COPD: Chronic Obstructive Pulmonary Disease

Generality

COPD is the acronym of Chronic Obstructive BronchoPneumopathy, a pathology of the respiratory system from the subtle character, which at the beginning is asymptomatic, while in the more advanced stages, after a slow and progressive course, it is responsible for very serious symptoms, such as dyspnea (ie respiratory difficulty due to lack of breath even during small efforts), cough with phlegm, recurrent fatigue, edema of the ankles, loss of appetite and predisposition to the development of respiratory infections.

The most known and common cause of COPD is smoking, that is the habit of smoking tobacco; after smoking, the other most important causal factors are: passive smoking, constant exposure to dust and toxic substances in the professional environment, prolonged exposure to severe environmental pollution and, finally, the presence of a genetic condition known as alpha-1-antitrypsin deficiency.

Currently, COPD is a condition from which it is impossible to heal; however, its control, through appropriate symptomatic therapies, is fundamental to slow down the inexorable progression of the alterations that the aforesaid condition determines for the bronchi and lungs.

What is COPD?

COPD is the name of a serious respiratory disease, resulting from the combination of conditions associated with the pathological narrowing of the airways of the bronchial tree ( bronchi and bronchioles ) and a series of consequent breathing difficulties, especially during the exhalation phase.

What medical conditions does it include?

Different medical conditions contribute to the presence of COPD; among these medical conditions, the most important and worthy of a citation, given also their spread in a single form, are: chronic bronchitis and pulmonary emphysema .

• Chronic bronchitis: literally, it is the persistent or long-lasting inflammation of the bronchi and bronchioles.

  Constituents of the aforementioned bronchial tree, bronchi and bronchioles represent the tract of the airways that begins after the trachea and penetrates into the lungs, preceding only the so-called pulmonary alveoli .

  Chronic bronchitis is responsible for a marked production of mucus and bronchial sputum.

• Pulmonary emphysema: it is a serious chronic disease of the pulmonary alveoli (or simply alveoli), that is the small saccular cavities of the lungs in which gas exchange takes place between blood and atmospheric air introduced with the respiration.

  In the presence of pulmonary emphysema, the alveoli are damaged and no longer function properly; therefore, those suffering from pulmonary emphysema have severe difficulties in oxygenating the blood, a fundamental process to keep the internal organism healthy.

In COPD patients, the simultaneous presence of chronic bronchitis and pulmonary emphysema is very frequent.

What does COPD mean?

COPD is the acronym for Chronic Obstructive Pulmonary Disease :

• "BronchoPneumopatia" refers to the fact that COPD affects the bronchi (it is the case of chronic bronchitis) and the lungs (it is the case of pulmonary emphysema), causing its deterioration.

  The deterioration of the bronchi and lungs leads to the loss of the elasticity characteristic of these elements of the respiratory system, with negative repercussions on the general respiratory capacity.

• "Chronic" refers to the typical slow, progressive and irreversible course of COPD and the medical conditions behind it.
• "Obstructive", finally, recalls how COPD causes an obstruction of the airways, which hinders the normal flow of air during expiration.

NOTE: in English the abbreviation COPD changes to COPD, an acronym for Chronic Obstructive Pulmonary Disease .

Epidemiology

According to a 2010 estimate, people with COPD would have been around 329 million, or 4.8% of the global population.

Unlike in the past, where men were the most affected, today COPD affects males and females equally.

In most cases, COPD sufferers are people over the age of 40 with a smoking habit.

According to various statistical studies, the worldwide number of deaths from COPD has increased significantly over the last 20-25 years: if in 1990 the deaths from chronic obstructive pulmonary disease were around 2.4 million, in 2015 they were as many as 3, 2 millions.

Causes

COPD occurs when the lung airways, due to inflammatory processes and damage to them, undergo a narrowing that prevents correct and complete exhalation.

The main cause of COPD (and of the above) is smoking ; in cigarette smoke, in fact, there are substances that are highly harmful to the lung tissues.

