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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme no. 3 - COPD
RADIO 4
THURSDAY 13TH MARCH 2008
PRESENTER: BARBARA MYERS
CONTRIBUTORS: KEITH PROWSE
PRODUCER: JOHN WATKINS
NOT CHECKED AS BROADCAST
MYERS
Hello. We used to hear a lot about chronic bronchitis and emphysema. One is where the airways become narrow and blocked with mucus, the other where the small air sacks in the lungs lose their elasticity. These days chest problems like these tend to go under the umbrella term of chronic obstructive pulmonary disease or COPD for short. COPD is very common, it affects an estimated three million people and it's mainly caused by smoking. Quitting is of course the best way of stopping it getting any worse but if the damage has been done what treatments are available to help you breathe more easily? Well the Department of Health will be announcing the first national service framework for COPD later this year, that'll be aimed at improving the quality of care across the country. How might that help you if you're struggling with this condition?
Here to answer some of the many questions that are already coming in today I'm joined in the Check Up studio by Dr Keith Prowse. He's a respiratory physician, he's also chairman of the British Lung Foundation.
First to the phones is Rita in Liverpool, who's been given a diagnosis of COPD but has got no symptoms, how can that be Rita?
RITA
Hello?
MYERS
Hello.
RITA
Well I have a very occasional slight breathing problem and for some time, very, very occasionally. But I went and had a test, told the doctor, had a test, now I'm not sure what it's called - spiro something ...
MYERS
Spirometer maybe?
RITA
That's the one.
MYERS
Okay.
RITA
I was told I had COPD. Now I'm in my late 70s, I walk miles, I can run for a bus without getting puffed, I went hill climbing recently and I don't take any medication of any sort and when I spoke to a hospital doctor he said you couldn't possibly have it. So what I want to know do I have it or not?
MYERS
Well confusion all round. Would you say from what Rita has said, given that she has so few symptoms and appears to be so fit, would she had COPD?
PROWSE
I think it would depend on what the spirometer test showed. If it does show that she can't breathe out in one second as much as she ought to be able to then clearly there's some problem with the air passages.
MYERS
So that's a real definitive test is it?
PROWSE
It's a fairly definitive test. I mean there are other tests that one sometimes has to do to exclude asthma, as opposed to COPD, but it's pretty definitive. But of course from what Rita says it's at the very early stages and many people with early COPD can do an awful lot, the lungs have a huge reserve and that's the advantage of them. So yes you could have, but I wouldn't worry about it and you don't need treatment, unless you're getting problems.
MYERS
So are we talking really about a spectrum in that case, when we talk about COPD, of symptoms that can be mild and can get much worse?
PROWSE
Yes I think the general picture people have is of somebody who's very limited in their activity and can perhaps 10, 20, 50 yards, can't go upstairs easily but of course it has to start somewhere and we know that even in the early 20s, for many people, the first changes can be shown on tests - breathing tests - and the first symptoms may develop, like a smokers' cough or a bit of breathlessness going uphill. And there's a whole spectrum from that and it covers many years to deteriorate to the severe condition. And let me reassure Rita - many people don't deteriorate to the severe condition.
MYERS
Hope that's been reassuring Rita, even if you've been given the diagnosis, it's not necessarily something you should be worried about at this point. Thank you for calling us but we'll go to another caller in Southend-on-Sea, she's Jennifer Jones and also, I think, has been diagnosed with COPD. Doubting the diagnosis again I think, is that right Jennifer?
JONES
Well I haven't been diagnosed yet, I've been asthmatic all my life, nothing has really helped, I've used the blue inhaler. I was put on the seretide inhaler in September last year and it basically changed my life, in that I could start jogging - I've never been able to jog - although I've always been active, I've never really led a restricted lifestyle. I had bad flu at the beginning of this year which went to bronchitis and as you can hear I then developed croaky throat, which has just not gone away. I was sent for a lung x-ray, the results of which I haven't got back yet, and I have to go for a spirometry test as soon as the x-ray results come back. And the GP did suggest that he thought I might have COPD which I am reluctant to believe as well because I feel - I've started jogging again even though I'm still croaking and when I jog I don't have to use a reliever inhaler. So I'm reluctant to believe that I can possibly have COPD, I've never smoked, never worked in a polluted environment and I'm self-employed and I work from home in an easy environment.
