The editorial content below has been developed solely between Guidelines in Practice and the expert author.
Guest Editor—Dr Elizabeth Sapey
Honorary Respiratory Consultant, Queen Elizabeth Hospital, Birmingham
Senior Lecturer in Respiratory Medicine, University of Birmingham
‘Many of the symptoms of COPD are shared with other diseases, and it is important to try to establish what the main cause of the symptoms is. In this article we will work through a practical approach to breathlessness, cough, and fatigue when it is not clear if COPD is the main problem.’
Our population is ageing, but living longer does not always mean living in good health. For an increasing number of older people, frailty and ill health have an impact on their quality of life.1
The incidence of chronic, non-infectious diseases increases with age.2 For example, 1.9% of adults aged 40–49 years have chronic obstructive pulmonary disease (COPD), increasing to 19.2% of those over 70 years of age.3 Similarly, the prevalence of cardiovascular disease (including hypertension, coronary heart disease, heart failure, and stroke) increases from 40% in people aged 40–59 years of age to 70–75% in people aged 60–79 years.4
It is also increasingly common for older people to have a number of different medical conditions—multimorbidity—defined as two or more chronic diseases in one person.5 In one study of 1099 adults over 75 years of age, 70% were affected by multimorbidity and 69% of deaths in this group were attributable to multimorbidity.6
COPD and co-morbidities
Patients with COPD commonly have several other health problems, and many can be considered to be ’multimorbid’. A recent study found that over 97% of patients with moderate-to-severe COPD had at least one co-morbidity and over half had four or more co-morbidities.7
This study has been replicated across different countries and healthcare systems, including in a larger USA-based study where patients with COPD had on average six other medical conditions and where, perhaps unsurprisingly, the presence of multimorbidity was associated with a greater risk of death, irrespective of the severity of lung disease.8
Studies describe at least four COPD comorbidity clusters, disease groups that commonly co-occur with COPD, more than might be predicted, even when known risk factors including cigarette smoking, being in a lower socioeconomic group, and low exercise levels are taken into account.7,9 These clusters include:7
- patients with COPD and hypertension and atherosclerosis
- patients with COPD and weight loss, muscle wasting, osteoporosis, and renal impairment
- patients with COPD and obesity, atherosclerosis, dyslipidaemia, hyperglycaemia, and hypertension
- patients with COPD and depression and anxiety.
Many of the symptoms of COPD are shared with other diseases, and it is important to try to establish what the main cause of the symptoms is. In this article we will work through a practical approach to breathlessness, cough, and fatigue when it is not clear if COPD is the main problem.
Case study: Mr Pravadhra
Mr Pravadhra is a 61-year-old man who presents with ‘his chest playing up’—mainly breathlessness and a dry cough. He was recently diagnosed with COPD (moderate severity on testing last year) but also has type 2 diabetes, chronic kidney disease, hypertension, and osteoarthritis. His main complaints are breathlessness (especially at night), a cough, and poor sleep.
He continues to smoke 15 cigarettes each day and drinks about 4 pints of strong lager each night (to help him sleep, he says). He is medically retired (previously working as a plumber) and does no exercise. His wife has been unwell recently, and he is very worried about her.
Mr Pravadhra is on several medications, including: aspirin, ramipril, simvastatin, bisoprolol, metformin, tiotropium, salbutamol, and codeine phosphate and also buys ibuprofen and paracetamol over the counter for his back pain. His weight has increased recently and his body mass index is now over 35 kg/m2.
This fictional patient has some of the most common medical conditions affecting an adult of his age. Taking ten medications, he also has polypharmacy (commonly defined as taking more than five drugs regularly).10
You are tasked with assessing what is causing his breathlessness and cough, which he feels is contributing to his poor sleep.
Progressive COPD might be contributing to Mr Pravadhra’s symptoms of breathlessness and cough, and repeating his spirometry and symptom questionnaire (COPD assessment test—CAT) could provide evidence for this. Smoking cessation and a step up in bronchodilator treatment (to dual therapy with a long-acting muscarinic antagonist and long-acting beta2-agonist in a combination inhaler) might be beneficial.11
It is, however, likely that the patient’s weight, deconditioning, and lack of exercise are contributing to his symptoms, and providing lifestyle advice and direct referral to a weight-loss programme, as well as referring for pulmonary rehabilitation could provide significant relief over time.12
This patient drinks approximately 56 units of alcohol a week. Studies suggest that >60% of adults with alcohol dependence experience sleep disturbance and insomnia and that reducing alcohol consumption can improve sleep quality.13 Reducing Mr Pravadhra’s alcohol use is also likely to help with his weight management and diabetic control.
The patient’s other known medical conditions may also be contributing to symptoms. Renal dysfunction and poorly controlled diabetes can be associated with symptoms including breathlessness and fatigue—even in the absence of significant fluid overload. This is poorly understood but is likely to reflect the presence of anaemia, uraemia, muscle wasting, and inflammation.14–16 Tighter management of these conditions may improve symptom burden.
There are a number of medications that could be contributing to this patient’s symptoms. Ramipril, an angiotensin converting enzyme inhibitor, can be associated with a cough,17 while some non-steroidal anti-inflammatories can impact negatively on renal function and control of hypertension18,19 and codeine use can be associated with sleep disturbances.20 Although it may not be possible to alter some of these therapies, reviewing their use and monitoring for potential side effects will be of benefit.