Following the habit of cigarette smoking, the other causes of COPD worthy of note are:

• Prolonged exposure, for business reasons, to certain types of dust and chemicals. They are associated with the onset of COPD: cadmium powders, powders produced by processing wheat, silica dust, metal welding fumes, isocyanates and coal dust;
• Exposure to so-called passive (tobacco) smoke. Passive smoking is, by definition, the smoke that non-smokers inhale involuntarily, when they are in the vicinity of smokers;
• Prolonged exposure to severe environmental pollution . Currently, studies are underway to understand how influential the pollution of the environment is on the appearance of COPD;
• The presence of a genetic disease known as alpha-1-antitrypsin deficiency . Alpha-1 antitrypsin is a protein produced by the liver and used to protect the lungs; therefore, if it is lacking, as in the case of alpha-1-antitrypsin deficiency, its protective action also fails and the lungs are more prone to develop COPD.

Outline of pathophysiology

Prolonged exposure to irritants (eg, smoke, pollution, toxic dust, etc.) triggers an inflammatory process in the bronchi and bronchioles.

This inflammatory process reduces the size of the affected airways, mainly because:

• Causes the thickening of the bronchial wall, with consequent decrease of the internal space to the bronchi;
• It causes an overproduction of phlegm, which, accumulating inside the bronchi, further contributes to the obstructing effect;
• It involves anatomical damage to the lung parenchyma and the consequent replacement of the latter with scar tissue; the formation of scar tissue is responsible for a severe reduction in the elastic retraction force of the still healthy lung parenchyma, which is an obstacle to the dilation of the bronchial airways.

CONSEQUENCES OF AIR TRAINING

The obstruction of the airways is in turn the cause of a particular phenomenon, known as pulmonary hyperinflation .

Pulmonary hyperinflation is essentially the trapping of air in the lungs, resulting from the difficulty, on the part of the pulmonary airways, in expelling the aforementioned air, due to the presence of an obstruction.

Pulmonary hyperinflation causes those affected to inhale new air even before having expelled the inhaled air with the previous breath; furthermore, it implies that, in the more advanced stages of COPD, the expiratory flows in resting conditions are of the same order of magnitude as those taking place during a forced expiration, due for example to a physical effort.

In response to chronic pulmonary hyperinflation - that is to the chronic accumulation of air does not expire inside the lungs - the diaphragm undergoes an unnatural flattening and the rib cage undergoes an abnormal dilatation (the so-called barrel thorax ), the all to try to improve breathing. These changes, however, prove to be not only ineffective, but also counterproductive, because they force the respiratory muscles accessory to overwork, which in the long run compromises their functionality.

Curiosity: where dyspnea also comes from moderate physical exertion

The loss of effectiveness of accessory respiratory muscles, associated with airway obstruction, decreases tolerance to exercise, causing dyspnea, even for modest efforts.

Symptoms, signs and complications

To learn more: COPD symptoms

COPD is a subtle condition, because at the beginning it lacks a clear and evident symptomatology, so it manifests itself with significant and debilitating disorders only when it enters an advanced stage and is now difficult to contain with therapies.

Unfortunately, the absence of an important symptomatology right from the start entails a certain carelessness, on the part of the patient, towards his own state of health, and this "makes the game" - so to speak - of COPD, which in the meantime continues, albeit slowly, to evolve.

Going further into the details of possible symptoms, early COPD is responsible for:

• Frequent cough with or without phlegm

and / or

• Limitations of expiratory flows, in the absence of chronic respiratory disorders.

In its more advanced phases, instead, it produces a much more articulated symptomatology, which includes:

• Chronic cough with severe expectoration (ie production of phlegm). In essence, the frequent cough and phlegm that characterized the early days became permanent;
• Shortness of breath ( dyspnea ) during important physical efforts. In the medical field, this symptom takes the specific name of dyspnea on exertion ;
• Lack of breath during moderate physical efforts. It is always dyspnea on exertion, but more serious than in the previous case, as it is due to more serious pulmonary problems.
• Breathing difficulties at rest, both day and night. In medicine, such difficulty in breathing falls under the name of dyspnea at rest .

  Dyspnea at rest prevents the normal performance of lighter daily activities and less heavy work activities; moreover, it is disturbing to sleep at night.

  In a context of dyspnea at rest, therefore, the quality of life of COPD patients is seriously compromised;

• Sense of recurrent exhaustion;
• Ankle swelling;
• Decreased appetite and consequent weight loss;
• Tendency to develop acute respiratory infections that sometimes require hospitalization;
• Slowness in healing even from the simplest respiratory tract infections (eg: colds).

