Chronic Obstructive Pulmonary Disease (COPD) is not one single disease but an umbrella term used to describe chronic lung diseases that cause limitations in lung airflow. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis.
Oxygen goes to the body through nose,mouth or both. Airways in the lungs look like upside down tree with many branches, air travels in the trachea/windpipe. this divides into two smaller breathing tubes or bronchi (left leads to left lung vv) bronchi further to bronchioles, and bronchioles end in tiny air sacs called alveoli
Alveoli/air sacs surrounded by network of blood vessels called capillary. Oxygen from alveoli diffuses in capillary then circulates to rest of body. CO2 diffuses from capillary to alveoli, eventually expelled when people exhale, (GAS EXCHANGE)
Chronic bronchitis: swelling narrowing of large and small airways/breathing tubes Emphysema - damage of air sacs or alveoli, losing elasticity of the lungs Damage in the lungs cannot be reversed. there is no cure for COPD. Stopping smoking can only slow down progression of disease, but wont be able to make the lungs normal again
These symptoms eventually limit the person's activities and sometimes make them unable to do simple things by themselves (eating, going to bathroom, grooming).
Mortality data also underestimate COPD as a cause of death because the disease is more likely to be cited as a contributory than as an underlying cause of death, or may not becited at all
Total deaths from COPD are projected to increase by more than 30% in the next 10 years without interventions to cut risks, particularly exposure to tobacco smoke.
Globally, tobacco use tends to be higher among groups with less education and less income. Poorer households spend greater percentage of income on tobacco than wealthier ones, usually children suffer most. 25% of household income spent on tobacco and given priority over food, clothing, health and educ.
COPD is a leading cause of mortality worldwideand projected to increase in the next several decades. In the US and Canada, COPD mortality for bothmen and women have been increasing. In the US in 2000, the number of COPD deathswas greater among women than men.
COPD is preventable. The primary cause of COPD is tobacco smoke (including second-hand or passive exposure). Other risk factors include:
occupational dusts and chemicals (vapors, irritants, and fumes); frequent lower respiratory infections during childhood.
Changes in small airways in COPD patients. The airway wall is thickened and infiltrated with inflammatory cells, predominately macrophages and CD8+ lymphocytes, with increased numbers of fibroblasts. In severe COPD there are also lymphoid follicles. The lumen is often filled with an inflammatory exudate and mucus. There is peribronchial fibrosis and airway smooth muscle may be increased, resulting in narrowing of the airway.
Changes in the lung parenchyma in COPD patients. There is loss of elasticity and alveolar wall destruction, and accumulation of inflammatory cells, predominantly macrophages and CD8+ lymphocytes. The destructive changes reduce the pulmonary capillary bed. The left panel shows a scanning electron micrograph of a patient with emphysema demonstrating the enlargement of alveoli and destruction of the alveolar walls.
Air trapping in COPD. During expiration small airways narrow but closure is prevented by the elasticity of alveolar attachments. In COPD patients there is a loss of elasticity with greater narrowing in small airways, which may close completely when there is loss of alveolar attachments as a result of emphysema. This results in air trapping and hyperinflation, leading to dyspnea and reduced exercise capacity.
Stopping smoking and avoiding harmful particles (pollution, dust, cooking and heating fumes) Bronchodilators: medicine widen the breathing tubes Antiinflamatory drugs : reduce swelling in breathing tubes Antibiotcs: treat infection
Spirometry should be performed after the administration of an adequate dose of a short- acting inhaled bronchodilator to minimize variability.
spirometry as the gold standard for accurate and repeatable measurement of lung function FEV 1 – Forced expired volume in the first second FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV 1 /FVC% - The ratio of FEV 1 to FVC, expressed as a percentage.
Non Communicable Diseases: COPD
COPD WHAT IS IT?
Definition of COPDCOPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.Its pulmonary component is characterized by airflow limitation that is not fully reversible.The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.
