Breathing bad

‘COPD is the third biggest cause of death worldwide,’ says Dr Nick Hopkinson, medical adviser to the British Lung Foundation and consultant physician at the Royal Brompton & Harefield Hospital. He continues, sadly, ‘But no one knows what it stands for.’

He’s right. In an informal poll of five acquaintances, only one knew that COPD stands for chronic obstructive pulmonary disease, and that person is a doctor. An umbrella term for chronic bronchitis and emphysema, it is one of several respiratory diseases which, all together, are responsible for one in five deaths in the UK, and — bean-counters take note — cost the NHS over £6 billion. Compared to other European nations, we are near the top of the chart that no one wants to be on: only seven European states have a worse record on lung disease than the UK, and five of those are underfunded ex-Soviet countries.

Respiratory problems — not bad backs — are the most common ailment that GPs have to deal with: 30 per cent of patients that cross the threshold of their local surgery are those with COPD or a chest infection, like pneumonia. Acute respiratory attacks also make up 30 per cent of emergency admissions, and those suffering severe COPD exacerbations took up one million bed days in 2004. These figures are increasing: as smokers get older, the burden of COPD on the NHS gets heavier. Although we may have reached the peak of COPD in the UK, total deaths from COPD globally are projected to grow by 30 per cent in the next ten years.

COPD symptoms start with a phlegmy cough, or breathlessness. The air sacs in lungs, called alveoli, are clustered like bunched grapes; with emphysema, just for example, the walls of the alveoli disintegrate, leaving a larger air sac — and less surface area for oxygen to be absorbed. ‘People often think breathlessness is a sign of getting older,’ says Dr Hopkinson. ‘It’s not, it’s a reason to go and see your GP’ — who will give a diagnosis of either unfitness or COPD. The earlier that symptoms of mild emphysema or bronchitis can be recognised, the more can be done about it. If the patient smokes, stopping is the obvious first step for any kind of lung disease (indeed, any disease, period). ‘Every person’s lung capacity increases until the age of about 20 to 30,’ says Dr Lieske Kuitert, consultant respiratory physician at the Lister Hospital, Chelsea. ‘After that, there’s a tiny year-on-year decline, although lung capacity should be sufficient to last you into your eighties and nineties. Smokers accelerate that decline so their lungs “age” faster than they do.’ In smokers, reserve capacity is lost, meaning that lung function is decreased, and the result is the breathlessness that characterises COPD. Giving up smoking slows the decline. While lung capacity won’t improve, it won’t get worse as fast as if you continue smoking. Over the past few years there have been improvements in the treatment of COPD. Lung transplants are fairly rare as there are few available donors, so to stretch the limited pool, lung organs tend to be transplanted into more than one patient — generally those who are young and otherwise healthy enough for the operation, and to benefit from a 50 per cent (say) increase in lung capacity. However, for those suffering very localised emphysema, pioneering work in the United States has seen the rise of lung volume reduction surgery, in which the surgical removal of diseased parts of the lung means that new, healthy lung tissue can grow to fill the space. This works only in a highly selective group of sufferers, although results are improving. Endo-bronchial valves — which are effectively reverse stents that, when inserted through a tube in the windpipe, block off the air flow to the diseased part of the lung — are probably the most encouraging COPD treatment advancement, being minimally invasive; although again, this method is only suitable for a selective group of patients with localised emphysema. Bronchial thermoplasty, meanwhile, is the relatively new practice of heating the muscle in the lung lining up to 65ºC, so that it can’t tighten and narrow the airways. ‘It’s very clever,’ says Dr Kuitert.

Chest infections and pneumonia — characterised by a cough, fever and difficulty breathing — are some of the other common lung conditions in the UK. With pneumonia — either viral or bacterial — there’s often a high incidence of hospitalisation after an influenza epidemic. The treatment is a double whammy of two types of antibiotics, although a small proportion may not react to treatment and have to be admitted to high-dependency units (even relatively youthful sufferers). To avoid this, a flu jab every winter is the best preventative measure, particularly for high-risk groups such as those with significant diabetes, heart, lung or liver disease. The triple vaccination formulated by the Centre for Disease Control and Prevention in America combines anti-swine flu with an antiserum for the two commonest strains of flu in the previous six months.

Surprisingly, the common cough accounts for 20 per cent of referrals to a secondary care specialist. Persistent coughs, lasting years not months, are a recognised cause of chronic depression — but they can be treated, although many patients end up going private. Three causes account for the vast majority of coughs, says Dr Kuitert: a post-nasal drip, which can be treated with nasal spray and/or tablets, usually decongestants; problems related to reflux, which require indigestion remedies and/or lifestyle changes; and variations of asthma, for which the right inhaler and dosage work wonders.

