Chronic obstructive pulmonary disease, or COPD, is a mixture of conditions, usually asthma, chronic bronchitis and emphysema.
“When you hear the term COPD, you think of smokers, but that is not always true,” said Dr. John Harrison of Baptist Pulmonary and Critical Care Associates. According to the American Lung Association, approximately 85 percent to 90 percent of COPD deaths are caused by smoking.
Harrison said a woman in her 60s might come into his office short of breath. She has been sedentary and never stressed herself, so she is surprised to learn from a pulmonary function test that she has a bad obstructive defect that does not reverse. It could be COPD.
“In general, anyone who currently smokes, has COPD in their family or has previous premature obstructive lung disease is more prone to develop COPD,” said Harrison.
Physicians should screen patients who may be susceptible to COPD. “If a patient has Alpha 1-antitrypsin deficiency, it is a familial problem, and you should test those people and their children,” said Harrison.
It is also wise to test anyone who develops shortness of breath on exertion, coughs or wheezes. Most family doctors have spirometers in their office and use them to determine evidence of airflow obstruction, which is often seen in obstructive lung disease and COPD.
“You have your physical signs, X-ray signs and pulmonary function tests, which are easy to read,” Harrison said. “If the patient has an FEX1 ratio of less than 70, that is an obstructive defect.”
Most physician offices also have a pulse oximeter to look at oxygen saturation. “I order blood gases when I suspect someone is significantly impaired,” said Harrison. “I want to know what is going on with the carbon dioxide level.”
The gold criterion is a staging of COPD. The actual ratio for FEZ1 mild COPD is 80 percent. Stage two is moderate or a ratio between 50 percent and 80 percent. Stage three is severe; the obstructive ratio is between 30 percent and 50 percent. Stage four is very severe, or less than 30 percent.
“Doctors should be doing more simple spirometries on people with minor complaints because those are the people who do not want to tell anyone they are short of breath with activities,” Harrison said. “They just cut activities down, do less and tolerate it until they cannot [tolerate it any longer], and then they tell somebody.”
There is hope for people with COPD. “While they will not get back to normal because some airways will not recover, they will improve,” said Harrison.
Physicians have a number of medications from which to choose when designing a treatment plan for COPD. They are primarily using short- and long-acting bronchodilators to treat COPD. Patients need a long-acting combination product and short-acting agents for rescue. “Under those areas there is what we call beta-agonists. You also have inhaled steroids and oral steroids,” said Harrison. “There is an argument about the use of inhaled steroids in patients with COPD.”
The best thing patients can do for COPD is stop smoking. Doctors should continue to ask the patient if he or she is smoking even if the patient says he or she has quit because there is a high recurrence rate of COPD. The physician can recommend help lines and counseling from the American Cancer Society and the American Lung Association. Patients may also benefit from nicotine replacement, NicoDerm patches or inhalers and other medications that will help them stop smoking.
For smoking cessation, choices include “quit-smoking” programs, oral medications and cutaneous patches. Diaban was the first oral medication used for smoking cessation; it is basically an anti-depressant known as wellbutrin. Chantix is another oral mediation that is now widely prescribed. Its side effect profile should be carefully considered.
Physicians need to follow COPD patients incrementally. “I think it is important to check pulmonary-function studies once a year and watch the pattern of loss or lack of loss,” said Harrison. If the physician sees the FEZ1 drop faster than expected, he or she may intensify the therapy. On the other hand, Harrison said therapy could be reduced if the patient is stable and never has problems.
The physician may discover it is not necessary to use both a long-acting inhaled beta-agonist and a long-acting beta-adrenergic, so the treatment may utilize one of them while the patient is encouraged to watch the frequency of his or her exacerbations over time.
Physicians should listen to the patient’s complaints, do a thorough physical examination with emphasis on auscultation of the lungs and then order screening tests such as a chest X-ray, oxygen saturation and pulmonary function tests. If the diagnosis is not clear or if there is a question about therapy, the patient should be referred to a pulmonary specialist.
By Jamie Lober, Staff Writer