Chronic Obstructive Pulmonary Disease (COPD):
Emphysema and Bronchitis
Chronic obstructive pulmonary disease (COPD) is also called chronic obstructive lung disease. When we think of diseases that obstruct the lungs, many people may think of asthma but the National Heart, Lung, and Blood Institute (NHLBI) says COPD specifically refers to two other respiratory diseases: chronic bronchitis and emphysema. These two diseases often, though not always, appear together in the same patient.
According to NHLBI, one other thing chronic bronchitis and emphysema have in common is this: many patients with these diseases have a long history of heavy cigarette smoking. In fact, the American Medical Association says cigarette smoking is the most important risk factor for COPD.
Other risk factors include:
- age
- heredity
- exposure to air pollution in the environment or the workplace
- a history of childhood respiratory infections
COPD is often progressive. It may start with shortness of breath and coughing. Then a chronic cough can develop, which can be accompanied by clear sputum. Later the cough often becomes more frequent and it's harder to get air into the lungs. Airways become obstructed. The National Emphysema Foundation says carbon dioxide can build up in the blood and blood oxygen levels diminish. Eventually the heart may be affected and the disease can be fatal if the lungs and heart can no longer deliver oxygen to the body's organs and tissues.
NHLBI says COPD is the fifth leading cause of death in the United States. It affects an estimated 16 million Americans. The number of Americans with emphysema is estimated to be 2 million, according to the National Institutes of Health (NIH). It usually develops in older people, and is more common in men than women. Chronic bronchitis affects over 14 million people in the United States, according to the American Lung Association (ALA). ALA says chronic bronchitis affects people of all ages, but is higher in those over 45 years old. Chronic bronchitis is also more common in women, than men.
Emphysema
In emphysema there is permanent destruction of the alveoli or tiny elastic air sacs of the lung. There is also narrowing of the smallest air passages of the lungs or bronchioles, which restricts airflow from the lungs.
What causes this to happen? NHLBI says there is a protein in the lungs called elastin that normally helps to maintain the strength of the alveolar walls. But in emphysema, this protein gets destroyed.
NHLBI says this can happen when there is a deficiency of an enzyme called alpha-l-protease inhibitor or alpha-l-antitrypsin (AAT) which normally protects the elastin. For example, people with familial emphysema have a hereditary deficiency of AAT. ALA says an estimated 50,000-100,000 Americans living today were born with this deficiency. According to NHLBI, 1 to 3 percent of all cases of emphysema are due to AAT deficiency.
The majority of cases of emphysema are not genetic, however. In the general population, the National Emphysema Foundation says emphysema usually develops in older individuals with a long smoking history. NHLBI says this far more common form of emphysema may also be the result of an imbalance between elastin-degrading enzymes (called elastase) and their inhibitors, and that this imbalance may actually be caused by smoking. On the other hand, NHLBI says that only 15 to 20 percent of smokers develop emphysema, so there must be other factors at play too. However, if someone has a family history of emphysema, a blood test can determine if they have a genetic AAT deficiency and if so, the National Emphysema Foundation says it would be critical for these people not to smoke.
The first and most noticeable symptom of emphysema is shortness of breath. There can also be coughing. During a physical exam, a doctor may listen to the chest with a stethoscope and listen to the heart to see if there are any signs of heart strain that may accompany advanced stages of emphysema.
Other tests include spirometry, in which a tube is connected to a machine, and the patient takes a deep breath and blows it out as quickly as possible, while the machine measures his or her airflow capacity. In addition, blood may be tested to determine the amounts of carbon dioxide and oxygen. A chest x-ray or computerized axial tomography (CAT) scan can be used in advanced cases.
Bronchitis
Chronic bronchitis is the other major lung disease grouped under COPD. The American Academy of Family Physicians (AAFP) says it is basically an inflammation of the lining of the bronchial tubes which connect the windpipe with the lungs. As a result, air flow to and from the lungs is restricted and a heavy mucus or phlegm is coughed up. Chronic bronchitis may also involve a narrowing of the large and small airways making it more difficult to move air in and out of the lungs.
You may have had a brief attack of acute bronchitis if you had a bad cold. In chronic bronchitis, however, the mucus-producing cough doesn't go away; instead it occurs most days of the month. NHLBI says someone is considered to have chronic bronchitis if cough and sputum are present on most days for a minimum of 3 months for at least 2 successive years or for 6 months during a single year.
