Chronic Obstructive Pulmonary Disease (COPD)

What is COPD?

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2024 report³, Chronic Obstructive Pulmonary Disease (COPD) is defined as “a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.”

COPD is a common, preventable and treatable disease, the result of long-term exposure and inhalation of harmful substances.

Globally¹,

• Currently there are 300 million individuals suffering from COPD
• COPD is the 3^rd leading cause of mortality

Risk Factors

Tobacco Smoke

• 90% of cases of COPD are caused by smoking. Tobacco smoke contains irritative, toxic and carcinogenic substances. Non-smokers who are passively exposed to tobacco smoke also have an increased risk for developing COPD.
• Water-pipe, cigars, pipes, roll your own cigarettes and marijuana are also risk factors

Factors during gestation period and childhood
In childhood, important risk factors for developing COPD later in life are:

• Exposure to maternal smoking in utero or in childhood
• Frequent respiratory infections
• Asthma and bronchial hyper-reactivity

Environmental Factors

• Pollution: harmful substances in the air and indoor air contribute to the onset, exacerbation and worsening of the disease.
• Occupational exposure to harmful substances for example working in mining, agriculture or food processing.

Genetic Factors

• Alpha-1 Antitrypsin Deficiency (AATD), a hereditary condition, represents a genetic risk factor for COPD Symptoms

Symptoms

Manifestations of COPD are subtle and gradual worsens over time. In the early stages, it is characterized by a persistent cough (sometimes referred to as ‘smokers cough’) with or without production of phlegm. In addition, other common symptoms are:

• Chronic cough
• Excess phlegm production especially during exacerbations most commonly caused by respiratory infections
• Wheeze (whistling sound) when breathing normally
• Difficulty taking a deep breath
• Shortness of breath, initially upon exertion which worsens over time when doing even minimal tasks or at rest.
• Shortness of breath, initially upon exertion which worsens over time when doing even minimal tasks or at rest.

Exacerbations of COPD are episodes of increased severity of symptoms, most commonly triggered by respiratory infections such as the seasonal flu. Exacerbations accelerate the decline in lung function and worsen the condition.
Individuals with COPD are considered a vulnerable population, at high risk for complications and death from influenza infection, pneumonia, surgery etc.

COPD & COVID-19 pandemic:

COPD is associated with an increased risk for more severe COVID-19 manifestations and poor outcome, although it is not considered a risk factor for acquiring COVID-19 more easily than the general population (Simons et al. Caring for patients with COPD and COVID-19: a viewpoint to spark discussion. Thorax.. December 2020 Vol 75 No 12).

Diagnosis

• Medical and smoking history and physical examination
• Spirometry testing: a non-invasive test widely used to identify and measure the characteristic air flow limitation of the disease. Therefore, spirometry is used in routine clinical practice for:
• Diagnosing COPD
• Staging disease severity
• Pre-operative evaluation
• Monitoring exacerbations
• Evaluating response to treatment

Treatment

COPD requires close monitoring by a pulmonologist who will evaluate your symptoms, complaints and Spirometry, will determine disease severity, as well as identify possible comorbidities, in order to provide the best treatment options for you. This includes quitting smoking and one or more of the following treatments:

• Medications such as inhaled bronchodilators and corticosteroids
• Antibiotics
• Oxygen therapy
• Physiotherapy and respiratory rehabilitation therapies for
• sputum elimination and increasing exercise tolerance
• Proper management of comorbidities
• Addressing depression and social isolation

Prevention

• The most effective measure to prevent COPD is to never smoke, while it is strongly recommended for smokers to quit.
• Avoiding passive exposure to second-hand smoke especially during pregnancy/gestation, childhood and adolescence since it damages the lungs that are still under development.
• Smokers are at high risk for COPD while many smokers in Greece are unaware that they have COPD. Therefore, smokers, especially those with “smoker’s cough”, warrant a spirometry test and a visit to their pulmonologist for early prevention

Secondary prevention (among those who have COPD) aims at reducing the frequency and severity of exacerbations by:

• Quitting smoking of cigarettes, roll-your own cigarettes, water-pipe, pipe, cigars and marijuana
• Getting the seasonal Flu vaccine and Pneumococcal vaccine
• Avoiding second-hand smoke • Avoiding exposure to other toxicants at work or at home

The Chest Foundation has published a facts sheet presenting common myths for COPD²

ANNA S. TZORTZI MD, FCCP
PNEUMONOLOGIST

References

1. Forum of International Respiratory Societies https://www.firsnet.org/news-and-events/news-article/154-world-copd-day-2020

2. CHEST Foundation  https://foundation.chestnet.org/wp-content/uploads/2020/05/COPD-Mythbuster.pdf

3. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (2024 REPORT) https://goldcopd.org/

ASTHMA

What is Asthma?

Most common misconceptions about asthma are:

1. Asthma is a childhood disease; individuals will grow out of it as they age
2. Asthma is infectious
3. Asthma sufferers should not exercise
4. Asthma is only controllable with high dose steroids

In the article below the correct information is included marked in italics.

Asthma is a chronic inflammatory condition that causes recurrent episodes of airway narrowing (bronchoconstriction), excess mucus production and thickening of the airway walls due to the underlying bronchial hyper-responsiveness, making it harder to breathe. 

Asthma can affect all ages but usually starts in childhood and only rarely presents with a new-onset in adults. Most cases of asthma diagnosed in adults usually had started in childhood whether or not unbeknownst to the individual. In many cases, childhood asthma subsides in adolescence, however it can recur in adulthood.

Asthma is the most common chronic non-communicable disease, affecting over 260 million people globally in 2019 (GINA).

In Europe, 30 million children and adults less than 45 years old have asthma. According to the epidemiological research study conducted by the Asthma team at the Hellenic Thoracic Society, the prevalence of asthma in Greece is 8.6%, in other words, approximately 900,000 children and adults have asthma.

Causes

While there is no known cause for asthma, it is certainly not infectious, nor transmissible. Asthma is the expression of an inflammatory disorder of the airways that depends on the interaction between the genetic predisposition of susceptible individuals and exposure to certain environmental factors such as pollution and Western lifestyle (ERS).

Asthma is characterized by hyper-responsiveness, an exaggerated reaction of the airways when exposed to irritative factors and triggers.

Symptoms

Asthma presents with episodic respiratory symptoms (flare-ups or attacks) characterized by one or more of the following:

• Shortness of breath
• Chest tightness/pain
• Coughing
• Wheezing (a whistle or wheeze sound when exhaling)
• Difficulty sleeping from coughing/wheeze or shortness of breath
• Intense cough or wheezing made worse by a viral cold or flu

Asthma is known to manifest by attacks of symptoms that can remit or relapse and are usually provoked by certain triggers. Symptoms vary in combination, frequency, severity and time course. Each person experiences asthma differently and it is therefore important to consult often with their physician.

Triggers

Often asthma attacks can be brought on by:

• Exercise (exercise-induced asthma).

While exercise may trigger asthma, the individual may indeed exercise, provided that they consult their physician and comply with the regimen that best controls their symptoms

• Occupationally-related irritants like chemical fumes, gases or dust (occupational asthma)
• Allergens such as pollen, pet dander, mold or cockroach waste
• Cold air
• Stress
• Viral respiratory infections i.e., the seasonal flu
• Sulfites and preservatives
• Gastro-oesophageal Reflux Disease (GERD)

Diagnosis

There is no specific test for diagnosis, however, the following criteria are used to aid in diagnosis of asthma:

• Indicative medical history (i.e., episodic symptoms, flare ups)
• Physical examination (i.e., wheezing)
• Obstructive pattern (airflow limitation) on spirometry

LABORATORY EVALUATION

Lung Function Tests:

• Spirometry: determines and measures the degree of airway obstruction

• Bronchodilator response: Spirometry pre- and post- bronchodilator administration evaluates the reversibility of the obstruction

• Broncho-provocation: an asthma trigger, such as inhaled metacholine, administered to individuals with normal spirometry, can reveal the characteristic bronchoconstriction of asthma.