Asthma is another prevalent lung condition, and a particular cause of concern because internationally, the UK had a higher rate of asthma than would be expected in the early years of the 21st century. The good news is that current diagnosis rates indicate that prevalence is falling. Still, 5.4 million Britons have the condition, 1.2 million of whom are children. In 2011, 1,167 people died of asthma attacks, 18 of them children. According to the charity Asthma UK, up to 90 per cent of deaths from the disease are avoidable. Allergic asthma, triggered by pollen, mould, animal ‘dander’ or dust mites, accounts for 60 per cent of cases and is genetic, while non-allergic asthma is caused by viral infections. Ultra-long-acting inhalers with treatments that last 24 hours (rather than 12) have recently come on the market, with two and sometimes three combinations of medicines in one inhaler. The once-daily dose improves adherence to the regimen, with better outcomes for sufferers of asthma — and COPD too. A new drug from Verona Pharma, RPL554, proposes to treat COPD, asthma and allergic rhinitis with two actions in a single molecule — an anti-inflammatory and a bronchodilator, which relaxes the constriction of the airways. ‘To target both with the one drug would be fantastic,’ says Dr Kuitert.

lung-stats

For allergic asthma sufferers, an injection of omalizumab has also given dramatic results — the antibody attacks the excess immunogobulin E responsible for the disease and its symptoms. It’s a new development which is part of a group of monoclonal antibodies that have been very effective in treating rheumatoid arthritis.

And then, of course, there’s lung cancer. The second most diagnosed kind of cancer, in its primary format (not having spread from somewhere else) lung cancer is the most deadly type, accounting for 22 per cent of cancer mortality, or 6 per cent of UK deaths overall. About 90 per cent of cases are due to smoking — but before readers get too judgmental, one in eight lung cancers are occupation-related, and in a large proportion of those, asbestos is responsible. Increasingly, women in the UK are diagnosed with lung cancer. The main reason it is such a killer is because there are few early signs: 70 per cent of people are beyond the point of curative surgery when diagnosed by a doctor. Because of the lateness of diagnosis, there is a current campaign to encourage anyone suffering a cough for more than three weeks to go to their GP. While diagnosis still pinpoints what type of cancer a patient has, increasingly cancer is being identified by the type of mutation it is expressing — EGFR, for example, or ALK. New chemotherapy agents target these mutations, so that treatment is bespoke rather than one size fits all. The results are ‘very encouraging,’ says Dr Kuitert. ‘This method can significantly reduce the cancer, and sometimes cure it.’

And how to avoid getting any of these conditions in the first place? Everyone agrees that not smoking is the key. ‘It’s never too late to give up, and e-cigarettes are a game-changer,’ says Dr Katherine Tryon, Head of Clinical Vitality for PruHealth. Other than that, lifestyle changes make a huge difference: a nudge in the direction of a healthy diet and plenty of physical activity when young, via behavioural economics, will give long-term benefits for the individual as well as for the NHS. ‘Offering incentives to change people’s defaults is where the future is at,’ says Dr Tryon.

What the experts wish everyone knew about lung disease

Dr Penny Woods

Chief Executive, British Lung Foundation

Investment in lung cancer research lags drastically behind breast cancer, bowel cancer and leukaemia, despite killing more people than all three put together. Unless we start seeing that level of investment into lung disease, the outlook for patients will remain dire.

Dr Nick Hopkinson

Consultant physician at the Royal Brompton & Harefield NHS Trust

The lungs are at the front line of the social determinants of health. Children born with a disadvantaged start in life never achieve the lung volume they should and smoking, together with certain occupations, cause more rapid lung function decline, leading to disease and breathlessness as they age.

Dr Richard Russell

Consultant Respiratory Physician at Wexham Park Hospital

Smoking is a significant cause of lung disease, but the notion that it is much more self-inflicted than other disease areas is a stigma we desperately need to tackle.

Dr John Moore-Gillon

Honorary Medical Adviser at the British Lung Foundation:

Why are people so obsessed with the heart? It has only one function: to transport around the body the oxygen taken into the body via the lungs. I wish everyone knew and understood this, and then medical research into lung diseases would not have been so ignored.

Dr Helen Parfrey

Consultant Respiratory Physician and Lead Clinician for ILD at Papworth Hospital:

The fast-acting lung disease idiopathic pulmonary fibrosis kills around 5,000 people in the UK every year and is on the rise. There is no known cause or cure and half of those diagnosed are dead three years after diagnosis. We urgently need more research.

Dr Noel Snell

Director of Research, British Lung Foundation

Respiratory disease causes one in five deaths in the UK yet receives less than 5 per cent of the NHS budget. We have a dismal record on respiratory mortality compared with other parts of Europe and the US. Until we start to make it more of a priority, it’s difficult to see how that record will improve.


  • Nick Hopkinson

    A small point: Though it’s fair to say that lung volume reduction surgery was pioneered in the US (by Joel Cooper) the first randomised controlled trial was actually conducted at Royal Brompton in London (Duncan Geddes NEJM 2000). The advanced COPD service there contiunues to be at the forefront of bronchoscopic treatments such as valves and coils for lung volume reduction in people with emphysema.