Chronic Obstructive Pulmonary Disease (COPD)

What is COPD?

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.

The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, and a chronic cough. However, COPD is not just simply a "smoker's cough", but a under-diagnosed, life threatening lung disease that may progressively lead to death.

Main risk factors for COPD

• Tobacco smoking
• Indoor air pollution (such as biomass fuel used for cooking and heating)
• Outdoor air pollution
• Occupational dusts and chemicals (vapors, irritants, and fumes)

In high income countries, COPD is growing as a cause due to increased tobacco use.

Smoking

The primary cause of chronic obstructive pulmonary disease (COPD) is tobacco smoke (including second-hand or passive exposure).

• Tobacco kills up to half of its users.
• Tobacco kills nearly 6 million people each year. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030.
• Nearly 80% of the world's one billion smokers live in low- and middle-income countries.

Other risk factors

The causes for COPD have opposite patterns according to the geographic areas. In high- and middle-income countries tobacco smoke is the biggest risk factor, meanwhile in low-income countries exposure to indoor air pollution, such as the use of biomass fuels for cooking and heating, causes the COPD burden.

Almost 3 billion people worldwide use biomass and coal as their main source of energy for cooking, heating, and other household needs. In these communities, indoor air pollution is responsible for a greater fraction of COPD risk than smoking or outdoor air pollution. Biomass fuels used by women for cooking account for the high prevalence of COPD among nonsmoking women in parts of the Middle East, Africa and Asia. Indoor air pollution resulting from the burning of wood and other biomass fuels is estimated to kill two million women and children each year.

Other risk factors for COPD include occupational dusts and chemicals (such as vapors, irritants, and fumes) and frequent lower respiratory infections during childhood. According to WHO estimates, 65 million people have moderate to severe chronic obstructive pulmonary disease (COPD). More than 3 million people died of COPD in 2005, which corresponds to 5% of all deaths globally. 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.

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 Diagnosis of COPD.

Spirometry

Spirometry is a simple and painless test which measures the capacity of your lungs. A chronic obstructive pulmonary disease (COPD) diagnosis is confirmed by a simple test called spirometry, which measures how deeply a person can breathe and how fast air can move into and out of the lungs.

Symptoms

Diagnosis of COPD should be considered in any patient who has symptoms of a chronic cough, sputum production, dyspnea (difficult or labored breathing) and a history of exposure to risk factors for the disease.

Where spirometry is unavailable, clinical symptoms and signs, such as abnormal shortness of breath and increased forced expiratory time, can be used to help with the diagnosis. A low peak flow is consistent with COPD, but may not be specific to COPD because it can be caused by other lung diseases and by poor performance during testing.

Chronic cough and sputum production often precede the development of airflow limitation by many years; although not all individuals with cough and sputum production go on to develop COPD. Because COPD develops slowly, it is most frequently diagnosed in people aged 40 years or over. COPD 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.

The goals of effective COPD management are to:

1. Prevent disease progression
2. Relieve symptoms
3. Improve exercise tolerance
4. Improve health status
5. Prevent and treat complications
6. Prevent and treat exacerbations
7. Reduce mortality

In selecting a treatment plan, the benefits and risks to the individual and the costs, direct and indirect, to the community must be considered. Patients should be identified before the end stage of the illness, when disability is substantial. However, the benefits of spirometric screening, of either the general population or smokers, are still unclear. Educating patients and physicians to recognize that cough, sputum production, and especially breathlessness are not trivial symptoms is an essential aspect of the public health care of this disease.

Component 1: Assess and monitor disease

• Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms
• Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea
• For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation. FEV1/FVC less than 70% and a post bronchodilator FEV1 < 80% predicted confirms the presence of airflow limitation that is not fully reversible
• Health care workers involved in the diagnosis and management of patients with COPD should have access to spirometry
• Measurement of arterial blood gas tensions should be considered in all patients with FEV1 less than 40% predicted or clinical signs suggestive of respiratory failure or right heart failure

Component 2: Reduce risk factors

• Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD
• Smoking cessation is the single most effective and cost-effective way to reduce the risk of developing COPD and stop its progression. Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to a health care provider
• Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment
• Several effective pharmacotherapies for tobacco dependence are available, and at least one of these medications should be added to counseling if necessary and in the absence of contraindications
• Progression of many occupationally induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases

Component 3: Manage stable COPD

• The overall approach to managing stable COPD should be characterized by a stepwise increase in treatment, depending on the severity of the disease
• For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation
• None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease. Therefore, pharmacotherapy for COPD is used to decrease symptoms and complications
• Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms
• The principal bronchodilator treatments are 2-agonists, anti cholinergics, theophylline, and a combination of one or more of these drugs
• Regular treatment with inhaled glucocorticosteroids should only be prescribed for symptomatic patients with COPD with a documented spirometric response to glucocorticosteroids or for those with an FEV1 less than 50% predicted and repeated exacerbations requiring treatment with antibiotics or oral glucocorticosteroids
• Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio
• All patients with COPD benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue
• The long-term administration of oxygen (less than 15 h per day) to patients with chronic respiratory failure has been shown to increase survival.

Component 4: Manage exacerbations

• Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD
• The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of approximately one-third of severe exacerbations cannot be identified
• Inhaled bronchodilators (particularly inhaled 2-agonists or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for treatments for acute exacerbations of COPD
• Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, or fever) may benefit from antibiotic treatment

WHO Activities

WHO is committed to fighting the global tobacco epidemic. The WHO Framework Convention on Tobacco Control entered into force in February 2005. Since then, it has become one of the most widely embraced treaties in the history of the United Nations with 178 Parties covering 89% of the world's population. The WHO Framework Convention is WHO's most important tobacco control tool and a milestone in the promotion of public health. It is an evidence-based treaty that reaffirms the right of people to the highest standard of health, provides legal dimensions for international health cooperation and sets high standards for compliance.

In 2008, WHO introduced a practical, cost-effective way to scale up implementation of provisions of the WHO Framework Convention on the ground: MPOWER. Each MPOWER measure corresponds to at least one provision of the WHO Framework Convention on Tobacco Control.

The 6 MPOWER measures are:

1. Monitor tobacco use and prevention policies
2. Protect people from tobacco use
3. Offer help to quit tobacco use
4. Warn about the dangers of tobacco
5. Enforce bans on tobacco advertising, promotion and sponsorship
6. Raise taxes on tobacco.

Source: World Health organization