While the patient in the case study has a number of co-morbidities, he may also have other, as yet undiagnosed, conditions that may be adding to his symptoms. Undiagnosed cardiac disease is common in COPD21 as symptoms of breathlessness and chest pain can be erroneously attributed to COPD rather than to angina or heart failure. In one study of nearly 900 patients admitted to hospital with an acute exacerbation of COPD, more than 200 had evidence of an acute myocardial infarction on admission—based on an echocardiogram scoring system—but only 68 had a recognised history.22 A raised N-terminal fragment of pro B-type natriuretic peptide is seen in up to 77% of patients with an exacerbation of COPD, and correlates well with echocardiogram findings.23 Screening for risk of heart disease and heart failure is, therefore, useful in this patient group and appropriate treatment can improve breathlessness and cough.
Due to his history of smoking, and potentially also due to this employment history, this patient may be at risk of other lung diseases, such as lung cancer or lung fibrosis, which could initially be screened for with a chest radiograph. Mr Pravadhra’s obesity also places him at risk of obstructive sleep apnoea, for which continuous positive airway pressure (CPAP) is a very effective treatment. The incidence of gastroesophageal reflux disease is higher in people with COPD, and this can be associated with a cough.24,25 Patients with COPD have high rates of anxiety and depression and screening for these and signposting for support or treatment can be of great benefit.26
There are, of course, other potential causes for this fictional patient’s symptoms, but I hope that this illustrates that not all breathlessness in a patient with COPD is due to COPD. Taking a holistic approach to management might improve a patient’s symptom burden without unnecessarily stepping up their COPD treatments.
- Parker M, Thorslund M. Health trends in the elderly population: getting better and getting worse. The Gerontologist 2007; 47 (2): 150–158.
- World Health Organization. Noncommunicable diseases fact sheet. www.who.int/mediacentre/factsheets/fs355/en/ (accessed 18 April 2018).
- Hanania N, Sharma G, Sharafkhaneh A. COPD in the elderly patient. Semin Respir Crit Care Med 2010; 31 (5): 596–606.
- Yazdanyar A, Newman A. The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs. Clin Geriatr Med 2009; 25 (4): 563–vii.
- Barnett K, Mercer S, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380: 37–43.
- Rizzuto D, Melis R, Angleman S, et al. Effect of chronic diseases and multimorbidity on survival and functioning in elderly adults. J Am Geriatr Soc 2017; 65: 1056–1060.
- Vanfleteren L, Spruit M, Groenen M, et al. Clusters of comorbidities based on validated objective measurements and systemic inflammation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2013; 187 (7): 728–735.
- Divo M, Cote C, de Torres J, et al. Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012; 186 (2): 155–161.
- Sevenoaks M, Stockley R. Chronic obstructive pulmonary disease, inflammation and co-morbidity – a common inflammatory phenotype? Respir Res 2006; 7: 70.
- Masnoon N, Shakib S, Kalisch-Ellett L, Caughey G. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017; 17: 230.
- Global Initiative for Chronic Obstructive Lung Disease. Global strategy for prevention, diagnosis and management of COPD. GOLD, 2018. Available at: goldcopd.org
- Corhay J-L, Dang D, Van Cauwenberge H, Louis R. Pulmonary rehabilitation and COPD: providing patients a good environment for optimizing therapy. Int J Chron Obstruct Pulmon Dis 2014; 9: 27–39.
- Brower K, Aldrich M, Robinson E, et al. Insomnia, self-medication, and relapse to alcoholism. Am J Psychiatry 2001; 158 (3): 399–404.
- Jhamb M, Liang K, Yabes J, et al. Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue. Am J Nephrol 2013; 38 (6): 489–495.
- Salerno F, Parraga G, McIntyre C. Why is your patient still short of breath? Understanding the complex pathophysiology of dyspnea in chronic kidney disease. Semin Dial 2016; 30 (1): 50–57.
- Konen J, Curtis L, Summerson J. Symptoms and complications of adult diabetic patients in a family practice. Arch Fam Med 1996; 5: 135–145.
- British National Formulary. Ramipril. Available at: bnf.nice.org.uk/drug/ramipril.html (accessed 19 April 2018).
- Aljadhey H, Tu W, Hansen R et al. Comparative effects of non-steroidal anti-inflammatory drugs (NSAIDs) on blood pressure in patients with hypertension. BMC Cardiovasc Disord 2012; 12: 93.
- Whelton A, Hamilton C. Nonsteroidal anti-inflammatory drugs: effects on kidney function. J Clin Pharmacol 1991; 31 (7): 588–598.
- British National Formulary. Codeine phosphate. Available at: bnf.nice.org.uk/drug/codeine-phosphate.html (accessed 19 April 2018).
- Rutten F, Cramer M, Grobbee D, et al. Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005; 26 (18): 1887–1894.
- Brekke P, Omland T, Smith P, Søyseth V. Underdiagnosis of myocardial infarction in COPD—cardiac infarction injury score (CIIS) in patients hospitalised for COPD exacerbation. Respir Med 2008; 102: 1243–1247.
- Adrish M, Nannaka V, Cano E, et al. Significance of NT-pro-BNP in acute exacerbation of COPD patients without underlying left ventricular dysfunction. Int J Chron Obstruct Pulmon Dis 2017; 12: 1183–1189.
- Benson V, Müllerová H, Vestbo J et al. Associations between gastro-oesophageal reflux, its management and exacerbations of chronic obstructive pulmonary disease. Respir Med 2015; 109 (9): 1147–1154.
- Gaude G. Pulmonary manifestations of gastroesophageal reflux disease. Ann Thorac Med 2009; 4 (3): 115–123.
- Yohannes A, Alexopoulos G. Depression and anxiety in patients with COPD. Eur Respir Rev 2014; 23 (133): 345–349.
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COPD and co-morbidities: when COPD is only part of the problem