Chronic obstructive pulmonary disease

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Gross pathology of lung showing centrilobular emphysema characteristic of smoking. Closeup of fixed, cut surface shows multiple cavities lined by heavy black carbon deposits.

Chronic obstructive pulmonary disease (COPD) is a persistent and chronic obstruction of the flow of the air to and from the lungs. This obstruction is generally permanent and is progressive through time. The primary and most common cause of COPD is cigarette smoking. It is comprised of three related conditions – chronic asthma, chronic bronchitis, and emphysema. A patient with COPD is diagnosed based on the symptoms that they manifest during the time of the exacerbation of their disease.

Asthma causes obstruction of the air flowing out of the lungs. This obstruction may be reversible for some people. However, if asthma is left untreated, the chronic inflammation that is causing the obstruction of the airway may become permanent and fixed. Thus, this person is considered to have COPD.

If a person complains of having cough with mucus or sputum production that is not related to any other condition for more than three months, the patient is considered to have chronic bronchitis. In patients with chronic bronchitis, the mucous glands in the lungs become larger. Inflammation occurs in the airways, and eventually, the bronchial walls thicken. The airway walls deform and the airway lumen becomes narrow, thus the air flow in and out of the lungs becomes limited.

In emphysema, the usual complaint of a person is having shortness of breath. There is an abnormal, permanent destruction of the alveolar walls. These alveolar walls support the air sacs or alveoli that make up the lungs. Enlargement of some alveoli also occurs.

However, overlapping of symptoms is frequent in COPD patients. This means that a patient with chronic asthma may manifest some symptoms of emphysema and chronic bronchitis, and vice versa. Diagnostic and laboratory examinations are done to further evaluate the symptoms manifested.


Signs and symptoms

The manifestation of symptoms usually occurs in a person after smoking 10 to 20 cigarettes per day for 20 years or more. The diagnosis of COPD is usually on the fifth to sixth decade of life. The common symptoms of a person with COPD are as follows:

  • Dyspnea - Difficulty of breathing.
  • Wheezing. - Musical or whistling sound produced when breathing out. This sound is commonly heard in persons with asthma.
  • Productive cough - There is production of mucous or sputum.
  • Cyanosis - Discoloration of the skin due to lack of oxygen. The skin turns blue and it is most noticeable on the nail beds, lips, palms of the hands, and soles of the feet.
  • Anorexia and Weight Loss- These often develop when the case is severe and it suggests a worse prognosis.

Causes and risk factors

The primary and most common cause for COPD is cigarette smoking and tobacco use. Fifteen percent of cigarette smokers develop COPD. Meanwhile, tobacco users pose a higher percentage of 90%. Second-hand smoke or environmental tobacco smoke increases the risk of developing respiratory tract infections. Frequent exposure to second-hand smoke can result to the deterioration and alteration of the lung function of a person.

Most of the cases of COPD involve males as more men than women smoke constantly. However, this does not mean that females are not at risk of developing this disease. Constant exposure to air pollution has not yet been proven to actually cause COPD. Moreover, changes in the weather can also contribute to the development of COPD.

Diagnosis and tests

  • Clinical history. A health care provider will interview a person regarding the history of illnesses, onset and frequency of symptoms, smoking history, and other related matters.
  • Physical examination. A physical examination is not sensitive enough to detect mild to moderate cases of COPD. For severe cases, this mode can be used as one of the basis for diagnosis. Symptoms such as tachypnea (rapid breathing) and respiratory distress with or without any activity can be observed on a person with severe COPD.
  • Sputum examination. A sample of sputum will be collected and sent to the laboratory for analysis of presence of any bacteria or blood.
  • Chest X-ray or high resolution computed tomography scan (HRCT scan). It is done to evaluate the condition of the lungs and to observe for irregularities in the lung's appearance. An HRCT scan is often done to provide a more detailed result compared to chest x-ray. It is also useful in the detection of emphysema.
  • Pulmonary function test (PFT). Usually done to assess the degree of severity of the lung disease. It assesses the function of the lungs by measuring how much air a person can breathe in and how much air and the time it takes for a person to breathe out. This test uses a device called the spirometer.
  • Arterial blood gas (ABG). This laboratory exam measures the ability of the lungs in transferring oxygen to the blood and in removing the carbon dioxide from it. Unlike the usual blood tests where blood is extracted from the veins, ABG uses oxygenated blood extracted from the arteries which are in a deeper location compared to the veins.
  • Pulse oximetry. This is a non-invasive method which allows the monitoring of the percentage of oxygen saturation of the blood. A device called the pulse oximeter is attached to the finger or the ear lobes.

Treatment and prevention

  • Quit smoking. Stopping smoking reduces the amount of sputum, lessens cough, and slows down the development of shortness of breath.
  • Avoid exposure to irritants. Avoiding second-hand smoke or any other airborne irritants of the respiratory tract can lessen the risk of developing or progressing COPD.
  • Nicotine replacement therapy. This can be done to avoid the withdrawal symptoms that can occur from instant cessation of tobacco use. Nicotine is an addictive substance.

Pharmacologic Interventions

  • Inhaled Steroids. Inhaled steroids decrease the frequency of exacerbations and helps alleviate disease-specific issues and the health-related quality issues for people with COPD. However, these are less effective (yet lesser side effects) compared to oral steroids.
  • Bronchodilator. It relaxes and opens the constricted breathing passages, thus making breathing easier.
  • Oral Steroids. Oral steroids are used to treat acute exacerbations. It improves the lung function of a person. Long term use of oral steroids is not recommended because of its side effects.
  • Antibiotic Chronic infection of the lower airways is common in people with COPD. Treatment of acute exacerbation and not to eliminate the organisms is the primary goal of antibiotics.
  • Mucolytics. For the reduction of sputum viscosity and for easier expectoration from the lungs.
  • Oxygen Therapy. Provision of oxygen to persons with COPD has been proven to prolong life. The need for oxygen varies from person to person. Some people who have COPD requires continuous oxygen therapy while others may only need oxygen therapy while doing an activity or during sleeping. ABG results can also be a basis for oxygen therapy, so as to avoid giving excessive oxygen to the person that would result to complications.

Possible Complications

  • Respiratory infections. Having COPD increases the risk for developing respiratory infections such as colds, flu, or pneumonia.
  • Heart problems. COPD increases the risk of having heart problems, especially heart attack. The reason behind this is still unknown.
  • Lung cancer. The development of cancer is higher in smokers who have chronic bronchitis than those who do not have chronic bronchitis.
  • Depression. Since dyspnea or difficulty of breathing is the hallmark symptom of COPD, it affects the activities of daily living of a person. Depression can also occur when the disease becomes progressive and incurable.

Cases in the Philippines

Chronic obstructive pulmonary disease, together with other respiratory diseases, is one of the top ten causes of death in the Philippines. The highest cases come from drivers and commuters; air pollution and smoking have been identified as its key causes. Chronic cough, chronic phlegm, wheezing, and shortness of breath are the most common symptoms manifested by the persons with COPD.

A study has been conducted in the US predicting that the growth of COPD worldwide can dislodge heart diseases as the fifth or sixth causes of mortality. Anti-smoking campaigns have been implemented by the Department of Health (DOH)and other non-government organizations in order to make people become more aware of the negative effects of smoking.