• Measurement of Exhaled nitric oxide: the concentration of NO in the exhaled breath increases in cases of eosinophilic inflammation of the airways.

Blood Tests: are used as an aid to diagnosis, they are not specific.

• Complete Blood Count, eosinophils count, total serum IgE, allergen specific IgE (ELISA, RAST)

Allergy Skin Tests: do not diagnose asthma, but help reveal the triggers

Prevention

The aim is to:

• Avoid exposure to known triggers and environmental pollution
• Avoid smoking and exposure to passive smoke
• Monitoring of symptoms and lung function
• Ensure adherence to treatment
• Ensuring proper treatment during pregnancy: all pregnant women should be asked about asthma and advised about appropriate treatment during their pregnancy

Treatment

Aims to:

• Reduce frequency, duration and severity of attacks
• Preserve a normal lung function
• Minimize risk and avoid or reduce permanent adverse outcomes
• Reduce hospital admissions

Treatment is adjusted for the individual patient once his asthma has been evaluated in regards to severity, frequency, precipitating factors and symptom control and according to the international guidelines. (GINA) Medication includes one or more of the following:

• Combination of long-acting bronchodilators and corticosteroid inhalers
• Oral corticosteroids
• Oral theophylline,
• Anti IgE therapy
• Monoclonal antibodies

With the possible exception of acute exacerbations, maintenance treatment achieves control of asthma symptoms with inhaled corticosteroids usually in low doses. The attending physician will adjust the treatment, step medication up or down accordingly and help design an action plan for the individual patient. (GINA)

Asthma and COVID-19

• Asthma does not increase the likelihood of SARS-CoV-2 infection
• Well controlled mild to moderate asthma does not increase the likelihood of severe COVID-19 or death due COVID-19
• Recent asthma treatment with oral corticosteroids and hospitalization with severe asthma, may increase the risk for COVID-19 related por outcomes.

Asthma and COVID-19 vaccines

Individuals with asthma should consult the attending physician regarding their eligibility for vaccination and best timing, considering medical history, asthma status, type of treatment (i.e. biologic agents) or any other medical aspects.

Some general considerations based on current data:

• Although allergic reactions to vaccines against SARS-CoV-2 have been rarely reported, it is advised is to perform mRNA vaccinations in a hospital setting equipped to treat possible anaphylactic reactions.
• Individuals with severe allergy to any of the vaccine ingredients including propylene glycol should not be offered the vaccine.
• Anaphylaxis to food, insect venom, or other medication is not associated with increased risk for anaphylactic reaction due to COVID-19 vaccination.
• In case of concurrent infection vaccination should be postponed

“At present, based on the benefits and risks, and with the above caution, GINA recommends COVID-19 vaccination for people with asthma”. Global Initiative for Asthma, April 26, 2021

ANNA S. TZORTZI MD, FCCP
PNEUMONOLOGIST

References

World Asthma Day 2021

https://ginasthma.org/wad/
European Respiratory Society. “Adult Asthma.” In European Lung White Book, https://www.erswhitebook.org/chapters/adult-asthma/ (April 19, 2019)

Hellenic Thoracic Society
https://ginasthma.org/wp-content/uploads/2021/04/Whats-new-in-GINA-2021_final.pdf

https://ginasthma.org/wp-content/uploads/2021/04/GINA-2021-Main-Report_FINAL_21_04_28-WMS.pdf

LUNG CANCER

November, lung cancer awareness month.

Cancer is a generic term for a group of diseases which can affect any body organ or system characterized by rapid, uncontrollable and abnormal cell growth and division, as well as the ability to spread throughout the body (metastasis). The cancer is usually named after the organ where it started from, for example lung cancer whereas metastasis from another organ to the lungs is not lung cancer, but cancer of the organ of origin that has spread to the lungs.

Lung cancer is the most common cause of death from cancers in Greece¹.

