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Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease
(COPD)
COPD is one of the leading causes of illness and deaths
in the world. It is estimated that there are currently over
280 million cases globally. The number of COPD cases is
projected to rise in the near future, owing to increased exposure
to risk factors and population ageing.
What is COPD?
COPD is characterised by airflow limitation. The airflow limitation
is usually associated with an abnormal inflammatory
response of the lungs to particles and gases which irritate
them. Significant airflow blockage may be present before
the person is aware of it. COPD is also a preferred term for
patients with airflow obstruction who were previously diagnosed
as having chronic bronchitis or emphysema.
Risk factors of COPD
Tobacco smoke
COPD is more common in smokers and ex-smokers than
in non-smokers. The age at which a person started smoking,
the number of years they have been a smoker and their
current smoking status all play a role.
Cannabis
Smoking cannabis (dagga) is associated with a dose-related
airflow blockage. One cannabis joint is equivalent to 2.5
to 5 tobacco cigarettes.
Occupational dusts and chemicals
Occupational dust and chemical exposure is another cause
of COPD. The National Health and Nutrition Examination
Survey (NHANES III) of almost 10 000 adults estimated
that the percentage of COPD caused by the type of jobs
COPD sufferers had was 19% overall and 31% among individuals
who had never smoked.
Indoor air pollution
The burning of biomass and fossil fuels (wood, animal dung,
crop residues and coal) in open fires or poorly functioning
stoves in poorly aired spaces leads to very high levels of
indoor air pollution.
Outdoor air pollution
Outdoor air pollution, mainly from motor vehicles and
smoke from bush and forest fires, is associated with loss
of lung function.
Infections
Childhood respiratory infections are associated with reduced
lung function in adults. Several studies have shown
that previous lung tuberculosis may lead to COPD. Additionally,
viral and bacterial infections may worsen the progression
of COPD.
Socio-economic status
The presence of COPD is higher among lower socioeconomic
groups, most likely as a result of increased exposure
to smoking, indoor and outdoor air pollution, vulnerability to
infections and poor nutrition.
Nutrition
The role of nutrition in the development of COPD is not
clear. Severe malnutrition, however, has been associated
with emphysema.
In this issue of CMScript we focus on Chronic Obstructive Pulmonary Disease or COPD.
Medical schemes are required to fund the prescribed minimum benefits or PMBs
highlighted in the Medical Schemes Act. COPD is one of the PMBs and must be
covered by medical aids. Medical cover for COPD includes diagnosis,
treatment and care of the condition.
CMScript Member of a medical scheme?
Know your guaranteed benefits!
Issue 2 of 2014
The patient will experience:
• breathlessness on exertion;
• chronic progressive dyspnoea (difficulty in breathing);
• chronic cough with or without mucous production;
• frequent winter ‘bronchitis’ (inflammation or swelling of
the bronchial tubes);
• wheezing (whistling sound during breathing).
One of the primary symptoms of COPD is progressive and
persistent breathlessness.
The following may also be present:
• weight loss;
• inability to be active;
• waking at night;
• ankle swelling;
• fatigue;
• occupational hazards;
• chest pain;
• haemoptysis (coughing up blood).
However, chest pain and coughing up blood are not common
in COPD and so could be as a result of other diseases
or illnesses.
Diagnosis of COPD
COPD should be considered in patients over the age of 35
who have smoked for more than 10 years. There is no single
diagnostic test for COPD. Making a diagnosis relies on
clinical judgement based on a combination of history, physical
examination and confirmation of the presence of airflow
obstruction. COPD may sometimes be misinterpreted as
asthma. Below is a guide for differentiating between COPD
and asthma.
Features suggesting COPD
• a long history of smoking or exposure to other risk factors;
• persistent difficulty in breathing, wheezing and productive
cough despite treatment;
• slow progression;
• hyperinflation (excessive expansion) of the lungs;
• abnormal spirometry (breathing tests) that persist during
a stable phase of the disease;
• cyanosis (blue or purple colouration of the skin or mucous
membranes).
Features that suggest asthma
• young age when breathing difficulties begin;
• presence of atopy (genetic predisposition to allergies)
and/or allergic rhinitis (inflammation of the inside of the
2
http://whatiscopdsymptoms.com/156/common-symptoms-copd/
What are the signs and symptoms of COPD?
nose caused by allergens);
• day-to-day variation, variation during the day and seasonal
variability;
• marked improvement in lung function after a bronchodilator
(medication that helps open the lungs and
airways) and/or a two-week trial of treatment with systemic
steroids.
Additional considerations in the diagnosis of asthma
and COPD
• asthma and COPD may co-exist, and distinguishing
them may be difficult;
• breathlessness occurs late in COPD;
• asthmatics who smoke may have an accelerated decline
in lung function.
Tests to confirm the presence of COPD
• Spirometry
This is a test done using an apparatus called spirometer
to measure how much air is taken in and breathed out by
the lungs.
The test is essential for the detection, assessment and
management of patients with COPD. Spirometry should
be done before a patient is given puffs of medicines called
short-acting beta-2 agonist bronchodilators like salbutamol,
fenoterol or terbutaline. The test should be repeated 20
minutes after giving the medicine.
