The “Unaccounted” – the frustrating pursuit to diagnose those with COPD

Two recent published studies highlight the challenges faced by physicians to diagnose COPD among those who suffer from chronic shortness of breath. From past research studies and practical experience, pulmonology professionals believe there are as many as 12 million people in the U.S. who have COPD but have not been diagnosed – a group sometimes referred to among respiratory health professionals as the “unaccounted”.

For a frame of reference, there are approximately 12 million U.S. adults who have been already diagnosed with COPD – meaning that roughly 50% of all U.S. adults with COPD have no idea they have this degenerative, largely irreversible condition. Due to this substantial under-diagnosis, the “unaccounted” are not gaining access to the full range of treatment options that could help slow down and possibly halt the progression of lung disease.

Why are so many people that are suffering from chronic shortness of breath undiagnosed as COPD patients? In our view, the three most common reasons, in order of prevalence, seem to be as follows:

(1) Many people don’t visit their doctors to be evaluated and discover they have COPD only after an acute exacerbation (doctor-speak for a shortness of breath attack serious enough to land you in a hospital).

(2) Some people who do visit a doctor about their shortness of breath are evaluated only by their primary care physician, not a pulmonologist. Primary care physicians sometimes incorrectly diagnose the patient and/or don’t refer the patient to a pulmonologist to conduct respiratory function tests even if COPD risk factors are present.

(3) Some people who do undergo respiratory function tests (most notably spirometry) receive a false-negative diagnosis – meaning the tests do not confirm COPD even though later testing confirms a COPD diagnosis. This happens most often because the spirometry test was either poorly administered or interpreted.

Reason (1) is reinforced by a recent study published in Chronic Respiratory Disease. In this study, a group of U.K. researchers set out to examine the case records of people admitted to a London area hospital over a 1-year period. They wanted to determine the percentage of COPD patients who received their initial COPD diagnosis as a result of a first-time hospitalization related to an acute exacerbation event.

The research team discovered that 34% of the 41 patients admitted for the first time related to an acute exacerbation were previously undiagnosed with COPD. These patients received respiratory function tests during their hospitalization that confirmed a COPD diagnosis. More troubling, 57% of those who were previously undiagnosed presented severe COPD symptoms – meaning that the majority of the undiagnosed waited so long to seek help for their chronic shortness of breath that they were deep into lung disease before gaining access to treatment. (Bastin AJ, et al. High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first hospital admission with acute exacerbation. Chron Respir Dis. 2010: March 18. [Epub ahead of print])

Reason (2) is highlighted by the results of another recently published study, this one in the April 2010 Canadian Medical Association Journal. In this study, Canadian researchers surveyed a group of 1,003 COPD patients who were at least 40 years of age and had smoked for at least 20 years (the mean age of the group was approximately 60) and who had visited their primary care physician for any reason between April 2006 and February 2007. In particular, the researchers wanted to know whether COPD diagnosis was determined by the primary care physicians.

The study found that 21% of the surveyed patients had either Stage II (moderate) or Stage III/IV (severe to very severe) COPD but were not diagnosed by the primary care physician they visited. The research team further noted, “Although more than three-quarters of the patients with COPD reported at least one respiratory symptom, two-thirds were unaware of their diagnosis. These findings suggest that adults who attend a primary care practice with known risk factors for COPD are important targets for screening and early intervention.” (Hill K, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. CMAJ 2010. DOI: 10.1503/cmaj.091784).

Reason (3) is supported by a research study we wrote about last month. You can access that article by clicking here.

The bottom line for you – if you suspect that your shortness of breath is increasingly affecting your ability to participate in everyday activities you owe it to yourself to see your doctor ASAP. Yes, you’ll probably have to undergo some tests and you will likely hear an earful about stopping smoking, exercising more and/or changing your dietary habits (all excellent recommendations for making an immediate impact on your shortness of breath). When you visit your doctor, ask for a referral to a local pulmonologist and in turn ask the pulmonologist to order a spirometry test. You are far more apt to get a correct diagnosis by seeking an evaluation from a qualified pulmonologist trained to administer and interpret spirometry results than through any other means. In the end , you have a far better chance of limiting the ravaging effects of severe lung disease by seeking treatment sooner rather than later – even if some of the prescribed solutions mean altering your long practiced habits.

