3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production.
COPD is a progressive disease, meaning it typically worsens over time. Eventually everyday activities, such as walking up stairs, become difficult. Chronic bronchitis and emphysema are older terms used for different types of COPD.
The term “chronic bronchitis” is still used to define a productive cough that is present for at least three months each year for two years.
As of 2015 COPD affects about 174.5 million (2.4%) of the global population. It typically occurs in people over the age of 40. Males and females are affected equally commonly. In 2015 it resulted in 3.2 million deaths, up from 2.4 million deaths in 1990.
More than 90% of these deaths occur in the developing world. The number of deaths is projected to increase further because of higher smoking rates in the developing world, and an aging population in many countries. It resulted in an estimated economic cost of $2.1 trillion in 2010.
Tobacco smoking is the most common cause of COPD, with factors such as air pollution and genetics playing a smaller role. In the developing world, one of the common sources of air pollution is poorly vented heating and cooking fires.
Long-term exposure to these irritants causes an inflammatory response in the lungs, resulting in narrowing of the small airways and breakdown of lung tissue. The diagnosis is based on poor airflow as measured by lung function tests. In contrast to asthma, the airflow reduction does not improve much with the use of a bronchodilator.
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Most cases of COPD can be prevented by reducing exposure to risk factors. This includes decreasing rates of smoking and improving indoor and outdoor air quality. While treatment can slow worsening, there is no cure.
COPD treatments include stopping smoking, vaccinations, respiratory rehabilitation, and often inhaled bronchodilators and steroids. Some people may benefit from long-term oxygen therapy or lung transplantation. In those who have periods of acute worsening, increased use of medications and hospitalization may be needed.
Symptoms and Signs
The most common symptoms of COPD are sputum production, shortness of breath, and a productive cough. These symptom are present for a prolonged period of time and typically worsen over time.
It is unclear if different types of COPD exist. While previously divided into emphysema and chronic bronchitis, emphysema is only a description of lung changes rather than a disease itself, and chronic bronchitis is simply a descriptor of symptoms that may or may not occur with COPD.
There is no known cure for COPD, but the symptoms are treatable and its progression can be delayed. The major goals of management are to reduce risk factors, manage stable COPD, prevent and treat acute exacerbations, and manage associated illnesses.
The only measures that have been shown to reduce mortality are smoking cessation and supplemental oxygen. Stopping smoking decreases the risk of death by 18%. Other recommendations include influenza vaccination once a year, pneumococcal vaccination once every five years, and reduction in exposure to environmental air pollution.
In those with advanced disease, palliative care may reduce symptoms, with morphine improving the feelings of shortness of breath. Noninvasive ventilation may be used to support breathing.
Providing people with a personalized action plan, an educational session, and support for use of their action plan in the event of an exacerbation, reduces the number of hospital visits and encourages early treatment of exacerbations.
Long-term antibiotics, specifically those from the macrolide class such as erythromycin, reduce the frequency of exacerbations in those who have two or more a year. This practice may be cost effective in some areas of the world.
Concerns include that of antibiotic resistance and hearing problems with azithromycin. Methylxanthines such as theophylline generally cause more harm than benefit and thus are usually not recommended, but may be used as a second-line agent in those not controlled by other measures. Mucolytics may help to reduce exacerbations in some people with chronic bronchitis. Cough medicines are not recommended.
4. LOWER RESPIRATORY INFECTIONS
Lower respiratory tract infection (LRTI), while often used as a synonym for pneumonia, can also be applied to other types of infection including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, fever, coughing and fatigue.
There are a number of symptoms that are characteristic of lower respiratory tract infections. The two most common are bronchitis and pneumonia. Influenza affects both the upper and lower respiratory tracts.
Antibiotics are the first line treatment for pneumonia; however, they are not effective or indicated for parasitic or viral infections. Acute bronchitis typically resolves on its own with time.
In 2015 there were about 291 million cases. These resulted in 2.74 million deaths down from 3.4 million deaths in 1990. This was 4.8% of all deaths in 2013.
Vaccination helps prevent bronchopneumonia, mostly against influenza viruses, adenoviruses, measles, rubella, streptococcus pneumonia, haemophilus influenza, diphtheria, bacillus anthracis, chickenpox, and bordetella pertussis.
Antibiotics do not help the many lower respiratory infections which are caused by parasites or viruses. While acute bronchitis often does not require antibiotic therapy, antibiotics can be given to patients with acute exacerbations of chronic bronchitis.
The indications for treatment are increased dyspnoea, and an increase in the volume or purulence of the sputum. The treatment of bacterial pneumonia is selected by considering the age of the patient, the severity of the illness and the presence of underlying disease.
Amoxicillin and doxycycline are suitable for many of the lower respiratory tract infections seen in general practice.
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