A common controversial topic has been the use of spirometry for screening COPD. Under the acknowledgement that COPD is on the rise and that respiratory symptoms are common in our society, the big question is if we need to look for spirometry results to “screen” for COPD.

The statement: Spirometry only for the symptomatic

According to these guidelines “Spirometry should be used to diagnose and determine the severity of airflow obstruction, but only in patients with respiratory symptoms (evidence grade: strong)”.

The only issue with this perspective is that most patients with COPD in their early stages prefer to disregard their symptoms or even hide them.

Then, a huge number of patients might not be informed properly about their health because they are not going through further evaluations (e.g. spirometry).

Unfortunately, the spirometry might also result in false positive diagnoses for other patients leading to inappropriate or unnecessary treatment. It is then when a combination of trust and good clinical judgment is required. A transparent communication of symptoms as well as the good clinical analysis and association of these symptoms to search for a diagnosis, can lead to the right decisions.

Where are the symptoms? (Where is Waldo?)

Communication comes to the desk again. Once the relationship between physician and patient is open, the patient has to concede space to the trust and talk about breathlessness during physical activity, cough in the morning, sputum production. These are common symptoms that patients think that are not abnormal and the idea of acceptance of them would imply the label of “illness”. The physician has also to look for these symptoms, assess and define their relevance and orientate the judgment to the use of additional tools for confirmation of diagnosis when necessary.

Without fear but cautious

There is a general evolution in the understanding of the disease. Although a statement like “Spirometry should be used to diagnose and determine the severity of airflow obstruction, but only in patients with respiratory symptoms” may be confusing, patients and physicians have to take it carefully.

Recognize the symptoms, look for them, go through a good physical examination, and, under good environment for decisions, consider the spirometry to confirm the diagnosis.

The upset snakes
The obstruction is determined by contraction of muscle bands that surround the airways like snakes around branches of trees, as well as the swollen interior walls of those airways. Not that being enough, the mucous secretion also reduces the space inside the airways.

Time for air
In fact, the obstruction is a partial obstruction since some air can still travel in and out of the lungs through the narrowed airways. However it is more difficult to get air out with each exhalation because the time has been predetermined.

The air in the train
It’s almost like: “you have 5 to 7 seconds to get out of the train because some people have to board. If you have less space to get out, you’ll take longer and people will enter anyway. You can’t get out. Next station same situation. And next. And next. Then, at one station you and others get upset and push everybody out leaving more space for others to come in”.

Breathing out at the next station
Each station is your breathing in and out through the narrowed passages and at that last station … you may want to cough that trapped air.

When cough is there (air trapped)
COPD patients start coughing early in the course of their disease. Besides the irritation of the airways originally caused by cigarette smoke, the obstruction creates the need to cough with certain regularity. Then, air trapping in COPD patients due to airflow obstruction could be considered a prominent cause of cough.

Acknowledge cough as not-normal
The continuous denial of disease by many respiratory patients leads to the hidden “smokers” cough to run without “noise”. When the patient needs more air like during physical activity, the breathlessness appears but cough was already there.

Cough (and deal with this important indicator)
Considering cough as an important symptom of COPD, leads to understanding of a key issue of the condition. When cough is prominent, think about the obstruction that is happening and the air that is trapped in the lungs. Taking the time to generate an efficient cough is also important.

Don’t wait
It is not necessary to wait for the breathlessness during exertion to realize that there are symptoms. It is important to consider cough as an abnormality instead of an inert part of the disease.

What to do
In fact, the treatment of the disease helps with cough specially when they include bronchodilators to relax those “snakes” aroung the airways in order to let the air flow.

Are we understanding what a COPD exacerbation is?

It is a kind of crisis of increased or worsened symptoms. COPD is a chronic condition but some times patients may have worse times. Those periods of time when symptoms make patients feel scared are “Exacerbations”. Don’t forget the term: Exacerbations. They are real crises and might require a different approach to manage them and control the consequences.

In fact: Not unknown
Patients with COPD really know what Exacerbations are. They even avoid calling them by its name because some may require a visit to ER or the doctor’s office. It’s ok to let your health care giver to know about the symptoms, the change in intensity, as well as the fear to having an exacerbation in progress.

These days, we know about this problem as part of the disease. It is necessary to recognize it on time, because some other measures are required. Not only being compliant with the usual management of the disease helps but some temporary adjustments can be of benefit.

Continue your medications to reduce serious complications

Recently, it has been shown how important is to have a regular daily use of bronchodilators in order to reduce the frequency of exacerbations. That is a an expected benefit that patients can consider with their doctors. However, it does not mean that exacerbations will not occur if patients are compliant with their medications. Reducing the frequency of symptoms’ worsening or the need to change medications, is also part of the general goals when controlling patients with COPD.