Causes of Lung Cancer

Tobacco smoke through both active and passive smoking is responsible for more than 80% of all lung cancer cases indicating it is a highly preventable disease. A much smaller percentage of cases are attributed to occupational and environmental exposures to known carcinogenic factors such as asbestos, radiation, radon, beryllium, chromium, diesel exhaust and arsenic. ²

Symptoms

An important characteristic of lung cancer is that it develops slowly over time usually taking up to two decades for signs and symptoms to appear (time-lag effect).

In reality, the negative health effects begin from the first cigarette and cumulatively add-up over time (dose and duration-dependent). That’s why physicians ask about the number of cigarettes smoked per day and years of smoking so they can calculate number of pack-years (PY).

PY= number of packages smoked per day multiplied by years of smoking

Symptoms of lung cancer are relatively vague and vary by each person. Many times symptoms do not present until the cancer has spread to the rest of the body. Some of the symptoms can include³:

• • Coughing that progressively worsens and persists
• • Chest pain
• • Shortness of Breath
• • Wheezing
• • Coughing up blood
• • Feeling tired
• • Excessive unexplained weight loss
• • Clubbing of fingernails (when the tip of the finger is enlarged and appears like the round part of an upside-down spoon)

Diagnosis and Treatment⁴

Lung cancer has several histological types. Prognosis is different for each case depending on several factors, most importantly, the histological type and disease stage at the time of diagnosis. In clinical practice the main lung cancer differentiations are small cell and non-small cell lung cancer, requiring different therapeutic approaches.

Treatment options include surgery, chemotherapy and radiotherapy. Recent advances in chemotherapy (immunotherapy, molecular, targeted or precision therapy), in surgery (minimal invasion and video-assisted procedures) and in diagnosing and staging (CT scan, PET scan, endoscopic ultrasound) have led to early diagnosis, improved prognosis and quality of life.

Prevention:

Lung cancer caused by tobacco smoke is completely preventable through tobacco smoking prevention and cessation.

There is no safe limit for smoking or passive smoking. It is highly recommended to avoid smoking and second-hand smoke in order to prevent ever occurrence of lung cancer. Smokers are considered a population at high risk for developing lung cancer. Therefore, the United States Preventive Services Task Force (USPSTF)⁵, in their 2021 updated guidelines5, strongly recommend an annual screening with low dose chest CT scan for asymptomatic smokers and former smokers aged 50 to 80 who have smoked 20 pack years or more and either continue to smoke or have quit within the past 15 years.

What’s Happening in Greece?

Lung cancer is the 3rd overall cause of death in Greece. Additionally, tobacco use is the risk factor responsible for the highest mortality and disability in Greece^6.

Lung cancer represents the most common cancer incidence in males (18.7% of new cancer cases in 2020)⁷, and the 3rd most common cancer incidence in females (7.7%), following breast (27.5%) and colorectum (11.9%) . However, lung cancer incidence in women is expected to increase in the future due to increased smoking prevalence among women in recent years⁸.

The Good News:

Smoking and Passive smoking are decreasing in Greece! Smoking prevalence has been steadily declining in Greece since 2012, in particular in a nationwide survey conducted in 2012 smoking prevalence was 37%, whereas in a study conducted in 2020 smoking prevalence was 28%, showing a 24% reduction⁸! This reduction supports the expectation of a future reduction in lung cancer cases .

