COPD is obstructive lung disease arising from common COPD causes like smoking. Timely COPD diagnosis and treatment can save from complications like lung cancer.

Chronic Obstructive Pulmonary Disease (COPD)

Humza Khizer

Overview

A disease state characterized by the presence of airflow limitation due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperreactivity, and may be partially reversible<a href="#accordion">[4]</a>.

Chronic obstructive pulmonary disease (COPD) is a blanket term that covers emphysema and chronic bronchitis. Having one or both of these conditions falls under COPD.&nbsp;

Emphysema is the result of damage that occurs to an individual&rsquo;s air sacs (alveoli), which leads to the destruction of the walls inside and causes them to converge into a single big air sac. This means that the individual&rsquo;s lungs stretch more than the normal size, affecting their elasticity. Damaged alveoli also affect the lungs&rsquo; ability to absorb oxygen. Therefore, the air gets trapped in the lungs and the individual can feel difficulty in breathing, resulting in less oxygen reaching the bloodstream.

&nbsp;

Chronic bronchitis leads to the loss of an important structure present in an individual&rsquo;s bronchial tubes called cilia. Cilia is a hair-like structure that is present inside the bronchial tubes and its main function is to move the mucus out. So, with chronic bronchitis leading to the loss of cilia, an individual has difficulty getting rid of mucus. This results in increased shortness of breath and coughing that in turn creates even more mucus. 
&nbsp;

Chronic Obstructive Pulmonary Disease (COPD) is a blanket term that covers Emphysema and Chronic Bronchitis. Having one or both of these conditions falls under COPD.&nbsp;Emphysema is a result of damage that occurs to an individual’s lungs’ air sacs (alveoli) which leads to the destruction of the walls inside and causes them to converge into a single big air sac. This means that the individual’s lungs stretch more than the normal size and affect their elasticity. Damaged alveoli also affect the lungs’ ability to absorb oxygen therefore the air gets trapped in the lungs and the individual can feel difficulty in breathing also resulting in less oxygen reaching the bloodstream.Chronic bronchitis leads to losing an important structure present in an individual’s bronchial tubes called Cilia. Cilia is a hair-like structure that is present inside the bronchial tubes and its main function is to move the mucus out. So, with chronic bronchitis leading to the loss of cilia, an individual has difficulty in getting rid of mucus which results in increased shortness of breath and coughing that in turn creates even more mucus.

Signs And Symptoms

Chronic obstructive pulmonary disease can be categorized into two broad stages: 
&nbsp;

<h5>Mild COPD</h5>

During this initial stage of the disease, the patient faces inflammation of the peripheral airways. However, a prominent airway wall neutrophilia is not present in mild COPD. 
&nbsp;

<h5>Severe COPD</h5>

During this stage, the individual develops an airway wall neutrophilia, and there is a predominant lesion on the parenchymal destruction. The other general symptoms with mild COPD increase in severity for the individual and so do their effects on the health of the individual. Another prominent feature of severe COPD is pulmonary hypertension, which represents a major predictive factor of hospitalization for acute exacerbation of the disease<a href="#accordion">[5]</a>. 
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Causes

Chronic obstructive pulmonary disease is mainly caused by air particles and affects the lungs and breathing system. To date, three main causes have been identified: 
&nbsp;

<h5>Smoking&nbsp;</h5>

The smoke emitted by cigarettes contains high levels of reactive oxygen species with 1014 free radicals per inhaled puff. This leads to processes such as lipid peroxidation, neutrophil sequestration, inactivation of antiproteases, and transcription of stress-related genes<a href="#accordion">[2]</a>.

These ROS (Reactive Oxygen Species) induced by high levels of cigarette smoking cause critical damage in the airway epithelial cells, and other airways as well as the alveoli. Also, the leakage of ROS causes drastic effects outside the lungs too. Hence, making smoking a leading cause of COPD.

Moreover, cigarette smoking causes an inflammatory process in the central airways, peripheral airways, and lung parenchyma as mentioned by several studies. Smokers also have an increased number of macrophages and T lymphocytes as compared to non-smokers, and that is an indication of increased chances of COPD disease. Moreover, smokers also have increased inflammation in their alveolar walls which correlates with increased parenchymal destruction<a href="#accordion">[5]</a>.

