COPD (chronic obstructive pulmonary disease)

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The Problem

COPD is a progressive lung disease that makes it difficult to breathe. It is general term which includes the conditions of chronic bronchitis and emphysema those can cause obstruction (narrowing) of the airways.[1-20] By 2020, it is expected to rank third in the list of the 10 most frequent global causes death. Smoking is the primary cause of COPD.[1,4,16] Other than that is because of the air pollution, the occupational dust from cadmium, silica and workplace chemical fumes are considered as dangerous which may affect the passive smoker.[1-6]

Common symptoms include shortness of breath, morning cough and increase sputum (a mix of saliva and mucus in airways) production. COPD can be prevented. However, once it develops, it will progressively worsen lung function and limit airflow if left untreated. At this time, there is no cure and doctors can only ease the sometimes distressing symptoms of COPD by treatment. There are many treatments may help to relieve the disorder symptoms. The medication treatment which the doctors always suggest and prescribe to manage stable COPD is bronchodilators which contain two major types; anticholinergics and beta2-agonists.[1-12] So, how does both of these drugs are effective to the action for bronchodilators?

A Possible Solution

Bronchodilators are a medication treatment which helps to relax the muscle around the bronchi to allow easier breathing. It is usually breathed into the lungs directly taken using a device call inhaler or via a nebulizer.[3,4,9-12,22] Anticholinergics bronchodilators, short-acting beta2-agonists, long-acting beta2-agonists, and also a combination of an anticholinergic bronchodilator and a short-acting beta2-agonists fall into this class of COPD medication.

Anticholinergics block the stimulation of cholinergic nerves to relax the airway smooth muscle and reduce severe exacerbations and respiratory deaths in COPD patients. Anticholinergics are most often administered through metered-dose inhalers. The effects of the medication generally last from four to six hours, so physicians typically prescribe use four times a day.[3,4,12] Ipratropium as short-acting anticholinergics provide rapid relieve of COPD symptoms and Tiotropium acts as long-acting anticholinergic is more specificity for M3,muscarinic receptors. Anticholinergic bronchodilators, as a class, are the number one prescribed bronchodilator used in the treatment of COPD.[4,10,12]

Beta2-agonists bronchodilators relax bronchial smooth muscle by stimulating the receptors in the symphatetic nerves which lead to dilation of air passage. Short-acting beta2-agonists such as Salbutamol were recommended for COPD patients who experienced intermittent symptoms and as a "rescue" to avoid an imminent attack of shortness of breath. It is typically prescribed along with anticholinergics to open up airways of COPD patients with continuing symptoms. Long-acting beta2-agonists(LABAs) such as salmeterol and formoterol are used as maintenance therapy and lead to improved airflow, exercise capacity, and quality of life.[4,10-12]

Combination Bronchodilators of an anticholinergic and short-acting beta2-agonist works via the part of the nervous system that controls airway size, as well as the part that controls muscle tissue around the airways.[10] Increased efficacy is seen with this combination agent over the individual components, without an increase in side effects. These combination bronchodilators are usually for moderate COPD patients.[4]

"Risk for moderate COPD exacerbations, but not severe exacerbations, was lower with combined therapy". Allan S. Brett, MD[20]

Studies show that patients receiving combination treatment have slightly better response than patients receiving only beta-2 agonists. Ipratropium bromide is an anticholinergic bronchodilator that is not as fast acting as short acting beta-2 agonists or as potent, but it has a longer duration of action and perhaps is more reassuring. Ipratropium bromide remains as cornerstone

unique therapy which acts via parasympathetic pathway and virtually free of cholinergic side effects. The two types of bronchodilators, anticholinergics and beta2-agonists, have generally been considered to be equivalent choices for use in patients with COPD.