Measurements used in the diagnosis of COPD are
forced expired volume in one second (FEV1), forced vital
capacity (FVC) and FEV1/FVC percentage pre-and postbronchodilator.
Vital capacity refers to the maximum
amount of air a person can breathe out
from the lungs after a maximum inhalation.
The FEV1 is usually reduced, that is, less
than 80% of the predicted value, and is used
as a measure of the severity of the condition. If
FEV1 is more than 80% of the predicted value, a
diagnosis of COPD should only be made in the
presence of respiratory symptoms, for example
breathlessness or a cough. An improvement in
FEV1 more than or equal to 12% from baseline
and more than or equal to 200 ml indicates
considerable reversibility compatible with asthma but also
seen in many patients with COPD. Generally, the improved
results demonstrate the likelihood that the diagnosis may
be asthma, taking into consideration other symptoms and
signs.
Further investigations
During the initial medical evaluation,
the following are done in
addition to spirometry:
• a chest x-ray to exclude
other abnormalities;
• a full blood count to identify
anaemia or polycythaemia
(increase in the total red cell
mass);
• a body mass index (BMI)
calculation.
Additional investigations
• CT scan of the chest
– to investigate symptoms that
seem inconsistent with the
spirometric results;
– to investigate abnormalities
seen on a chest X-ray;
– to assess appropriateness
for surgery.
• Echocardiogram – to assess cardiac status if there are
features of cor pulmonale (right sided heart failure)
• Pulse oximetry – to assess need for oxygen therapy
• Sputum culture – to identify micro-organisms if sputum
(mucous) is persistently present and purulent (contains
pus)
3
www.nlm.nih.gov
Treatment
The aim is to alleviate breathlessness and improve effort
tolerance. The following methods of treatment are used for
COPD:
Inhaled short-acting beta-2 agonists (SA BA)
These work quickly; examples include Salbutamol, Fenoterol
and Terbutaline.
Inhaled long-acting beta-2 agonists (LA BA)
These are Salmeterol and Formoterol. LA BAs improve
symptoms, reduce worsening of the disease, reduce the
need for rescue therapy and improve exercise capacity.
Formoterol may also be used as a relief treatment because
it works quickly.
Combination of inhaled corticosteroids (ICS) and LA
BAs
Inhaled corticosteroids, particularly in combination with LA
BAs, have been shown to improve lung function and quality
of life.
Inhaled anti-cholinergics
Anticholinergic agents are effective bronchodilators for
COPD to relieve constriction of the airways. Tiotropium may
be used as a first-line, long-acting bronchodilator treatment
in COPD or may be used in combination with LA BAs. Ipratropium
bromide may be prescribed for relief from symptoms.
Nebuliser treatment
This is an alternative for Stage 3 and 4 patients with poor
inhalation technique and/or acute dyspnoea (shortness of
breath). Nebulised Ipratropium plus beta-2 agonists can be
used.
Combination bronchodilator treatment
The following combinations are effective:
• short-acting beta-2 agonists + Ipratropium;
• long-acting beta-2 agonists + Ipratropium;
• long-acting anti-cholinergic + short-acting beta-2
agonists;
• long-acting anti-cholinergic + long-acting beta-2
agonists.
Oral theophylline may be added to any combination of inhaled
treatment.
Theophyllines
Theophyllines have similar bronchodilator effects to beta-2
agonists and improve quality of life.
Oral corticosteroids
Oral corticosteroids are no longer recommended for stable
COPD. Low-dose oral corticosteroids only cause small improvements
in lung function. Higher doses (≥30 mg/d) are
associated with improvements in lung function but also
with major side-effects that include high blood pressure,
hyperglycaemia (high blood sugar) and osteoporosis (bone
disease).
Mucolytics and mucokinetic agents
Coughing up persistent mucous is a distressing symptom.
Unfortunately, the effectiveness of mucolytics, mucokinetic
drugs, cough syrups and acetylcysteine (oral and inhaled)
has not been proven, and therefore these are not recommended.
Newer phosphodiesterase inhibitors
Phosphodiesterase inhibitors such as Roflumilast have
been shown to be effective in phase III clinical trials but are
not yet registered for use in South Africa.
4
What are the stages of COPD?
Stages of COPD (FEV1/FVC <70%)
SAMJ 2011:66
Chest physiotherapy
A cough may be improved by instruction from a physiotherapist,
who plays an important role in advising on breathing
and coughing techniques.
Venesection/phlebotomy
An increased haematocrit (volume of red blood cells in the
blood) causes aggravation of cardiac failure, increased
abnormal breathing and an increased incidence of blood
clots. Therapeutic venesection (drawing of blood) should
be considered as this can keep the volume of red blood
cells in the normal range.
Long-term oxygen therapy (LTOT)
Oxygen is administered by facemask or nasal cannula device
for a total of at least 16 hours per 24-hour day at a
flow rate of 1 to 2 litres/minute. Oxygen can be delivered by
oxygen concentrators or by cylinders. With these systems,
patients do not have to be confined to their homes.
