Question

1- Describe signs and symptoms of a patient with COPD?

2- Explain the differences between Bronchitis and Emphysema ?

3- What acid base imbalance are COPD patients at risk for?

4- What are the risk factors for developing COPD?

Answer 1

1) Signs and symptoms of a patient with COPD

The early symptoms of COPD include:

• shortness of breath, especially after exercising
• recurrent cough with mucus
• needing to clear your throat often, especially first thing in the morning
• fatigue

As lungs get more damages the symptoms become more severe:

• shortness of breath, after even mild exercise such as walking up a flight of stairs
• wheezing or a whistling or squeaky sound while breathing
• chest discomfort or tightness
• chronic cough, with or without mucus
• need to clear mucus from your lungs every day
• frequent colds, flu, or other respiratory infections
• lack of energy

In advanced stage the symptoms of COPD include:

• swelling of the feet, ankles, or legs
• weight loss
• The most common symptoms of COPD are shortness of breath, and a cough that produces sputum.
• These symptoms are present for a prolonged period of time and typically worsen over time.
• It is unclear whether different types of COPD exist. While previously divided into emphysema and chronic bronchitis, emphysema is only a description of lung changes rather than a disease itself, and chronic bronchitis is simply a descriptor of symptoms that may or may not occur with COPD.

i) Cough

• A chronic cough is often the first symptom to develop.
• Early on it may just occur occasionally or may not result in sputum.
• When a cough persists for more than three months each year for at least two years, in combination with sputum production and without another explanation, it is by definition chronic bronchitis.
• Chronic bronchitis can occur before the restricted airflow and thus COPD fully develops.
• The amount of sputum produced can change over hours to days.
• In some cases, the cough may not be present or may only occur occasionally and may not be productive.
• Some people with COPD attribute the symptoms to a "smoker's cough".
• Sputum may be swallowed or spat out, depending often on social and cultural factors.
• In severe COPD, vigorous coughing may lead to rib fractures or to a brief loss of consciousness.
• Those with COPD often have a history of "common colds" that last a long time.

ii) Shortness of breath

• Shortness of breath is a common symptom and is often the most distressing.
• It is commonly described as: "my breathing requires effort," "I feel out of breath," or "I can't get enough air in."
• Different terms, however, may be used in different cultures.
• Typically, the shortness of breath is worse on exertion of a prolonged duration and worsens over time.
• In the advanced stages, or end stage pulmonary disease, it occurs during rest and may be always present.
• Shortness of breath is a source of both anxiety and a poor quality of life in those with COPD.
• Many people with more advanced COPD breathe through pursed lips and this action can improve shortness of breath in some.

iii) Physical activity limitation

• COPD often leads to reduction in physical activity, in part due to shortness of breath.
• In later stages of COPD muscle wasting (cachexia) may occur.
• Low levels of physical activity are associated with worse outcomes.

iv) Other symptoms

• In COPD, breathing out may take longer than breathing in.
• Chest tightness may occur, but is not common and may be caused by another problem.
• Those with obstructed airflow may have wheezing or decreased sounds with air entry on examination of the chest with a stethoscope.
• A barrel chest is a characteristic sign of COPD, but is relatively uncommon.
• Tripod positioning may occur as the disease worsens.

2) Differences between Bronchitis and Emphysema

Emphysema and chronic bronchitis are two different lung conditions that make up an overall condition called COPD. Both conditions can cause breathing difficulty and shortness of breath. People with chronic bronchitis will have a long-term cough that produces mucus. A doctor can use a variety of tests to diagnose these conditions. Emphysema and chronic bronchitis require similar treatment methods for people to manage the symptoms.

• The main difference between these conditions is that chronic bronchitis produces a frequent cough with mucus. The main symptom of emphysema is shortness of breath.
• Emphysema can sometimes arise due to genetics. An inherited condition called alpha-1-antitrypsin deficiency can cause some cases of emphysema. People tend to notice the symptoms of lung disease linked to the condition when they are 20–50 years old.
• Gastroesophageal reflux disease can lead to chronic bronchitis. Older adults and people who have respiratory problems when they are younger may also have a higher risk of chronic bronchitis.
• Emphysema is irreversible, but it is possible to stop the condition from worsening. People may be able to reduce their risk of developing chronic bronchitis by quitting smoking or avoiding being around secondhand smoke, as well as getting yearly flu vaccines.
• People with severe emphysema may require lung reduction surgery. This is a procedure that removes areas of the diseased lung to allow healthier parts to work better. This can enable people to stay active and improve their quality of life.