If you are unfamiliar with the treatment options available for COPD, we have detailed the full range of treatment options in our Breathe Better for Life guide and companion CD-ROM. We developed the guide and CD to provide people who suffer from chronic shortness of breath with self-management strategies for reducing shortness of breath, improving physical conditioning, and improving overall quality of life (whether you have COPD already or you are a current/former smoker and you'd simply like to breathe & feel better). However, our guide and CD describe the full range of COPD treatment options including pictorial demonstrations. To purchase the guide & CD, visit www.breathebetterforlife.com.

Alternatively, for a brief overview of COPD treatment options you can visit the COPD treatment options page on the American Lung Association web site by clicking here.

Spring is Upon Us - Remember Your Pursed Lip Breathing!

Now that warmer (and more humid) weather is emerging across the U.S. pollen and other allergenic plant matter is exploding into our breatheable air. Most of us tend to increase our outdoor physical activity as temperatures become more temperate and the unwelcome allergens in the air can make it more challenging to breathe when we do so.

So this is a perfect time of year for you to reintroduce yourself to the breathing technique known as pursed lip breathing. It is a highly effective method for overcoming shortness of breath attacks. Though I am not personally a smoker nor do I have COPD I use pursed lip breathing regularly when I am pushing myself in a workout at the gym or if I am out on a run or if I am about to climb a significant number of steps. I can tell you categorically it is amazingly effective at improving my capacity to breathe when I am under cardiovascular stress. I have also introduced this valuable breathing technique to my 71 year-old father, who is a former smoker and does have COPD. Ironically, until he read my Breathe Better for Life guide/CD, he had never heard of pursed lip breathing from his pulmonologist nor ever tried it. Needless to say, he is a convert and regular practitioner now.

If you are unfamiliar with the technique, I've included a link to a printable step-by-step instruction sheet from our Breathe Better for Life CD. To access the instructions, click here . If you are interested in ordering the full Breathe Better for Life guide/CD, visit www.breathebetterforlife.com.

New Test May Reveal Early Signs of Emphysema Among Smokers

Earlier this week, WebMD.com posted an article describing a new test that may help identify smokers most at risk of developing emphysema. The test is a new type of "multidetector row CT" otherwise known as a MDCT. To read the article, click here. Though the new test does not appear to be commercially available at this point it is a potentially useful tool to help identify emphysema earlier in its development among smokers.

Genetic testing in general is a growing area of focus within pulmonary medicine (among other disciplines) as physicians seek to find ways to get in front of the curve of lung disease. There are at least two other genetic tests that are commercially available for those who are concerned about chronic shortness of breath. One we have written about a couple times before, alpha-1 antitrypsin deficiency (otherwise known as AATD, see our article by clicking here), and one for cystic fibrosis (a test known as a sweat chloride test).

Surprisingly, even though interest in genetic testing is rising in the medical profession, not many doctors are familiar with the emerging test methods as pointed out in a Chest editorial published in March 2010 (Chest is the journal of record for the American College of Chest Physicians). In that editorial, the authors pointed to a recent study that found 72% of clinicians not trained in genetics rated their knowledge of genetics as fair to poor. (Liss D, et al. Diagnosis of Adult Hereditary Pulmonary Disease and the Role of Genetic Testing. Chest 2010; 137: 748-750)

So, don't assume your doctor knows what tests are available. If you have been diagnosed with emphysema and haven't been tested for AATD, ask your doctor to be tested. If he/she doesn't know about the AATD test, suggest they visit the site www.testtodaychangetomorrow.com for more information. If you are experiencing chronic shortness of breath but you have yet to be diagnosed with a lung disease, ask your doctor to order the AATD test and the cystic fibrosis test to either help confirm or rule out these potential genetic disorders.

Pulmonary rehab just as effective for elderly COPD patients as it is for younger patients

Over the years, there has been a bias in pulmonary rehab studies to exclude evaluating the impact of a pulmonary rehab program on elderly COPD patients (those 70+ years of age). A study just published in the March/April 2010 edition of the Journal of Cardiopulmonary Rehabilitation and Prevention demonstrates that pulmonary rehab for elderly COPD patients is just as effective in improving physical conditioning, reducing shortness of breath, improving quality of life and decreased hospital admissions. (Sundararajan, L. et al. Effectiveness of Outpatient Pulmonary Rehabilitation in Elderly Patients with Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention 2010; 30: 116-120)

The U.K. based research team highlighted their belief as to why this bias exists as follows, “There have been suggestions that older patients are ‘too old,’ would not tolerate aggressive treatment, or would have limited ability to improve exercise capacity because of the physiological effects of aging and comorbid illness.”