MYERS
Well all of those things are good things but let's just talk about the asthma and the possible connection. Can a prolonged asthma then cause or lead to COPD would you say Dr Prowse?
PROWSE
Yes, some people who have asthma over many, many years do develop COPD. It doesn't necessarily progress at the same rate as other causes. But it seems to me, just from what was said, that a severe attack, an infection, or something like that, aggravates asthma, often makes it difficult to get it settled down. Seretide often helps both conditions, so that doesn't give us a clear diagnosis. And I think it's a question of Jennifer waiting until she has the relevant test results. I have to say I suspect the x-ray will be normal and won't help at all.
MYERS
Alright. Well stay listening to the rest of the programme if you will Jennifer. We've got another caller in Bristol this time, Tracey wants to talk about her dad who's got emphysema, struggling with that is he Tracey?
TRACEY
Yes he's finding it increasingly difficult just to do ordinary things but my question was really that he's on several drugs, one of which you've just mentioned, but I wanted to know whether any test physio or whether there was anything physical really that could help just for him to get increasingly better even though I know it's a progressive disease?
MYERS
I think he's a had a history of smoking which partly explains the story I believe?
TRACEY
Yes, he gave up 25 years ago just in case he's listening.
PROWSE
Well that was the important thing to have done, he made a very good decision there. The answer to your question is possibly. What I mean by that is that if he's having trouble clearing mucus from his chest then physiotherapy is often helpful. What is important is to try and stay as active as possible and I don't mean by that going to the gym and trying to walk on treadmills or ride bicycles, I just mean walking to the garden gate or the local shop and back but fairly regularly. There's absolutely no point in pushing oneself so hard that you take a week to recover but regular exercise we know is beneficial, it keeps people active, it helps the breathing muscles and the other muscles and it makes the way the body uses oxygen much more efficient. So that is to be encouraged very much.
MYERS
What about physiotherapy though where someone actually does something to you, perhaps helps clear your chest in that way?
PROWSE
Yes clearing mucus, sputum, particularly after an infection sometimes that's helpful. And sometimes if people get very anxious or very upset when they become breathless it helps them to control their breathing much more easily. But it doesn't help that much if somebody's stable and hasn't got a lot of sputum and not getting variable breathlessness.
MYERS
I'm wondering if you think your dad would definitely welcome some help, perhaps more than he feels he's getting or that you feel he's getting?
TRACEY
Well I just felt it would help to have some physio because he basically went downhill, sort of when he got a chest infection just before Christmas, and so I just thought - well I kind of had this idea that it would be like cystic fibrosis and if you could move things around a bit then that might help him clear - I just want someone to help him in any way they can really. And I just want to know would any physio be able to do that or would it have to be a specific chest physio?
PROWSE
Most physios are trained to do chest exercises and sputum clearance, clearly if you have somebody who specialises in it you'll probably get a better level of attention. The other thing is that what I would call general physio - literates the exercises - keeping the arms and legs and the muscles generally fit is also important after a chest infection because people stop doing what they were doing, they become less active and you've got to get back to the activity again.
MYERS
I wonder if we can just take a little bit further that question about smoking, I mean Tracey you've said that dad used to smoke, gave up 25 years ago, does that mean that if you've been a smoker and give up it's not going to make any difference to your lung function - the damage is done and you can't reverse it?
