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SPOTLIGHTS
The struggle to blow a simple pinwheel
For patients with Chronic Obstructive Pulmonary Disease, a progressive chronic respiratory disease, they struggle to blow a single pinwheel from an arm’s length. Dr. Lee Yeow Hian sheds more insight on this condition and treatments available to relieve the symptoms.

Chronic Obstructive Pulmonary Disease (COPD) is the term used to describe a number of conditions affecting the lungs including emphysema and chronic bronchitis, which makes it difficult to breathe, and daily tasks a real challenge. COPD Day held on the 15 of November 2017 aims to raise awareness of this condition and that with the right support, it is possible to live well with COPD. Dr. Lee Yeow Hian shares about this devastating but preventable disease.

You specialize in respiratory medicine. What attracted you to this field of medicine?

I specialize in Respiratory, Sleep & Intensive care medicine. This combination allows me to care for patients across a spectrum of diseases ranging from those who are relatively well, all the way to those who are critically ill on life support.

Which diseases are classified under COPD?

Chronic Obstructive Pulmonary Disease (COPD) is as an umbrella term predominantly referring to two main diseases – emphysema and chronic bronchitis. Whilst other respiratory diseases such as chronic asthma and bronchiectasis may exhibit similar symptoms to COPD, both are not classified under the term itself.

How common is COPD in the Asia-Pacific region?

The prevalence of COPD can range between 5-15% of the population. The number of COPD sufferers tends to increase as people get older. According to the World Health Organization, around 56.6 million people in Asia Pacific suffer from moderate to severe COPD1.

Countries that are rapidly industrializing and experience a high level of environmental pollution such as China tend to have higher prevalence of COPD. This is true especially in developing countries in the region.

What common misconceptions do you often hear when it comes to COPD?

The biggest misconception among the medical fraternity is that COPD is an incurable and untreatable disease. The truth is that COPD is a treatable disease, although not curable. This misconception came about because there were not many good and effective treatments for COPD for the longest time, and there was not much you can do for COPD patients in the past, leading to pessimism about COPD.

From the patient’s perspective, there is and continues to be a general lack of awareness and information about COPD. Patients often associate symptoms such as breathlessness with ageing, while others may feel that their chronic cough is a “smoker’s cough” solely caused by their years of smoking, when in fact it is caused by COPD. Smoking is by far one of the leading causes of COPD, but it can also be caused by environmental factors such as air pollution and exposure to noxious particles or gases.

How is COPD diagnosed? What is one test you make your patients do to diagnose them with COPD?

A spirometry test is the “Gold Standard” way of diagnosing COPD. This test evaluates one’s lung function and requires an individual to blow hard into a machine, which measures the amount of air one can blow out in the first second as well as one’s lung volume. This is used to gauge the amount of obstruction present in the air passages and gives us a way to measure the severity of the patient’s lung disease.

In terms of tell-tale signs and symptoms, a persistent chronic cough is one of the indicators of COPD, as well as frequent production of phlegm or a feeling of breathlessness especially upon exertion. However, by the time the patient exhibits these symptoms, the disease may be quite advanced.

COPD is generally considered irreversible with no cure. Why is it not possible to cure COPD?

The reality is that the lung does not regenerate or heal itself, and once damaged, the damage tends to be permanent. So despite the advances in the medical field, COPD patients cannot be cured completely, although there are treatments to help relieve symptoms, improve day to day functioning and quality of life.

By alleviating the symptoms, this helps to reduce the complications arising from COPD. For example, breathlessness can cause a patient to become less mobile, leading to osteoporosis and resulting in depression and social isolation. Although medical treatments do not cure COPD, by alleviating the symptoms, this reduces complications and resulting problems, allowing patients to regain a normal way of life.

After COPD is diagnosed in a patient, what are their current treatment options?

The pillars of COPD treatment are:

  1. Smoking cessation. Cigarette smoke is damaging to one’s lungs. It is thus important to stop smoking so further damage does not occur.
  2. Medications. The newest class of medications available for the treatment of COPD is a combined inhaler comprising a Long Acting Beta receptor Agonist (LABA) and a Long Acting Muscarinic receptor Antagonist (LAMA). These have been proven to work by opening up the airways and reducing air trapping, thus improving breathlessness and resulting in improved lung function; quality of life and reduces exacerbations.
  3. Immunization. Exacerbations of COPD result in loss of lung function, hospitalization and poorer quality of life are commonly the result of viral infections. It is therefore important to try to reduce these attacks by training one’s immune system such that an effective defence can be mounted in response to these infections. The annual influenza vaccination is recommended by most health authorities worldwide.
  4. Pulmonary rehabilitation. Regular exercise helps maintain physical fitness. As patients with COPD become more breathless, they become less and less active and more unfit. This physical deconditioning results in worsening breathlessness upon exertion, leading to further immobility.