Lung surgery
The following surgical techniques can improve lung function
and symptoms of COPD:
• A bullectomy may be performed to decompress adjacent
lung tissue if there are large, localised bullae (bubbles).
• Lung volume reduction surgery – this is where parts
of the lung are removed to reduce hyperinflation. This
is an alternative to lung transplantation in patients with
severe inhomogeneous emphysema who continue to
suffer from symptoms despite the best medical treatment
plan.
• Lung transplantation – this approach may be used in
patients with diffuse severe emphysema, but access to
transplantation is very limited in South Africa. Its effect
on survival after two years remains controversial.
Pulmonary rehabilitation
Pulmonary rehabilitation is a multidisciplinary programme
of care for patients with chronic respiratory impairment to
improve a patient’s physical and social performance and
independence.
What is covered under PMBs for COPD?
Medical aid cover includes diagnosis, treatment and care
if you have COPD. According to the Chronic Disease List
(CDL), all patients should stop smoking, avoid irritants and
have an annual influenza immunisation.
The doctor may prescribe the treatment as follows:
It is important for the doctor to register the condition with the
scheme so that benefits for treatment can be paid as PMB.
The scheme must make provision beyond the drugs listed
on its CDL in cases where the medication on the CDL
does not work for the member or causes harm.
Confirm with your medical scheme about the diagnostic
tests covered for the condition and how many per year
they cover before the investigations are done. This is important
because the scheme is allowed to limit the number
and types of tests covered per year. If the doctor deems it
necessary for additional tests to be done, the doctor should
write a clinical motivation to the scheme for payment for the
tests to be considered as PMB.
Prevention and care
Stop smoking
Encouraging patients with COPD to stop smoking is one of
the most important components of management.
Vaccination and anti-viral therapy
Pneumococcal vaccination and an annual influenza vaccination
should be offered to all patients with COPD as recommended
by the doctor.
Nutritional factors
The normal range for body mass index (BMI) is 20 to less
than 25. BMI should be calculated in patients with COPD:
• if the BMI is abnormal (high or low), or changing over
time, the patient should be referred for dietetic advice;
• if the BMI is low, patients should also be given nutritional
supplements to increase their total intake of calories
and be encouraged to exercise to enhance the effects
of nutritional supplementation.
References
Abdool-Gaffar MS, Ambaram A, Ainslie GM, Bolliger CT,
Feldman C, Geffen L, Irusen EM , Joubert J, Lalloo UG,
Mabaso TT, Nyamande K, O’Brien J, Otto W, Raine R, Richards
G, Smith C, Stickells D, Venter A, Visser S & Wong M.
2011. Guideline for the management of chronic obstructive
pulmonary disease. South African Medical Journal 101 (1):
61 – 73.
D’Urzo AD, Tamari I, Bouchard J, Jhirad R & Jugovic P.
2011. New spirometry interpretation algorithm: Primary
Care Respiratory Alliance of Canada approach. Canadian
Family Physician (57): 1148-52.
National Institute for Health and Care Excellence. 2010.
Chronic obstructive pulmonary disease: Management of
chronic obstructive pulmonary disease in adults in primary
and secondary care (partial update). Clinical guideline 101.
United Kingdom: London. From: http:/www.guidance.nice.
org.uk/cg101 (accessed 15 April 2013).
http://www.nlm.nih.gov (accessed 16 April 2013)
Rodney Ehrlich R & Jithoo A. Chronic respiratory diseases
in South Africa. Cape Town: Medical Research Council.
From: http://www.mrc.ac.za/chronic/cdlchapter11.pdf (accessed
17 April 2013)
http://whatiscopdsymptoms.com/156/common-symptomscopd/
(accessed 17 April 2013)
Prescribed minimum benefits (PMBs) are defined by law.
They are the minimum level of diagnosis,treatment, and
care that your medical scheme must cover – and it must
pay for your PMB condition/s from its risk pool and in full.
There are medical interventions available over and above
those prescribed for PMB conditions but your scheme may
choose not to pay for them. A designated service provider
(DSP) is a healthcare provider (e.g. doctor, pharmacist,
hospital) that is your medical scheme’s first choice when
you need treatment or care for a PMB condition. You can
use a non-DSP voluntarily or involuntarily but be aware
that when you choose to use a non-DSP, you may have
to pay a portion of the bill as a co-payment. PMBs include
270 serious health conditions, any emergency condition,
and 25 chronic diseases; they can be found on our website
by accessing the link provided
(www.medicalschemes.com/medical_schemes_pmb/index.
htm).
PMBs
The Communications Unit would like to thank Kate
Kgasi for assisting with this edition of CMScript.
information@medicalschemes.com
Hotline: 0861 123 267
Fax: 012 430 7644
The clinical information furnished in this article is
intended for information purposes only and professional
medical advice must be sought in all instances
where you believe that you may be suffering from a
medical condition. The Council for Medical Schemes
is not liable for any prejudice in the event of any
person choosing to act or rely solely on any information
published in CMScript without having sought the
necessary professional medical advice.