Pooled results from 22 trials with 15,276 participants found that anticholinergic use significantly reduced severe exacerbations (RR 0.67, confidence interval [CI] 0.53 to 0.86) and respiratory deaths (RR 0.27, CI 0.09 to 0.81) compared with placebo. Beta2-agonist use did not affect severe exacerbations (RR 1.08, CI 0.61 to 1.95) but resulted in a significantly increased rate of respiratory deaths (RR 2.47, CI 1.12 to 5.45) compared with placebo. There was a 2-fold increased risk for severe exacerbations associated with beta2-agonists compared with anticholinergics (RR 1.95, CI 1.39 to 2.93).[8] As a conclusion, both anticholinergics and beta2-agonists may be effective bronchodilators and improve symptoms in patients with COPD. Anticholinergics reduced severe exacerbations and respiratory deaths in patients with COPD. However, beta2-agonists had no effect on severe exacerbations and resulted in an increased rate of respiratory deaths, possibly owing to a reduction in disease control. Concomitant corticosteroids were used in over one-half of patients treated with beta2-agonists, but it is not clear if this provided some protection against the adverse effects.

Social and Economic Implications

Initially, COPD might not be considered a disease that is stigmatizing. However, patients with COPD feel stigmatized by people around them also by their physicians. They feel personal embarrassment and shame about using oxygen due to COPD with smoking. They also feel distressed when people stared at them were working hard to breathe. Plus, their physicians biased them because of their smoking history.[25] As a result, these may affect self-esteem in patients with COPD and engagement in social activities, thus having implications for social support, which may lead to isolation. Stigma from physicians may affect health care access. They may hesitate to seek care for fear of judgment or negative repercussions associated with having the condition. Patients may also decrease their use of specific treatments that are associated with stigma or that show that they have COPD. High co-morbidity of COPD leads to anxiety and depression. Social implications are severe and concurrent psychiatric disorders may impair quality of life.[25,26]

Besides that, patients require great adherence to treatment or hospitalization which would cause huge financial burden and economic impact.[16] In order to create the most accurate picture, both direct costs (medications and oxygen, services through health-care providers, inpatient stays, institutional care, diagnostic testing, and visits to the emergency room) and indirect costs (lost income due to illness that cover both patients and caregivers, decreased productivity on the job, and travel) must be taken into account. The costs associated with COPD are substantial. For instance, in the U.S. in 2007 was about $42.6 billion in health care costs and lost productivity.[16,17]

Benefits and Risks

Bronchodilators had been proved by studies that it could relieve COPD symptoms by relaxing the muscle bands that tighten around the airways, letting more air come in and out of the lungs.[18-21] As a result, breathing improves. Bronchodilators also help clear mucus from the lungs. As the airways open, the mucus moves more freely and can be coughed out more easily. Thus, people do get better and can do whatsoever things they want happily without any consequences.[22,23] So, medications can boost the quality of life.

However, the treatment also gives side effects to human health. Some side effects might happen are fast heartbeat, irritability, difficulty sleeping, muscle cramps and shaky hands. They are usually less noticeable. Since patients are using inhalers, this would cause occasional dry mouth. The use of inhalers containing corticosteroids to treat COPD might also increase the risk of pneumonia by as much as 70% -researchers report.[24] To prevent these, patients should take medicine as directed by the doctor, rinse mouth with water, gargle and spit the water out after each dose and use a spacing chamber with their puffer.[23]

"I have just been diagnosed with COPD and am on all the usual inhalers and steroids which I am not happy about". Carole Didlock [14]

Moreover, non-adherence of therapy is also common in patients when continued use of a drug required for daily functioning. Normal reasons are forgetting to take medicine and feeling that the medication is unnecessary plus the resulting side effects. This increases the risk of relapse of symptoms and repeated hospitalization. It is crucial to educate patients about the risks.

Alternative Solutions

Smoking cessation

Smoking is the main cause of COPD.[1-14,16] It is critically important that COPD patients quit smoking to slow down the progression of COPD even at a late stage of the disease.[3,4,5,12,17] However, it is very difficult to quit smoking cigarette because they are psychologically and physically addictive but it can be done. Some smokers can achieve long-term smoking cessation through "willpower" alone but many smokers need further support.[4] The chance of successfully stopping smoking can be greatly improved through social support and engagement in a smoking cessation program. They can get advice from healthcare practitioners. Also can ask family members and friends to support in efforts to quit and try to avoid secondhand smoke. Coverage for cessation therapy should be universal and programs should be in place for relapse prevention. Cessation therapy remains among the most highly cost effective rather than other intervention. So, it is crucially the best alternative to ease COPD.[17]