In the advanced stages of COPD, the lung function may be so poor that the blood levels of oxygen are insufficient, and patients may require the use of an oxygen concentrator to enrich the oxygen content of the air that they breathe.

For very severe COPD patients with frequent exacerbations and respiratory failure, some patients may benefit from having a Bilevel Positive Airway Pressure (BiPAP) machine such as the Philips BiPAP AVAPS at home to offload the breathing, especially if their blood carbon dioxide levels are very high. These machines help them to breathe easier and rest the breathing muscles, especially at night. There is emerging evidence that in the right patient, BiPAP use can reduce breathlessness, improve quality of life and reduce attacks and hospitalizations.

The latest news on COPD treatment was the FDA approval of Magnair, an eFlow closed system nebulizer. What are other latest research in the management on COPD?

The main method to COPD management is unfortunately still pharmacological, through medicine. Personally I do not have experience with Magnair as it is still a very new product, however the most widely-accepted and newest forms of treatment is still the LAMA/LABA combination treatment, in fact it has only emerged in the past few years. This treatment is available in Singapore and across APAC. Besides this, treatments such as pulmonary rehabilitation/exercise and smoking cessation form the pillars for COPD treatment.

What was your most memorable experience with a patient suffering from COPD?

I do recall an elderly patient who had end-stage COPD, experiencing frequent exacerbations needing frequent admissions to hospital and was on all available medications that were licensed for use at that time. In the end, we had to put him on non-invasive ventilation (BiPAP) to bring down the carbon dioxide levels and rest his respiratory muscles. Back then, non-invasive ventilation was not as well-established for the chronic treatment of COPD but it was our last resort, having exhausted all the other treatment options. This enabled him to stay at home, allowing him to spend quality time with his family.

Anything you’d like to share with our readers that they should know?

The biggest cause of COPD is still cigarette smoking, and this is true worldwide. In terms of prevention of COPD, the best one can do is to stop smoking. While non-smokers may also get COPD, they are far less likely to get COPD, although environmental pollution or chronic asthma that has not been appropriately treated can contribute to the burden of COPD. As mentioned, smoking cessation, pharmacological treatment, pulmonary rehabilitation and appropriate immunization are the mainstays of COPD treatment.

References:

  • World Health Organisation (n.d.) Chronic respiratory diseases. [online]. Available at: https://www.who.int/gard/publications/chronic_respiratory_diseases.pdf

About the Author

Dr. Lee Yeow Hian
Consultant Chest and Sleep Physician
Specialist in Intensive Care Medicine
Mount Elizabeth Novena
Mount Alvernia Hospital

Dr. Lee is one of the few Sleep Medicine Specialists in Singapore with formal qualifications registrable with the Singapore Medical Council and previously worked with Professor Colin Sullivan, the inventor of CPAP (Continuous Airway Pressure) therapy. He is an accredited specialist in intensive care medicine by the Ministry of Health in Singapore and an appointed trainer in intensive care medicine by the joint committee on specialist training. Dr. Lee is recognised in his expertise in Sleep Medicine and has been invited to speak at major scientific conferences, including the World Congress of Sleep Apnoea in Seoul in 2009.

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EDITORS' CHOICE  
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APBN Editorial Calendar 2018
January:
Obesity / Outlook for 2018
February:
Searching for the fountain of youth
March:
Women in Science - Making a difference
April:
Digestive health in the 21st century - Trust your guts
May:
Dental health - The root to good health
June:
Cancer - Therapies and strategies for better patient outcomes
July:
Water management - Technologies for biotech and pharmaceutical industries
August:
Regenerative technology - Meat of the future
September:
Doctor Robot - The digital healthcare revolution
October:
Bones / Breast cancer
November:
Liver health / Top science research nations & institutions
December:
AIDS / Breakthrough of the year/Emerging trends
Editorial calendar is subjected to changes.
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