Chronic obstructive pulmonary disease

Overview of Chronic obstructive pulmonary disease

• Exacerbations and comorbidities contribute to the overall severity in individual patients.
• Extra-pulmonary effects include weight loss and skeletal muscle dysfunction commonly associated comorbid conditions include cardiovascular disease, cerebrovascular disease, the metabolic syndrome, osteoporosis, depression and lung cancer. [1]
• The prevalence of COPD is directly related to the prevalence of tobacco smoking and, in low- and middle-income countries, the use of biomass fuels.
• Current estimates suggest that 80 million people worldwide suffer from moderate to severe disease. [1]

Epidemiology

Lancet Respiratory Medicine (2018):

Estimated 55.3 million COPD cases in India in 2016. Crude prevalence high in Himachal Pradesh, Uttarakhand, Haryana, and Jammu & Kashmir. [9]

Annals of the National Academy of Medical Sciences (India) (2022):

In a study conducted in Delhi, the overall prevalence rate of COPD was 9.8/1,000 population, and among the population over 30 years of age, the prevalence rate was 21.2/1,000. [10]

Global Burden of Disease Study (2017):

Chronic Respiratory Diseases, which includes COPD, accounted for 10.9% of total deaths and 6.4% of total Disability Adjusted Life Years (DALY) in India. [11]

World Health Organization (WHO):

COPD is the third leading cause of death worldwide, and while the majority of COPD deaths occur in low- and middle-income countries, India faces a significant burden. [12]

It’s important to note that these are just a few examples, and the epidemiology of COPD in India may vary depending on the specific population studied and the methodology used.

Causes

• Cigarette smoking represents the most significant risk factor, and the risk of developing COPD relates to both the amount and the duration of smoking.
• It is unusual to develop COPD with less than 10 pack years and not all smokers develop the condition, suggesting that individual susceptibility factors are important. [1]

Types

The two most common conditions of COPD are chronic bronchitis and emphysema. Some physicians agree that asthma should be classified as a chronic obstructive pulmonary disease, while others do not.

1.Chronic bronchitis
Chronic bronchitis is a long-term inflammation of the bronchi (breathing passages in the lungs), which results in increased production of mucus, as well as other changes.

• These changes may result in breathing problems, frequent infections, cough, and disability.

2. Pulmonary emphysema

Emphysema is a chronic lung condition in which alveoli (air sacs in the lungs) may be:

• Destroyed
• Narrowed
• Collapsed
• Stretched
• Over-inflated

This can cause a decrease in respiratory function and breathlessness. Damage to the air sacs is irreversible and results in permanent "holes" in the lung tissue.

3. Asthma
Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. The characteristics of asthma include the following:

• The lining of the airways become swollen and inflamed.
• The muscles that surround the airways tighten.
• The production of mucus is increased, leading to mucus plugs. (5)

Risk factors

• Exposure to air pollution
• Breathing second hand smoke
• Working with chemicals, dust and fumes
• A genetic condition called Alpha-1 deficiency
• A history of childhood respiratory infection [4]

Pathogenesis

• Chronic Inflammation: COPD is characterized by chronic inflammation of the airways and lung parenchyma. Inhaled noxious particles and gases, primarily cigarette smoke, trigger an abnormal inflammatory response involving neutrophils, macrophages, and lymphocytes.
• Protease-Antiprotease Imbalance: An imbalance between proteases (enzymes that break down proteins) and antiproteases (enzymes that inhibit proteases) is thought to play a crucial role in the development of emphysema, a component of COPD. Increased protease activity, particularly from neutrophils, can lead to the destruction of alveolar walls and loss of lung elasticity.
• Oxidative Stress: Oxidative stress, caused by an imbalance between reactive oxygen species (ROS) and antioxidants, contributes to lung damage in COPD. Inhaled toxins and inflammatory cells generate ROS, which can damage lung tissue and impair its repair mechanisms.
• Small Airway Remodeling: Chronic inflammation and repeated injury lead to structural changes in the small airways, including fibrosis, increased mucus production, and smooth muscle hypertrophy. These changes contribute to airflow obstruction and impaired gas exchange.
• Systemic Effects: COPD is not just a lung disease. It can have systemic effects on other organs and systems, leading to comorbidities such as cardiovascular disease, skeletal muscle dysfunction, and metabolic abnormalities. [13] 

Pathophysiology of Chronic obstructive pulmonary disease

• COPD has both pulmonary and systemic components The presence of airflow limitation combined with premature airway closure, leads to gas trapping and hyperinflation, reducing pulmonary and chest wall compliance.
• Pulmonary hyperinflation also flattens the diaphragmatic muscles and leads to an increasingly horizontal alignment of the intercostals muscles, placing the respiratory muscles at a mechanical.
• The work of breathing is therefore markedly increased, first on exercise, when the time for expiration is further shortened, but then, as the disease advances, at rest Emphysema may be classified by the pattern of the enlarged airspaces as centri acinar, pan acinar or Para septal.
• Bullae form in some individuals. This results in impaired gas exchange and respiratory Failure.[1]

Clinical Features

Key Clinical Features from Harrison’s:

1. Dyspnea (Shortness of Breath):

   • The most common and disabling symptom of COPD.
   • Progressive and persistent, worsening with exertion.
   • May be accompanied by chest tightness.

