and other diseases frequently associated to this disease.

How and why it is chronic

The disease is chronic which means that it is not acute, it didn’t happen suddenly and is the result of a long time of progressive damage. With that said, we can’t not reverse it to normal as soon as we can start therapy. It’s awful to say that “damage is done” because is an over-simplification of the fact that damage can continue if we don’t take appropriate actions. What we can say is “It’s not too late” to start taking control of some domains of the disease. So, let’s be sure that we all understand that one medication, one exercise, one visit to the doctor will be enough. Let’s be sure that we understand that it started some time ago and it may take some other time to be under control.

What obstruction means

Obstruction is a kind of complicated. The reasons for this is because, in pulmonology, obstruction means any reduction in the caliber of the airway. We (the complicated-in-physiology pulmonologists) have one word that prefer not to use (occlusion) because it may imply that the airway is closed or blocked indefinitely. The latter can happen with some tumors in the space of the airways and can be an undesirable mess. Obstruction in COPD, however, is complex because the continuous contraction of the very muscles around the lung airways lead to strong/permanent contraction and it can be complicated with the excessive  mucus production of some patients (like long term asthmatics and chronic bronchitis). However, not all patients produce excessive mucus (which is associated to a particular type of inflammation) which leads us to think that the main therapy for COPD should be a long acting bronchodilator (airway muscle relaxant).

Worthy to treat

The disease has been shown to be treatable. Give that “some” of the mechanisms associated to obstruction in the airways has been described, several medicines and non-pharmacological interventions have shown to be of benefit reducing the bronchospasm (obstruction) as well as improving different outcomes related to this (like power to inhale, physical and social engagement, etc.). Even more, if the patient has stopped smoking the probability to get more control is outstanding.

Oh, no! … progressive

The progression shouldn’t make us feel scared. The disease is progressive, it’s true but aging is also progressive, hair loss is also progressive, skin wrinkling is also progressive, as well as some vision changes and it doesn’t mean that the worst will happen no matter what you try. Let’s face it: rehabilitation, medications, control of other factors may help in the delay of the progression although mathematical-scientific data can’t show it sometimes.

Prevent

Prevention definitely works because if you don’t smoke or are not exposed to the factors involved in the development of the disease, you don’t develop it. So, it is key to stop smoking, to avoid risk factors, to control associated diseases (e.g. asthma) to help the physician’s efforts to put you in your best shape.

So, don’t forget it: be realistic but not unnecessarily pessimistic. Help your doctor understanding where you are and getting more of their directions for coping in the best way with your disease.

From Smoking to COPD: what’s going on in the middle?

Doubtful association
It has been said that there is no a definite correlation between the spirometric standard FEV1 and the clinical manifestations in COPD. The FEV1 may be extremely low but the patient may be doing well. So where is the real assessment of the condition? Why COPD seems to be a big puzzle for doctors and patients?

Smoking and a show of symptoms
A long time ago smoking has been linked to development of serious health conditions. Symptoms have been associated with the smoking behavior but some say that it may not be any disease.

What is normal?
This is the most enigmatic perspective about a disease: symptoms being considered normal when we all know that smoking is not normal, coughing frequently with or without sputum is not normal, a development of exaggerated breathlessness with less extenuating efforts is not normal.

Some Learning

This is what teaches us that some times (if not every time) it is better to hear the patient, to assess them from a more clinical (humanitarian) perspective than relying in para-clinical procedures. Making diagnosis only based on technical methods may bring huge disastrous consequences. Particularly when it is expected to find changes in numbers more than in the body that can be assessed with appropriate developed strong skills. When it may be easy to evaluate a patient more physically than going into an algorhythm that may simplify the “clinical” decision making process but waiting for cold results. 

What to do to start?
Smoking cessation is fundamental based on clinical scientific data but we also know that symptoms associated to the continuous irritation of the airway don’t go away after smoking cessation.

