Up to 300,000 people may suffer from COPD in Ireland, but why is this disease relatively unknown?
FIVE YEARS ago I saw a 58-year-old patient in my clinic who had been referred for evaluation of breathlessness. She had recently found that climbing inclines had become difficult for her. She had stopped smoking 20 cigarettes a day 10 years previously.
One of her big fears related to her sister who had died from a lung disease which required her to use oxygen and resulted in her being housebound prior to her death. The patient was understandably concerned that she was heading in the same direction.
Following investigations, including spirometry, a measure of lung function, I was able to tell her that she had COPD or Chronic Obstructive Pulmonary Disease. This was met with the lack of comprehension often seen in patients told they have this diagnosis. The alternative explanation that COPD used to be referred to as chronic bronchitis and emphysema was greeted with the concern usually associated with the word emphysema.
So what is COPD? It is a chronic or long-term illness of the lungs associated with narrowing of the airways, predominantly, though not always, caused by cigarette smoking. The damage to the lungs is not completely reversible, but usually there is some reversible component. If undiagnosed, it can advance to where the patient suffers progressive shortness of breath.
Patients are susceptible to acute deterioration in their symptoms often associated with infections leading to what are known as exacerbations. Such exacerbations cause the patient to require medical attention and frequent admission to hospital.
COPD is not rare. In Ireland, 110,000 people are diagnosed with it and perhaps 200,000 more have the disease undiagnosed. Many of these have milder forms of the disease, but some can have advanced disease without knowing it.
About 12,000 patients a year are admitted to hospital spending an average of 10 days each there. The group of patients with the most severe form of the disease often require frequent readmissions. This more severe group can be incapacitated with shortness of breath and a minority will require long-term oxygen. Most patients need a combination of inhalers and tablets.
Why is there so little public recognition in Ireland of a disease with such a big footprint? The first problem relates to the name. COPD is quite a mouthful and is the modern name for what has been previously called chronic bronchitis, emphysema or “smoker’s asthma”.
The confusion with asthma is most common. Asthma is a different lung disease occurring more frequently, though not exclusively, in younger people and requires different treatment. Understandably, there is confusion among doctors and patients in differentiating between asthma and COPD. A disease that is sometimes difficult for even healthcare professionals to define is going to have a problem with name recognition.
COPD develops gradually and patients may believe this is part of the ageing process. We start off with a large reservoir of lung function which smokers puff away as they progress through life. Patients present when what is left is what they need of their lung function for day-to-day living.
The principal cause of COPD is cigarette smoking, which is more concentrated in the lower socio-economic groups. Consequently, as many patients with COPD come from relatively disadvantaged sectors of society, this translates into less recognition for this as a public health problem. The chronic nature of the disease, together with a degree of guilt associated with the perception that the disease is self-induced, leads to reluctance to demand better resources.
Until recently. there had been considerable nihilism among healthcare professionals about COPD treatment with a feeling that the only approach was to get the patient to stop smoking. The high morbidity, frequent re-attendance and perhaps a view that it may have been self-induced did not lead to COPD being the most attractive disease to treat. All these factors may have led to reluctance in the past to demand the appropriate treatment for COPD patients.
Even as cigarette smoking declines, COPD as a problem is on the increase. We are still suffering from the past decades of cigarette smoking. Even in California, which has been very proactive in reducing cigarette smoking, there seems to be a hardcore of about 20 per cent of people who do not seem to be able to abandon the habit. Consequently, this is a problem we will continue to have in the future.
It is not all doom and gloom as there have been advances over the past few years. New drugs have made a major impact on the quality of life, exercise ability and breathlessness in patients with COPD. There’s evidence that patients who exercise on a regular basis are less likely to require admission to hospital.
The availability of pulmonary rehabilitation, a structured management programme for patients, also makes a big difference. We are becoming more adept at organising the care that we deliver to these patients and there are a number of examples of this in the Irish healthcare system such as the COPD outreach programme pioneered at Beaumont Hospital.
So what of my patient? Spirometry had demonstrated that she had a forced expiratory volume (FEV1) of 45 per cent predicted. This means that she had smoked away over half of her lung function and would indeed have followed the path of her unfortunate sister had she continued to smoke. She was now getting to the stage where she needed what was left of her lung function for day-to-day activities.
She started on a series of inhalers, received advice on how to deal with chest infections and did a programme of pulmonary rehabilitation. Over the following five years, her lung function has stabilised. She took on the exercise message to the extent that this year she completed the women’s mini-marathon.
Tomorrow is World COPD Day. Many hospitals will be offering information and/or spirometry to raise awareness of COPD. For further information, see itsbreathtaking.ie and IrishThoracicSociety.com
Dr Tim McDonnell is consultant respiratory physician at St Vincent’s University Hospital and director of the National Clinical Programme for COPD