So the team set out to investigate whether the basis of this bias was valid. They combed through two U.K. hospital pulmonary rehab records from 1998-2003 to select out a group of 70+ aged adults (yielding 102 patients with a mean age of 76) and another group of <70 aged adults (yielding 98 patients with a mean age of 61). The combined 200 patients had all been through the same 6 week pulmonary rehab program consisting of 2 days/week in-clinic endurance training (30 minutes each day) and 1 additional day per week on their own outside of the clinic. The researchers compared the two groups’ improvement in physical conditioning, perceived breathlessness, perceived quality of life, and subsequent hospital admissions.

The retrospective study’s results showed that both the under-70 and over-70 groups experienced notable improvements on all measurements. For example, in the shuttle-walk test, the over-70 group saw a 20% increase in distance walked while the under-70 group experienced a 33% increase – both significant jumps. The shuttle walk test is a standard test used by respiratory care professionals to measure physical conditioning whereby patients walk as far as possible within a specific period of time – the farther you walk in the time allotted, the better your physical conditioning. Both groups demonstrated very similar levels of improvement in the other measures examined including perceived breathlessness, quality of life, subsequent hospital admissions and length of subsequent hospital stays.

So, in effect, the researchers demonstrated that the bias among respiratory care professionals to exclude the elderly from pulmonary rehab research was misplaced. As the research team noted, “The physiological effects of aging, including worsening cardiovascular status with reduction in aerobic endurance, changes in body composition such as skeletal muscle atrophy and weakness, and bone loss, DO RESPOND TO EXERCISE TRAINING (our emphasis added). Thus, it should not be surprising that elderly patients are capable of similar improvements from PR (pulmonary rehab) as are younger patients.”

We wholeheartedly agree. In our opinion, COPD patients of any age can benefit from a pulmonary rehab-style exercise program. Whether you are 45 or 75, we recommend pursuing an ongoing exercise program. The best place to start is by asking your doctor to refer you to a pulmonary rehab program in your area. If your doctor won’t prescribe it or there is no such program in your area, go to your local fitness center or community center and ask to speak to a fitness instructor who is certified in structuring exercise programs for people with chronic health conditions.

We would also encourage you to consider purchasing our Breathe Better for Life guide (http://www.breathebetterforlife.com/) which, among other things, provides a detailed 8 week endurance and strength training exercise program that is tailored for those with breathing difficulties. The program we recommend is based on guidelines established by the American Thoracic Society, European Respiratory Society and the American College of Sports Medicine. Our program also explains how you can establish your baseline physical condition at home and how you can monitor your progress over time. Whether you choose to follow our recommended program or not, the guide may serve as a valuable resource for you to discuss an exercise program with your doctor.

If none of those options appeal to you, please consider at least starting and maintaining a regular walking program (3-5 days a week, 30 minutes to 60 minutes per walking session). A number of research studies have demonstrated that COPD patients and smokers can benefit from such a walking program. Though the conditioning benefits won’t be as great from a simple walking program as you can achieve from an endurance/strength training program of moderate to vigorous intensity you can still improve how you feel and breathe.

In the end, no matter your age or current physical condition, you have the capacity to make a meaningful difference in how you breathe and live. So don’t let physician bias stop you from at least trying!

Resveratrol as an antioxidant for smokers and COPD patients

Both COPD and asthma are characterized by chronic airway inflammation that is caused in part by oxidative stress in the body. A new study review article published online ahead of print suggests that an antioxidant known as resveratrol may be a powerful antioxidant in moderating airway inflammation among smokers, COPD patients and asthmatics (Wood LG, Wark PA, Garg ML. Antioxidant and anti-inflammatory effects of resveratrol in airway disease. Antioxid Redox Signal. 2010 Mar 9. [Epub ahead of print]).


