COPD under-diagnosed among heart disease patients

About a year ago, I was discussing the woeful levels of patient access to pulmonary rehabilitation with one of the chief pulmonology scientists at the National Institutes of Health. During our conversation, the scientist indicated that diagnosing and treating lung disease/COPD is becoming more complicated because of the growing prevalence of lung disease among people who have other significant health conditions – most notably heart disease, hypertension or diabetes.

It seems that among these diseases/conditions, lung disease is the one that is often under-diagnosed by doctors. In a way, one can understand how this happens. The diagnostic tests to assess heart disease, hypertension and diabetes are relatively easy to administer and interpret by most practitioners (generalists and specialists alike) while the primary test for determining a person's lung function, spirometry, is not. In addition, the shortness of breath symptoms that typically are warning signs of emerging lung disease can be associated with symptoms of heart disease, hypertension and diabetes.

A recent study published in Chest underscores this point. A group of Spanish researchers hypothesized that COPD was under-diagnosed among patients with cardiovascular disease and coronary artery disease. For the study, the research team sought out people who had been previously diagnosed with these two heart conditions but who had not been assessed for lung disease. They then administered spirometry tests to these patients to determine whether there was notable airflow limitation in the study population. (Soriano JB, et al. High Prevalence of Undiagnosed Airflow Limitation in Patients With Cardiovascular Disease. Chest. 2010 Feb; 137 (2):333-40)

In a spirometry test, a patient blows air into a spirometer (a device that measures the volume of air expired in either 1 second or 6 seconds). The output of the test is a statistic called either FEV1 or FEV6 (the amount of air expired in either 1 or 6 seconds). While this sounds easy to interpret, it is not. The output of the test is actually a graphic depicting the curve of the expired air. It takes a skilled practitioner to look at the results and determine whether the FEV1 or FEV6 values reveal emerging lung disease.

What the researchers found was astonishing. Over 20% of those diagnosed with cardiovascular disease had airflow limitation consistent with COPD diagnosis. The spirometry tests in the patient group with coronary artery disease showed 33% with COPD-like levels of airflow limitation. The researchers concluded that in order to catch and treat lung disease more aggressively, physicians should administer spirometry tests for all patients who have been diagnosed with heart disease. Sounds like a worthy recommendation.

These findings are somewhat consistent with a different study published in Thorax in 2008. In this study, the researchers desired to understand what co-morbidities existed among COPD patients undergoing pulmonary rehabilitation (meaning what other chronic diseases where present among these COPD patients). (Chrisafulli E. Role of co-morbidities in a cohort of patients with COPD undergoing pulmonary rehabilitation. Thorax. 2008 Jun; 63(6):487-92)

Overall, over 50% of the study patients had at least one co-morbidity with the most prevalent co-morbidities being hypertension (27%), heart disease (20%), and diabetes (10%). The study researchers, echoing the sentiments shared by the NIH scientist I spoke with last year about the increasing complexity of treating lung disease, said, "Complex chronic co-morbidities may significantly affect the clinical severity of COPD being present in up to 56% of patients with COPD compared with non-COPD subjects of the same age."

The takeaway - if you have heart disease, hypertension or diabetes and you suffer from chronic shortness of breath, ask your doctor for a referral to a pulmonologist to conduct a spirometry test. It's a quick and easy test to take (not so much to interpret) but it may help you spot lung disease earlier in its development when you have a better chance of slowing or halting the progression of disease through applying the practices and principles of pulmonary rehabilitation and otherwise treating short-term symptoms with medication.

CoEnzyme Q10 – helpful for smokers/COPD patients who exercise?

For those of you who are active nutritional supplement users or are considering adding nutritional supplements to your healthy living routine, one of the key nutrients you should learn about is a powerful antioxidant called CoEnzyme Q10 (or CoQ10 for short). This is especially true if you are engaged in an active exercise program or expect to start one in the near future.

So what is CoQ10? The authors of a recent research article examining CoQ10 and exercise summarized this nutrient as follows, "CoQ10 is a vitamin like, fat-soluble substance existing in all cells. It is intimately involved in several important roles in the body including the transferring of electrons within the mitochondrial oxidative respiratory chain and hence, ATP production; acting as an essential antioxidant and supporting the regeneration of other antioxidants; influencing the stability, fluidity and permeability of membranes; and, stimulating cell growth and inhibiting cell death." (Cooke M, et al. Effects of acute and 14-day coenzyme Q10 supplementation on exercise performance in both trained and untrained individuals. J Int Soc Sports Nutr. 2008 Mar 4; 5:8)

While there is scant research indicating that CoQ10 has strong efficacy among smokers or COPD patients, there is a significant amount of research supporting CoQ10's efficacy for those engaged in exercise programs and for people suffering from a range of maladies including congestive heart failure, hypertension and diabetes.