ANNA S. TZORTZI MD, FCCP
PNEUMONOLOGIST

References

1. OECD/European Observatory on Health Systems and Policies (2019). Greece: Country Health Profile 2019, State of Health in the EU. https://www.oecd.org/greece/greece-country-health-profile-2019-d87da56a-en.htm
2. European Lung Foundation. Lung cancer.http://www.europeanlung.org/en/lung-disease-and-information/lung-diseases/lung-cancer.
3. US. Center of Disease Control and Prevention. CDC – What Are the Symptoms of Lung Cancer? https://www.cdc.gov/cancer/lung/basic_info/symptoms.htm. Published 2013.
4. National Cancer Institute. Treatment for Cancer – National Cancer Institute. https://www.cancer.gov/about-cancer/treatment. Published 2015.
5. U.S. Preventive Services Task Force https://uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
6. Institute for Health Metrics and Evaluation. University of Michigan. Greece profile 2019. http://www.healthdata.org/greece
7. The Global Cancer Observatory. World Health Organization. Greece. Source Globocan 2020. https://gco.iarc.fr/today/data/factsheets/populations/300-greece-fact-sheets.pdf
8. Tzortzi A., Kapetanstrataki M., Evangelopoulou V., Behrakis P. 2020. “Smoking in Greece Where we stand in 2020”. Pneumon. 33 (2): 59-67.

Legionnaire’s Disease

What is Legionnaire’s disease?

A bacterium called Legionella that causes an acute respiratory infection and be found in freshwater environments or in other complex water systems such as:

• Water supply systems
• Water pipes (pipes with a little water, with corrosion and salts, shower heads)
• Heating and cooling systems
• Hot or cold water tanks such as swimming pools, hot tubs, fountains but also natural hot water tanks for example thermal baths etc.
• Mechanical devices such humidifiers or medical devices that use running water

Environments with temperatures of 20-45°C are ideal conditions for Legionella to grow and multiply. Of the many different strains of the bacterium, legionella pneumophila is the strain associated with the human illness, presenting in two clinical forms called Legionnaires’ Disease and Pontiac Fever.^1,2

Legionnaire’s disease can present

• Sporadically: when it is not connected to a particular source
• In outbreaks: when two or more people are sick in the same area at the same time.

Depending on the environment in which it presents, it can be distinguished as:

• Hospital Legionnaires’ disease: when hospitalized for the past 2-10 days
• Traveler Legionnaire’s disease: when a trip has taken place over the previous 2-10 days.

Modes of transmission²

• By inhalation of contaminated water droplets
• By ingestion of contaminated water, although this is rare
• Human-to-human transmission is extremely rare

Risk Factors²

Not everyone who is exposed to Legionella will get ill. People at risk for getting sick from Legionella include:

• Ages> 50 years old
• Smoking: Smokers and ex-smokers
• Chronic respiratory disease for example, Chronic Obstructive Pulmonary Disease
• Diabetes
• Renal, Hepatic insufficiency
• Cancer
• Immunosuppression due to disease or treatment (ie. chemotherapy, radiotherapy)

Legionnaire’s Disease (Legionella Pneumonia)^1,2

Incubation period of this illness is ~2-10 days. Legionella Pneumonia is a serious pneumonia that requires hospitalization with a mortality rate of 1-10%. However, early treatment with antibiotics has significantly improved the prognosis and outcome of the disease.
SYMPTOMS: fever, cough, shortness of breath, headache and nausea, diarrhea, confusion. Symptoms begin 2-10 days after exposure.
DIAGNOSIS: Chest X-ray, urine test, bacterial culture in sputum (prior to antibiotic treatment)
TREATMENT: antibiotics with macrolides or fluoroquinolones while also treating the symptoms

Pontiac Fever^1,2

Less severe, it usually resolves in 3-5 days. Symptoms may begin within a few hours of exposure, with flu-like symptoms such as fever and muscle aches. No specific medical treatment is needed except for symptoms treated with antipyretic analgesics.

Prevention^1,2

Prevention is based on regular management and treatment of complex water systems to keep Legionella from growing. The following is important for controlling outbreaks:

• Regular cleaning and management of all complex water systems
  • With use of water disinfectants (ie. chlorination, ionization, hydrogen peroxide, ultraviolet radiation)
• Search for the source of the original outbreak and treat immediately with either:
  • Chlorine treatment or
  • Heat shock

Monitoring and Surveillance1

In Greece there is a diligent system for monitoring and controlling the quality of water resources and water supply facilities through multiple parameters including the search for toxic substances and pathogenic microorganisms. Audits of water systems are made systematically throughout the country and especially in tourist areas. The recent cases of Legionnaire’s disease in Greece are the first ever reported and are considered sporadic and not attributed to a specific source. The European Centre for Disease Prevention and Control is also regularly updated.³

Recording, monitoring and reporting Legionnaire’s Disease is obligatory in Greece and is completed by a special form of the Ministry of Health and the Hellenic Center for Disease Control and Prevention (HCDCP) for the effective epidemiological surveillance of the disease.