Disease Trajectory ofPatients with COPD Symptoms Exacerbations Exacerbations Deterioration Exacerbations End of Life
SYMPTOMS• The most common symptoms of COPD are breathlessness, or a need for air, excessive sputum production, and a chronic cough.• Others include wheezing, tiredness and chest tightness• However, COPD is not just simply a "smokers cough", but a under-diagnosed, life threatening lung disease that may progressively lead to death.• COPD develops slowly, it may take years before shortness of breath is noticed. Most of the time, COPD diagnosed among middle aged people 40 years old above
EPIDEMIOLOGY• According to the latest WHO estimates (2004), currently 64 million people have COPD and 3 million people died of COPD.• Prevalence and morbidity data greatlyunderestimate the total burden of COPD because the disease is usually not diagnosed until it is clinically apparent and moderately advanced.• In the Philippines, COPD is one of the 10 leading cause of death (DOH)
BURDEN• COPD is a leading cause of morbidity and mortality worldwide and results in an economicand social burden that is both substantial and increasing.• The burden of COPD is projected to increase in the coming decades due to continued exposure to COPD risk factors and the changing age structure of the world’s population.• Most of the information available on COPD prevalence, morbidity and mortality comes from high- income countries. Even in those countries, accurate epidemiologic data on COPD are difficult and expensive to collect. It is known that almost 90% of COPD deaths occur in low- and middle-income countries.
BURDEN• At one time, COPD was more common in men, but because of increased tobacco use among women in high-income countries and the higher risk of exposure to indoor air pollution (such as biomass fuel used for cooking and heating) in low-income countries, the disease now affects men and women almost equally.• In 2002 COPD was the fifth leading cause of death. Total deaths from COPD are projected to increase by more than 30% in the next 10 years unless urgent action is taken to reduce the underlying risk factors, especially tobacco use. Estimates show that COPD becomes in 2030 the third leading cause of death worldwide.
Burden of Tobacco Use• WB estimates in 1993 that global net social cost of smoking was US$200B each year. This huge economic burden is now shifting from developed to developing countries.• About 75% of todays tobacco users live on developing countries. By 2030, estimates are developing countries shall account to 70% of all tobacco deaths.• In Vietnam, tobacco spending 1.5x higher than education, 5x higher than health expenditure. Even homeless children in India spent significant portion of income purchasing tobacco.
Burden of Tobacco Use• In India, 1M die every year due to tobacco related diseases.• In the Philippines, researchers estimate total annual cost of illness for just four smoking related diseases - cerebrovascular diseases, coronary artery disease, COPD, and lung cancer - at US$2B, while real costs may be as high as US$6.05B each year.
Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970Source: Jemal A. et al. JAMA 2005
COPD Mortality by Gender, U.S., 1980-2000Number Deaths x 1000 70 60 50 Men 40 Women 30 20 10 0 1980 1985 1990 1995 2000 Source: US Centers for Disease Control and Prevention, 2002
COPD Mortality by Gender U.S., 1999-2006Between 1999and 2006,death rates forCOPD havedeclined amongU.S. men.There has beenno significantchange amongdeath ratesamong U.S.women. Source: US Centers for Disease Control and Prevention, 2011
Risk Factors for COPD Genes Lung growth and Exposure to particles development Tobacco smoke Oxidative stress Occupational dusts, Gender organic and Age inorganic Indoor air pollution Respiratory from heating and infections cooking with biomass Socioeconomic in poorly ventilated status dwellings Nutrition Outdoor air pollution Comorbidities
MANAGEMENT• An effective COPD management plan includes four components: – (1) assess and monitor disease; – (2) reduce risk factors; – (3) manage stable COPD; – (4) manage exacerbations.