Looking at the patient beyond the tech
Given these two considerations (smoking related symptoms and their persistence) we should look at the COPD patient as a real patient. It seems to be disregarding from the medical side that there is an abnormal condition due to COPD and maybe FEV1 will not be the best or definitive assessment to follow the disease up.

How to look at a COPD patient
Patients need to be considered more than a scientific set of individuals, a population to be seen from a statistical standpoint. Patients need to be seen individually and treated according to what has been shown in clinical trials but adjusted to the individual clinical reality.

History to be written
So… it is still required to look for a more clear and fair standard to monitor smoking and its effects. I hope that beyond FEV1 physicians are starting to take into account the sufferer.

Evolving Definition of COPD

Challenges of a disease

Experts from around the world have been challenging the burden of COPD since a couple of decades ago. However, one of the most relevant challenges has been the education on the disease and what it really represents not only for the medical community but for the very patient.

The history

Years ago, scientists didn’t see light in the chronicity of the disease. It’s perpetuating agressive cycle was like a ghost that physicians didn’t want to deal with and so… the patient. The decline in lung fuction no matter the measures was deppressing and the pulmonologist was like a priest at the end of life.

Words

The word emphysema meant the worst thing a person could suffer (after cancer of course). Patients considered that it was their fault and didn’t want to see a doctor since the only solution would be smoking cessation and some unproductive support.

Advances

Recently, due to research and a careful assessment of sufferers, the definition of COPD has evolved. Traditionally it was considered relentless, lethal, no effective measures allowed… Now we define the disease in terms of airflow obstruction, chronic but partially reversible and, said this, treatable.

Armamentarium of opportunities

Bronchodilators, the corner stone for airflow obstruction management started to show their benefits. Pulmonary rehabilitation opened a window to better health related quality of life. Oxygen for advanced stages was found to help too. Antiinflamatory drugs started to be formulated in inhalers. The disease was reorganized according to spirometry measurements and evidence based recommendations.

And now: a treatable disease

These days we can now talk about a chronic treatable disease associated to cigarette smoking among other risk factors. More opportunities for the patient to find out what to do. More resources to understand their doctors (with their typical limited time). And more investigations on progress on the field.

Work in progress

Although there’s a long way to walk through, never it’s to late to understand that diseases may occur but our empowerment is fundamental to confront them with good will, appropriate medical support, and self education well controlled. Great that we all can deal with problems…

Who’s smoking this days?

COPD and its associations
Chronic Obstructive Pulmonary Disease is associated to cigarette smoking in more than 70% of cases. However, COPD is only one of the consequences of smoking. Everybody knows that this behavior is also associated to lung cancer, a wide spectrum of cardiovascular diseases, other cancers, and many other conditions.

Measures against smoking
Here in New York it has been adopted the measure of banning smoking in almost everywhere. Airports around the world understood that they are closed spaces and need clean air to breath. Buses, trains, planes, etc also need clean air (as well as apartments, corridors, stairs, sidewalks, etc).

Origins of smoking behavior
Many years ago smoking was a male behavior. Men were then affected by its related conditions in a higher rate than women or younger populations.
When it was announced that smoking was not the best choice for an off moment, the target of marketing changed to women and the youngest (just see the publicity from the 60s, 70s, and 80s).

The change
The nightmare just then started. This days it is known that COPD has changed its population too. COPD is currently affecting more and more women than ever. In 2000 the number of hospitalizations associated to COPD in women outnumbered those for men and women also started reporting more than half of cases by 2004. The sad part of the unnecessary tale is that COPD deaths almost tripled in women from 1980 to 2000. Of course this is another evidence that smoking incidence has increased in women.

More than a woman
COPD has started to create a burden for younger population. Patients with less than 65 years old are increasing in number at medical offices and hospitals. It has also seen that COPD is as common as diseases of younger crowds like asthma and diabetes in those between 45 and 54 years old.

