COPD: The chronic misery of breathing

Almost always caused by tobacco smoking, chronic obstructive pulmonary disease kills 3,000 Israelis per year. Treatments can’t reverse the symptoms but can halt deterioration.

Dr. Benjamin Fox  (photo credit: PR)
Dr. Benjamin Fox
(photo credit: PR)
Some patients say they live with a constant feeling that they are breathing underwater, as if they were always drowning; others describe their breathlessness (even at rest), frequent coughing and never being able to exhale all the stale air in their lungs. Nearly 330 million people around the globe (including 330,000 Israelis) are trying to live with it, and three million of them (among them 3,000 Israelis) die of it in an average year.
It is chronic obstructive pulmonary disease (COPD), which used to be known as emphysema and chronic bronchitis, but these are only the symptoms and description of changes in the lungs. Emphysema was identified as early as the late 17th century.
“If there were no tobacco, I would probably be out of a job,” noted with irony Dr. Benjamin Fox, a UK-born pulmonologist and internal medicine specialist at the Rabin Medical Center-Beilinson Campus in Petah Tikva who spends much of his time treating COPD patients. But he still would rather there were no such deadly weed. “If tobacco were a new product that had to receive marketing approval from the authorities, it would never be authorized, just like heroin or cocaine. Young people think ‘it’ will never happen to them. The danger is not only from cigarettes but also from nargilas, cigars and pipes.”
In the majority of cases, you yourself have to smoke to get COPD; much less often, victims are non-smokers exposed passively to another’s smoke. “You have to be exposed to a big dose of sidestream smoke to get COPD,” noted Fox.
Tobacco is almost the sole cause of COPD in the developed world; a much less common cause is intense and prolonged occupational exposure to workplace dusts, chemicals and fumes; in the Third World, the chronic disease can also result from indoor air pollution in the form of poorly ventilated cooking fires, often fueled by coal or biomass fuels such as wood and animal dung (making women the more common victims). There are no coal miners in Israel, but miners abroad often get something that looks like COPD clinically; their lungs are destroyed by coal dust. People exposed to asbestos fiber can get asbestosis, which looks like pulmonary fibrosis,” Fox said.[seems a bit of an orphan sentence!] COPD is not really a genetically transmitted disorder, “There is, however, a rare genetic disease involving the deficiency of an enzyme called alpha-1 antitrypsin that can also cause COPD.”
Of those who smoke, about a fifth will get COPD, but among those who have puffed away for decades, about half will develop it, and the disease will kill many of them. In many developed countries such as the US and the UK, between 80 percent to 95% of COPD patients are either current smokers or previously smoked. There is no cure, but kicking the dirty habit can slow the progression and maybe even improve the situation a bit but can’t cure it; there are medications that can also ease the symptoms, thus early detection is important.
Respiratory rehabilitation and surgery to remove non-functioning lung tissue can also help. Lung transplants can eliminate the problem, but only a few donor organs are available; there are 40 or 50 per year at Rabin Medical Center, which is Israel’s only lung transplantation center.
Most of the sufferers are over the age of 55, and a majority are male, but due to their smoking habits, women are quickly catching up. It’s an unfortunate outcome of feminism, said Fox, that women want to smoke like men and thus are the fastest-growing group suffering from lung cancer and COPD.
By 2020, it is expected that COPD will be the third most common cause of death in the world and the fifth in engendering disability. This trend is ironic, as the prevalence of heart disease, which is also related to smoking, is decreasing. It takes years of exposure to tobacco to produced COPD.
Fox gave an interview to The Jerusalem Post to mark World COPD Day, which is to be marked on Wednesday, November 19 here and abroad.
Fox studied at the University of Cambridge and earned his medical degree at Oxford University Medical School. After he came on aliya in 2002, he specialized in internal medicine and pulmonology at the Rabin Medical Center and went to Mcgill University in Montreal to do a sub-specialty in pulmonary hypertension. Now he is head of the pulmonary vascular diseases unit at Rabin and serves as a senior lecturer at Tel Aviv University’s Sackler Medical Faculty. His wife is an ophthalmologist, and they have three daughters.
The airways and air sacs are elastic, so when you inhale, each air sac fills up with air like a little balloon.
When you exhale, these sacs deflate and the air exits. But in COPD, less air flows out because the airways and air sacs lose their elastic quality; the walls between many of the air sacs are destroyed; the airway walls become thick and inflamed; and the airways are clogged with mucus .
ALL COPD patients have both chronic bronchitis and emphysema; some have more of one than the other. The first involves a persistent cough, significant amounts of mucus (sputum), fatigue, shortness of breath, chest discomfort .
