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COPD 1: Pathophysiology, Diagnosis and Prognosis

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COPD 1: Pathophysiology, Diagnosis and Prognosis Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Keywords Chronic obstructive pulmonary disease/Respiratory disease Review This article has been Respiratory disease double-blind peer reviewed In this article... ● Characteristics and prevalence of chronic obstructive pulmonary disease ● Signs and symptoms and the role of spirometry and assessment tools ● Understanding disease progression and prognosis COPD 1: pathophysiology, diagnosis and prognosis Key points Author Stephen Gundry is COPD nurse, Newcastle Hospitals NHS Foundation Trust. Chronic obstructive pulmonary disease Abstract Chronic obstructive pulmonary disease is a common and incurable is a common respiratory condition that is largely preventable and treatable, pharmacologically and respiratory non-pharmacologically. It involves progressive and permanent damage to lung condition, with structures, leading to symptoms of breathlessness, cough, wheeze and sputum significant mortality production. Early diagnosis and treatment allows patients to benefit from symptom- and morbidity relieving treatment to maximise their quality of life. This article, the first in a two-part series, describes its pathophysiology, diagnosis and prognosis. The disease is an umbrella term for a Citation Gundry S (2019) COPD 1: pathophysiology, diagnosis and prognosis. Nursing group of conditions Times [online]; 116: 4, 27-30. involving progressive and irreversible lung hronic obstructive pulmonary and the need for medication reviews, damage disease (COPD) is a common res- including the correct use of inhalers. piratory condition, affecting Although COPD is a significant concern Symptoms are often 4.5% of people over the age of 40 countrywide, BLF figures show its distri- referred to as a C in the UK (statistics.blf.org.uk/copd). The bution is uneven across the UK population; ‘smoker’s cough’ or British Lung Foundation estimates 1.2 mil- prevalence is highest in the North East, a natural part of lion people have been diagnosed with COPD, North West and Scotland, and the disease ageing rather than and this is thought to represent a third of is three times more common in the most an incurable disease people who have the disease, many are as yet deprived populations compared with pop- undiagnosed. COPD is responsible for ulations that are least deprived (statistics. Early and accurate nearly 30,000 deaths a year or around 5.3% of blf.org.uk/copd). diagnosis can make all UK deaths; in Europe, the UK lags only While the prevalence of COPD is rising, a real difference to behind Denmark and Hungary in mortality and more people have a diagnosis than ever patients’ lives rates for COPD, and ranks 12th worldwide in before, since early 2000 the number of new terms of deaths per million population a diagnoses has been slowing (statistics.blf. Care and year (statistics.blf.org.uk/copd). org.uk/copd). However, it is not clear management plans Lung health is one of the priorities in the whether this is due to a fall in the number of should reflect the NHS Long Term Plan, as part of a recognition people developing COPD or changes to highly individual of the needs of patients with long-term con- record-keeping practice. One possible nature of the disease ditions, including COPD (NHS England, explanation could be the ongoing reduction 2019). The plan includes a commitment to in tobacco smoking over recent decades, improve the availability and quality of but this is not a reason for complacency and spirometry to support accurate and timely early diagnosis of COPD is essential. The diagnosis, and highlights the value of pul- insidious onset of the disease means monary rehabilitation and the need to patients may dismiss early symptoms, such expand the scope of rehabilitation pro- as a cough and subtle increases in breath- grammes to include more patients. It also lessness, as normal age-related changes or acknowledges the importance of patients ‘smoker’s cough’, instead of a serious condi- receiving the correct inhaled medication tion that needs medical assessment. Nursing Times [online] April 2020 / Vol 116 Issue 4 27 www.nursingtimes.net Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Review Fig 1. Difference between a healthy lung and a lung with COPD Healthy lung Small airways Airway lining Lung with COPD Airways Inflamed airway Floppy elastic Damaged tissue lining Source: British Lung Foundation (2019) BLF figures also show around 10% more and chemical fumes that can be inhaled levels (hypoxaemia) and raised blood men than women have a COPD diagnosis. into the lungs present an underestimated carbon dioxide levels (hypercapnia) result Although the difference