6. - Apccm

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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 studies overall 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:
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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
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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–
24 months 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 increases with 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 is an 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 proinflammatory 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
onset atrial 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 CoA reductase 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
ASSOCIATED WITH COPD
PSYCHIATRIC
DISORDERS
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
mood elevating 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 smoke and 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
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