Curiosity

In patients with COPD, dyspnea at rest is one of the main reasons behind the need to use oxygen therapy at home.

The exacerbation phenomenon

As mentioned on other occasions, COPD is a disease that usually worsens gradually over time.

Sometimes, however, it can happen that he is the protagonist of sudden, unpredictable and particularly marked deteriorations. To better understand, in these circumstances, it is as if the typical symptoms of COPD - which are always in a continuous pejorative evolution - underwent a sudden acceleration in terms of gravity (eg, the cough suddenly becomes more marked, the production of phlegm it is all of a sudden bigger).

In medical jargon, these sudden and unpredictable deteriorations of COPD are called exacerbations .

Currently, the causes of exacerbations are little known; according to experts, some bacterial or viral infections would play a decisive role.

SYMPTOMS OF COPD SEPARATED FOR GRAVITY OF THE DISEASE
PEOPLE AT RISK OF COPD	COPY LIEVE	MODERATE COPD	SERIOUS COPD
Frequent cough with or without expectoration	Chronic cough with or without phlegm. Shortness of breath during or after a moderately severe effort (eg: walking quickly).	Chronic cough almost always accompanied by mucus expectoration. Sense of breathlessness and dyspnea that arises even during mild physical efforts, such as walking briskly. The recovery times of a cold or a trivial respiratory infection are definitely longer than normal.	Chronic cough with sputum presence. Breathing difficulties even at rest, both day and night, which make it impossible to carry out the most normal daily activities (eg cooking, shopping, making scales, etc.).

Complications

From the most advanced stages of COPD, various complications can arise, some of which are fatal to patients.

Possible complications of COPD include:

• Acute pneumonias . In individuals whose lung health is already seriously compromised, these events can further reduce respiratory capacity.
• Heart problems . For reasons still unknown, COPD promotes the onset of heart disease, such as heart attacks.
• Lung cancer . COPD is closely linked to a significant increase in the risk of pulmonary adenocarcinoma .
• Pulmonary hypertension . It is the pathological elevation of blood pressure within the pulmonary arteries, ie the arteries that carry blood from the heart to the lungs. It is a condition whose possible consequences are potentially lethal.
• Depression . It derives from the need for continuous care, from the incapacity to be able to perform a simple physical activity, etc. without worries; in other words, it is the result of a quality of life seriously compromised because of the illness.

Diagnosis

The diagnostic procedure for the detection of COPD begins with an accurate physical examination and a careful medical history ; objective examination and anamnesis are fundamental to establish the precise symptom picture present and the causes from which the symptoms may depend.

Then, the diagnostic investigations continue with a test called spirometry, which records the inspiratory and expiratory capacity of the lungs, and the patency (ie opening) of the pulmonary airways.

Finally, laboratory tests are performed, such as blood tests, catarrh analysis, oximetry, blood gas analysis and quantification of alpha-1-antitrypsin levels, and instrumental examinations, such as chest radiography, l echocardiogram, the electrocardiogram and the chest CT scan. All these tests are fundamental to clarify, in a definitive way, the causes and degree of severity of the current COPD.

Therapy

Currently, unfortunately, COPD patients can only rely on symptomatic treatments (that is, they act against the symptoms), because, despite the numerous efforts of medical research, there are still neither treatments able to restore normal lung anatomy, where it is formed scar tissue, nor cures able to block the progressive character of the pathological condition in question.

In other words, COPD is a condition from which it is impossible to heal, but which is treatable in symptoms.

Having clarified these fundamental aspects concerning the possibilities of treating COPD, readers are reminded that, along with symptomatic treatments, the adoption of a series of behaviors in line with a healthy lifestyle also plays an important role.

Symptomatic therapy: what does it consist of?

With the aim of improving patients' quality of life, symptomatic therapy for COPD includes treatments that are essentially able to:

• Relieve symptoms e
• Slow down (NOT block) the progression of alterations that disrupt the normal pulmonary anatomy.

The symptomatic treatments in question mainly include:

• The so-called respiratory rehabilitation or pulmonary rehabilitation . It consists of subjecting the patient to a program of motor exercises (use of the exercise bike, use of the treadmill for walking, etc.), the purpose of which is to improve tolerance to physical efforts and reduce the severity of dyspnea.
• Oxygen therapy . It is the administration of oxygen through special medical dispensing instruments, some of which are also portable.

