Chronic Obstructive Pulmonary Disease (COPD) – Reading & Sharing

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States. It is highly prevalent, and as it progresses, causes patients to become too disabled to work, thus creating substantial economic and social burdens. In 2010, U.S. healthcare data estimated the total economic burden from COPD at $50 billion, of which $30 billion was related to direct medical expenditures and the remaining $20 billion related to morbidity, loss of work, and premature death. There are also unacknowledged and unquantified costs including the economic value of care provided by family members and their potential lost wages as they stay home to care for the patient.

As the disease progresses, some patients will choose mechanical ventilation as a palliative treatment option. although the patient with advanced disease is eligible for hospice care, many hospices cannot afford to accept the patient with mechanical ventilation into their programs because this high-tech intervention drives the cost of care beyond the standard insurance reimbursement. Thus, patients and families may be deprived of the benefits of hospice care.

Pathophysiology:

Cigarette smoking is the leading cause of COPD in industrialized countries, and environmental pollutants are important causes in developing countries. Interactions between environmental factors, socioeconomic status, and a genetic predisposition to COPD may render individuals more prone to COPD than others. Irritants deposited in the lower respiratory tract from cigarette smoke or pollutants and the resulting histopathological responses produce alveolar wall destruction (emphysema) and mucus hypersecretion (chronic bronchitis). Smoking cessation slows but does not appear to halt the inflammatory process in the airways suggesting that there are perpetuating mechanisms once there is inflammation.

Over time, the person with COPD develops a chronic cough. Sputum changes in volume, tenacity, and purulence result in a decline in pulmonary function. Many patients experience weight loss and fatigue because their shortness of breath makes eating difficult. The lungs become hyperinflated, which produces an increased anterior-posterior thoracic diameter (barrel-chest), retrosternal airspace, bullae, and hilar vascular prominence. Hypoxemia, hypercarbia, and reduced peak expiratory flow rate develop.

Advanced-stage disease is characterized by a continued decline in respiratory status, decreased ability to complete activities of daily living (ADLs), and frequent emergency department visits or hospital admissions for acute exacerbations. In addition, right-sided heart failure and atrial arrhythmias often develop due to increased pulmonary pressure, leading to subsequent enlargement of the right ventricle and atria. Due to higher death rates with comorbid conditions, it is important to note that patients with COPD often have significant associated chronic disease which increase morbidity and mortality. Reliabile prediction of a survival interval of less than 6 months is not possible with existing tools or guidelines.

“When” to initiate advanced care planning?

• forced expiratory volume in 1 sec less than 30%, oxygen dependence
• one or more acute exacerbation COPD hospital admissions in the past 12 months
• weight loss or cachexia
• decreased functional status
• increased dependence on others
• age >70
• lack of additional therapeutic options

Conventional COPD treatments:

• Inhaled therapy
  • Inhaled bronchodilator therapy: metered-dose inhalers and spacers, dry powder inhalers, or wet nebulizers
  • The inhaler technique should be assessed to ensure that a patient is able to use a device effectively.
  • The combination of a long-acting anticholinergic with an as-needed short-acting beta-agonist is a standard initial approach.
  • For many patients with advanced COPD, the addition of a combination inhaler containing a long-acting beta-agonist and an inhaled corticosteroid to a long-acting anticholinergic agent provides benefits in terms of symptom management and quality of life.