ALA says cigarette smoking is the most common cause of chronic bronchitis. In addition, the bronchial tubes of people with chronic bronchitis may also have been irritated initially by a number of other substances including:
- bacterial infections
- viral infections
- air pollution
- industrial dusts and fumes
The number of irritants someone is exposed to can add up and create a heightened effect. For example, ALA says coal miners, grain handlers, metal molders, and other workers exposed to dust are particularly at risk, and if someone in this type of work is also exposed to heavy air pollution or if they smoke, their symptoms can get even worse. In addition, once the bronchial tubes have been irritated over a long period of time, they can become even more susceptible to infections.
Pulmonary Hypertension
One of the potential consequences of COPD is pulmonary hypertension (PH). Pulmonary hypertension happens when the blood pressure in the pulmonary artery rises far above normal levels. The pulmonary artery is the blood vessel carrying oxygen-poor blood from the right ventricle, one of the pumping chambers of the heart, to the lungs. In the lungs, the blood picks up oxygen and then flows to the left side of the heart, where it is pumped by the left ventricle to the rest of the body through the aorta.
Hypertension is the medical term for an abnormally high blood pressure. Normal mean pulmonary-artery pressure is approximately 14 mm Hg at rest. In the PH patient, the mean blood pressure in the pulmonary artery is greater than 25 mm Hg at rest and 30 mm Hg during exercise. This abnormally high pressure (pulmonary hypertension) is associated with changes in the small blood vessels in the lungs, resulting in an increased resistance to blood flowing through the vessels.
This increased resistance, in turn, places a strain on the right ventricle, which now has to work harder than usual against the resistance to move adequate amounts of blood through the lungs.
When the cause, such as COPD is known, it is called secondary pulmonary hypertension. There is also primary, or unexplained, pulmonary hypertension (PPH). It is a rare lung disorder in which the blood pressure in the pulmonary artery rises far above normal levels for no apparent reason. PPH remains a diagnosis of exclusion. This means that it is diagnosed only after the doctor finds pulmonary hypertension and excludes or cannot find other reasons for the hypertension, such as a chronic obstructive pulmonary disease (chronic bronchitis and emphysema), blood clots in the lung (pulmonary thromboemboli) , or some forms of congenital heart disease.
Treatment and Prevention of COPD
Survival of patients with COPD is closely related to the level of their lung function when they are diagnosed and the rate at which they lose this function. Patients with severe lung damage may need to sleep in a semi-sitting position because they can't breathe when they lie down. They may need to breathe oxygen. Breathing oxygen can often correct the blood oxygen levels, but this does not help remove carbon dioxide. When carbon dioxide accumulation becomes a severe problem, mechanical breathing machines called respirators, or ventilators, must be used.
If caught and treated early on, however, a patient can reduce the amount of damage that occurs. A doctor will decide on the best course of treatment, depending on the type and severity of the patient's condition. But it's essential that the patient follow their treatment program carefully.
For someone with emphysema, the Food and Drug Administration (FDA) says there are a number of treatments that can help, but the most important step is to stop smoking. It's also essential to avoid exposure to other airborne irritants besides smoke. Beyond that, FDA says medications can include bronchodilator medicines, which relax the muscles around the airways, and anti-inflammatories or corticosteroids which can soothe the lining of the air passageways. Patients should discuss all possible side-effects with the doctors. In some cases, surgery may be needed to improve a patient's breathing ability. Again, a patient should discuss all options with their doctor, as well as their best course of action with regards to physical activity and special breathing exercises.
For someone with bronchitis, ALA says it's essential to reduce the irritation in the bronchial tubes. A patient with bronchitis should see their doctor at the first sign of a cold or respiratory infection. Antibiotics may be used if there is an infection. Bronchodilator drugs may be prescribed to help relax and open up air passages in the lungs, if there is a tendency for these to close up. A patient should avoid polluted air and dusty working conditions, maybe even change jobs if necessary.
ALA says people with bronchitis, emphysema or both should also follow a healthy diet and maintain a healthy body weight. They should talk with their doctor about getting vaccinated against flu or pneumonia. AAFP says they should ask their doctor about an exercise program called pulmonary rehabilitation that can help improve breathing. Above all, they must give up smoking and avoid exposure to all secondary smoke.
The hopeful news, according to NHLBI, is that many patients with COPD have some degree of reversible airways obstruction. And although there is no cure for COPD, the disabling symptoms can often be reduced. Above all, keep in mind that the disease can be prevented in many cases. Because cigarette smoking is the most important cause of COPD, NIH says not smoking almost always prevents COPD from developing, and quitting smoking slows the disease's progression.
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