Furthermore, studies have also shown a high level of significant correlation between lung inflation and destruction around both peripheral airways, the overall parenchyma, and loss of elastic recoil pressure in the lungs of the individuals who smoked. This also shows how smoking plays a crucial role in the inflammation of the airway, Therefore, there is a lack of elasticity in the lungs of individuals who smoke.&nbsp; 
&nbsp;

<h5>Toxic Fumes</h5>

Exposure to different chemicals and a variety of toxic fumes have been shown to cause COPD. Certain types of chemicals damage the lungs and alveoli which in turn results in a higher risk of COPD. The substances that have been linked to COPD by the National Health Service of the UK are the following: 
&nbsp;

<ul>
	<li>Cadmium dust and fumes</li>
	<li>Grain and flour dust</li>
	<li>Silica dust</li>
	<li>Welding fumes</li>
	<li>Isocyanates</li>
	<li>Coal dust 
	&nbsp;</li>
</ul>

<h5>Genetics</h5>

The complex interplay of environment and genetics can be appreciated in COPD. For example, a smoker who has close relatives with COPD is at a higher risk of developing the disease in the future. This also suggests that smoking is the primary cause too.

Certain genetic conditions increase susceptibility to developing COPD, e.g., an estimated 1 in 100 people who develop COPD have a condition called alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin enzyme plays a crucial role in the protection of the lungs for any individual. Therefore, this deficiency makes individuals more prone to lung damage and developing COPD. 
&nbsp;

Diagnosis

Diagnosing COPD starts with identifying certain symptoms in the individual followed by conducting some tests. Doctors will start by reviewing the medical history of the individual, and then go over certain factors of exposure to risk factors of COPD, such as the individual&rsquo;s exposure to firsthand or secondhand smoke, exposure to toxic fumes and dust or air pollutants, and other relevant questions. The common symptoms doctors look for are the following: 
&nbsp;

<ul>
	<li>Chronic cough</li>
	<li>Shortness of breath in daily tasks (dyspnea)</li>
	<li>Frequent respiratory infections</li>
	<li>The blueness of the lips or fingernail beds (cyanosis)</li>
	<li>Fatigue</li>
	<li>Production of excess mucus (also called phlegm or sputum)</li>
	<li>Wheezing 
	&nbsp;</li>
</ul>

After the identification of symptoms and the history of the individual, the doctors can conduct certain tests, and these include:&nbsp; 
&nbsp;

<ul>
	<li>Lung (Pulmonary) Function Tests:&nbsp;These are the most common type of tests conducted for diagnosing COPD in individuals. They are used by doctors to measure the amount of air that can be inhaled and exhaled by the individual&nbsp;and then measures whether the lungs deliver a sufficient amount of oxygen to the bloodstream or not. One of the widely conducted tests is the spirometry test. In this test, the subject blows air in a large tube that is connected to a small machine at the end. This machine then measures how much air the subject&rsquo;s lungs can hold, and the speed of air blown out from the lungs. Some other tests conducted also include measuring the volume of the lungs and the diffusing capacity.&nbsp; 
	&nbsp;</li>
	<li>Chest X-Ray:&nbsp;This test can detect emphysema in the chest of the individual which is a cause of COPD. Chest X-rays also help doctors to rule out other heart and lung-related diseases to offer an accurate diagnosis for COPD. 
	&nbsp;</li>
	<li>Computed Tomography Scan (CT Scan):&nbsp;A Computed Tomography scan, commonly known as a CT scan, of the lungs, helps determine the presence or absence of diseases such as emphysema. In complicated cases, ruling diseases out helps in confirming the diagnosis of COPD for patients.&nbsp; 
	&nbsp;</li>
	<li>Arterial Blood Gas Analysis:&nbsp;This test is conducted to measure the ability of the lungs of individuals in bringing oxygen into the bloodstream&nbsp;and remove carbon dioxide from the bloodstream. Weak lung strength as presented in the arterial blood gas analysis can indicate the possibility of COPD in patients. 
	&nbsp;</li>
	<li>Laboratory Tests:&nbsp;These tests are usually used to determine genetic factors for COPD such as the identification of genetic conditions that increase the risk for COPD such as the genetic disorder alpha-1-antitrypsin deficiency. 
	&nbsp;</li>
</ul>