2. Chronic Cough:

   • Persistent cough, often worse in the morning.
   • May produce sputum (mucus) that can be clear, white, yellow, or green.

3. Sputum Production:

   • Increased production of mucus, especially during exacerbations.
   • Can be a sign of airway inflammation and infection.

4. Wheezing:

   • A high-pitched whistling sound when breathing, particularly during exhalation.
   • Indicates airflow obstruction in the airways.

5. Chest Tightness:

   • A feeling of pressure or discomfort in the chest.
   • May be associated with dyspnea and wheezing.

6. Fatigue and Exercise Intolerance:

   • Reduced ability to perform physical activities due to shortness of breath and fatigue.

7. Recurrent Respiratory Infections:

   • Increased susceptibility to respiratory infections like bronchitis and pneumonia.
   • Exacerbations often triggered by infections.

8. Weight Loss (in Later Stages):

   • Unintentional weight loss due to increased energy expenditure for breathing and reduced appetite.

9. Peripheral Edema (in Severe Cases):

   • Swelling in the ankles, feet, or legs due to right-sided heart failure (cor pulmonale).

Additional Clinical Features:

• Barrel Chest: An increased anteroposterior diameter of the chest due to air trapping in the lungs.
• Decreased Breath Sounds: Reduced intensity of breath sounds on auscultation.
• Prolonged Expiratory Phase: Longer time taken to exhale compared to inhale.
• Cyanosis (in Severe Cases): A bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. [14]

Sign & Symptoms of Chronic obstructive pulmonary disease

• COPD should be suspected in any patient over the age of 40 years who presents with symptoms of chronic bronchitis and/or breathlessness.
• Cough and associated sputum production ‘smoker’s cough’.
• Breathlessness
• Physical signs are non-specific, correlate poorly with lung function, and are seldom obvious until the disease is advanced. Breath sounds are typically quiet.
• Crackles may accompany infection but, if persistent, raise the possibility of bronchiectasis.
• Tuberculosis [1]

Clinical examination of Chronic obstructive pulmonary disease

Appearance of the Patient

• Cyanosis
• Tachypnea
• Respiratory distress indicated by use of accessory respiratory muscles. Hoover sign presenting as paradoxical indrawing of lower intercostal spaces is evident (known as the Hoover sign)
• Elevated jugular venous pulse (JVP)
• Peripheral edema can be observed.

Lungs

Inspection

• Hyperinflation (barrel chest)

Percussion

• Hyper resonance

Auscultation

• Prolonged expiration; wheezing
• Diffusely decreased breath sound
• Additional sounds – coarse crackles with inspiration. (6)

Diagnosis of Chronic obstructive pulmonary disease

• The best test for COPD is a lung function test called spirometry. This involves blowing out as hard as possible into a small machine that tests lung capacity.
• Using a stethoscope to listen to the lungs can also be helpful. Pictures of the lungs (such as x-rays and CT scans) can be helpful
• Sometimes patients need to have a blood test (called arterial blood gas) to measure the amounts of oxygen and carbon dioxide in the blood. [2]

Differential diagnosis of Chronic obstructive pulmonary disease

• Asthma
• Congestive heart failure
• Bronchiectasis
• Tuberculosis
• Obliterative bronchiolitis (7)

Complications

1. Acute Exacerbations:

   • Episodes of worsening respiratory symptoms (increased dyspnea, cough, sputum production).
   • Often triggered by respiratory infections or environmental pollutants.
   • Can lead to hospitalization and increased mortality risk.

2. Respiratory Failure:

   • Inability of the lungs to maintain adequate gas exchange (oxygenation and carbon dioxide removal).
   • May require supplemental oxygen therapy or mechanical ventilation.

3. Pulmonary Hypertension:

   • Elevated blood pressure in the pulmonary arteries.
   • Can lead to right-sided heart failure (cor pulmonale).

4. Cor Pulmonale (Right-Sided Heart Failure):

   • Enlargement and weakening of the right ventricle due to increased workload from pulmonary hypertension.
   • Symptoms include peripheral edema, jugular venous distention, and hepatic congestion.

5. Pneumothorax:

   • Air leakage into the pleural space, causing lung collapse.
   • More common in patients with emphysema.
   • May require chest tube insertion or surgery.

