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Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a term referring to two lung diseases, chronic bronchitis and emphysema, that are characterized by obstruction to airflow that interferes with normal breathing. Both of these conditions frequently co-exist, hence physicians prefer the term COPD. It does not include other obstructive diseases such as asthma.

  • COPD is the fourth leading cause of death in America, claiming the lives of 127,049 Americans in 2005 and the number of women dying from the disease has surpassed the number seen in men.
  • This is the fifth consecutive year in which women have exceeded men in the number of deaths attributable to COPD. In 2005, almost 66,000 females died compared to 61,000 males.
  • Smoking is the primary risk factor for COPD. Approximately 80 to 90 percent of COPD deaths are caused by smoking. Female smokers are nearly 13 times as likely to die from COPD as women who have never smoked. Male smokers are nearly 12 times as likely to die from COPD as men who have never smoked. Any current or former smoker over age 40 or never-smoker with a family history of COPD, emphysema or chronic bronchitis, those with exposure to occupational or environmental pollutants and those with a chronic cough, sputum (matter discharged from air passages) production or breathlessness, should seek testing for COPD with spirometry.
  • Other risk factors of COPD include exposure to air pollution, second-hand smoke and occupational dusts and chemicals, a history of childhood respiratory infections and heredity. Particulate matter from cigarette smoke and air pollution, including smoke from poorly ventilated wood stoves and the burning of biomass, are related to lung damage.
  • Occupational exposure to certain industrial pollutants also increases the risk for COPD. One study found that the fraction of COPD attributed to work was estimated as 19.2% overall and 31.1% among never smokers.
  • In 2006, 12.1 million U.S. adults (aged 18 and over) were estimated to have COPD. However, close to 24 million U.S. adults have evidence of impaired lung function, indicating an under diagnosis of COPD.
  • An estimated 721,000 hospital discharges were reported in 2005; a discharge rate of 24.4 per 100,000 population. COPD is an important cause of hospitalization in our aged population. Approximately 65% of discharges were in the 65 years and older population in 2005.
  • A Lung Association survey revealed that half of all COPD patients (51%) say their condition limits their ability to work. It also limits them in normal physical exertion (70%), household chores (56%), social activities (53%), sleeping (50%) and family activities (46%).
  • In 2007, the cost to the nation for COPD was approximately $42.6 billion, including $26.7 billion in direct health care expenditures, $8.0 billion in indirect morbidity costs and $7.9 billion in indirect mortality costs.
  • Chronic bronchitis is the inflammation and eventual scarring of the lining of the bronchial tubes. When the bronchi are inflamed and/or infected, less air is able to flow to and from the lungs and a heavy mucus or phlegm is coughed up. The condition is defined by the presence of a mucus-producing cough most days of the month, three months of a year for two successive years without other underlying disease to explain the cough.
  • This inflammation eventually leads to scarring of the lining of the bronchial tubes. Once the bronchial tubes have been irritated over a long period of time, excessive mucus is produced constantly, the bronchial tubes lining thickens, an irritating cough develops, air flow may be hampered, and the lungs become scarred. The bronchial tubes then make an ideal breeding place for bacterial infections within the airways, which eventually impedes airflow.
  • In 2006, an estimated 9.5 million Americans reported a physician diagnosis of chronic bronchitis. Chronic bronchitis affects people of all ages, although people aged 65 years or more have the highest rate at 60.9 per 1,000 persons.
  • Females are over twice as likely to be diagnosed with chronic bronchitis as males. In 2006, 2.9 million males had a diagnosis of chronic bronchitis compared to 6.6 million females.
  • Symptoms of chronic bronchitis include chronic cough, increased mucus, frequent clearing of the throat and shortness of breath.
  • Chronic bronchitis does not strike suddenly and is often neglected by individuals until it is in an advanced state as people mistakenly believe that the disease is not life-threatening. By the time a patient goes to their health care provider the lungs have frequently been seriously injured. Then the patient may be in danger of developing serious respiratory problems or heart failure.
  • Emphysema begins with the destruction of air sacs (alveoli) in the lungs where oxygen from the air is exchanged for carbon dioxide in the blood. The walls of the air sacs are thin and fragile. Damage to the air sacs is irreversible and results in permanent “holes” in the tissues of the lower lungs. As air sacs are destroyed, the lungs are able to transfer less and less oxygen to the bloodstream, causing shortness of breath. The lungs also lose their elasticity, which is important to keep airways open. The patient experiences great difficulty exhaling.
  • Emphysema does not develop suddenly. It comes on very gradually. Years of exposure to the irritation of cigarette smoke usually precede the development of emphysema. Of the estimated 4.1 million Americans ever diagnosed with emphysema, 93 percent are 45 or older.
  • Men are 68% more likely than women to receive a diagnosis of emphysema. In 2006 almost 2.5 million men has emphysema (23.4 per 1,000 population) compared to almost 1.6 million women (13.9 per 1,000 population).
  • Symptoms of emphysema include cough, shortness of breath and a limited exercise tolerance. Diagnosis is made by pulmonary function tests, along with the patient’s history, examination and other tests.
  • Alpha1 antitrypsin deficiency-related (AAT) emphysema is caused by the inherited deficiency of a protein called alpha1-antitrypsin (AAT) or alpha1-protease inhibitor. AAT, produced by the liver, is a “lung protector.” In the absence of AAT, emphysema is almost inevitable. It is responsible for 5% or less of the emphysema in the United States.
  • An estimated 100,000 Americans, primarily of northern European descent, have AAT deficiency emphysema. Another 20 million Americans carry a single deficient gene that causes Alpha-1 and may pass the gene onto their children.
  • A recent study suggested that there are at least 116 million carriers among all racial groups, worldwide.
  • Symptoms of AAT deficiency include shortness of breath and decreased exercise capacity. They rarely appear before 25 years of age and sometimes never develop, mostly in nonsmokers. In those who smoke, symptoms occur between 32 and 41 years of age on average. Smoking significantly increases the severity of emphysema in AAT-deficient individuals.
  • Blood screening is primarily used to diagnose whether a person is a carrier or AAT-deficient. In addition, a DNA-based cheek swab test has been recently developed for the diagnosis of AAT-deficiency.