Make yourself familiar with your own symptoms pattern

Then, be sure to know your symptoms, to be familiar with the level of their intensity. A change in your usual pattern can be an exacerbation. As such, the management of the disease may need some adjustment.

Causes/Triggers of exacerbations

The most common causes are respiratory infections of any type. A common cold in COPD can result in a severe exacerbation if it is not addressed appropriately and on time. Discuss with your people at home and let them know when you don’t feel as usual. Let them know that you may have an exacerbation.

Be in control

While you feel controlled, don’t forget to take your medications as prescribed by your doctor. Be active and avoid environments that you know may have bad results on your health: symptomatic patients with a cold, pollution, smokers, excess conditioned air (heat, cold). Be patient and take control of your condition with a little help of friends (including your doctor, of course).

Diverse Feelings

The COPD patient is in fact diverse. Some tend to be dependent on others for coping with the disease. Some prefer to assume the condition as part of the smoking “habit”. Some other think and truly believe that there is no such condition with such weird acronym. Some are afraid and don’t want to deal with their fears.

With all of this being said, it is interesting how many of us forget the fact that behind a health condition is more than a patient. The is a human being with individual issues and feelings. These personal issues need to be taken into consideration, not only by health care givers, but by same patients.

Asking yourself?

Questions as: How I am confronting these symptoms?, Am I afraid?, Am I upset because I smoke(d)?, Do I understand what I have? … can help the patient to be clear about their personal conceptions on the disease and how they can affect the way they talk to doctors, feel the symptoms, help in the management of the disease, and so on.

It is relevant to do some introspection and assess the own sense of health when a disease has entered into the room to stay. Although it can be human attitude, being in denial, afraid, stubborn, upset might not help to get the best care, to breath easier, to exercise, to enjoy life. These attitudes could make the condition much more difficult to cope with and accelerate the speed of progression of it.

… So help your doctor

So … think about it again. How do you as a patient see your disease when the clinicians say that it is progressive and chronic but treatable? Are you helping in order to control what happens to you?

It’s not your fault, it is your current condition and, as such, you may prefer to take the lead and help in its management and earlier, the best.

Decrease in levels of Oxygen in blood is an important consequence of COPD. Compromising the air flow in the lungs leads to diminished blood Oxygen. The amount of Oxygen in blood is taken from arterial blood levels with samples (Presure of Oxygen gas) or with devices using infrared readings (Saturation by Oxymeter). Presure of the Oxygen Gas in arterial blood is symbolized by PaO2.

Terms related to diminished Oxygen

Decreased PaO2 (also called hypoxemia) has different presentations and severity in COPD. It can be continuous, dis-continuous. The non-continuous for of hypoxemia makes of it manifested during exercise (from activities of daily living to strenuous physical exercise) or during rest (day or nocturnal which can be during sleep or just lying down). The severity of hypoxemia can go from mild to severe.

Benefits of Oxygen Therapy

he subset of patients with COPD who develop severe hypoxemia has shown to improve their survival with Oxygen therapy. Oxygen therapy can be short-term (including bursts or as needed) or long-term. Long-term Oxygen therapy (LTOT) has been under assessment since it is costly and uncomfortable for patients. LTOT has shown to be clearly beneficial for patients with COPD and severe resting hypoxemia. However, it is still work in progress to define the benefit of LTOT for patients with non-severe hypoxemia at rest or during exercise in terms of survival.

For patients with hypoxemia during exercise (or perhaps at the end of it), Oxygen Therapy has shown to enhance the exercise performance. In patients who show hypoxemia during nights, the benefits are not clear yet.

Deciding Oxygen Therapy Use

Discussing hypoxemia with doctors implies reading of results. Severe and very severe COPD is a special field since the disease can be more complicated and the use of LTOT adds some difficulty in the management of the patient. The difficulty is in fact associated with other gases in blood (like CO2) which can be affected if higher amounts of Oxygen are administered. This situation requires close follow up to avoid additional complications.

Deciding with your doctor when to use LTOT is an important part of the conversation which may lead to use or delay of Oxygen Therapy. Oxygen is not a solution for COPD but an element to help patients to cope with a consequence of the disease. This consequence leads to impaired extra-pulmonary functions that can make the patient feel worse. Use of Oxygen therapy requires a careful assessment and not a pure simple decision based on the breathlessness.

… and there is Oxygen in the clean air.

Many years ago, Chronic Obstructive Pulmonary Disease (COPD) was considered to be a conglomerate of syndromes mainly manifested as Chronic Bronchitis or Emphysema. At some point it was made clear that most COPD patients, in fact had both “forms” of the disease. Perhaps one was predominant in some, while the other was obvious in others. Some confusion appeared among some practitioners and there was need to look for some clarity. Why not all COPD patients look the same? Why some have a slower progression? Why some cough up phlegm in the morning while others don’t?