6. Depression and Anxiety:

   • COPD can significantly impact quality of life, leading to psychological distress.
   • Depression and anxiety are common comorbidities.

7. Nutritional Depletion and Weight Loss:

   • Increased energy expenditure for breathing and decreased appetite can lead to malnutrition and weight loss.
   • Contributes to muscle weakness and decreased exercise tolerance.

8. Osteoporosis:

   • Chronic inflammation and corticosteroid use (a common treatment for COPD) can increase the risk of osteoporosis.
   • Leads to increased fracture risk.

9. Lung Cancer:

   • COPD is a significant risk factor for lung cancer.
   • Screening for lung cancer is recommended for individuals with a history of smoking and COPD.

Additional Complications:

• Infections: Increased susceptibility to respiratory infections (pneumonia, bronchitis).
• Polycythemia: Increased red blood cell mass due to chronic hypoxemia.
• Sleep Apnea: Obstructive sleep apnea is more common in people with COPD. [15]

Investigation of Chronic obstructive pulmonary disease

• A chest X- ray is essential to identify alternative diagnoses, such as cardiac failure, other complications of smoking such as lung cancer, and the presence of bullae.
• A blood count is useful to exclude anaemia or polycythemia, and in younger patients with predominantly basal emphysema, α1-antiproteinase should be assayed.
• Measurement of lung volumes provides an assessment of hyperinflation.
• Emphysema is suggested by a low gas transfer value (p. 653). Exercise tests provide an objective assessment of exercise tolerance and a baseline for judging response to bronchodilator therapy or rehabilitation programmed; they may also be valuable when assessing prognosis.
• Pulse oximetry of less than 93% may indicate the need for referral for a domiciliary oxygen assessment.
• The assessment of health status provides valuable clinical information.
• HRCT is likely to play an increasing role in the assessment of COPD, as it allows the detection, characterization and quantification of emphysema and is more sensitive than a chest X-ray for detecting bullae. [1]

Treatment of Chronic obstructive pulmonary disease

1. There is no cure for COPD. However, there are many things you can do to relieve symptoms and keep the disease from getting worse.
2. Persons with COPD must stop smoking. This is the best way to slow down the lung damage.
3. Medications used to treat COPD include:

• Inhalers (bronchodilators) to open the airways, such as ipratropium (Atrovent), tiotropium (Spiriva), salmeterol (Serevent), formoterol (Foradil), or
• Inhaled steroids to reduce lung inflammation.
• Anti-inflammatory medications such as Montelukast(Singulair) and roflimulast are sometimes used.

4. In severe cases or during flare-ups, you may need to receive:

• Steroids by mouth or through a vein (intravenously)
• Bronchodilators through a nebulizer
• Oxygen therapy
• Assistance during breathing from a machine (through a mask, BiPAP, or endotracheal tube)

5. Antibiotics are prescribed during symptom flare-ups, because infections can make COPD
6. You may need oxygen therapy at home if you have a low level of oxygen in your blood.
7. Walk to build up strength.
8. Use pursed lip breathing when breathing out (to empty your lungs before the next breath)
9. Things you can do to make it easier for yourself around the home include:

• Avoiding very cold air
• Making sure no one smokes in your home
• Reducing air pollution by getting rid of fireplace smoke and other irritants

10.Surgery may be used, but only a few patients benefit from these surgical treatments:

• Surgery to remove parts of the diseased lung can help other areas (not as diseased) work better in some patients with emphysema
• Lung transplant for severe cases [2]

Prevention of Chronic obstructive pulmonary disease

• Don’t rub your eyes, as this can transmit germs to your nasal passages via the tear ducts.
• Quitting smoking and avoiding secondhand smoke (the smoke from a burning cigarette or cigar and the smoke exhaled by a smoker) are important steps you can take to protect your lungs from infection.
• Follow your doctor’s medication guidelines.
• Get enough sleep and rest.
• Manage your stress.
• Talk to your doctor or healthcare provider about getting a flu shot every year and get the pneumonia vaccine if you haven’t had one.
• Be careful to avoid infection when traveling. In areas where the water might be unsafe, drink bottled water or other beverages (order beverages without ice). Swim only in chlorinated pools.(8)

Homeopathic Treatment of Chronic obstructive pulmonary disease

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Chronic obstructive pulmonary disease

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

1. Aconitum Napellus:

• The first remedy that is often indicated at the onset of the infection. It is effective only within the first twenty-four hours.
• Useful when there is a short, dry cough, a temperature and an irritation of the throat, chest and trachea.
• There is a chilly restlessness, anxiety and a full, bounding pulse, with general weakness.

2. Antimonium Tartaricum:

• Useful when there is a accumulation of considerable loose, rattling, moist mucus in the chest.
• For children breathing and a loose cough, but little phlegm is expectorated.
• There may be vomiting and labored breathing. Pronounced physical and mental exhaustion.

