COPD – TAKE CONTROL AND LIVE WELL

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and death throughout the world. The disease is mainly caused by smoking, but environmental pollution and α1–antritrypsin deficiency may also cause the development of COPD. In 2000 about 16 million people suffered from COPD in the USA alone, with the number of women suffering from this disorder increasing. In Indian scenario as per various studiesoverall prevalence of chronic bronchitis in adults >35 yr was 3.49 per cent.The disease is progressive, but the severity and progress can be moderated by actions such as smoking cessation, careful management of infections and appropriate rehabilitation.

The most common symptom of COPD is shortness of breath. While it’s common to feel short of breath after physical exertion, simple everyday activities, such as getting dressed or walking up a few steps, can cause someone with COPD to feel seriously short of breath. Sometimes, people with COPD will knowingly or unknowingly limit their activity in an attempt to avoid feeling short of breath.

Other symptoms of COPD include:

Frequent cough-: Everyone coughs from time to time, but a cough that lingers can be a symptom of chronic bronchitis and COPD. In fact, a cough that lasts at least 3 months a year for 2 consecutive years is the primary symptom of chronic bronchitis.

Cough with mucus (phlegm)-: It’s normal to cough up mucus sometimes. But a continuously productive cough—a cough that regularly brings up mucus—can be a symptom of COPD.

Inability to maintain activity levels due to fatigue or shortness of breath-: People with COPD can become less active over time. They may notice that they rest much more than they used to, or that they get less done in a day, due to the need to move slowly and rest.

Blueness of the lips or fingernail beds-: A blue-tinge to the lips or fingernail area indicates a serious lack of adequate oxygen in the blood and can be a symptom of COPD.

Frequent colds and nose and throat infections-:Chronic bronchitis (one of the diseases that make up COPD) causes excess mucus production in the airways. That excess mucus makes the body prone to upper respiratory infections.

COPD exacerbations are also responsible for a substantial health, financial, and human burden (e.g., frequent hospitalizations, increased medication consumption, functional impairment, and death). Not only do patients have to deal with the physical consequences of the disease, but they must also deal with the psychological consequences of COPD. Researches has shown that psychological distress is significantly elevated and common among patients with COPD, with up to 55% of patients suffering from a clinical diagnosis of anxiety and/or depression.

PROBLEMS FACED BY COPD PATIENTS

RESPIRATORY/PULMONARY

  • Air hunger/baseline dysnoea
  • Frequent COPD exacerbations

NON RESPIRATORY/ OTHER SYSTEMIC ISSUES:

  • Skeletal muscle weakness
  • Osteoporosis
  • Cardiac arrhythmias,
  • Ischemic heart disease
  • Stroke
  • Diabetes Mellitus/Metabolic syndrome
  • Anemia
  • Depression
  • Sleep Disorders
  • Cancer

The presence of these extra-pulmonary manifestations of COPD increases morbidity and mortality.

SKELETAL MUSCLE WEAKNESS/DYSFUCTION (SMD)

Muscle atrophy is associated with increased mortality risk independent of disease staging based on severity of airflow obstruction. SMD in COPD is characterized by a reduction in strength and endurance of the muscle.

In COPD, shift of muscle fiber type I to type II, Type I fibers - resistant to fatigue,

Type II fibers - more fatigable. In COPD Muscle glycogen content lower,

and lactate concentrations are higher. Elevated levels of inflammatory mediators, such as TNF-α and IL-6, cause skeletal muscle to atrophy.

Mechanism of skeletal muscle weakness:

  • Deconditioning is a major contributor to the muscle dysfunction in COPD patients
  • Inflammatory mediators in COPD may be responsible for weight loss and muscle wasting.
  • Reduced levels of circulating hormone(GH, Test,) in COPD patients
  • Chronic steroid myopathy after prolonged administration of lower doses of corticosteroids
  • Chronic hypoxemia or hypercapnia or the effects of cigarette smoking cause muscles damage

Treatment options:

  • Pulmonary Rehabilitation
  • Exercise training – Upper and lower extremity endurance training, respiratory muscle training, strength training
  • Education – Self-management strategies
  • Psychological and behavioral intervention
  • Support groups for stress management
  • Oxygen Therapy
  • Anabolic Hormones