In addition, pulmonary medicine researchers continue to examine the benefit of antioxidants for smokers and COPD patients given that both populations experience higher levels of oxidative stress (meaning blood levels of antioxidants are depressed for smokers and COPD patients, most commonly as a direct result of the oxidants inhaled while smoking).

Indeed, in a 2008 research article, the study author introduced his study results by indicating, "Oxidative stress is intimately associated with the progression and exacerbation of COPD and therefore targeting oxidative stress with antioxidants or boosting the endogenous levels of antioxidants is likely to have beneficial outcome in the treatment of COPD." (Rahman I. Antioxidant therapeutic advances in COPD. Ther Adv Respir Dis. 2008 Dec; 2(6):351-74).

So while a number of researchers agree that taking supplemental antioxidants is likely indicated for smokers and COPD patients, there is considerable debate over what antioxidants to recommend and what dosages are appropriate and effective – and most studies on a range of antioxidants have been inconclusive. Our own view is that CoQ10 is an antioxidant worthy of your consideration based on two main factors:

1. While there is not a strong body of research on CoQ10 for smokers and COPD patients, there is notable prevalence of heart disease, hypertension and diabetes among COPD patients and smokers and CoQ10 has been shown to provide statistically significant benefits for people with these conditions. For example, the same authors of the Journal of the International Society of Sports Nutrition article referenced above state, "In CHF (congestive heart failure) patients, a disease characterized by lower than normal CoQ10 levels, CoQ10 supplementation has shown to improve stroke volume, ejection fraction and exercise capacity in several double-blind, placebo-controlled studies."

2. Regular exercise is a key treatment recommendation for COPD patients (and should be for smokers) and CoQ10 has been shown in numerous studies to reduce fatigue and improve exercise tolerance in healthy adults as well as those with heart disease and hypertension. As a 2008 study noted, "Oral administration of coenzyme Q10 improved subjective fatigue sensation and physical performance during fatigue-inducing workload trials and might prevent unfavorable conditions as a result of physical fatigue" (Mizuno K, et al. Antifatigue effects of coenzyme Q10 during physical fatigue. Nutrition. 2008 Apr; 24(4):293-9. Epub 2008 Feb 13).

So if you're a smoker or COPD patient engaged in an exercise program and you are open to the use of nutritional supplements, take a closer look at CoQ10. Most of the studies we examined for this article used daily dosage levels that ranged between 60mg – 200 mg with the most commonly used daily dosage level being 100 mg. Of course, before adding CoQ10 to your daily regimen, you should consult your doctor to ensure there are no counter-indications with medications you are currently taking.

Home-based pulmonary rehabilitation – a viable option for COPD patients

Within pulmonary medicine circles, there is an ongoing debate regarding the effectiveness and safety of home-based pulmonary rehabilitation programs for COPD patients. A home-based pulmonary rehab program is one in which practitioners provide initial exercise sessions in a clinical environment or at the patient’s home, and then periodically check-in with patients to see how they are doing with the at-home program and to encourage them to continue (typically the check-ins are conducted once or twice a month).

On one hand there are practitioners and researchers who contend that to really get measurable benefit out of home based exercise programs, COPD patients need to increase intensity of exercise as they progress through their program. In their opinion, to do so at home without medical professional observation is risky (i.e. what if the patient has an exacerbation event, meaning a shortness of breath attack, with no medical professionals available to assist them respond to the exacerbation).

On the other hand, the practical reality is that very few COPD patients are admitted to hospital outpatient pulmonary rehabilitation programs for a variety of reasons. And for those who are admitted, the programs only last 6-8 weeks before patients graduate and are expected to indefinitely continue a self-managed program on their own thereafter. For these folks, there is no choice. It’s either a self managed home-based or fitness center-based pulmonary rehab program or nothing.

So, another group of practitioners and researchers have been studying the effectiveness and safety of home-based pulmonary rehab programs to determine how closely they resemble outpatient programs in terms of improved physical conditioning, self-reported quality of life, and incidence of dyspnea (shortness of breath attacks/episodes).

To that end, a recent review of 12 average-quality home-based pulmonary rehabilitation studies concludes that in general home-based pulmonary rehab programs for COPD patients produce outcomes equivalent to hospital outpatient programs and that the incidence of dyspnea events is not significantly different between the two – even in studies where patients were asked to notably increase the intensity of their exercise over the course of their program (Vieria D, Maltais F, Borbeau J. Home-based pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Curr Opin Pulm Med. 2010 Mar; 16(2):134-43). If you are interested, the full text of this article can be purchased by clicking here. The cost of the article is $35.00.

