Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity.

An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.

Karen Anne Claridad 1, Albert Albay1, Pacifico Armando Cruz1, Isabel Luisa Acosta1

1Philippine General Hospital, Philippines

Inhalation injury is associated with significant morbidity and mortality among thermally injured patients. Along with age and percent total body surface area (TBSA) involvement, inhalation injury is a significant predictor of death. We present a case of a 42 year old male who came in for burn injury involving 35% TBSA. RT PCR for SARS‐COV‐2 taken on admission was positive. Baseline chest radiograph showed no active lung parenchymal infiltrates. Arterial blood gas showed PaO2/FiO2 ratio of 232. Fiberoptic bronchoscopy (FOB) was done post‐burn day 0 and revealed widespread plaque and soot formation with sloughed off mucosae in the trachea, carina and all bronchopulmonary segments. The severity of inhalation injury on the initial FOB was massive based on the Abbreviated Injury Score (AIS). Lavage with six vials of N‐acetylcysteine (NAC) was done. Repeat FOB on post‐burn day 1 showed markedly reduced adherent plaque and soot. Subsequent chest radiographs on post‐burn day 1, 2 and 4 remained unremarkable. PaO2/FiO2 ratio were 160, 167 and 261 respectively. Patient however expired on post‐burn day 6 from septic shock secondary to invasive burn wound infection. No relevant literature or evidence‐based guidelines were identified regarding NAC instillation during bronchoscopy for inhalation injury. Whether NAC lavage in this patient with massive inhalation injury has prevented the development of acute respiratory distress syndrome (ARDS) and pneumonia is still controversial. Indeed, the value of this approach are to be questioned by authors but evidence to disprove this is still lacking. Our case report adds to the limited literature on this.