Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary disease (COPD) is a slowly progressing, long time disease of the lungs which produce obstruction of the airway which is not fully reversible.(complete recovery is not possible with or without treatment.)

COPD is a preventable disease

COPD is the third leading cause of death (In 1990 it was the sixth leading cause death) in the world.

Causes of COPD

COPD is mainly caused by longtime tobacco smoking (80%). Both active and passive (second-hand smoke) can produce COPD.

Long time exposure to other smoke, dust, chemicals and other types of pollution can also produce COPD.

In women, cooking with biogas or firewood in the poorly ventilated kitchen can also produce COPD.

Long drawn (Chronic) poorly treated diseases like Asthma and tuberculosis can also become COPD.

Congenital (hereditary) absence or deficiency of Alpha1antytripsin can also produce COPD.

Types of COPD

In COPD there are 2 types.

Chronic Bronchitis

When the patient suffers from cough for more than three months in a year, for two or more continuous years, the patient is said to be suffering from Chronic Bronchitis.

Pathology of Chronic Bronchitis

In Chronic bronchitis, due to long-time exposure to smoke the bronchial wall becomes thick (bronchial wall hypertrophy) and the inflammation and increased mucus secretion narrow the airway producing wheezing. As there is not much bronchial constriction, improvement after bronchodilators in minimal or nil (not fully reversible) unlike Asthma where bronchial constriction is relived after medication.

Emphysema

Destruction of elastic property of the alveoli leading to shortness of breath.

Pathology of Emphysema

In a normal person, the amount of Alpha1 antitrypsin and the protease enzyme Elastase are equal. Alpha 1 antitrypsin will neutralize the action of elastase.  When the person smokes, the neutrophils produce more Elastase, and the extra elastase produced will destroy the elastic property of the alveoli. This leads to overinflation of the alveoli with each inspiration. Over-inflation of alveoli leads to the destruction of alveolar membrane and few alveoli may burst together to become a bulla. Air becomes trapped in the alveoli and perfusion and ventilation are affected.

Symptoms of COPD

Cough for more than three months,

Slowly progressing difficulty in breathing (dyspnoea),

Mucus production,

Wheezing, Tightness in the chest.

Signs of COPD

Patient may have shortness of breath, Respiratory rate increased,

May have barrel chest (In Emphysema),

Lip & tongue may become blue (cyanosis)

Breath sounds may be diminished (emphysema) or may have wheeze (chronic bronchitis)

Tests to be done in COPD

Spirometry (pulmonary function test) is done to differentiate between Asthma and COPD.

Spirometry is done, then inhaled bronchodilators are given to the patient and spirometry is repeated again to note the reversibility. If FEV1 is less than 80% of normal, there is obstruction and improvement after broncho-dilator is less than 12% it is COPD.

X-ray chest- may show hyperinflated lungs with flat diaphragms and narrow heart.

ECG is taken to rule out Cor- Pulmonale (Heart involvement due to long-standing respiratory disease.)

ABG (Arterial Blood Gas Analysis) done to find the blood gas levels.

Stages in COPD

According to the PFT (pulmonary function test) reading, the severity of COPD is divided into 4 stages.

Mild: if the FEV 1 (forced expiratory volume in 1 second) is above 80 % of the predicted value and the FEV1/FVC (Forced vital capacity) is less than 0.7  and the reversibility is less than 12% it is termed as mild COPD.

Moderate:  FEV 1 – between  80 %  and 50 %.

Severe:  FEV 1 – less than 50 %.

Acute Exacerbation of COPD

When there is a sudden flare-up of symptoms due to infection or exposure to irritants patient may have severe shortness of breath. Hospitalization may be necessary with oxygen therapy and antibiotics.

Treatment of COPD

The main aim of the treatment is to relieve shortness of breath and improve the respiratory functions.

This will improve quality of life of the COPD patient and make him live independently in this society.

The Treatment regimen is like that of Asthma. Bronchodilators and anti-inflammatory drugs (Steroids) are given and they are not very effective as COPD is not fully reversible.

Bronchodilators like salbutamol, levosalbutamol, salmeterol and formoterol reduce the bronchospasm.

Anticholinergics like tiotropium, ipratropium, albuterol and aclidinium dilate the bronchus and reduce the secretions.

Steroids like fluticasone, budesonide, and beclometasone deduce swelling of the bronchial wall and mucous membrane.

Inhaled medicines (Inhalation therapy) are best for COPD and Asthma than oral medicines or injections.

Inhalers having beta-agonists and anticholinergics (2 drugs) or 3 drugs combination along with steroids are used.

In Acute Exacerbation, Oxygen therapy and antibiotics along with inhalation therapy are given.

Mucolytics and Expectorants are given to bring out excess mucus from the airway.

Long-term oxygen Therapy: For severe COPD patients Long time oxygen therapy is given using an oxygen concentrator.

Roflumilast: a phosphodiesterase 4 inhibitor is given to reduce inflammation and to improve the FEV1.

Vaccines: Influenza vaccination and pneumococcal vaccine are given to elderly patients to prevent exacerbations.

Alpha 1 Antitrypsin augmentation (replacement) therapy is given in patients with congenital Alpha 1 Antitrypsin deficiency.

Smoking Cessation: Smoking cessation will stop the progression of the disease. This involves psychological counseling, health education, nicotine replacement therapy (like nicotine patches and nicotine chewing gum).