Treatment

There are several methods used by healthcare professionals to minimize and treat the symptoms of COPD, which include the following: 
&nbsp;

<ul>
	<li>Quitting Smoking: The first and the most crucial step to treat COPD is to quit smoking as the negative effects of smoking on the lungs and its correlation with COPD have been mentioned above. Cigarettes are one of the most addictive substances and it is difficult to quit smoking for most users. Therefore, doctors often prescribe nicotine replacement products such as nicotine patches and other medications which help the individual handle relapses. To quit smoking, having a healthy support group is known to help many people as well as avoid spaces with cigarettes.&nbsp; 
	&nbsp;</li>
	<li>Lung Therapies: Two main types of lung therapies are done for patients suffering from mild or severe COPD. These include oxygen therapy and pulmonary rehabilitation programs. Oxygen therapy means that there is a lack of oxygen in the bloodstream and a supply of oxygen is provided to that individual. Certain devices are used in this process, and modern development in technology has led to some devices being portable and easy to carry by the individual. Oxygen therapy is also proven to extend the life expectancy of patients with COPD. Therefore, this is a popular form of treatment. The second type of lung therapy is a pulmonary rehabilitation program that includes a combination of education and integration of healthy lifestyle choices, such as incorporating or improving an exercise routine and increasing the intake of nutritious food. In this program, a multidisciplinary approach is offered to the COPD patient.&nbsp; 
	&nbsp;</li>
	<li>In-Home Ventilation Therapy: As suggested by the name this treatment does not take place in the hospital or clinic but in the comfort of one&rsquo;s own home. The machine used in this therapy comes with a mask which is used by COPD patients to help improve their breathing&nbsp;and reduce hypercapnia (increase in partial pressure of carbon dioxide (PaCO2) above 45 mmHg), a leading cause of respiratory failure in patients. 
	&nbsp;</li>
	<li>Surgery: This is a form of treatment that is used by individuals who face severe COPD and medications have not proven to be effective. There are several options for surgery and these include lung volume reduction surgery, lung transplant, and bullectomy. The lung volume reduction surgery includes the removal of wedges of lung tissues that are not healthy and are damaged in the upper part of the lungs. This leads to the creation of extra space in the chest cavity, resulting in much more space for the healthy lung tissue to grow and expand, allowing the diaphragm to work more effectively. Moreover, a lung transplant is needed in cases of severe damage. However, this comes with certain risks such as organ rejection which can result in complications after the transplant. The third type of surgery is bullectomy, a procedure that is used to treat the large air spaces created in the lungs due to damaged alveoli in COPD patients. This is done by the removal of these bullae (air pockets) which are a major cause of breathing problems. Thus, a successful bullectomy leads to improved breath flow for the individual.&nbsp; 
	&nbsp;</li>
	<li>Medications: Several types of medications are prescribed to treat and minimize the symptoms of COPD. These medications include bronchodilators. Bronchodilators usually come in the form of inhalers, and they are used to relax the muscles around the patient&rsquo;s airways. This makes breathing for COPD patients easier as there is relief from cough and shortness of breath, the most common symptoms of COPD. Bronchodilators can be divided into two main categories called short-acting bronchodilators and long-acting bronchodilators. The prescription depends on the severity of the conditions and other factors. Some examples of short-acting bronchodilators are - Albuterol (ProAir HFA, Ventolin HFA, others), Ipratropium (Atrovent HFA), and Levalbuterol (Xopenex). Whereas, some examples of long-acting bronchodilator medications are Aclidinium (Tudorza Pressair), Arformoterol (Brovana), Formoterol (Perforomist), Indacaterol (Arcapta Neoinhaler), Tiotropium (Spiriva), Salmeterol (Serevent), and Umeclidinium (Incruse Ellipta). 
	&nbsp;</li>
	<li>Inhaled Steroids: These can be used to reduce airway inflammation. The use of inhaled steroids helps prevent exacerbations in COPD patients. Examples of inhaled steroids are Fluticasone (Flovent HFA) and Budesonide (Pulmicort Flexhaler). 
	&nbsp;</li>
	<li>Combination Inhalers: These are the combination of some bronchodilators and inhaled steroids. Examples of combination inhalers that are used to treat COPD are Fluticasone and Vilanterol (Breo Ellipta); Fluticasone, Umeclidinium, and Vilanterol (Trelegy Ellipta); Formoterol and budesonide (Symbicort); Salmeterol and Fluticasone (Advair HFA, AirDuo Digihaler, others). 
	&nbsp;</li>
	<li>Oral Steroids: These are mostly used to treat the symptoms faced by patients who suffer from severe COPD for short courses of time. For example, 4-5 days of oral steroids may prevent further suffering caused by severe COPD. On another note, long-term use of these medications can have negative consequences for the users such as weight gain, diabetes, and increased risk of infection.&nbsp; 
	&nbsp;</li>
	<li>Phosphodiesterase-4 inhibitors: This is a type of medication that has been approved for people who exhibit signs of severe COPD. The medication leads to a decrease in the inflation of airways and relaxes it. 
	&nbsp;</li>
	<li>Theophylline: This is a much more cost-effective treatment used for treating COPD. This improves breathing, reduces cough, and prevents COPD from worsening.&nbsp; 
	&nbsp;</li>
	<li>Antibiotics: These are used to treat the symptoms of respiratory infections, including acute bronchitis and influenza that can exacerbate COPD. Examples of such antibiotics include azithromycin (Zithromax), which prevents the worsening of COPD symptoms. 
	&nbsp;</li>
</ul>