3. Belladona:

• A high temperature, dry cough, a pounding, pulsating headache and a flushed face with a dry, hot skin.
• The cough is worse at night and when lying down.

4. Bryonia Alba:

• A painful, violent, dry, stitching cough with a headache and pain in the chest wall.
• Worse with coughing and better when supporting the area with both hands.
• The expectoration is yellow and often blood streaked. The cough is worse after meals.
• Patient drinks large quantities of fluids at long intervals.

5. Iodum:

• Difficult expansion of chest, blood-streaked sputum; internal dry heat, external coldness.
• Inspiration difficult. Croupy cough with difficult respiration; wheezy.
• Cold extends downwards from head to throat and bronchi. Great weakness about chest.
• Palpitation from the least exertion. Iodum cough.

6. Calcarea carbonica:

• Extreme Dyspnoea. Suffocating spells, tightness, burning and soreness in chest.
• Chest very sensitive to touch, percussion or pressure. Longing for fresh air.
• Bloody expectoration.

7. Phellandrinum:

• Respiratory remedy. Good remedy for offensive expectoration and cough phthisis.
• Tuberculosis, affecting generally the middle lobes. Everything tastes sweet.
• Dyspnoea and continuous cough early in morning.
• Cough, with profuse and fetid expectoration; compels him to sit up. Hoarseness.[3]

Diet & Regimen of Chronic obstructive pulmonary disease

• Eat 20 to 30 grams of fiber each day, from items such as bread, pasta, nuts, seeds, fruits and vegetables.
• Eat a good source of proteinase least twice a day to help maintain strong respiratory muscles.
• Good choices include milk, eggs, cheese, meat, fish, poultry, nuts and dried beans or peas. [2]
• Eat a healthy diet with fish, poultry, or lean meat, as well as fruits and vegetables.

Terminology

The article utilizes several medical terms specific to COPD and its homeopathic management:

• Chronic Obstructive Pulmonary Disease (COPD): A progressive lung disease characterized by airflow limitation, making it difficult to breathe.
• Emphysema: A component of COPD where the air sacs (alveoli) in the lungs are damaged, leading to shortness of breath.
• Chronic Bronchitis: A persistent inflammation of the bronchial tubes, causing cough and mucus production. Often coexists with emphysema in COPD.
• Exacerbations: Flare-ups or episodes of worsening COPD symptoms, often triggered by infections or environmental pollutants.
• Comorbidities: Additional medical conditions that occur alongside COPD, such as cardiovascular disease or osteoporosis.
• Pathogenesis: The biological mechanisms that lead to the development of a disease. In COPD, this includes inflammation, protease imbalance, oxidative stress, and airway remodeling.
• Pathophysiology: The functional changes in the body that result from a disease. In COPD, this includes gas trapping, hyperinflation, and reduced lung compliance.
• Dyspnea: Shortness of breath, the most common and disabling symptom of COPD.
• Wheezing: A high-pitched whistling sound heard during breathing, indicating airflow obstruction.
• Miasmatic Tendency: A homeopathic concept referring to an individual’s predisposition to certain types of illnesses, often used to guide treatment selection.
• Homeopathic Remedies: Substances used in homeopathy to treat disease based on the principle of "like cures like." Examples include Aconitum Napellus, Antimonium Tartaricum, and Bryonia Alba.
• Potency: A measure of the dilution of a homeopathic remedy. Higher potencies are thought to have a deeper-acting effect.
• Repetition: The frequency with which a homeopathic remedy is administered.

References 

1. Davidsons Principles and Practice of Medicine
2. Chronic obstructive pulmonary disease – PubMed Health
3. Homoeopathic Therapeutics By Lilienthal
4. https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/what-causes-copd
5. https://stanfordhealthcare.org/medical-conditions/chest-lungs-and-airways/chronic-obstructive-pulmonary-disease/types.html
6. https://www.wikidoc.org/index.php/Chronic_obstructive_pulmonary_disease_physical_examination
7. https://my.clevelandclinic.org/health/diseases/8709-chronic-obstructive-pulmonary-disease-copd#prevention
8. Lancet Respiratory Medicine (2018)
9. Annals of the National Academy of Medical Sciences (India) (2022)
10. Global Burden of Disease Study (2017)
11. World Health Organization (WHO)
12. Fishman’s Pulmonary Diseases and Disorders (5th Edition) by, Michael Grippi, Robert Mason, John Murray, Jay Nadel (2015)
13. Harrison’s Principles of Internal Medicine (20th Edition) by, Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo (2018) published by McGraw Hill Education
14. Goldman-Cecil Medicine (26th Edition) by, Lee Goldman, Andrew Schafern (2020) Published by, Elsevier.