Relaxation therapy

Relaxation is one of the methods of dealing with the anxiety and nervousness which often accompanies COPD. Indirectly, COPD symptoms can be relieved gradually. Acupressure and Shiatsu which are both finger pressure massage system based on the principles of Traditional Chinese Medicine (TCM). The idea is to treat special points along meridians, invisible channels of energy flow within the body. The pressure unblocks the energy and restores comfort. This gentle approach helps people with COPD to breathe easier.Massage also as a balance to conventional medicine. For COPD, a massage can strengthen respiratory muscles, reduced heart rate, increase oxygen saturation in blood, decrease shortness of breath, and improved pulmonary functions. The controlled breathing in yoga can ease anxiety, provides relaxation, and more oxygen to the blood stream. The exercises help open blocked airways caused by bronchitis or emphysema, which are linked to COPD, and improve the function of circulation. Simple yoga moves can even aid those with advanced COPD.[13]

"Those who suffer from COPD may believe exercise will make their condition worse, but studies have showed that simple exercises helps improve endurance, reduces anxiety levels, which in turn helps those with COPD to breathe more easily and improve their ability to perform normal activities." (Victoria Abreo, BellaOnline's Alternative Medicine Editor)[13]

Evaluation

Anticholinergics and beta2-agonists have been found those they are effective in the use for bronchodilators drug to treat COPD patient which they help to ease the sometime distressed symptoms, from reference [8,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831628/?tool=pmcentrez]. This source is reliable since it also agrees with many other sources cited, and the following extract. "Bronchodilator medicines open up the airways (breathing tubes) in your lungs. When your airways are more open, it's easier to breathe. Doctors may prescribe more than one kind of bronchodilator to treat COPD. There are two main types of bronchodilators that come in inhalers: anticholinergics and beta2-agonists". By The American Lung Association [http://www.lungusa.org/lungdisease/COPD/treatment/medicationsforCOPD/049=0]. Moreover, the article based on peer-reviewed results that have gone through all the stages ensuring they are valid and addresses the complications with research progression. In addition, the source is service of World Health Organization (WHO) and the U.S National Library of Medicine and the National Institute of Health which are trustable.

Bibliography

  1. Suzanna Pillay - 'Coping with COPD.' New Straits Times, Nov 24,2009 : (Cover Story); 8-9.
  2. Hogg JC, Chu F, Utokaparch S, et al. (2004). "The Nature of Small-Airway Obstruction in Chronic Obstructive Pulmonary Disease". New England Journal of Medicine 350 (26): 2645-2653.
  3. http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html
  4. http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease
  5. http://www.who.int/mediacentre/factsheets/fs315/en/index.html
  6. http://pats.atsjournals.org/cgi/content/full/4/8/692
  7. http://www.lungusa.org/assets/documents/COPD_APRIL_2009.pdf
  8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831628/?tool=pmcentrez
  9. http://www.nlm.nih.gov/medlineplus/ency/article/000091.htm
  10. http://www.aarc.org/klein/treatments.asp
  11. http://www.pulmonologychannel.com/copd/treatment.shtml
  12. http://www.mayoclinic.org/copd/treatment.html
  13. http://www.bellaonline.com/articles/art34015.asp
  14. http://www.thehealthierlife.co.uk/natural-health-articles/lung-problems/natural-remedies-copd-00181.html
  15. http://www.dovepress.com/safety-tolerability-and-risk-benefit-analysis-of-tiotropium-in-copd-peer-reviewed-article-COPD
  16. http://www.erj.ersjournals.com/cgi/content/full/21/41_suppl/29S
  17. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707159/
  18. https://www.researchgate.net/publication/6792864_COPD--chronic_obstructive_pulmonary_disease_and_its_implications_for_the_human_organism
  19. https://mospace.umsystem.edu/xmlui/handle/10355/3016
  20. http://www3.interscience.wiley.com/journal/118582574/abstract?CRETRY=1&SRETRY=0
  21. http://medind.nic.in/iac/t02/i1/iact02i1p15o.pdf
  22. http://www.scielo.br/scielo.php
  23. http://www.lungusa.org/lungdisease/COPD/treatment/medicationsforCOPD/049=0
  24. http://www.medicinenet.com/script/main/art.asp?articlekey=97538
  25. http://www.informahealthcare.com/doi/abs/
  26. http://pats.atsjournals.org/cgi/content/full/4/8/680

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