Affecting the working population

The pain that this give to the society is aggravated by the reality that this age range is the working population. The bitter reality of all this is that 70% of patients with COPD are younger than 65 years old.
It’s then important to realize that everybody needs smoking cessation counseling as well as educational efforts should never stop being aggressive as they can.

Effort requested
Every minute accounts in the medical office to chat about smoking and its effects on the health and its related quality of life. Every effort at home to ban smoking and educating about cigarette smoking and illness may be so relevant that its results will provide with sense of feeling grateful for the years ahead. Parents talk frequently about candies, vicious snacks, hand washing, etc but they should talk openly about smoking and its associated decline in lung health and general well being.

Finally
So… women, girls, and boys: no smoking please. A condition called COPD is being reported more in all of you and it’s not by coincidence.

Behind the Best Treatment for COPD?

Many Components

COPD is a multifactorial disease. Thinking about its treatment requires to consider this reality. It’s not a knot in the hair that you can cut and nothing else happens. Since most of the cases are associated to cigarette smoking there’s no doubt that the best management starts with this measure. However, its several components need to be addressed when planning its follow up.

… cigarette-cigarette: stop doing that!

After taking into account the reality of cigarette smoking as the physical and chemical element responsible for the origin, it’s necessary to consider the response of the organism as a target for management. The classical response of the organism after a repetitive injury is the protection. In case of lungs what they can do (if we accept the similitude with an entire being) is to close the airways.

Closing the door to protect

Although there’s no doubt that the irritation leads to some type of inflammation, the persistent feature will be the airways closure (bronchoconstriction). If this is the situation, the most open we can keep the airways the most we help to ease breathe. Medications which mechanism of action implies the relaxation of the muscles around the lung airways are called bronchodilators.

Bronchodilators

It seems reasonable that as soon as a diagnosis of chronic airways obstruction in the lung is made, it should be initiated therapy with bronchodilators. The point of sensitivity with bronchodilators is that they should be inhaled to allow a most effective local action and less general consequences. Guidelines have been recommended to start with bronchodilators soon after diagnosis. Unfortunately, the scientific evidence has not been enough to support an early continuous therapy with bronchodilators and they are being suggested to be used as on a needed basis (as if there were not chronic disease).

Bronchodilators can be of short action or long acting. Short acting agents only help to relieve sudden symptoms while long acting point toward a prolonged relieve. Since the disease is chronic and progressive, all COPD patients will require long acting bronchodilators to maintain their symptoms under control.

Effects of Bronchodilators

Bronchodilators have shown to increase the airflow in and out of the lungs. This effect is seen in the improvement of FEV1 values. The improvement in FEV1 will eventually lead to reductions in the air trapped inside lungs that is said to be responsible for breathlessness. If the air trapping is reduced, dyspnea decreases and patients may tolerate more physical activities, which has been demonstrated in trials associating increases in airflow and exercise tolerance in the laboratory.

More than bronchodilators

However, it’s also relevant to mention that the complex nature of the disease may require adjustments of therapy according to patient responses, incidence of exacerbations, presence of other diseases (comorbidities), etc.

Said this, it should be consider that some patients may require more than one medication to cope with excess risk of exacerbations, infections, physical attiude, etc.

So..

So, let’s keep in mind: there’s no better treatment for COPD but key elements to cover followed by the consideration of the complexity of the illness and individual features that will help address the different aspects of the disease.

COPD: Basic Steps to help

Just Dyspnea and It’s my fault

The COPD patient complains of breathlessness when cough and (sometimes) phlegm have been present for a longer period of time. Some experts have considered that when breathlessness is already installed there are chances for improvement. There are options and no space for regrets. Although the self blaming changes the perspective of some patients, physicians and other health care givers may reinforce the power of the patient.

Patients need to consider their own will since not all the control is on health system’s hands. So what a patient can do?