Each Patient is Different

Each patient is different and it is more obvious that each COPD patient is different from another. Some patients have more flare ups (exacerbations) per year. Some patients develop cardiovascular complications and others require long-term Oxygen therapy (LTOT) earlier. There are some who get exhausted during activities of daily living while some (with the same lung function results) just … do real physical exercise.

Recent Investigations on COPD diversity

The ECLIPSE cohort (more than 2000 individuals with COPD) was assessed by a group of investigators looking for diversity among disease manifestation. It was interesting to see that Lung Function Tests (FEV1) was “poorly related to the degree of breathlessness, health status, presence of co-morbidity, exercise capacity and number of exacerbations reported in the year before the study”. This means that the compromise seen in the FEV1 value may not predict the intensity of the fatigue, existence of other diseases, tolerance of physical activity or number of flare-ups.

What it means

The reason for this disparity might be because some patients may be more prone to develop more breathlessness than others. Some may develop complications easier or even be frequent exacerbators. Those type of details are necessary to be discussed by patients and physicians to understand the management they are sharing as well as what to expect during the course of the disease since there are different trends in the common clinical course of this condition.

The role of physicians and patients on COPD diversity

It will be important for patients to discuss with physicians analysis on where they fit among the diverse population of COPDers. Because not all COPD patients are the same, the patient might need to describe themselves with some more detail to support more individual decisions on therapy and follow up. It is getting clearer that COPD is a more delicate condition with more details to unveil. It is necessary for physicians to get more sense of their patients to help educate them on their disease and what is around most corners.

The airflow limitation is common but there is more than that in the disease

One thing seems to be clear: there is a physiologic disturbance (decreased FEV1 or air flow limitation) with potential consequences and potential associated events with a frequency and severity that varies and that could be prevented and/or treated. Let’s face it: there is clear guidance on the management approach but there is uncertainty on what is the definite look of the patients and what to wait for in the settlement of the condition. Because … each COPD might be really different.

Is the COPD of today the same as yesterday’s?

Low Oxygen in blood: Hypoxia

In COPD patients, some changes occur in blood levels of oxygen. It has been described how the low oxygen levels might be responsible for most of systemic manifestations of disease. If the disease has some other body consequences, these can be associated to lack of good amounts of oxygen in the related cells.
In July 2010 Dr. Ramsey Sabit (Ramsey S et al. CHEST 2010;138(1):47-51) reported findings of a research looking for effects of low oxygen on some blood clot formation substances in COPD patients.

Results of a new clinical trial

The Ramsey’s investigation was based on the fact of certain conditions that predispose individuals to develop blood clots (venous thromboembolism or VTE) lead patients to arouse this effect during trips of prolong flight duration. Cabins can have low pressures at high altitudes generating decreased oxygen concentrations in blood. This can also get worse the COPD patient oxygen levels.
After inducing low levels of oxygen in a set of COPD patients (on ground), the researchers found how coagulation can be activated and also associated with increases in some markers of inflammation.

Again: make plans for travel but talk to your doctor

Then, this is a reason to inform your doctor if you plan to travel by air soon and especially if your trip is a long one. The oxygen level in blood may be assessed by your doctor in advance and some measures can be implemented.

Travel good and tell your doctor before doing so.

Cough and COPD

When cough is a symptom of Chronic Obstructive Pulmonary Disease, it lasts longer that if the disease were an acute condition. Often, smokers tend to call it “smoker’s cough” which is true but requires a careful assessment. Cough in the smoker goes beyond a pure irritation of the airway. The smoker’s cough can be symptom of the airway obstruction. The  trapped air  inside the lungs  (due to airway obstruction) is partially released with an extra expiratory effort. That extra expiratory effort can be the regular cough that seems to be a fake reliever. It doesn’t work completely because every cough effort is also accompanied by a full inspiration that might bring more air to be trapped in the lungs.

The forgotten symptom?

The complete functional description of the COPD’s cough has not been established. What is clear is how common cough and COPD are together. What is also clear is how oblivious the symptom is for most patients. It seems more relevant to patients when the symptom becomes exhausting or even associated with pain. At this point it is important because there is no “smoker’s pain” or “smoker’s exhaustion” that patients might consider “normal”.

A cough class

Cough can be dry (without phlegm) or humid (with phlegm). The humid cough can be productive (when the patient can release the phlegm) or not (when the secretions stagnate inside the chest). It is important to cough in most respiratory illnesses because it can become in a defense/protective mechanism.

Exercise coughing

According to a recent non-COPD-related article by Dr. Wen-Lin Su and cols. in CHEST 2010;137(4):777-82; Cough is a defined sequence: “deep inspiration followed by strong expiration against a closed glottis (-where your vocal chords are-), then opens with an expulsive flow of air, followed by a restorative inspiration”.