COPD Treatment

  • Emphysema and chronic bronchitis often co-exist in COPD. The quality of life for a person suffering from COPD diminishes as the disease progresses. At the onset, there is minimal shortness of breath. People with COPD may eventually require supplemental oxygen and may have to rely on mechanical respiratory assistance.
  • Aggressive treatment efforts can and should be employed in the early stages of COPD. Smoking cessation is the single most effective – and cost effective – intervention to reduce the risk of developing COPD and slow its progression.
  • COPD lung damage is irreversible, but there are treatments that can improve a patient’s quality of life. Pharmacologic treatment can improve and prevent symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve the ability to exercise.
  • Bronchodilator medications (prescription drugs that relax and open air passages in the lungs) are central to the symptomatic management of COPD. They can be inhaled as aerosol sprays or taken orally. Inhaled or oral steroids are used to help decrease inflammation in the airways in some people. Antibiotics are often used to treat infections. Expectorants are sometimes used to help clear mucus from the airways.
  • The efficacy of inhaled glucocorticosteroids in modifying long-term decline in lung function continues to be under study, however short-term benefit has been demonstrated. Corticosteroids have been shown to decrease cardiovascular and lung cancer deaths and the frequency of exacerbations. Chronic treatment with systemic steroids involves the risk of serious side effects; therefore these are used mostly for acute exacerbations. Use of inhaled steroids has been shown to increase the risk of pneumonia among those with COPD.
  • If children are diagnosed as AAT-deficient through blood screening, they may undergo a liver transplant. A second treatment alternative is administration of the missing AAT protein. AAT replacement therapy is costly however, and it must be given intravenously, on a weekly basis, for life. Its long-term effects are still being studied.
  • Non-pharmacologic treatment such as pulmonary rehabilitation, oxygen therapy, and surgical interventions can improve a person’s quality of life. One factor that can help protect against COPD development or its progression is physical activity, which can help slow lung function decline.
  • Pulmonary rehabilitation is a preventive health-care program provided by a team of health professionals to help people cope physically, psychologically, and socially with COPD.
  • The long-term administration of oxygen (>15 hours per day) to patients with chronic respiratory failure increases survival and has a beneficial impact on exercise capacity, lung mechanics, and mental state. Close to one million persons living in the U.S. are on long-term oxygen therapy.
  • Lung transplantation is now being performed and may be a more readily available option in the future.
  • Lung volume reduction surgery (LVRS) is an operation in which a portion of the most severely damaged lung tissue is removed in order to ease the burden on the remaining tissue and chest muscles. The procedure has been shown to help with a number of limitations and symptoms related to COPD and that these effects are long lasting.
  • In August 2003, the Centers for Medicare and Medicaid Services (CMS) announced that they intend to cover LVRS for people with non-high risk severe emphysema who meet certain criteria. CMS decided that LVRS is “reasonable and necessary” only for qualified patients that undergo therapy before and after the surgery. CMS is currently composing accreditation standards for LVRS facilities and will use these standards to determine where the surgery will be covered.