Changes in Small Airways in COPD Patients Inflammatory exudate in lumen Disrupted alveolar attachments Thickened wall with inflammatory cells - macrophages, CD8+ cells, fibroblasts Peribronchial fibrosis Lymphoid follicle Source : Peter J. Barnes, MDPathogenesis, Pathology, Pathophysiology
Changes in the Lung Parenchyma in COPD Patients Alveolar wall destruction Loss of elasticity Destruction of pulmonary capillary bed ↑ Inflammatory cells macrophages, CD8+ lymphocytesSource : Peter J. Barnes,
Air Trapping in COPD Normal Mild/moderate Severe COPD COPDInspiration small airway alveolar attachments loss of elasticity loss of alveolar attachmentsExpiration closure ↓ Health Dyspnea Air trapping status ↓ Exercise capacity Hyperinflation Source : Peter J. Barnes,
DIAGNOSIS AND TREATMENT• COPD is confirmed by a simple diagnostic test called "spirometry" that measures how much air a person can inhale and exhale, and how fast air can move into and out of the lungs. Because COPD develops slowly, it is frequently diagnosed in people aged 40 or older.• COPD is not curable. Various forms of treatment can help control its symptoms and increase quality of life for people with the illness. For example, medicines that help dilate major air passages of the lungs can improve shortness of breath.
COPD and Co-morbiditiesCOPD patients are at increased risk for: • Myocardial infarction, angina • Osteoporosis • Respiratory infection • Depression • Diabetes • Lung cancer • Extrapulmonary (systemic) effects: Weight loss, Nutritional abnormalities, Skeletal muscle dysfunction
Diagnosis of COPD EXPOSURE TO RISK SYMPTOMS FACTORS cough tobacco sputum occupationshortness of breath indoor/outdoor pollution SPIROMETRY
Physical signs• Large barrel shaped chest (hyperinflation)• Prominent accessory respiratory muscles in neck and use of accessory muscle in respiration• Low, flat diaphragm• Diminished breath sound
Spirometry: Normal and Patients with COPDDiagnosisAssessing severityAssessing prognosisMonitoring progression
Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failureSPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.
Therapy at Each Stage of COPDI: Mild II: Moderate III: Severe IV: Very Severe Add long term oxygen if chronic respiratory failure. Consider surgery Add inhaled glucocorticosteroids if repeated exacerbations Add regular treatment with one or more long- acting bronchodilators* (when needed); Add rehabilitationActive reduction of risk factor(s); influenza vaccinationAdd short-acting bronchodilator (when needed) * ß2- agonists, anticholinergics and methylxanthines
LIMITATIONS1. The limited reach of individual and small group programs;2. Low penetration of programs to some segments of the population; and3. The desire to develop programs to achieve change in populations.
National collaborative approach to tobacco control issues,nominating a range of government, non-government andcommunity partnerships and linkages, under six keystrategy areas: • Strengthening community action • Promoting cessation of tobacco use • Reducing availability and supply of tobacco • Reducing tobacco promotion • Regulating tobacco; and • Reducing exposure to environmental tobacco smoke
– Agenda Setting– Increasing the salience of tobacco control issues– Facilitating acceptance of tobacco control policy initiatives to achieve structural change– Behaviour change– Increased preparedness to quit– Prompting quit action– Prompting supportive action for quitters– Providing reinforcement for ex-smokers and never smokers.
ANTI- TOBACCO INDUSTRY• Quit campaigns • Fragmented• Health departments - infrastructure State/Territory and • Cooperative rather than Commonwealth coordinated approach• Cancer councils • Limited funding• National Heart • Smokers targeted Foundation through multiple• Action on Smoking and approaches with varying Health research to support• Peak medical bodies• Quitline• Pharmaceutical companies
% of smokers 10,0 20,0 30,0 40,0 50,0 60,0 0,0 R U S G EO C H N AR G G ER PH I AU T SU I PO L C ZE BR A KO R N ED JP N M E X SY RCountry U SA U K PO R N O R R SA Percent of Smokers M A L IT A KG Z TH A AU S C AN SW E SI N
In Asia, most men smoke1) CHN 70,2 %2) RUS 63,0 %3) GEO 57,5 %4) SYR 46,0 %5) JPN 43,3 %6) KGZ 41,4 %
In Europe, most women smoke1) BRA 30,0 %2) RUS 30,0 %3) NED 28,0 %4) CZE 28,0 %5) GER 28,0 %6) AUT 26,0 %
Warning labels on cigarette packs Are available in all surveyed countries! But: No COPD warning in most countries!Except: NOR, CZE, USA, CAN, JPN, THA, AUS, RSA
Smoking can damage health• Is known throughout all countries• But smoke of indoor heating and cooking with biomass fuels is not recognized to be harmful!
