Fergus Bescoby examines COPD and looks at the factors surrounding a growing number of cases and how to underwrite this disease.
COPD is the overall term used to describe a variety of illnesses, including chronic bronchitis, emphysema and chronic obstructive airways disease.
People with COPD have permanently damaged lungs and find it difficult to breathe most of the time. It is possibly one of the most frustrating diseases to treat and to witness as in most instances it is self inflicted with the patients having the choice to smoke or not.
It is also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD) and is now the preferred term for patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema.
COPD is a disease characterised by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and as already mentioned, usually gets progressively worse over time.
The noxious particles or gas are most commonly created from tobacco smoking, which triggers an abnormal inflammatory response in the lung. The inflammatory response in the larger airways is known as chronic bronchitis, which is diagnosed clinically when people regularly cough up sputum.
In the alveoli, the inflammatory response causes destruction of the tissues of the lung, a process known as emphysema. The natural course of COPD is characterized by occasional sudden worsening of symptoms called acute exacerbations, most of which are caused by infections or air pollution.
What are the causes?
• Smoking
Smoking is to blame for COPD in the majority of cases. The chemicals in cigarette smoke causes inflammation and fibrosis or scarring in the lungs and destroy the elasticity that allows the lungs to expand and contract as we breathe. Approximately 80 to 90% of cases of COPD are due to smoking. Exposure to cigarette smoke is measured in pack-years, the average number of packages of cigarettes smoked daily multiplied by the number of years of smoking. Not all smokers will develop COPD, but continuous smokers have at least a 25% risk after 25 years.
• Occupational exposures
Intense and prolonged exposure to workplace dusts found in coal mining, gold mining, and the cotton textile industry and chemicals such as cadmium, isocyanates, and fumes from welding have been implicated in the development of airflow obstruction, even in nonsmokers. Workers who smoke and are exposed to these particles and gases are even more likely to develop COPD. The effect of occupational pollutants on the lungs appears to be substantially less important than the effect of cigarette smoking.
• Air pollution
Studies in many countries have found that people who live in large cities have a higher rate of COPD compared to people who live in rural areas. Urban air pollution may be a contributing factor for COPD as it is thought to slow the normal growth of the lungs although the long-term research needed to confirm the link has not been done.
• Genetics
This factor is probably a genetic susceptibility. COPD is more common among relatives of COPD patients who smoke than unrelated smokers. The genetic differences that make some peoples' lungs susceptible to the effects of tobacco smoke are mostly unknown. Alpha 1-antitrypsin deficiency is a genetic condition that is responsible for about 2% of cases of COPD. In this condition, the body does not make enough of a protein, alpha 1-antitrypsin. Alpha 1-antitrypsin protects the lungs from damage caused by protease enzymes, such as elastase and trypsin that can be released as a result of an inflammatory response to tobacco smoke.
Signs and symptoms
The damage to the lungs is gradual, which is why most people are over 40 by the time symptoms begin. Research suggests that it takes about 20 years from onset of initial damage to the lung until it is actually diagnosed.
An early morning cough, often called a smoker's cough, is common and produces a lot of phlegm. Wheezing, chest tightness and difficulty breathing are often noticed first.
People may find themselves short of breath when doing very little or even when they're just sitting down. It becomes harder and harder to do any exercise until even crossing a room becomes impossible. People with COPD commonly describe this as: "My breathing requires effort", "I feel out of breath", or "I cannot get enough air in"
These symptoms are usually worse in winter, with recurrent lung infections adding to the problem. If severe, these recurrent infections and worsening of lung function (known as exacerbations) may prove fatal - ten per cent of those admitted to hospital with an exacerbation will die in hospital and as many as 40 per cent will die within a year.
Common signs are:
• Tachypnea, a rapid breathing rate
• wheezing sounds or crackles in the lungs heard through a stethoscope
• breathing out taking a longer time than breathing in
• enlargement of the chest, particularly the front-to-back distance (hyperinflation)
• active use of muscles in the neck to help with breathing
• breathing through pursed lips
• increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).
Treatment
It's not possible to cure COPD, but the damage can be slowed. Treatment aims to improve symptoms like breathlessness, increase the amount of exercise a person can manage, reduce the risk of exacerbations, hospital admissions and complications, and generally improve their quality of life.
By far the best way to do this is to stop smoking. It's also vital to avoid other people's smoke.
Exercising as much as possible helps keep the lungs (and heart) strong and builds self-confidence. Pulmonary rehabilitation programmes help improve symptoms and increase exercise capacity.
Physiotherapy helps to clear mucus from the lungs and most people with COPD are taught exercises they can do every day to help themselves.
Medicines that make the airways wider so it's easier to breathe can be given through an inhaler or as tablets. Another important target for medicines is to reduce the inflammation in the lungs in COPD - the best drugs for this are steroids which are also usually given through an inhaler type of device. Steam inhalation and humidifying rooms can also help breathing by loosening mucus. Medication is available that helps to thin mucus.
Underwriting considerations
When faced with a case of COPD, the underwriter will need to consider the following:
• Is the client still smoking? What is the smoking history?
• The age of the client (the younger the client is, generally the more severe the rating will be).
• What are the signs on exam, e.g. smokers cough, excercise intolerance, cyanosis etc
The results of up to date pulmonary function tests (PFT's). These determine how much air the individual's lungs can hold, how quickly air can be moved in and out, and how well the lungs put oxygen into and remove carbon dioxide from the blood.
Generally the client will be classified as having mild (FEV1=65-80% of predicted) moderate (51-64% of predicted) or severe COPD (FEV1=35-50% of predicted) and this will be based on the result of the current PFT's. When an FEV1 is measured at below 35% of predicted all terms will normally be declined.
For this test, you breathe into a mouthpiece attached to a recording device (spirometer). The information collected by the spirometer may be printed out on a chart called a spirogram.
The more common lung function values measured with spirometry are:
Forced vital capacity (FVC). This measures the amount of air you can exhale with force after you inhale as deeply as possible.
Forced expiratory volume (FEV). This measures the amount of air you can exhale with force in one breath. The amount of air you exhale may be measured at 1 second (FEV1), 2 seconds (FEV2), or 3 seconds (FEV3). FEV1 divided by FVC can also be determined.
Fergus Bescoby is underwriting development manager at PruProtect
Key Facts
COPD usually affects people over the age of 40. Approximately 900,000 people in the UK have been diagnosed with COPD in the UK but more recent research suggests that COPD may be hugely under-diagnosed - based on reported symptoms, over 3.2 million people may have the condition (that's as many as one in ten people over 40).
COPD is the sixth most common cause of death in England and Wales, causing over 30,000 deaths a year. It estimated that by 2020 it will be the 3rd biggest killer in the world - it's the only major cause of death that has actually increased significantly in recent years.
24,160 people in the UK died as a result of COPD in 2005.The disease kills more people every year in the UK than bowel cancer, breast cancer or prostate cancer
COPD is the third biggest cause of respiratory death in the UK, accounting for more than one fifth (23%) of all respiratory deaths In 2005 COPD killed more women than breast cancer: 11,302 died of COPD, 10,969 died of breast cancer.
In the UK, the rate of COPD has been increasing nearly three times faster amongst women than men. Women are more susceptible to developing COPD than men.
References
Patient UK Newspaper
British Lung Foundation
WebMD