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Developing COPD can lead to a wide range of complications for the individual and this includes, but is not limited to, the following: 
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Respiratory Infections:&nbsp;People suffering from COPD have a greater chance to catch colds and flu. This means that other respiratory infections can worsen the already prevalent symptoms, such as difficulty breathing and coughing.

Heart Problems: The development of COPD also increases the risk of heart diseases in the individual, such as heart attack.&nbsp;

<a href="https://merisehat.pk/disease/lung-cancer-67">Lung Cancer</a>: People who have COPD also have a high risk of developing lung cancer due to the damage incurred by the lungs from the underlying disease.

<a href="https://merisehat.pk/disease/hypertension-57">High Blood Pressure</a>: COPD also increases risk of pulmonary hypertension (high blood pressure in the lung arteries which transport blood to the lungs).&nbsp;

<a href="https://merisehat.pk/disease/depression">Depression</a>: Depression<a href="https://www.merisehat.pk/disease/depression" target="_blank"> </a>is not a direct complication caused by COPD, but an indirect one. This means that COPD symptoms, such as shortness of breath, prevents the individuals from taking part in various social and physical activities. Therefore, resulting in isolation along with feelings of loneliness and hopelessness, which can indirectly lead to depression in the COPD patients. 
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There are several risk factors for COPD, including the following mentioned below: 
&nbsp;

<ul>
	<li>Exposure To Smoke: Exposure to tobacco smoke either through active or passive smoking is the number one risk factor in the development of COPD in any individual. This smoke can be from a numerous range of sources such as cigarettes, hookah pipes, cigars, etc. However, all of these exposures especially long-term exposure to tobacco smoke can lead to a high risk of COPD. 
	&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/asthma">Asthma</a>: This is another risk factor for COPD as people who suffer from asthma have a greater risk of developing COPD, as a result of their high sensitivity to different factors. Therefore, asthma combined with tobacco smoke can result in an even higher risk of developing COPD. 
	&nbsp;</li>
	<li>Exposure To Toxic Fumes: Long-term exposure to toxic fumes, chemicals, and dust is also known to be a major risk factor in the development of COPD. This can occur due to the nature of the job for different individuals. For example, a person working in a coal mine as a miner will have a higher risk of developing COPD than a banker. These toxic fumes disturb the inflow of clean air and oxygen in the body and irritate the lungs through the inhaling of toxic fumes. Moreover, in urban areas, the citizens are exposed to air contaminated by fumes of burning fuel from cars, homes, and other places such as factories. This increases the risk of developing COPD proving that people living in densely populated cities have a higher exposure to fumes in the air. Therefore, they are at a higher risk of developing COPD. 
	&nbsp;</li>
	<li>Genetics: As mentioned in the causes genetics also play a role in developing risk factors for COPD. One common genetic disorder that is found in patients with COPD is called alpha-1-antitrypsin deficiency. 
	&nbsp;</li>
</ul>