ANNA S. TZORTZI MD, FCCP
PNEUMONOLOGIST

References

1. Κέντρο Ελέγχου & Πρόληψης Νοσημάτων. ΝΟΣΟΣ ΤΩΝ ΛΕΓΕΩΝΑΡΙΩΝ/ΛΕΓΕΩΝΕΛΛΩΣΗ. http://www.keelpno.gr/el-gr/νοσήματαθέματαυγείας/λοιμώδηνοσήματα/νο%CF. Accessed August 2, 2018.
2. Centers for Disease Control and Prevention. Legionella (Legionnaires Disease and Pontiac Fever). https://www.cdc.gov/legionella/about/index.html. Published 2018. Accessed August 2, 2018.
3. European Centre for Disease Prevention and Control. European Legionnaires’ Disease Surveillance Network (ELDSNet). https://ecdc.europa.eu/en/about-us/partnerships-and-networks/disease-and-laboratory-networks/eldsnet. Accessed August 2, 2018.

Τuberculosis

Tuberculosis (TB) is an infectious disease caused by the Mycobacterium Tuberculosis, that most commonly affects the respiratory system, but disease can also manifest in other organs, called extrapulmonary Tuberculosis.

Globally, Tuberculosis is considered among the 10 major causes of death and first cause of death among HIV/AIDS patients¹. The economical and disease burden of the current pandemic is expected to reverse the progress made in TB prevention, by aggravating the poverty and malnutrition in the developing world¹.

Inhalation of infected aerosol droplets, usually exhaled by a patient, is the route of disease transmission. This first contact may lead either to immediate elimination by the host defenses, either to the gradual onset of pulmonary disease, or to a latent infection that bears the potential to be activated at any time in the future¹.

Epidemiology:

25% of the global population is estimated to be infected, mostly in the developing countries¹.

In Greece, the prevalence among citizens of Greek nationality is declining, however there is an increasing prevalence of cases observed among other nationalities, mainly refugees and immigrants².

Symptoms³:

Persistent cough, weight loss, fever, night sweats, lymphadenopathy.

Diagnosis³:

• Imaging tests (Radiography, CT scan)
• Tuberculin skin testing
• Interferon-gamma release assay (IGRA)
• Culture of Mycobacterium tuberculosis in sputum, bronchoalveolar lavage and pleural fluid
• Pleural or lung biopsy
• Sputum acid-fast bacilli (AFB) smear
• Nucleic acid amplification (NAA) testing

Treatment³:

Active pulmonary disease is treated for 6 months, starting with a four-drug regimen for the first 2 months and continuing with two drugs for the remaining 4 months. During treatment patients are monitored for possible side effects and for their adherence to treatment as interruptions may lead to treatment failure and /or drug resistance. A special disease entity among types of drug resistant TB is the multidrug resistant TB representing a major and public health threat.

Prevention:

The bacille Calmette–Guérin (BCG) vaccine, offers partial protection, especially from severe forms of TB in children³.

Research for the development of a more successful vaccine, effective across all age groups, is ongoing, and some promising candidates are used in the course of clinical trials.⁴

ANNA S. TZORTZI MD, FCCP
PNEUMONOLOGIST

References

1. https://apps.who.int/iris/bitstream/handle/10665/337538/9789240016095-eng.pdf
2. https://eody.gov.gr/wp-content/uploads/2019/01/tuberculosis2004_2010.pdf
3. https://www.uptodate.com/contents/table-of-contents/infectious-diseases/tuberculosis
4. https://www.who.int/teams/global-tuberculosis-programme/vaccines