PROWSE
If you're a smoker and there's some damage then that damage is done and you can't reverse much of it, it may not be bothering you, for instance, when you're in your 30s, 40s or even 50s but we all lose a bit of lung function as we get older, just as other things show signs of wear and tear and that's when it becomes obvious. But I think the important thing to say is that it doesn't matter how severe the damage is or how severe the symptoms are if you stop smoking there is almost always some improvement in the symptoms, it may take a month or two to happen, but more importantly the rate at which things go downhill is very much slowed down. And if you're in your 30s, 40s and 50s and you stop then in 10 or 15 years time the fall off in your breathing function will be back to almost normal level, it'll start from a lower level if there's damage but it'll be almost normal.
MYERS
And of course we're pointing the finger at smoking because it's a well known pollutant and lung damage does follow from smoking but I guess we should also refer to the fact there are other forms of pollution which can cause lung damage in some people.
PROWSE
Very, very much so, I mean the obvious example is air pollution and another obvious example is that certain jobs, certain work, leads to it and this is exposure to fumes and dust in industry for example. And then there are a few people who get it because they're genetically predisposed to it and a few people get it because in infancy or as babies they have a lot of chest trouble and that hangs over - that damage holds over until they get into adult life and start to get the symptoms.
MYERS
Let's go to Ireland for our next call, Martin Collins wants to speak to us and Martin, someone else with a diagnosis of COPD yes?
COLLINS
That's right yes. I went to Poland recently to a private chest clinic, I went as an asthmatic and was there for two weeks, right? And they did all sorts of tests while I was there. They diagnosed me as suffering from COPD but they recommended that I have oxygen treatment for six to eight hours every night. And then again I was quite shocked about that because they said you needed to do it continuously and they said that that's what - they changed my medication. I came back to Ireland I told my GP, he agreed to change the medication but he felt that they would only recommend oxygen when you're on your way out.
MYERS
Well Martin, so you've been left with a dilemma - someone, in Poland, in this case, has recommended oxygen and your own GP thinks not. Perhaps I can ask Keith, our expert today, what is the role and value of oxygen in COPD, it does sound as though it's rather the last resort I guess?
PROWSE
To a point yes, we're talking about what's usually called long term oxygen. I'm a bit surprised at the advice Martin got because there's general agreement among the European chest physicians groups that if you need long term oxygen - and I'll come back to that in a second - then you need 15-16 hours a day via things usually called nasal specs that you just park round your ears and put in the nose. And in order for that to be helpful you have to have a level of oxygen below a certain level and I don't know what Martin's tests showed so I can't comment on that but if it's below that level and regularly below that level oxygen will help. It sounds to me as though Martin's more active than that so I think the first thing would be to get a referral and get the tests looked at. Some people use oxygen short term, just when they're breathless, there's no evidence that helps at all in this situation.
MYERS
Well it might make them feel a little bit more comfortable.
PROWSE
It makes them more comfortable, yes, because everybody knows oxygen is generally a good thing. But it's not always a good thing in people with COPD. If we're breathing normally, for you or I, the thing that keeps us breathing is a drug called - a gas called carbon dioxide, which is produced by muscle activity in the body's general activity. And we breathe at a particular rate to get rid of it. It just so happens that that rate also gives us the right level of oxygen. If you get quite marked COPD the level of carbon dioxide becomes such that the body can't get rid of it and it starts to rise and at that point it stops driving the breathing. And the problem then is that you're dependent on the fact that you're short of oxygen to keep breathing. So if you give oxygen you can see that that has a harmful effect and there isn't another backstop. So if you give oxygen to the wrong people with COPD, I'm talking about people with advanced disease, then it can be positively harmful which is why you need to do proper tests.
MYERS
Martin, I think that's very clear, you need a bit more advice on this, so it's back to the specialist I think in this case. And speaking about specialists and whether to go to your GP, whether to find expert opinion, I've got an e-mail from Freda who's concerned about her husband and he's quite a diagnosis which includes asbestosis, emphysema and bronchiectasis. He's 85 years old, he's been seen by the chest specialist but he's now back with his GP and according to Freda his breathlessness and cough are bad but the GP says it's due to old age. In other words she's very concerned he's not really getting the kind of after care that he needs with that kind of diagnosis.