Understanding the basic: Chronicity

Patients with COPD must understand the chronicity of the disease. It’s not by coincidence that it occurs or develop. More than a lotto result is one of the potential reactions to continuous exposure to noxious particles and gases. Although this exposure happened a long time ago there is a trend in our organism to keep living and the immunological reactions continue. 

The risk factors

Smoking is a key risk factor and of course the most important. However, our current environments are polluted and there is some concentration of population in big cities or industrial areas where it’s easier to inhale low quality air. At the same time, there are some occupations that predispose to continuous inhalation of bad air.

Old “Normal” Symptoms

The COPD patient develops symptoms progressively. The progressive appearance of symptoms allows certain level of adaptation. Most of the patients consider their symptoms as normal and tend to accept them as natural until they become bothersome not only for them but for people around. It’s not the cough what bothers people as much as somebody breathing with difficulty continuously.

Education as basics

Considering the relevance of self education in the management of the disease, an appropriate interaction of the patient with themselves, and with information sources, care givers, health system, may help them to cope better with the disease. Some patients may prefer an academic source, while others tend to go to news or friendly scientific writers, but the important issue is to select a few that answer and help according to the individual needs.

It may be good to create regularity visiting some sources of getting information from certain books. However it is the patient who must choice to get the most of the current evolving knowledge on COPD.

Some considerations on self education

As general recommendations, given the constant flow of information, there are some basic things that COPD patients may do to help in their health support:

1. Understand the basics of the disease
2. Conceive it as chronic and progressive
3. Identify the cause and modify it
4. Precise a few sources of written information based on individual needs
5. Stick to the physician directions in terms of medication and office visits

In a next post let’s define more features that may help in the selection of written sources of COPD information.

COPD: Changing and not the Same for all Sufferers

Heterogeneous Disease

COPD has shown to be a heterogeneous disease. As with any other disease, there seems to be very unique and common features to help physicians in the diagnostic process as well as in therapeutic decisions. Long time ago, COPD was considered to be a syndrome based on a reaction to the continuous aggression by cigarette smoking imposed against the beautiful lung airway structure. Patients were considered to have one of two typical expressions of consequences: chronic bronchitis or emphysema.

Santa Klaus maybe had COPD (because of the chimneys?)

There are some patients with more features of chronic bronchitis but we never forget the classical emphysematous patient: skinny, always smoking, with their head among shoulders instead of above them, dry cough, etc, etc. In the meantime, the chronic bronchitis patient was fatter, smiling, coughing and producing sputum, and breathing with difficulty (just imagine Santa Klaus after he inhaled smoke while working…).

Question

The big question is: why some patients show one or other predominant characteristic of the disease? why ones are emphysematous while others have predominant chronic bronchitis?

Some help but different

That reminds us that categories help but are not definite. That reminds physicians that each patient is different to the other although key features may be common. Not all patients respond the same to cigarette smoking injure so they maybe don’t have to respond equally to same therapeutic measures. They even neither have the same behavior nor have the same attitude during the medical office dialogue. Understanding the actual or potential differences may help support a better approach to disease management.

More differences

So, will everybody have same adverse events? will they have same set of surrounding diseases? (which we call comorbidities). Maybe not and perhaps some may be followed up with spirometry, while others need to be followed up with activity levels, or breathlessness (dyspnea) scales, or symptoms exacerbations, or oxygen levels changes, just for mentioning a few couple of parameters.

Changing focus of investigations

These considerations, fortunately, have led some investigators to start talking about different phenotypes of COPD. Although it challenges our current understanding of the disease, already considered complex and under continuous evaluation to make it look simpler, patients and multiple clinical trials have been shown that the damage is not as homogeneous as we could have thought in the population.

Similarities

We also know that in metabolic diseases some patients present different complications (e.g. diabetics with more renal impairment than neuropathy). In hypertension, some have stroke while other have heart predominant damage. They all have different medical approaches and require different directions: some need to loss weigh, others have to change diet, others respond to a drug better than others, etc.

