Chronic toll of winter

Medical matters:'Sometimes I think, if only I was a dog, I could be shot" - A patient with severe chronic obstructive pulmonary disease (COPD).

Even though, meteorologically speaking our weather has been benign of late, November marks the beginning of "clinical winter".

The term reflects the annual increase in hospital admissions due to heart and lung conditions such as pneumonia, heart-failure and respiratory failure. During the clinical winter season from November to March, our acute hospitals typically see a 40-50 per cent increase in the number of people admitted due to an exacerbation of COPD.

During an exacerbation, a person with COPD will experience a rapid worsening of uncontrolled symptoms such as severe breathlessness, wheeze, nasal congestion and cough. Infected mucus in the lungs leads to a huge increase in sputum production.

COPD refers to a condition previously described as chronic bronchitis (inflammation and narrowing of the airways) and emphysema (weakening of the structure of the lung). A progressive disease, it causes chronic breathlessness that can lead to severe disability.

Essentially, COPD limits the flow of air leading to excess air being trapped in the lungs after a person has breathed out. Known as "airtrapping" it is the main cause of breathlessness in a person with COPD.

Although COPD is the fifth leading cause of death worldwide, claiming 2.75 million lives annually, it is estimated that up to 75 per cent of patients in Europe are undiagnosed.

Speaking at the recent annual meeting of the Irish Thoracic Society, Dr David Price, professor of primary care respiratory medicine at the University of Aberdeen, said many patients with COPD were misdiagnosed or else not diagnosed until relatively late in the disease.

This is reflected in the finding that just 40 per cent of patients with COPD are alive some 48 months after hospital admission with the disease. This compares with a figure of 80 per cent for patients admitted with unstable heart disease, he told the meeting.

What causes the chronic breathing illness? The chief culprit is smoking, causing almost 90 per cent of cases. It is thought that genetic factors modify the risk in the other 10 per cent.

A proven genetic risk factor for COPD is a hereditary deficiency of protein alpha-1 anti- trypsin. Heavy exposure to certain dusts and chemicals in the workplace can also trigger the disease. And indoor air pollution from biomass fuel has also been implicated in the development of COPD.

The diagnosis of COPD is made on the basis of symptoms and by measuring airflow limitation using a breathing test called spirometry. But because there is a lack of serious symptoms early in the disease, neither patient nor doctor are alerted to the problem.

In order to improve this unsatisfactory state of affairs, doctors are now encouraged to ask specific questions of people who smoke. So if you are coughing up phlegm first thing in the morning or if you wheeze frequently, then it's a good idea to have your breathing formally tested.

Doctors are trained to look for the disease in smokers over 40 using respiratory question- naires and by testing them using the spirometer screening test. Indeed some experts have argued for a 10-yearly lung health check starting from 25 years old but it is hard to support such a radical proposal on scientific grounds.

The quote at the top of the column is a reflection of the burden felt by a patient with COPD. As the disease progresses they find that ordinary daily activities can only be accomplished slowly and with frequent rests. "You can only wash half the dishes and then you've got to wait for breath and then start again . . . it has to rule your life," is how one patient described the effects of the disease.

A stoic lot, people with end-stage COPD are notably undemanding. The smokers will readily say, with a shrug of their shoulders, that it is their own fault they have the disease.

In the past, this has led to a certain therapeutic nihilism on the part of doctors, certainly as far as a preventive approach was concerned.

In drug terms, patients will benefit from inhalers that relax and open up the narrowed airways. Some long-acting versions have been shown to be especially effective. And for those with severe COPD, the regular use of inhaled steroids may reduce exacerbations.

But there are other interventions available. Flu vaccination is very important. Pulmonary rehabilitation has been shown to improve exercise levels and the quality of life for people with COPD. Specific nutritional advice helps, by building up the muscle bulk of underweight patients with severe disease. And long-term oxygen therapy is also effective.

Although these measures will collectively improve a person's prognosis, winter exacer- bations are a fact of life in established COPD. Because most are triggered by infection, early treatment with antibiotics is a must.

And even though some patients will require intravenous drugs and nebulisers, it is now possible to offer intensive treatment using a "hospital at home" approach, thereby avoiding hospital admission.

Dr Muiris Houston welcomes readers' comments at mhouston@irish-times.ie but regrets he cannot respond to individual medical queries.