• Systemic therapy
  • Theophyllines (Theo-24, Elixophyllin)
    • Has been shown to have beneficial anti-inflammatory effects and can reduce oxidative stresses that are increasingly recognized as a feature of COPD.
    • ***side effects continue to be an issue and the adverse effects often outweigh the benefits for many patients. Risks of toxicity through interactions with some antibiotics also pose potential limitations to their use and the need to monitor blood levels can be especially difficult for the many patients who are housebound as a result of their advanced disease.
  • Phosphodiesterase 4 (PDE4) inhibitors
    • Have been shown to reduce key inflammatory cells and mediators, but they do not have bronchodilator properties and their effect on patients’ perception of dyspnea is modest at best.
    • The most commonly reported adverse effects including diarrhea, nausea, headache, and weight loss. The potential for gastrointestinal toxicity suggests that the PDE4 inhibitors should be used with caution in cachectic patients.
  • Corticosteroids
    • Systemic steroids are not recommended for long-term use due to negative side effects and lack of compelling data demonstrating significant benefit.
      • Common side effects:
        • Oral corticosteroids: fluid retention, swelling in lower extremities; high blood pressure; problems with mood swings, memory, behavior, and other psychological effects, such as confusion or delirium; upset stomach; weight gain with fat deposits in your abdomen, face, and the back of the neck. (long term used may also experience elevated pressure in eyes; clouding of the lens in one or both eyes; mood face; high blood sugar, increased risk of infections especially with common bacterial viral and fungal microorganisms; thinning bones and fx; suppressed adrenal gland hormone production that may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness; thin skin, bruising, and slower wound healing.
        • Inhaled corticosteroids may also experience oral thrush and hoarseness
• Oxygen therapy
  • In acute exacerbations of COPD
    • Common symptoms of COPD: worsening shortness of breath, increased cough (with or without increased sputum production), change in sputum colors, wheeze, chest tightness, fatigue, decreased appetite, and for some, change in mood.
  • Long-term oxygen therapy for hypoxaemic COPD
  • supplemental oxygen for the mildly hypoxaemic patient

COPD symptom burden related to dyspnea- Dyspnea and fear coexist

• Fear, anxiety, depression, and panic, are common in advanced COPD, when unrecognized, underestimated, and untreated, can cause overwhelming “dyspnea crises” the occurrence of which may be adding to the fear of death when dyspnea worsens.
• Dyspnea Crises are defined in a recent American Thoracic Society consensus statement as a sustained and severe resting breathing discomfort that occurs in patients with advanced often life-limiting illness and overwhelms the patient and caregivers’ ability to achieve symptom relief.
  • Anxiolytics seem relatively unhelpful in the management of dyspnea, but may be useful for treating coexisting anxiety that can worsen dyspnea
  • a start low goes slow titration schedule for opioids, an approach supported by recent clinical trial data is suggested.

Fear of prescribing and administering opioids and /or benzodiazepines in terminal dyspnea for palliative sedation often occurs because of the 2 reasons:

1. Clinicians recognize the possibility of respiratory depression as an adverse effect
2. Clinicians fear the appearance of hastening death.

Additionally, given the current opioid epidermic, clinicians are reluctant to prescribe opioids for non-pain-related symptoms. Respiratory depression was not found in any of the studies that comprised the systematic review of opioid benefit. Results of these studies suggest that prudent administration of opioids and sedatives beginning with low doses and titrating to patient effect do not hasten death. Withholding opioids and sedatives in the face of unrelieved respiratory distress is a moral breach as patients have the right to relief from suffering.

Psychosocial Problems with COPD

As mentioned above, patients with COPD have a high prevalence of generalized anxiey disorder, depression, and panic disorder compared to the general population. Prior to the terminal stage, antidepressant therapy, particularly SSRIs may alleviate anxiety and reduce panic disorder. However, therapeutic effects are often not seen until 2-4 weeks after treatment initiation; thus, benzodiazepines may be the most useful agent to reduce psychological symptoms associated with acute dyspnea. Even when treatment with an antidepressant is adequate, benzodiazepines may still be necessary, particularly during acute exacerbations.

And as COPD progresses, the increasing pulmonary disability leads to a number of detrimental effects. Frustration and fatigue were identified as commonly shared experiences of patients living with COPD. Functional disabilities produce difficulty in previously “taken for granted” activities of daily living, such as bathing, bending ot tie shoelaces, and leaving the house. Patients are often concerned about their image if they must use a wheelchair or wear oxygen in public, causing some to stay home, which can eventually lead to social isolation.