Awareness in % 0,0 100,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 ITA NOR NED SWE AUS AUT GER CAN POL SUI CZE UK USA JPN CHNCountry THA SYR PHI MAL POR BRA KGZ GEO RSA RUS MEX Awareness of COPD is low in public ARG SIN KOR
Patients don’t seek help• Smokers showing symptoms of COPD like – Coughing, – Sputum production – Shortness of breath• Smokers do not relate these signs to smoking or COPD• And do not seek medical treatment
GPs generally do not diagnose ortreat COPD• The awareness of COPD among GPs is quite high• The opinion of the interviewed ICC members revealed that only few GPs would diagnose COPD• As a consequence, GPs do normally not treat COPD• Only in Austria, Italy, The Netherlands and Canada, more than 80 % of GPs will diagnose and treat COPD
% of GPs with spirometer 0 10 20 30 40 50 60 70 80 90 KO R AU T AU S SU I PO L G ER C AN JP N N ED U K M E X PO R N O R SW E SI N AR GCountry IT A U SA R SA R U S PH I M A L C ZE BR A TH A C H N KG Z G EO Most GPs do not have access to spirometry SY R
Not in all countries treatment costs willbe covered by health insurances •In most of the developed countries, health insurances •No full coverage in Mexico, Argentina, Brazil, Russia, •Large population can’t afford treatment
Huge information about COPD isavailable• In nearly all surveyed countries COPD patient organizations exist• Guidelines for diagnosis and treatment exist• The GOLD guidelines are mainly known by specialists• Many GPs don’t know the GOLD guidelines or don’t follow them
Biggest Unmet Needs• Awareness among patients about disease and risk factors (e.g. smoking)• Lack of smoking cessation programs• More anti-smoking campaigns are needed (TV etc.)• Need for a better approach to prevention and treatment of cigarette smoking• Lack of early diagnosis• Huge number of undiagnosed/untreated COPD patients• Diagnosis among GPs (spirometry needed)• Differentiation between asthma and COPD unclear to many GPs• Treatment algorithms are not followed/known by GPs• No proper disease management by GPs• Lack of rehabilitation facilities• Funding of all drugs needed for treatment• Lack of lung specialists• More access to oxygen therapy• Governmental programs to fight COPD
Public• Percentage of smokers is too high• More effective anti-smoking campaigns are needed• Raise public awareness of COPD• Drive patients with symptoms to GPs• Enable smoking cessation programs
Physicians• Increase knowledge regarding diagnosis, treatment and management of COPD among GPs• Follow GOLD guidelines• Spirometry is needed• More rehabilitation centres needed• More specialists needed
Government• Increase coverage for medical treatment• Make medications available for poor patients• Smoking bans in public areas needed• COPD labeling on cigarette packs needed
Environment: Behavioral: Economic Smoking Cessation Diagnosis (Spirometric confirma Health seeking transport and work Rehabilitation PolicyDepression/ helplessness Healthcare organization diet tobacco physical activity COPD Access to Support groups Govt/ Community Programs Education/ Advertising Medication Availability Non Modifiable: Age, Sex, Genes
Further Readings• Global Initiative for Chronic Obstructive Lung Disease. Spirometry for Healthcare Providers. (2007)• Manual of Pulmonary Function Testing. Gregg l. Ruppel. Ninth Edition.• Interpretation of Pulmonary Function Tests. Robert E. Hyatt. Second Edition• Burden of Obstructive Lung Disease (BOLD) and participated in by the COPD Foundation of the Philippines and the COPD Council of the Philippine College of Chest Physicians