The tricky part for the review article authors is that none of the 12 studies are exactly the same. Some focused on the efficacy of home-based pulmonary rehab programs versus post-outpatient rehab standard care (standard care meaning sending folks home with modest advice/education/instruction to begin an unsupervised program at home with no further intervention). Other studies focused on comparing home based versus outpatient pulmonary rehab programs. Further, the program durations were different across the studies as well as the measurements of improvement utilized in the clinical trials and how the study researchers presented their measurement results.

But even with these disparities looking across the spectrum of the studies, it was clear to see that home-based rehab programs are effective. In the studies where the comparison was against standard care (i.e. self manage with minimal instruction and no subsequent check-ins), home-based rehab programs showed significantly higher levels of physical conditioning, self-reported quality of life and incidence of dyspnea. In comparison to hospital based programs, home-based programs were generally as effective as outpatient programs on these same basic evaluation criteria. And as mentioned at the outset of this article, home-based programs that involved increasing intensity of exercise during the program showed no measurable differences in reported exacerbation events compared to outpatient programs.

So what’s the takeaway here?

Exercise programs for COPD patients (or anyone who experiences chronic shortness of breath) have been shown to be very helpful in improving physical conditioning, reducing shortness of breath, and improving patient quality of life – whether in a home-based program or in a clinical setting. If you can gain access to an outpatient rehab program, by all means give it a try. If you can’t or don’t want to, ask your physician to recommend a program you can do at home or at a fitness center. If your doctor doesn’t have an exercise program to recommend, take your doctor the program we outline in our Breathe Better for Life guide as an option to consider (available at www.breathebetterforlife.com for $29.99). If you use a fitness center, consider enlisting the services of a personal trainer who is certified in chronic disease management training (many trainers these days carry such certifications) to structure a program for you and provide observation during your training program (personal trainers charge by the hour but many will provide an initial consultation for free).

Exercise as medicine for smokers

To begin, let’s agree that quitting smoking permanently provides powerful lasting health benefits, including greater life expectancy and lower incidence of chronic cardiac and respiratory disease among other positive consequences. Let’s further agree that stopping permanently is the number one way that smokers can improve their health – quite quickly and dramatically.

But let's be real – smoking cessation success rates are dismal. Somewhere between 4-7% of people who try to stop smoking on their own are successful in abstaining for one year or more. For those who receive cessation assistance through some combination of counseling, nicotine replacement therapy, and other treatments, success rates range from 15-33% abstinence for at least six months. Overall, nicotine addiction is excruciatingly difficult to shake off – even the minority of smokers who are successful in stopping require 8-10 attempts before they finally break through. The Center for Disease Control reports that in a given year in the U.S. less than 5% of our 43 million current adult smokers successfully stop for 3-12 months!

So if you aren’t ready to quit or you’ve tried in the past without success, what can you do to help protect your health?

Believe it or not, research has shown that exercise rehabilitation programs for smokers reduces lung function declines, reduces the risk of developing COPD, and increases stop-smoking rates. In our opinion, an active exercise program, patterned after the principles and practices of pulmonary rehabilitation, is the next best defense available to you if you can’t or won’t stop smoking. By way of example we offer the below studies for your consideration.

In one study, researchers examined various levels of physical activity among active smokers, former smokers and never smokers. Their conclusion, “Among active smokers, we observed a dose–response relationship: the higher the level of physical activity, the lower the lung function decline or COPD incidence.” For more details about this study, see the free full text by clicking here. (Garcia-Aymerich J, et al. Regular Physical Activity Modifies Smoking-related Lung Function Decline and Reduces Risk of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2007 Mar 1; 175(5):458-63.)

Another study in the August 2008 issue of the Journal of Rehabilitation Medicine described the positive impact of combining rehabilitation therapy (including pulmonary rehabilitation) with smoking cessation programs on stop-smoking rates. In this study, the researchers divided the study participants into two groups. One group participated in a smoking cessation program while also undergoing a rehabilitation program (rehabilitation group). The second group received just the smoking cessation program (control group). The results – 68% of the rehabilitation group were successful in stopping smoking at one year after the study compared to only 32% for the control group. The free full text of the study can be found by clicking here. (Paone G, et al. The Combination of a Smoking Cessation Programme With Rehabilitation Increases Stop-Smoking Rate. Journal of Rehabilitation Medicine. 2008 Aug;40(8):672-7).

Further still, researchers in another article published in November 2009 regarding prescribing exercise for smokers noted, "Studies have shown that physical exercise helps reduce the intensity of some of the main symptoms that may arise when a smoker attempts to quit, yet doctors and sport therapists are generally unaware of this benefit and do not know how to prescribe exercise appropriately." Ayan, Perez C. Prescribing Exercise in Tobacco Smoking Cessation Therapy. Arch Bronconeumol. 2009 Nov; 45(11):556-60. (the full study is available for free in Spanish by clicking here. An English abstract of the study can be found by clicking here).