PROWSE
Right. I certainly wouldn't agree it's due to old age, it's due to the medical condition that he has. Asbestosis is scarring within the lungs caused by being exposed to asbestos, it makes it your breathless and it sometimes gives you a cough. Emphysema's part of COPD and the characteristic symptoms of breathlessness and cough again. The interesting one here is the bronchiectasis, which is usually areas of localised damage in the air passages often caused by infections such as pneumonia or whooping cough but which very much predispose a person to infection. And of course if you get an infection on top of those three conditions you get deterioration. In terms of longer term management it's very common for patients with these conditions to be managed by their GP because management is usually fairly straightforward and as long as he's on the right treatment, he can get antibiotics very quickly in the event of infections, bacterial infections, and as long as he has access to hospital services if there's a complication or if things are not improving, say after a bad infection, then I think he's probably in the right place. There's always the slight risk - and we became aware of this I guess in the '70s - that people going regularly to chest clinics often picked up infections rather than them getting better, which was what we were trying to do.
MYERS
Always stay out of hospital if possible. Let's go to another caller - Lilian is waiting to speak to us, she's in Essex and concerned about her husband who's got COPD. What's the particular issue for you and indeed for him Lilian?
LILIAN
Hello.
MYERS
Hello.
LILIAN
He was diagnosed about three years ago, having sadly given up smoking a long time before that. Over the last three years, since he was diagnosed, he seemed to be losing lung function to the point where he's very breathless when he walks. And we just wondered whether or not it's sensible for him to carry on trying to walk a little way very regularly, rather than just sort of lurking round the house and the back garden, whether or not it's the kind of exercise keeps these things going regime or whether he ought to just stop and not worry about it?
MYERS
Yes a bit of conundrum because if you're feeling breathless you don't really feel as though you should be pushing it and yet we know that exercise is good for you and to feel a little bit breathless is the objective of most exercise, at least for people who are relatively well, so how are we going to solve this?
PROWSE
Well I think a lot of people get very worried if they or their relatives become breathless because they think it must be doing harm or putting strain on the heart or something like that. Most of that belief is nonsense. If you make yourself - there's no point in making yourself excessively breathless but it doesn't do any harm to make you a bit breathless, even normal people get breathless if they do - say run a marathon or run a hundred yards or run upstairs ...
MYERS
Or run for the bus in my case.
PROWSE
Or run for the bus. I would - the thing I would say very strongly is I would encourage him enormously to carry on doing some form of regular exercise and it's the regularity that's the thing. And it doesn't matter if it's walking to the garden gate or the newspaper shop or even as some of the videos on this show somebody sitting in a chair lifting up cans up baked beans in each hand. But doing it regularly to keep the muscles fit and make best use of the oxygen that you can get is good value. The other problem is if you give into it and just lurk about the house many patients with this condition then get very depressed because they've got no social contacts, they feel they can't go out because they get embarrassed or they're not able to do it and that's a pretty miserable existence. So I would very much encourage him to keep as active as possible.
MYERS
And do the health services offer something perhaps by way of a rehabilitation clinic, perhaps along the lines they do after a cardiac problem?
PROWSE
There are hospitals and clinics that offer pulmonary rehabilitation, which is the equivalent of the cardiac thing. Sadly the numbers it's available to are limited and probably only about 3% of patients have access and this is one of the things that we've been pushing very hard for in the National Service framework. We're also encouraging people, after that initial course, to carry on doing some regular exercise. And the British Lung Foundation has started a thing called BLF Active, which is aimed at trying to promote that and we're trying to get the cooperation of many of the commercial sports clubs and gyms so that they can give some time and some of their instructors some help. And we've had quite an enthusiastic response from the instructors for that because it can't all be done in hospital, the numbers are too great.
MYERS
And I know there's a lot of very good advice on the British Lung Foundation website, we'll give details of how to get to that at the end. But let's go to Mike Butler, who I think is trying to do exercise of a kind using something that's called a resistance trainer, can you tell us about that Mike?