COPD AND OSTEOPOROSIS

Patients with COPD show increased prevalence of osteoporosis. This is at least partly independent of the effects of steroids, being seen even in the absence of steroid use. Vertebral fractures may be present in 50% of steroid-naïve males with COPD.32 Osteoporosis may be related to elevated TNF-a and Interleukin-1, which stimulate the differentiation of macrophages into osteoclasts via mesenchymal cells releasing receptor activator of nuclear factor-k B ligand, a member of the TNF-a superfamily.33 High levels of TNF-a are found in osteoporosis associated with both post-menopausal states and COPD.34,35 This suggests that COPD associated osteoporosis is also due to systemic inflammation, and therefore a systemic consequence.Age, limited physical activity, low Body Mass Index (BMI), smoking, decreased gonadal function (due to both age

and smoking) and malnutrition are also contributing factors.

Treatment Options:

Measure BMD in the following high-risk patients at baseline:

  • Those on chronic oral glucocorticoids or high-dose inhaled glucocorticoids
  • Postmenopausal women.
  • Premenopausal women with amenorrhea
  • Hypogonadal men
  • History of fracture
  • BMI <22

Follow BMD every 6–12 mo in those receiving oral glucocorticoids or every 12–24months in those not taking oral glucocorticoids. Give supplements to daily intake of 1,000–1,500 mg calcium and 400–800 IU vitamin D. Encourage an exercise program to improve strength and balance.

Gonadal hormone replacement to all postmenopausal women, premenopausal

women with amenorrhea, and hypogonadal men (unless contraindicated). Consider bisphosphonates or calcitonin in patients with osteoporosis or in high-risk patients in whom HRT is not effective or indicated.

CACHEXIA/EXCESSIVE WEIGHT LOSS IN COPD

Cachexia is defined as excessive weight loss in the setting of ongoing disease, associated with disproportionate muscle wasting. It is associated with poor functional capacity, reduced health status, and increased mortality. The prevalence of weight loss in COPD increaseswith COPD disease progression.

In mild to moderate COPD, only 10 to 15% and severe COPD, nearly 50% of patients have significant weight loss. COPD-related cachexia isan independent risk factor for morbidity and mortality. COPD patients frequently take inhaled or systemic glucocorticoids, which further contribute to a catabolic state.

Treatment Options:

  • High protein diet and muscle strengthening exercises.
  • Avoid frequent use of oral corticosteroids.
  • Anabolic steroids for low BMI.

COPD AND CARDIOVASCULAR MANIFESTATIONS.

COPD and CHD have shared risk factors including advancing age, cigarette smoking, and environmental air pollution. However, even among relatively young

nonsmokers, COPD is an independent risk factor for incident cardiovascular disease suggesting other mechanisms.

In COPD, persistent pulmonary inflammation promotes the release of pro-inflammatory chemokines and cytokines into the circulation. The systemic inflammation in turn adversely impacts the blood vessels, contributing to plaque formation and, to plaque instability and rupture. Hemostasis and thrombotic pathways may also play relevant roles in COPD and ischemic heart disease.FEV1 >50% of predicted, CVD account for approximately 50% of all hospitalizations and nearly a third of all deathsIn more advanced disease, cardiovascularevents account for 20–25% of all deaths in COPD.

For every 10% reduction in FEV1, all cause mortality increase by 14%, cardiovascular mortality increase by 28%, and nonfatal coronary event increase by almost 20%.

Arrythmia in COPD

Stable COPD patients: 72 % of arrhythmias were ventricular in origin, while 52 % were supraventricular. Reduced FEV1 is an independent predictor of new

onsetatrial fibrillation in patients with stable COPD. Atrial fibrillation and ventricular arrhythmia were independent predictors of death. In patients with acute respiratory failure, the presence of arrhythmia may be associated with increased mortality.

Treatment options:

  • Inhalational corticosteroids – to control systemic inflammation.
  • HMG CoAreductase inhibitors in primary and secondaryprevention of coronary heart disease.
  • Statins -: Reduction of all cause mortality in COPD patients (role questionable)
  • Infliximab , TNF alpha antagonists, antioxidants (trials going on). Initial results are favourable.