Certain diseases have many directions that are required to be followed to prevent them from occurring however in the case of COPD the preventive measures as very simple.&nbsp;

As the major cause of the disease is cigarette smoke then the best preventive measure is to not smoke or quit smoking if one does smoke at present. Quitting smoking is easier said than done but as mentioned previously in the treatments, there are many resources available for tobacco use that help them in quitting cigarettes such as nicotine patches and less unhealthy options such as vape pens. Moreover, there are support groups available along with therapy that aids in quitting cigarettes in the long run and prevents relapses for the users.&nbsp;&nbsp;

Furthermore, the people who have to face toxic fumes in their jobs can take certain steps to decrease this such as talking with the management about protective masks and materials that help the workers decrease their exposure to the chemicals damaging the lungs and causing COPD. 
&nbsp;

There has been extensive research on COPD which has led to the development of better diagnostic procedures and treatments. Interestingly, recent research has shed light on even more surprising facts about the disease, leading to an increase in our knowledge about COPD. Starting with diagnosis, the most common form of diagnosing has been a test called spirometer as discussed previously. However, this method is known to be ineffective in detecting COPD in its earlier stages. But a recent study has found a new technique called parametric response mapping. This test could identify early damage in bronchioles, which are small airways. Parametric response mapping involves using a computerized tomography (CT) scan to measure inhalation and exhalation<a href="#accordion">[1]</a>. Through this breakthrough in the research of COPD, doctors will soon be able to spot the damages present in the small airways in the lungs of patients resulting in the early detection and diagnosis of COPD. 
&nbsp;

To date, smoking was considered the main culprit behind COPD. However, some people were not smokers and spent no time in the company of smokers, and yet they developed COPD. Statistics show that 1 out of every 4 patients with COPD has never smoked a cigarette in their life. Recent research has shown some possible reasons behind this. For example, a recent study done in 2019 by the European Respiratory Journal, found that people who have high exposure to air pollution in their surroundings were at a higher risk of developing COPD in the future. Researchers suggested that pollution damaged the lungs to a great extent and was a risk factor for the development of COPD. Not only this but a study conducted in 2020 by Columbia University studied 6500 adults in JAMA and they concluded that people with smaller airways were at high risk for developing COPD and this has no correlation with the smoking status of the individual.&nbsp; 
&nbsp;

Another recent development by the latest research done by a Danish team in the Thorax Journal suggested that being physically fit during middle age is negatively correlated with developing COPD in individuals. Furthermore, the study suggested that people who suffered from COPD but had a healthier lifestyle and good fitness habits in their 40s lived an estimated 1.5 to 2 years longer than patients with COPD who did not. This study also proves that exercise and having a healthy nutritious diet can decrease the possibility of lung and heart diseases for an individual and even if they end up with chronic diseases such as COPD, the path to treatment and life expectancy is much higher for them. 
&nbsp;

Key Points

Chronic obstructive pulmonary disease sounds scary and overwhelming to go through. However, there are only a few simple things related to this disease that should be kept in mind:

<ul>
	<li>COPD affects the lungs of individuals and the most common symptoms are shortness of breath in daily tasks, excessive production of mucus, and cough.</li>
	<li>The leading cause of COPD is smoking cigarettes, and being exposed to toxic fumes and chemicals.&nbsp;</li>
	<li>The risk of contracting COPD can significantly be reduced by avoiding exposure to smoke and toxic fumes.&nbsp;</li>
	<li>There is a wide range of treatments available for COPD which include different types of medications, lung therapies, and surgeries.</li>
	<li>A healthy lifestyle including not smoking, daily exercise, and having healthy meals is known to decrease the chances of COPD. 
	&nbsp;</li>
</ul>

[1] Dragoş M. Vasilescu, F. J. (2019). Noninvasive Imaging Biomarker Identifies Small Airway Damage. American Journal of Respiratory and Critical Care Medicine, 575-581.

[2] E-J.D. Oudijk, J.-W. L. (2003). Systemic inflammation in chronic obstructive pulmonary disease. European Respiratory Journal, 5-13.

[3] MARINA SAETTA, G. T. (2001). Cellular and Structural Bases of Chronic Obstructive. American Journal of Respiratory and Critical Care Medicine, 1304-1309.