Emphysema gradually damages the air sacs in the lungs, causing progressive shortness of breath. The interior walls of the alveoli (air sacs) weaken and eventually rupture, creating one larger air space instead of many small ones. This reduces the lungs’ surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream. In COPD, it may take longer to exhale than to inhale.
When you exhale, the damaged alveoli don’t work properly, and “old” air becomes trapped, leaving no room for fresh, oxygen-rich air to enter. Treatment may slow the progression of emphysema, but it can’t reverse the damage.
Some people with COPD attribute the symptoms to “only a smoker’s cough.” Powerful and frequent coughing aimed at removing sputum may even lead to rib fractures or a brief loss of consciousness. Those with COPD often have a history of “common colds” that last for longer than usual.
To get a proper diagnosis, individuals suffering from symptoms need to undergo lung-function tests by a trained healthcare professional.
“A chest x-ray is useful as additional tool for diagnosing COPD, but if you never underwent a lung function exam, the diagnosis may be incorrect.”
Lung function is tested with a device called a spirometer, which is really a tube with a flow-meter that measures how much and how fast air is exhaled . “One’s total lung volume may even be high, but with COPD, the speed in which one can exhale stale air is impeded,” said the pulmonologist.
A CHRONIC cough is usually the first symptom to appear. When it exists for more than three months a year for more than two years, in combination with sputum production and without another explanation, there is by definition chronic bronchitis.
Any general practitioner can refer patients for lung-function tests.
Some of the health funds sent members to the hospital, said fox, “but I have my own spirometer at the health fund clinic in Rehovot where I also work, besides receiving patients at Rabin.” The hospital’s lung unit caters not only to people with COPD who live in the area, but it is also a referral center for patients who have reached the maximum of what their own physicians can do for them, Fox said. When he diagnoses a patient, many quit smoking within a year of being told, but some don’t. “Ninety percent is willpower. Free smoking cessation courses paid for by the health fund and medical treatment combined are better than each of them alone.”
COPD patients “have to want to kick the habit. Drugs can help deal with cravings,” said Fox. “I tell them that they have a disease with little hope of reversal of damage, but they can stop an ever-further rapid decline.”
Fox advises all of his patients to get flu shots in the fall to reduce the risk of potentially fatal complications.
As for medications, inhaled bronchodilators, sometimes combined with corticosteroids are usually the first after the initial diagnosis to be prescribed. There are long-acting beta antagonists and long-acting muscuranic antagonists that can reduce symptoms and the number of “exacerbations” of chronic bronchitis. These are a sudden worsening of COPD symptoms that typically lasts for several days.
It may be triggered by an infection with bacteria or viruses or by environmental pollutants. Infections account for about three-quarters or even more of exacerbations, and they are treated with antibiotics.
Airway inflammation is increased during the exacerbation resulting in increased hyperinflation, reduced expiratory air flow and the worsening of transfer of oxygen and carbon dioxide.
ORAL CORTICOSTEROIDS can help with symptoms, but they can’t be taken over long periods because they cause harmful side effects such as osteoporosis or skin changes; there are fewer complications when they are only inhaled, Fox said.
Many patients require oxygen therapy at least 16 hours – and sometimes 24 hours – a day. Most patients have oxygen concentrators (machines that extract oxygen from air) at home, but mobile oxygen concentrators are not included in the basket of health services (they have to be purchased by the patient). An option for very severe COPD cases is lung volume reduction surgery, in which non-functional lung tissue is removed. This tissue causes the lungs to get overinflated and squashes the alveoli that still do function. “It works well in some patients, but we actually do very few of these operations,” said Fox. “There are some minimally invasive techniques of lung volume reduction coming into use, we’ll have to see how well they work.”
As patients are often very limited in their daily functioning with no hope of reversal, some suffer from depression; “there probably also are suicides, but I don’t know of specific cases.”
Pulmonary rehabilitation, or exercise in a medical setting, is provided to COPD sufferers as part of the health basket. It improves the quality of life, and reduces the number of hospital admissions, said Fox, “but not enough are actually participating even though it’s cheap to provide and effective. It doesn’t do anything to improve lung function, but it does a lot for the rest of the body and spirit. They don’t feel so alone; the sessions are like support groups. Health fund members are entitled to two sessions a week over three months for rehabilitation. They can also go to a commercial gym or buy exercise machines to use at home.”
Looking over the horizon, Fox doesn’t see any medication or treatment that could dramatically reverse the devastation caused by COPD except “maybe injecting stem cells to create healthy, new alveoli.”