Resveratrol is a naturally occurring compound found in a variety of plants, most notably red grapes. However, it is also found in berries, peanuts and an herb known as hu zhang. It is actually a phytonutrient that plants produce as a defense mechanism to ward off parasites and other threatening microbes. Resveratrol is most often mentioned in relation to studies showing red wine’s protective effects against heart disease but has been studied for a wide range of potential health benefits.


In the Wood review article, the authors examined the body of studies conducted on resveratrol’s impact on COPD patients, smokers and asthmatics. They conclude that enough evidence exists of resveratrol’s benefits among these audiences to warrant further research investigation. In particular, a number of studies noted in the Wood article have shown resveratrol reduces airway inflammation, mucus hypersecretion, epithelial shedding (shedding of the protective layer of airway lining tissue), and vascular exudation (fluid secretion in the lungs).


To take a step back, airway inflammation in smokers and COPD patients is most often initiated by exposure to cigarette smoke. Cigarette smoke produces an enormous amount of oxidative chemicals - in fact, the Wood article authors note that a single puff of cigarette smoke contains approximately 10,000,000,000,000,000 oxidative particles known as free radicals!


Unchecked, free radicals damage human tissue (including the lungs). Normally, free radicals are offset in the body by compounds known as antioxidants. Antioxidants bind with free radicals and thereby neutralize the free radicals ability to inflame and damage tissue. But in smokers and COPD patients, free radicals inhaled in cigarette smoke typically far outnumber the body’s supply of stored antioxidants (partly because the volume of free radicals consumed through smoke is very high, and partly due to the fact that the majority of COPD patients and smokers do not consume an antioxidant rich diet – the highest concentration of antioxidants typically are found in colorful fruits and vegetables).


As a result, most respiratory care professionals recommend improving dietary intake of antioxidant rich foods and pursuing smoking cessation to reduce free radical damage among smokers and COPD patients (excellent advice to be sure). But from our perspective it is unlikely that smokers and COPD patients could consume enough antioxidant rich food to offset the effects of cigarette smoke, especially if they continue to smoke. Therefore, in our opinion it is worth COPD patients and smokers considering complementing an antioxidant rich diet with targeted antioxidant nutritional supplements.


Resveratrol is one such antioxidant (other common antioxidants that have been studied in relation to COPD patients and smokers include Vitamin C, Vitamin E, lycopene, beta-carotene, glutathione, and quercetin). That said there is no standard recommended daily amount of resveratrol that has been studied related to respiratory benefits in COPD patients and smokers. According to the Wood article authors, the daily dosages examined in the studies they reviewed ranged from 1 nanogram up to 1500 milligrams. It should also be noted that many of the published resveratrol studies have been conducted on human tissue in the laboratory and in mice and few have been conducted on human subjects.


As a result of these two factors (unclear dosage range and quality of past studies), many respiratory care professionals are skeptical of resveratrol’s benefits for COPD patients, smokers and asthmatics. However, the Wood article authors conclude based on their investigation of research literature, "In each of the models reviewed, effects of resveratrol on inflammation were similar or superior to, the effects of glucocorticoids (steroids).”


For more information on foods and beverages with high resveratrol content, we’ve provided a link to a good summary from the Linus Pauling Institute at Oregon State University here.


If you are interested in trying a resveratrol nutritional supplement, resveratrol is widely available online and through retail stores (sometimes sold as grape seed extract). As one might imagine given the Wood article authors findings mentioned above there is also a wide range of dosages to choose from. From our own investigation, most of the really high potency resveratrol supplements (200mg+) are associated with dubious anti-aging claims and therefore we would recommend looking at resveratrol supplements in the 10 mg to 100 mg range. Of the many resveratrol products on the market, there were two approved by ConsumerLab.com for purity and label potency accuracy that appeared to us to be particularly good values - Swanson’s Ultra Resveratrol (100mg) and Country Life Resveratrol Plus (100mg). We’ve added all the Resveratrol products offered through Amazon.com (including these two products) to our Breathe Better Marketplace for you to conduct your own research and price comparison if so inclined. To visit our Marketplace, please click here. As always, we recommend that you consult your physician about whether Resveratrol or any nutritional supplement is appropriate for you based on your individual situation and current medications prior to purchasing and ingesting.