A Disease in evolution

COPD is starting its own cycle of research, adjustment according to the evidence, natural evolution of the crowd of patients, new and contradictory trends in management, followed by more research and so forth. The present is here and now and the hope is increasing thanks to the investigators who have given passion to this issue. Each patient is different because, simply: individuals are not the same.

Pulmonary Complications and Preoperative Pulmonary Evaluation

More pulmonary than cardiovascular complications

In general, any surgery imposes a risk to every system in our body. Most of the complications of surgery are related to cardiovascular events as well as infections. However Pulmonary complications after surgery are also frequent and probably more than the cardiovascular.

Which after-surgery complications in the lungs?

Typical pulmonary complications are local infections like pneumonia, disordered gas exchange with respiratory failure, bronchospasm (wit symptoms of asthma), marginal collapse of portions of the lungs (also called atelectasis), and/or exacerbations of previously existing pulmonary conditions (e.g. exacerbation of COPD).

What predisposes to pulmonary complications?

The nature of the pulmonary complications can be related to the surgical procedure itself or to the patient. The surgical procedure may be described according to site, duration, and anesthesia from which it may be expected that procedures close to the thorax, prolonged interventions, and general anesthesia are associated with subsequent pulmonary complications.

However, patients may also predispose to some risk of complications in the pulmonary structure and functions. Patients with chronic lung diseases tend to have more complications, especially patients with COPD. Age >60 years old, smoking condition, deficient health condition, and heart failure are potential elements of risk for pulmonary complications.

How a physician gather facts over issues to solve

These facts make it necessary to assess patients in plan of surgery for potential lung localized detrimental events. The interview of a patient under surgery program must include questions related to previous lung diseases, isolated respiratory symptoms, and smoking status. The physical examination must also be directed to find anomalies of the pulmonary area as well as trachea at the neck.

The laboratory studies of patients with positive findings in history of physical exam will mandate assessing with one or several of: pulmonary function tests (spirometry), arterial blood gas analysis, chest X-rays, and serum albumin.

Recommendations to the patient

After consideration of risk, patients would be able to receive instructions like: smoking cessation, COPD optimization of therapy, and some recommendations after surgery: lung expansion maneuvers, appropriate analgesia and prophylaxis of deep venous thrombosis. For some patients it may be required other methods of lung ventilation and controlled use of nasogastric tubes (indicating them just when really necessary and not as routine).

In summary

Patients are susceptible of lung complications when they go through a surgical procedure and an appropriate approach may minimize the occurrence of those complications.

The relevance of FEV1 measurement in COPD

 

FEV₁ is a key value to be known by smokers and COPD patients in order to assess the severity of the disease. FEV₁ means Forced Expiratory Volume in the First Second of a full forced exhalation after a full inhalation. It is obtained during the spirometry and represents the amount of air that leaves the lung when all the effort is put into exhalation. After the first second of a full exhalation there’s no much more opportunity to exhale additional amounts of air from the lungs.

 

How to get the FEV₁ value

 

It’s like blowing the candles in a birthday cake: the last ones require other inhalation to get turned off.

 

Although during the spirometry there’re no candles, the patient needs to exhale until he/she can not anymore and not breathing in. If there’s an interruption during FEV₁ measurement, this value will not be real and the interpretation will be wrong.

 

To obtain a FEV₁ value the continuous exhalation effort should last 6 seconds at least, when there’s no more flow from the lungs to the spirometer.

 

How different is FEV₁ value between COPD and asthma

 

FEV₁ gives a good estimate of obstruction in COPD and Asthma. In COPD, doesn’t revert so much. In most cases of asthma, it reverts when there aren’t any symptoms.

 

Everybody has a FEV₁ that modifies itself with aging. It increases until middle adulthood and starts to decrease 30 mL every year. In susceptible smokers, the rate of decrease of the FEV₁ is 60 mL every year which means that it is accelerated.

 

What’s the importance of FEV₁ value in research?