  The use of oxygen therapy is essential whenever there is a need to increase the amount of oxygen circulating in an individual's blood.

• The use of bronchodilator drugs. As their names indicate, bronchodilators are medicines capable of dilating the airways, in particular the bronchi, in order to improve breathing and the passage of air.

  The route of administration of bronchodilators is by inhalation.

• Use of mucolytics . Mucolytics are drugs that dissolve phlegm, alleviating the problem of chronic cough.
• Use of corticosteroids . Corticosteroids are powerful and effective anti-inflammatories.

  In the presence of COPD, they find employment when the aforementioned condition is very serious or when it is the protagonist of a sudden exacerbation; in both these circumstances, in fact, a severe inflammation of the airways is underway.

  Corticosteroids are medicines that should be used with extreme caution, as serious side effects may result from incorrect use.

• The use of antibiotics . Antibiotics are indicated whenever the patient with COPD has an infection of the respiratory tract of bacterial origin. Readers are reminded that patients with chronic obstructive pulmonary disease have a marked tendency to develop acute respiratory infections.
• Bullectomy surgery , lung volume reduction and lung transplantation . Surgery is reserved for the most serious patients and in whom all previous pharmacological remedies are completely ineffective.
• Bullectomy: it is the surgical procedure of removal of the so-called "pulmonary bubbles", which are typical alterations of pulmonary emphysema.

  Its realization should improve the patient's lung function, which should therefore breathe better.

• Lung volume reduction: it is the operation of removing the damaged portions of the lungs.

  Its execution should allow healthy portions of the lungs to work better than before.

• Lung transplantation: it is the operation to replace a diseased lung with a healthy lung, coming from a compatible donor.

  It is a very invasive treatment and with a low probability of success, which, however, if medicine ever managed to improve its efficiency, could be the starting point for the specific treatment of COPD.

Recommended lifestyle

The adoption of a healthy lifestyle is a valid support for symptomatic therapy for COPD, as it helps both to alleviate the symptoms and to slow down the inexorable progression of the alterations affecting the lungs.

The healthy behaviors that the patient with COPD should adopt include:

• Stop smoking . This recommendation is based on the evidence that most COPD sufferers are smokers and have developed the aforementioned condition precisely because of cigarette smoking.
• Practice physical exercise regularly . For patients with COPD, the most indicated physical activity consists of 20-30 minutes of walking for at least 3-4 times a week.

  As far as the intensity of this activity is concerned, it is good that this causes a slight wheezing during the practice, but should not be excessively tiring.

• Eat in a healthy and balanced way . For a COPD sufferer, it is very important to maintain normal body weight and enrich one's diet with foods such as fruits, vegetables, fish (eg salmon, tuna, etc.), fish oil, yogurt and milk.

  The ideal diet must provide all the nutrients the body needs to function properly and defend itself from infections, but it must also exclude all those unhealthy foods (eg fatty foods, fried foods, etc.).

Other important recommendations

In the presence of COPD, doctors also recommend: vaccinating annually against the influenza virus, vaccinating every five years against Streptococcus pneumoniae pneumonia and limiting exposure to environmental pollution as much as possible.

Prognosis

COPD is a condition with a poor prognosis. Moreover, it is: incurable, unstoppable and responsible for mortal complications.

It is good, however, to specify that:

• COPD is as serious and debilitating as the diagnosis and implementation of effective treatment are late. This means that, if identified and treated at an early stage, COPD has less serious consequences and is more controllable;
• Today's symptomatic treatments against COPD provide good results and can significantly improve patients' health status.

Mortality rate

Based on some reliable estimates, the mortality rate of COPD 5 years after its diagnosis fluctuates, depending on the severity of the condition, between 40% and 70%. This means that in a sample of 100 patients with COPD, the patients who died 5 years after diagnosis ranged from 40 to 70.

Causes of death

In patients with COPD, death usually occurs due to respiratory failure (for example due to severe acute pneumonia) or severe heart disease .

Prevention

Do not smoke and, for those who work potentially at risk, using the protective equipment provided are the two main recommendations of doctors, when the topic of discussion is the prevention of COPD .