COPD

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Chronic obstructive pulmonary disease is a respiratory condition affecting a worrying percentage of the British population, says Rachel Hanslope

Chronic obstructive pulmonary disease (COPD), which encompasses both chronic bronchitis and emphysema, is one of the most common respiratory conditions for adults in the developed world.

COPD has had many names in the past including chronic obstructive airways disease; chronic obstructive lung disease; chronic airflow limitation; and chronic airflow obstruction.

The exact prevalence of COPD is difficult to determine because of problems with definition and coding. Sometimes it is difficult to differentiate between COPD and chronic severe asthma, and patients with mild to moderate disease may not be identified as suffering from COPD.

The definition of COPD, recognised by both the American Thoracic Society and the European Respiratory Society, is a disorder that is characterised by reduced maximal expiratory flow and slow forced emptying of the lungs - features that do not change markedly over several months. This limitation in airflow is only minimally reversible with bronchodilators - a medication intended to improve bronchial airflow.

Most patients will have been smoking cigarettes for many years, probably in excess of 20 years.

Symptoms

The two main symptoms of COPD are breathlessness and coughing that may or may not produce purulent sputum - mucus from the lungs. A history of a persistent productive cough or recurrent infections, especially in the winter months, is common. The cough is usually worse in the mornings, but bears no relationship to the severity of the disease. Excessive mucus volumes are unusual and may suggest bronchiectasis - permanent widening of the bronchi. Haemoptysis - the coughing up of blood or bloody sputum from the lungs - should alert the physician for the presence of a cancer of the bronchus as this is a frequent co-morbidity in patients with COPD, but is often just due to infective exacerbations.

Breathlessness is a common feature of acute infective exacerbations, but breathlessness during normal everyday activity develops insidiously over many years and most patients will have lost more than 50% of their predicted forced expiratory volume at one second (FEV1) by the time breathlessness becomes a problem. Wheezing is often an accompanying feature of breathlessness, which may be erroneously attributed to asthma.

Chest infections are more common in patients with COPD and recovery may be drawn out. As the disease progresses there is a pattern of acute exacerbations superimposed upon increasing shortness of breath and restriction of activities. More time is taken off work once moderate disease has developed, and complications such as depression and poor concentration may affect performance.

Patients with severe disease may find it impossible to work, and activities are markedly curtailed.

Not all people who smoke, however, develop COPD; and not all patients with COPD are smokers or have smoked in the past. There seems to be a varying susceptibility to lung damage due to cigarette smoke within the general population.

Pulmonary function tests (PFTs) are the primary diagnostic tools for COPD, after the medical history and physical examination. These tests demonstrate characteristic abnormalities in lung function that, in the proper clinical context, like medical history, physical examination, and chest x-ray, confirm or support the diagnosis of COPD and give some idea of the degree of impairment and prognosis. Lung biopsies are rarely used to diagnose emphysema.

The most reliable way to determine reversible airway obstruction is with spirometry, a procedure that measures the amount of air entering and leaving the lungs. This simple test can be performed in most physicians' offices, with the patient sitting comfortably in front of the spirometry machine. The patient inhales as deeply as possible and forms a seal around the tube with their mouth. Then the patient exhales, as forcefully and rapidly as they can, until they can not exhale any more. The machine measures airflow that passes through the inhalation port attached to the machine.

Those most commonly used for interpretation are FEV1, forced vital capacity (FVC), and peak expiratory flow rate (PEFR).

These results are expressed as percentages of what is predicted for normal lung function, depending on variables of height, age, race, and sex.

PEFR can also be obtained. PEFR can be compared with readings the patient obtains at home with a peak flow meter, which is a portable device that consists of a small tube with a gauge that measures the maximum force with which one blows air through the tube.

Mortality

COPD is a leading cause of illness and death, with a rising mortality rate in some countries. An average mortality rate is around 50 per 100,000 for men and 20 per 100,000 for women. Although death rates are higher for men, these have remained constant in contrast to the rising rate for women.

This is probably due to the increase in cigarette smoking, although trends in the mortality rates for COPD do not always follow alterations in smoking patterns. The disease takes decades to progress and most deaths occur in the 65 to 84 age group.

In the western world, COPD is probably the fourth most common cause of death in middle-aged to elderly men after ischaemic heart disease, lung cancer and cerebrovascular disease. In the UK, it is estimated that 18% of males and 14% of females aged 40 to 68 years may have developed features of COPD, and in the US, 13.6% of males and 11.8% of females aged 65 to 74 years are thought to have COPD. According to statistics produced by the American Lung Association, 15 million Americans suffer from COPD and it claimed the lives of 87,000 Americans in 1992.

In the UK, respiratory conditions are the third most common cause of chronic sickness in people age 45 to 64 years, and COPD is the most common cause of respiratory-related death. It accounts for 56% of days of certified incapacity due to respiratory conditions in males.

Rachel Hanslope is life and disability underwriter at Aegon Scottish EquitableUnderwriting considerationsWhen underwriting COPD it needs to be established whether the condition falls into the reversible or irreversible category. Irreversible is classed as reduced forced expiratory volume at one second and peak expiratory flow - less than 80% of predicted.

In the reversible stage, symptoms should not be severe enough for time off work or to restrict activities. If the bronchial irritant - usually smoking - is completely withdrawn, the pathological changes in the bronchi are able to resolve with the stopping of excessive mucous secretion, and the disease does not progress to the irreversible form.

When the condition becomes irreversible there is persistent widespread narrowing of the intrapulmonary airways causing increased resistance to airflow, especially on expiration. A degree of emphysema frequently co-exists, especially in the later stages. Airway obstruction may also be aggravated by attacks of acute bronchitis caused by infection or exposure to irritants - in advanced cases this may progress to pulmonary heart failure.

If the condition is at the reversible stage and the client is a non-smoker (and has been for more than two years) a 'standard rates' decision is likely for life cover. If it is at the reversible stage and the client continues to smoke, a small rating is usually appropriate.

Once the condition has reached the irreversible stage if the client is a non-smoker, there is likely to be a larger rating dependent on the severity of the symptoms, younger lives would be rated more heavily than older. If the condition is irreversible and the client continues to smoke, the cover is likely to be declined. Disability benefits and critical illness benefits are not usually available to anyone with the irreversible condition.

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