 

Dr. Robert Wise from John Hopkins University School of Medicine, Baltimore, Maryland, USA has been an advocate of the  FEV₁ relevance as a key value in the assessment of COPD (Am J of Med 2006:119;S4-S11).  This value represents the focus of investigations when evaluating the efficacy of approaches for the management of COPD.

 

Several years ago, in a famous, standard, reference publication Charles Fletcher and Richard Peto (Brit Med J, 1977:1:1645-1648) provided with data focused on FEV₁ change. Fletcher and Peto found that FEV₁ falls over time in London working men and this decline is accentuated in susceptible smokers. They also found that smoking cessation is the most effective measure to slow the acceleration toward the normal trend (particularly in those who stop smoking before 45 years old).

 

How the FEV₁value defines COPD severity

 

COPD stages are based on FEV₁ values and on how much it represents of the predicted value for gender, race, age, weigh, and height. For instance:

 

• Mild COPD exists when FEV₁ is 80% or more of predicted
• Moderate COPD exists when FEV₁ is 50% or more but less than 80% of predicted
• Severe COPD exists when FEV₁ is 30% or more but less than 50% of predicted
• Very severe COPD exists when FEV₁ is less than 30% of predicted or less than 50% of predicted with chronic respiratory failure (very low oxygen in blood and high levels of carbon dioxide)

 

Then… should we know the FEV₁ value in case of COPD?

 

Then, it’s good to know the FEV₁ to have a clear idea of the severity and change of the disease. This value is only obtained through spirometry and supports appropriate decisions for right measures to avoid rapid decline.

 

Remember: the most effective action to have a normal FEV₁ change during lifetime is quitting smoking as soon as possible.

 

Facts on our defense mechanism and COPD

After smoking, what?

There are cells in mucosal surfaces responsible for initiating the response when injure starts. They behave like gossip reporters when something wrong happens. When there is exposure to antigens, for instance, these cells engulf the substance an run away to present most of the constituents of the original antigen to the army of natural defenders.

A network of alarms

These cells have been originally called Langerhan Cells. According to Tsoumakidou M and cols. ( Am J Resp Crit Care Med 2008. 177:1180-1186) this group of cells are the Dendritic Cells. Dendritic Cells include three subsets: type 1 myeloid, type 2 myeloid, and plasmocitoid. Their origin is not at the lungs, however it is still under debate.

The migratory informers/spies

Those cells are relocated to the lungs by the circulating blood. Once in the lungs, dendritic cells settle down and wait for signals of danger like fish in submarine caves.

Thy are activated when find an antigen, which is engulfed and immediately drained from the area where it was caught. Dendritic Cells migrate to the lymph nodes and during the new relocation the mature expresing in their surface new markers like their uniform abandoning their camouflage and carrying some amounts of antigen.

Once in the lymph nodes, dendritic cells may induce tolerance or T-cell and B-cell responses which depends on how harmfull the antigen is.

Cigarette smoking and Dendritic Cells

How much are our gossip journalists (officially dendritic cells) involved in the reaction to cigarette smoke has not been clarified completely.

In the article by Tsoumakidou, they present a list of effects due to cigarette smoke on dendritic cells. Some studies have demosntrated that exposure to nicotine, cigarette smoke extract, as well as to lung secretions alter their functionality leading to a disarray in the orchestra conducting function.

Other studies have shown that dendritic cell’s function is also altered in experimental mice models of emphysema.

Hypothesis Tsoumakidou of dendritic cells involvement in COPD

Then, the hypothesis of Tsoumakidou is that the long term exposure of dendritic cells to cigarette smoke may be related to the disorder seen in patients with COPD. This situation is manifested through repeated exacerbations, as well as local infections, and the exaggerated inflammatory response seen in this “progressive chronic disease“.

Cigarette Smoking doesn’t help in this life

Although there’s more light in the understansding of COPD, there’s no doubt on the complexity of the cellular environment of this condition and how cigarette smoke really doesn’t help to make it better.