BUTLER
Hi, yeah. I just wondered if the doctor could comment on the efficaciousness of - I think they're called inspiratory muscle training devices.
MYERS
Which are what roughly speaking?
BUTLER
The devices that you blow into that require some effort to blow through and supposedly help the muscles that allow you to breathe improve in their effectiveness.
PROWSE
Yes that's the idea, you've got it absolutely right. I have to say that in general I don't think they're very effective except for a small number of patients in two ways. There is a small number of patients who really don't work out how to control their breathing and how to handle it and often concentrating on a device like that they learn how to control their breathing when they're getting breathless, they learn how to breathe more efficiently. I don't actually think it does much about breathing - sorry about improving the breathing muscles. People who get breathless have got enough exercise to their breathing muscles anyway and if you're doing some sort of regular exercise then it's likely that you're been training those muscles as well. I think that's just probably - I'm going to get attacked for this but I think it's just a convenient way of selling the device but it does have use for some people yes.
MYERS
Okay, hope that's helpful. Let's go to Maureen, who's got another form of exercise that she wants to mention in connection with COPD which is what Maureen?
MAUREEN
Well I've had a bronchiectasis but I started going through the GP to a local yoga class where I've met a load of people who are on oxygen some of them and some in wheelchairs and I find it very helpful in doing the proper breathing - deep breathing - without hyperventilating and to see other people, some of them in a worst state than myself it's really very uplifting, shall I say.
MYERS
It helps with the sort of sense of helplessness and perhaps hopelessness that you can often get with this kind of condition.
MAUREEN
That's right, when you're on your own particularly like I am it's marvellous to meet other people who are on their own too and come out to these classes. Some weeks are better than others but it's always good to be able to breathe properly. I've always been able to do that but I've got lots of things like the bronchiectasis that doesn't help. But I'm going through a quite bad period now ...
MYERS
I'm sorry to hear that but it does sound as though at least you know what does help and Keith is nodding in agreement, that it's really important not to kind of give up and just sit back and still to get out there and do what you can.
PROWSE
Yes absolutely. And yoga is one of the useful forms of exercise for helping you to control the breathing, keeping you deep breathing and in particularly with bronchiectasis also helping you to clear mucus. I think your other point is a very important one and that is about the contact with other people who have similar conditions. You can get very lonely with this condition, if you know other people are in the same boat other people will teach you ways to get round problems, it's very, very useful.
MYERS
And a final word I think is going to go to Peter Copeland in West Sussex who's got a bit of good news for us, tell us very quickly what your good news is about smoking, stopping smoking, COPD and so on?
COPELAND
Oh hi, yeah. I suppose the message I want to get across to everybody really is give up smoking, I've been smoking for years and years and years and getting more and more breathless but covering it up from people, afraid to go to the doctor because I thought I had cancer or something like that. In the end it just got to the point where my legs and my body started swelling until I got about four times the size and I was rushed into hospital and my COPD had led to right heart failure. Fantastic treatment from the GP and from the hospital. I'm on a few water tablets now and an ACE inhibitor but apart from that I'm taking the dogs for miles everyday and I feel so much better. So I think the message to everybody is give up smoking and if you're breathless go and see the doctor.
MYERS
Well you couldn't say better than that and I'll just get Keith, our expert, just comment on that very briefly - the idea, yes, stop smoking it really is the best thing you can do for yourself.
PROWSE
Yes and many congratulations, it's not always easy to do. But help from tablets or from non smoking clinics, quit smoking clinics, and anything else like acupuncture or hypnosis can help.
MYERS
Thank you very much indeed. Thanks to Keith Prowse our expert today. Thank you very much to all of you who have phoned and all those who have e-mailed. I do hope that we've been able to answer at least some of your questions, you can find more sources of information on our website, that's the usual address - bbc.co.uk/radio4 follow the prompts to Check Up. Or you can phone our free and confidential helpline, the number 0800 044 044.
And I hope you'll be joining me again next week at the same time, we'll be asking the question about how the way we sit and the way we stand may be causing our back pain.
ENDS
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