DEPRESSION AND OTHER PSYCHIATRIC DISORDERS ASSOCIATED WITH COPD

COPD and depression are significantly associated due to multiple reasons. About 40% of patients with COPD are found to have depression, compared to a prevalence of about 15-20 % in the general population.Loss of independence with increasing disability in COPD can cause, or aggravate, depression. A predisposition to depression may increase the risk of smoking, as nicotine has a moodelevating effect. Systemic inflammation may also play a role in depression.52 Continued smoking due to lack of motivation in depression to quit, increases the risk of developing COPD, and aggravates existing COPD.

Mortality is 3.11 times higher among severely depressed patients than non depressed patients. Greater mortality at 4 years in depressed patients. COPD with anxiety or depression face greater levels of cognitive decline, more functional

limitations, lower self-efficacy, and more serious life events.

The Cycle of Physical, Social, and Psychosocial Consequences of COPD

COPD AND SLEEP DISORDERS

Individuals with COPD tend to have a disturbed sleep pattern which is probably a major factor responsible for the chronic fatigue and impaired quality of life reported by patients with severe COPD. Also, those with COPD exhibit impaired gas exchange in all stages of sleep, an observation that becomes more marked during Rapid Eye Movement sleep. Moreover, COPD has been shown to be associated with the obstructive sleep apnoea-hypoventilation syndrome.

REPRODUCTIVE CHANGES:

Smoking during pregnancy is associated with increased incidence of menstrual irregularity, infertility, stillbirths, low-birth-weights and respiratory disorders in the newborn it has a dose-dependent relationship with placenta praevia and abruption placentae. Smoker males on the other hand do not suffer from sperm abnormalities but suffer from loss on libido and impotence arising from neurological alterations and pelvic atherosclerosis respectively.

CATARACT

Most commonly seen in COPD patients on chronic systemic steroids.

COPD AND LUNG CANCER

COPD is not only a risk factor for lung cancer, but also for death from lung cancer. The presence of moderate or severe airflow obstruction is a significant predictor of incident lung Cancer.Hypoxia-inducible transcription factors (HIF) may promote angiogenesis and involved in both ischemic diseases and cancer

Evidence suggests that angiogenic dysplasia is a prelude to invasive carcinoma. 49% of lung cancer patients have COPD and as many as 12% of COPD patients between the age of 65–69 years die as a consequence of lung cancer. Predisposition of COPD to lung cancer may be due to impaired mucociliary clearance, genetic predisposition, oxidative stress-mediated inflammation and carcinogenesis process.

Treatment Options:

  • Routine lung cancer screening
  • Quit smoking
  • Control of systemic inflammation

SELF CARE TIPS FOR COPD PATIENTS

• Don’t smokeand make sure no one smokes in your home. COPD is a long-term sickness and will get worse if you do not stop smoking.

• Stay active.Walking helps to build up strength. Talk to your doctor about how much activity is right for you.

• Eat healthy.Try fish, poultry, or lean meat, as well as fruits and vegetables. If it is hard to keep your weight up, talk to a doctor or nutrition expert about eating foods with more calories. If you are overweight, losing weight can help you breathe easier.

• Keep mucus out.Drinking plenty of water and using a cool mist humidifier can help to thin the mucus in your airways.

• Get a flu vaccine.Lung infections can worsen COPD symptoms. Get a flu vaccine each year and talk to your doctor about whether you need a pneumonia vaccine.

• Get support.It’s common to feel sad or hopeless sometimes when you have a long term illness. If these feelings last, be sure to tell your doctor. Counseling, medicine and support groups can help you cope.

• Control your breathing.Talk to your doctor or respiratory therapist about ways to help you breathe easier. Discuss breathing positions and ways to relax when you are short of breath.

• Avoid triggers.Stay away from things that can cause a flare-up, including smoking, indoor and outdoor air pollution, cold dry air, hot humid air, and high altitudes.

Author-: Dr.Tinku Joseph

Department of Pulmonary Medicine, Amrita Institute of Medical Sciences and Research Centre, Kochi-41, Kerala