is slowly nar- risk of COPD (GOLD, 2019). from impaired gas transfer and can worsen rowing, this has been a long-term finding as the disease inevitably progresses. and reflects the greater incidence of Pathophysiology smoking among men over previous years. COPD results from the combined pro- Diagnosis cesses of peripheral airway inflammation National Institute for Health and Care What is COPD? and narrowing of the airways. This leads to Excellence guidance advocates early diag- The Global Initiative for Chronic Obstruc- airflow limitation and the destruction and nosis of COPD, so that patients can benefit tive Lung Disease (2018) defines COPD as “a loss of alveoli, terminal bronchioles and from symptom-relieving treatment to common, preventable and treatable dis- surrounding capillary vessels and tissues, maximise quality of life (NICE, 2018). NICE ease that is characterised by persistent res- which adds to airflow limitation and leads says COPD should be suspected in people: piratory symptoms and airway limitation to decreased gas transfer capacity (Fig 1). ● Over the age of 35 who smoke; due to airway and/or alveolar abnormali- The extent of airflow limitation is deter- ● Who have smoked in the past and have ties usually caused by significant exposure mined by the severity of inflammation, one or more supporting symptoms, to noxious particles of gases”. It is an development of fibrosis within the airway such as chronic cough, sputum evolving condition that progresses over and presence of secretions or exudates. production, exceptional time, although the rate of progression is Reduced airflow on exhalation leads to air breathlessness, wheeziness or previous widely heterogeneous and varies unpre- trapping, resulting in reduced inspiratory ‘frequent winter bronchitis’. dictably from one individual to another capacity, which may cause breathlessness Accurate spirometry supports diag- (GOLD, 2019). COPD is an umbrella term (also known as dyspnoea) on exertion and nosis of COPD, with obstructive lung dis- that covers: reduced exercise capacity. ease confirmed by a ratio below 0.7 (70%) of ● Emphysema (loss of alveolar structure); Abnormalities in gas transfer occur due forced expiratory volume per second ● Chronic bronchitis (long-term to reduced airflow/ventilation and as a (FEV1)/forced vital capacity (FVC) (NICE, inflammation of the airways and result of loss of alveolar structure and pul- 2018) (see Box 1). Spirometry is a reliable mucus hyper-secretion). monary vascular bed. Low blood oxygen and valuable means of measuring lung The persistent respiratory symptoms consistent with the disease reflect the per- Box 1. Diagnosing COPD using spirometry manent changes that take place in the lung structures and include breathlessness, ● Forced vital capacity (FVC): the maximum amount of air the patient can blow out cough and sputum production. from a full inspiration to full expiration during a forced blow The most important cause of COPD in ● Forced expiratory volume in 1 second (FEV1): the maximum volume of air the the UK and other western countries is expo- patient can blow out in the first second of a forced blow sure to tobacco smoke – usually as a result ● FEV1/FVC: the volume of air expired during the first second of a forced blow, of smoking cigarettes. However exposure expressed as a percentage of FVC to any irritant, noxious airborne particles Source: Hughes (2017) FRANCESCA CORRA FRANCESCA (for example, organic and inorganic dusts) Nursing Times [online] April 2020 / Vol 116 Issue 4 28 www.nursingtimes.net Copyright EMAP Publishing 2020 This article is not for distribution except for journal club use Clinical Practice Review function in terms of severity of airflow lim- itation, and of assessing and monitoring Table 1. Medical Research Council dyspnoea scale/ future lung function decline. It provides a breathlessness scale useful measure of a patient’s response to Grade Degree of breathlessness related to activities bronchodilator medications and helps dif- ferentiate between obstructive disease 1 Not troubled by breathlessness except on strenuous exercise characterised by compromised airflow (as 2 Short of breath when hurrying or walking up a slight hill occurs in COPD) and restrictive disease of 3 Walks slower than contemporaries on level ground because of reduced lung volume due to parenchymal breathlessness, or has to stop for breath when walking at own pace scarring, pleura or chest wall disease (for example, interstitial lung disease). 4 Stops for breath after walking about 100 meters or after a few minutes Recorded FEV1, as a percentage of an on level ground individual’s predicted value (based on age, 5 Too breathless to leave the house, or breathless when dressing or gender, height and ethnicity), is generally
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