Medicines like varenicline, Bupropion and nortriptyline are given to stop smoking.

Antidepressants to relieve mental depression associated with COPD.

Surgical Treatment: In severe conditions, surgical treatment like Lung volume reduction surgery, Bullectomy or Lung transplantation may be necessary.

Rehabilitation: Rehabilitation of COPD patients involves treatment by pulmonologist, physician, psychologist, respiratory therapist and occupational therapists. The Rehabilitation program helps the patient live independently in the society.

How to prevent and treat Dengue fever

prevent dengue

How to prevent and treat Dengue fever

Dengue fever is a type of viral fever caused by the RNA virus called dengue virus. Dengue fever spreads from one person to another through mosquito bite.

There is no direct spread from person to person. Infected Aedes aegypti mosquitoes (Asian tiger mosquitoes) spread the disease. Aedes mosquitoes breed in stagnant, clean and fresh water found around our houses.

Aedes mosquitoes usually bite the lower part of our body like legs and foot. They feed mostly on daytime.

How to identify Aedes mosquitoes?

Aedes mosquitoes are small, dark (mostly Black) mosquitoes with white stripes on their bodies and legs. So they are called as Asian tiger mosquitos.

Dengue fever mostly occurs in tropical and subtropical regions, like Asia, Africa, South America and Europe. Dengue fever affects around 2 to 3 billion people around the world.

There are 4 strains of dengue virus.(Dengue virus Strain 1,2,3 and4). If the person is affected by one strain he will have lifelong immunity for that strain and other strains can affect him.

Signs and symptoms of dengue fever

High Fever (Around 104 degree F), severe frontal headache (behind the eyeballs), severe body and joint pain (Break bone fever), nausea, vomiting, fatigue and maculopapular rashes around the face, neck, back and chest are the common symptoms of dengue fever.

In Dengue hemorrhagic fever, bleeding under the skin, conjunctiva, nose or gums can be seen.

In Dengue shock syndrome the blood pressure may drop to dangerously low level. Dengue fever affects many but only people with low immunity (like people with diabetes, AIDs, people on long-term steroids), children and elderly people will develop complications.

Incubation period: The symptoms of dengue fever appear after a period of 3 to 15 days after the mosquito bite.

Pathophysiology

When Aedes mosquito infected with dengue virus bites a person, the virus enters the bloodstream and enters the white blood cells, grow and reproduce inside the cells. The infected cells produce chemicals which increases the body temperature and severe body pain. The chemicals increase the permeability of blood vessels and fluid leaks into the body cavities producing low blood pressure (Dengue Shock Syndrome). Infection of bone marrow reduces platelet count and produces bleeding (Dengue Haemorrhagic Fever).

Tests for Dengue Fever

Complete blood count: White cell count may be reduced.

Platelet count: May be reduced. ( Normal: 1.5 to 4.5 L)

If platelet count falls below 50,000 there will be bleeding tendencies and if it falls below 20,000 platelet transfusion is necessary.

Rapid NS1 test ( Non Structural protein 1 test): Dengue antigen test-done on first 5 days for rapid detection.

IgM and IgG: (dengue virus antibodies)-Done after 5 days of fever.

ELISA: (enzyme-linked immunosorbent assay) is the commonly used test to detect dengue antibodies.

Haemagglutination inhibition test (HI): This test helps to differentiate between primary and secondary infection.

Direct dengue viral detection and culture can be done.

Liver function test and renal function test can be done to rule out liver and kidney involvement.

X-ray chest and ultrasound abdomen to see fluid collection (Pleural Effusion and Ascites). Blood sugar estimation to be done to rule out diabetes.

Treatment For dengue fever

No antiviral drugs available to treat dengue virus. Antibiotics are not effective on dengue virus.

Treatment is supportive care and symptomatic treatment.

Temperature can be brought done by Antipyretics (paracetamol) and tepid sponging.

Nonsteroidal anti-inflammatory drugs like aspirin and ibuprofen to be avoided to prevent bleeding.

Hydrate the body by drinking lots of fluids like water, lemon juice or orange juice. Oral electrolytes can be given.

Treatment for Dengue shock syndrome: Maintain blood pressure by intravenous fluids or plasma or volume expanders.

Treatment for Dengue hemorrhagic fever: If platelet count is very low Platelets can be replaced or blood transfusion can be given.

To increase platelet count drink papaya leaf juice or papaya juice.

Prevention of dengue fever

As there is no antiviral drug for dengue virus, prevention is the only way of controlling the disease.

Vaccination for dengue fever

Now a vaccine called Dengvaxia, approved by World Health Organization is available since 2016 and the vaccine is in use in many countries.

Preventive measures

Prevent mosquito breeding by removing all Aedes mosquitos breeding places like empty discarded tyres, cups, broken pots, broken bottles, coconuts shells etc… from our surroundings. So there won’t be any water collection for mosquitos to breed. Cover all water storing places like water tank, sumps, buckets and vessels. Change the water in all flower washes often.

Antilarval measures: Spray oil or chemicals over open water sources to kill larva or can grow fish which feed on larva.

Prevent mosquito entering houses by fixing mosquitos screens on windows and using mosquito repellents.

Prevent mosquito bite by using long sleeved dresses or sleeping inside the mosquito net.

Mosquito repellent, Mosquito coils and mosquito repellent vaporizers can be used to prevent mosquito bites.

Natural repellents are better as they are less harmful.