To cough effectively, it is important to make a slow full exhalation after a normal exhalation. Then, the subject should prepare to inhale completely and slowly and, after doing so, focus in the abdominal muscles. An effort to contract the abdominal muscles should start and then cough to force phlegm (if any out) or to help part of trapped to air to be released. One way to help is to put a pillow on your lap when sitting to cough. Being conscious about the cough really help to cope with this symptom. And don’t feel embarrassed.

Help with respiratory exercises

Patients should be sure to train themselves on respiratory exercises like pursed lip breathing. It is also key to understand the role of exhalation in the breathing process because that is where the limitation becomes important in COPD’s lungs.

Be sure to cough and be sure it is “normal” …

Challenge the norm

When assessing the impact of the disease on patients it has been necessary to look for more. This is a typical feature of chronic diseases. Being clear that the disease doesn’t go away but it is treatable, is an important concept to discuss among patients, caregivers, and physicians. We all have to challenge ourselves and look for what else the condition has changed in the lives of patients and look for potential solutions.

COPD is understood as a disease beyond lungs. It affects the entire life of an individual and it is not about one inhaler as only solution. In the trend of discussions on the impact of disease on quality of life, mental health, social interaction, physical activity, and others, there are emerging concepts to redesign the management.

Physicians are looking for more in you

Fortunately, these days are a frame for patients and physicians to conceive the human being more than an research’s subject or a social entity. Today patients are meditating on their life beyond their symptoms. Physicians are trying to interact with patients and relatives in a less distant manner to get more information and provide with more support.

It’s also a patient’s responsibility

When discussing with physicians about COPD symptoms, being prolific in sharing thoughts, feelings, and perceptions of the disease more than the symptom is important. This environment will provide the physician with a sense of the care that patient is taking of their health. It will also invite the physician to foster a relationship intended to conceive the patient and their disease as an individual situation and try individual approaches.

Of course, it is important to respect the professional time to get the best of the service. Keeping a diary on feelings, ideas, symptoms and reading it back in time, might provide the patient with a broader perspective of the disease that can be summarized when visiting the doctor. A good doctor will pay attention to those key thoughts and will say a sentence that can help more than a prescription on a sheet of paper.

The doctor can be what patient might need

Patients must be sure to bring something engaging to doctor’s office. That something else should be their thoughts to help address their condition. Communication is a thing of more than oneself. Communication between doctors and patients implies confidence and truth. If a medicine seems not being working, it needs to be said. Doctors may help understand the nature of medicines work and what to expect of them. Symptoms are getting worse in spikes more frequently than previous years? … share with the doctor to implement new strategies and assess results in the future.

Keep track … not only about symptoms, but about emotions, social interaction, the general impact of the disease.

Realizing that the disease can be severe may be difficult when the condition is easy to adapt to. No matter how illness was produced there’s need for the sufferer to understand the fact that life can be in many more other details. Breathing is fundamental to enjoy life. Breathing marks the arrival of life. When breathing is impaired, there is no doubt that life is impaired too. However, how can you find that life is impaired because of COPD?

Your COPD, your life

If you consider what are the key domains that constitute your life, you may find out if your life has been altered without your awareness. Life (in a simplistic manner) can be see as a conjunction of individual feelings and interests and social engagement . The social engagement goes beyond talking to someone else and it is present in the multiple activities that help day to day interaction. These multiple activities can go from grocery shopping to visit friends and go with them for a talking walk. All these elements require a healthy breathing because talking, laughing, crying, are ways to breathe.

So COPD do affect the patient beyond the lungs and it invades a territory even unknown for many experts: the real life,

Addressing your needs

For COPD patients, the fact that the disease is due to smoking, air pollution, or any other environmental factors that could be avoided, it is not easy to establish necessities and priorities. Just realizing that there is an actual situation that needs the support of healthcare professionals, relatives, friends is a way to start control of the condition. With professionals there will be opportunities to address the physical consequences. With relatives and friends, an extra chance for support, for connecting with life, and for giving value to yourself.

Do not hesitate

Do not hesitate in considering your dues and how your life has been affected by your clinical condition. Talk to your doctor. Ask questions to the professionals. Provide them with the right to tell you trues and what you can do for yourself. Talk to your people and tell them what you have, what impacts your daily life, encourage them to keep you active with the fact that you still have a situation that slows down your day to day but you can still be active.

Breathing is your life

Your life is breathing and COPD is aggressive if you don’t help yourself. Don’t wait for breathlessness to get obvious but consider your smoking history, you cough, the sputum every morning to understand that there’s a disease around. That disease can be treated, controlled and your participation is fundamental.

COPD is chronic obstructive pulmonary disease and your breathing is impaired. It requires that you stop smoking, that you take your inhalers to keep your airways open and less inflamed, that you stay active, and that you participate in designing the support you might need for coping with your situation.

It’s your breathing, it’s your life.