Numerous other articles/studies reflect similar findings – regular exercise for smokers does generate positive respiratory function compared to smokers who don't exercise. And as mentioned above some researchers have demonstrated that exercise can actually improve smoking cessation success rates.

So whether you are frustrated with previous attempts to quit smoking but want to do something positive to protect your health, or you are ready to try a smoking cessation program again, consider implementing a pulmonary rehab-style exercise program such as the one described in our guide, Breathe Better for Life www.breathebetterforlife.com, in consultation with your physician. The exercise will benefit you whether you give up smoking or not and it appears the effects of regular exercise may ultimately improve your likelihood of smoking cessation success.

COPD and Vitamin D deficiency

If you are a COPD patient seeking to proactively manage your condition you might find it worthwhile investigating whether you are receiving enough Vitamin D from exposure to the sun, your diet and nutritional supplementation.

Two recently published research articles examined the connection between Vitamin D deficiency and compromised respiratory health and concluded COPD patients are at risk for Vitamin D deficiency and that COPD patients should consider supplementing their Vitamin D consumption. For your reference, the two studies are cited at the end of this article (one from the journal Clinical and Experimental Immunology and one from the journal Thorax).

As you may recall, humans can produce the majority of daily needed Vitamin D from exposure to the sun (UV-B light from sun interacts with human skin cells to produce Vitamin D naturally in the body). The National Institutes of Health indicates that the average healthy person can produce its daily requirement of Vitamin D with as little as 10 minutes direct sun exposure each day. In addition to the sun, many people receive additional Vitamin D through their diet (many dairy products, cereals and bread products are fortified with essential vitamins and minerals including Vitamin D), or through nutritional supplementation (Vitamin D is sold as a standalone supplement and is typically included in multivitamins – the recommended type Vitamin D as a nutritional supplement is Vitamin D3 in the form of cholecalciferol).

So what does Vitamin D have to do with COPD? As it turns out, quite a bit. Many COPD patients do not receive adequate Vitamin D given sedentary, indoor lifestyles where they do not receive consistent sun exposure to produce their own Vitamin D. This is especially true during the winter months when direct sunlight hours are reduced. Interestingly, COPD exacerbation events (meaning shortness of breath attacks) are most common during the winter months. The Clinical and Experimental Immunology article authors cite Vitamin D deficiency as a possible driver of winter exacerbation events.

In addition to exacerbation events, Vitamin D deficiency has been shown in various studies to be a contributing cause to upper respiratory infections, reduced lung function and skeletal muscle weakness. All three are common symptoms of COPD.

In the Thorax study, the researchers measured the serum levels of Vitamin D in 262 COPD patients and 152 healthy smokers. They discovered that Vitamin D deficiency was common in the COPD patient group but not as much in the healthy smoker group. They also reported that at each successive stage of COPD (there are four stages – Stage I - Mild, Stage II - Moderate, Stage III – Severe, Stage IV – Very Severe), the degree of Vitamin D deficiency was more pronounced.

So if you have COPD and you are not regularly exposed to direct sunlight for 10-30 minutes a day, it is worth discussing supplementing Vitamin D with your doctor. The National Institutes of Health recommends 2,000 IU of daily upper limit of supplemental Vitamin D for adults who do not receive adequate sunlight exposure. It should be noted though that some studies have recommended higher dosage levels for specific health conditions that range from 5,000 – 10,000 IUs but no study has pinpointed a recommended dosage level for COPD patients at this writing. You can find Vitamin D3 supplements for sale in dosages ranging from 100 IU to 5,000 IU. Whatever you choose, make sure you look at the ingredient panel to ensure that the Vitamin D3 you are purchasing is in the form of cholecalciferol. These supplements are widely available and generally inexpensive ($5-10/bottle).

If you are not interested in nutritional supplementation, then get up and go outside for a ten-thirty minute walk each day (making sure you have some portions of your skin directly exposed to sunlight). Not only will your body produce more Vitamin D but you will benefit greatly from the exercise benefits of walking. Both benefits are highly desirable for those with COPD.

Study references:
(Hughes DA, Norton R. Vitamin D and respiratory health. Clinical and Experimental Immunology. 2009 Oct; 158(1):20-5.) The free full text of the article is available by clicking here.

(Janssens W, Bouillon R, Claes B, et al. Vitamin D Deficiency is Highly Prevalent in COPD and Correlates with Variants in the Vitamin D Binding Gene. Thorax. Published online December 8, 2009. doi: 10.1136/thx.2009.120659). The free full text of this article is not available but can be purchased by visiting http://www.thorax.bmj.com/.