How to tell the difference

A doctor can carry out various tests to check if a person has emphysema, chronic bronchitis, both, or another lung condition.

i) Pulmonary function tests show the condition of the lungs by examining how air moves in and out of them. Doctors use these tests to diagnose both conditions.

Examples include:

a) Spirometry

During spirometry, a person will exhale into a tube that is attached to a machine called a spirometer, which then shows the volume of air they are inhaling and exhaling. Spirometry can show whether airflow is restricted or disrupted, as well as how serious a lung condition is.

b) Chest X-ray

A chest X-ray will show any damage to the lungs. People stand in front of the X-ray machine and hold their breath for the X-ray to produce images of their lungs.

c) Arterial blood gases

A doctor will take a blood from an artery to test for oxygen and carbon dioxide levels in the blood.

d) Peak flow monitoring

In peak flow monitoring, a machine measures how fast a person can blow air out from their lungs. This assesses how much the condition is blocking the airways.

• Using these tests, as well as performing a detailed physical examination and taking a thorough medical history, a doctor will be able to determine whether the condition is emphysema or chronic bronchitis.
• If a person has a persistent cough that produces mucus for at least 3 months of the year for 2 years in a row, it may signal chronic bronchitis.
• If tests show stretched lungs or lungs that are larger in places than usual, a person may have emphysema.

2) Acid-base disturbance in COPD.

Many COPD patients with respiratory acidosis are suffering other conditions or prescribed drugs that affect acid-base homeostasis and these patients can present with mixed acid-base disturbance,

for example: respiratory acidosis with metabolic acidosis or respiratory acidosis with metabolic alkalosis.

• A major complicance in COPD patients is the development of stable hypercapnia.
• Under normal conditions, the production of CO₂ is removed by pulmonary ventilation. However, an alteration in respiratory exchanges, as occurs in advanced phase of COPD, results in retention of CO₂.
• Carbon dioxide is then hydrated with the formation of carbonic acid that subsequently dissociates with release of hydrogen ions (H⁺) in the body fluids according to the following equation:

CO2+H2O⟹H2CO3⟹−HCO3+H+

Thus, the consequence of hypercapnia due to alteration of gas exchange in COPD patients mainly consists in increase of H⁺ concentration and development of respiratory acidosis, also called hypercapnic acidosis.

Risk factors for developing COPD

1) Smoking

• The main risk factor for COPD is smoking.
• It causes up to 90 percent of COPD deaths, according to the American Lung Association (ALA).
• Long-term exposure to tobacco smoke is dangerous.
• The longer you smoke and the more packs you smoke, the greater your risk is of developing the disease.
• Pipe smokers and cigar smokers are also at risk.
• Exposure to secondhand smoke also increases your risk.
• Secondhand smoke includes both the smoke from burning tobacco and smoke exhaled by the person smoking.

2) Air pollution

• Smoking is the principal risk factor for COPD, but it isn’t the only one.
• Indoor and outdoor pollutants can cause the condition when exposure is intense or prolonged.
• Indoor air pollution includes particulate matter from the smoke of solid fuel used for cooking and heating.

Examples include poorly ventilated wood stoves, burning biomass or coal, or cooking with fire.

• Exposure to environmental pollution is another risk factor.
• Indoor air quality plays a role in the progression of COPD in developing countries.
• But urban air pollution like traffic and combustion-related pollution poses a greater health risk worldwide.

3) Occupational dusts and chemicals

• Long-term exposure to industrial dust, chemicals, and gases can irritate and inflame the airways and lungs.
• This increases your risk of developing COPD.
• People exposed to dust and chemical vapors, such as coal miners, grain handlers, and metal molders, have a greater likelihood of developing COPD.

4) Genetics

• In rare cases, genetic factors cause people who have never smoked or had long-term particulate exposure to develop COPD.
• The genetic disorder results in a lack of the protein alpha 1 (α_{1) -}antitrypsin (AAT).
• But few people are aware of it. While AAT deficiency is the only well-identified genetic risk factor for COPD, researchers suspect that there are several other genes involved in the disease process.