In this 2-part post, we will hear from Karen McLeod, Senior Underwriter, about Chronic Obstructive Pulmonary Disease (COPD) and how those living with the disease can be assessed accurately. First, we’ll go over the basics of COPD and what you need to know about the disease. In part 2, we’ll dive deeper into what underwriters need to know when assessing an application on those affected by the disease.
Why is this important for life underwriters?
There are an increasing number of deaths related to Chronic Obstructive Pulmonary Disorder (COPD). It is not just simply a ‘smoker’s cough’ and is often overlooked. It is an under-diagnosed, life threatening lung disease that may progress to death and should be on the radar of life underwriters.
What is it?
COPD or Chronic Obstructive Pulmonary Disease is a generic umbrella term that is used to describe chronic lung diseases that cause limitations in lung airflow. It is a significant airway obstruction and can result in less than 15% improvement of lung function even with treatment from bronchodilators on spirometry (see more on these and other tests and treatments below). More common terms like chronic bronchitis and emphysema are no longer used but are also included under the COPD diagnosis.
According to the World Health Organization, there were 2.95 million deaths worldwide from COPD in 2000, compared to 3.17 million in 2015. This growing problem is a concern for insurers, healthcare providers, and people around the world.
When discussing COPD, it is helpful to recognize other related terms. Common terms and diagnoses include: chronic bronchitis, chronic obstructive airways disease (COAD), chronic obstructive lung disease (COLD), emphysema, and obstructive lung disease (OLD).
Causes and Main Risk Factors
The primary cause of COPD is tobacco smoke, including second hand or passive exposure.
The main factors that increase a person’s risk of developing COPD include:
- Tobacco smoking – this is the most prominent and is present in 80-90% of cases
- Second hand smoke
- Frequent lung infections as a child
- Genetic reasons – specifically, alpha-1 antitrypsin deficiency
- Indoor air pollution – i.e. biomass fuel used for cooking and heating
- Outdoor air pollution
- Occupational dusts and chemicals – commonly seen as vapours, irritants, and fumes
The rate, scale, and impact of COPD is large and important to grasp. These statistics help paint a picture of how critical it is to understand this disease.
- In 2005, 5.4 million people died due to tobacco use.
- Tobacco-related deaths are projected to increase to 8.3 million deaths per year by 2030.
- In high and middle-income countries, tobacco smoke is the biggest risk factor.
- For low income countries, exposure to indoor air pollution is the biggest risk factor.
- 3 billion people worldwide use biomass and coal for their main source for cooking, heating and other household needs.
- In these communities, the main risk factor for COPD is indoor air pollution.
- Biomass fuels used for cooking is related to a high prevalence of COPD in non-smoking women in parts of Middle East, Africa, and Asia.
- Wood burning that leads to indoor air pollution kills approximately 2 million women and children each year.
- Almost 90% of COPD deaths occur in low and middle-income countries.
- It is projected that in 2030, COPD will become the 3rd leading cause of death worldwide.
- COPD used to be more common in males, but increased tobacco use by women in high-income countries and higher risk of exposure to indoor air pollution has led to COPD affecting men and women equally
- In Canada in 2011, there were 1.3 million reported diagnosed cases of COPD.
- More than 4 million Canadians have a lung function that is indicative of COPD.
When you have COPD, your lungs are obstructed or blocked, making it difficult to breathe. COPD develops over time. In most cases COPD is diagnosed in people over 40 years of age. Someone with COPD may not realize that they are becoming short of breath until it becomes very hard to do simple tasks like walking up stairs.
A few other respiratory disorders are closely related to COPD. Chronic bronchitis is experienced when airways become swollen and can be filled with mucus, which makes it hard to breathe. Emphysema occurs when the alveoli (air sacs) in the lungs are damaged, also making it difficult to breathe. These can accompany or enflame COPD and these conditions are often directly related to each other.
Symptoms of COPD
The following symptoms can indicate COPD:
- Cough that lasts longer than 3 months
- Cough with mucus
- Feeling short of breath
- Lung infections (flu, acute bronchitis, pneumonia, etc.) that may last longer than other people you know
- Wheezing (a whistling sound when you breathe)
- Feeling tired
- Losing weight without trying
- Chest tightness
- Cyanosis (blueness of lips or fingernail beds)
- Swelling in ankles, feet, or legs
Full assessment and diagnosis from a medical professional is necessary to rule out other causes.
COPD cannot be cured but it can be treated. Early diagnosis increases the chances of improvement.
Lifestyle changes and appropriate drug treatments can be used to help those with COPD live a normal, active life. With proper care and treatment those affected by COPD will feel better and be able to stay out of the hospital
Quitting smoking is the most important step in treating COPD. It will help to quit smoking even if you already have COPD. In fact, quitting smoking is the best thing you can do to feel better. COPD will get worse if you continue to smoke or are around second-hand smoke or air pollution.
It is important to note that COPD medications cannot cure COPD but can greatly improve symptoms.
The following are medications that may be used to treat COPD patients. This list is not exhaustive and those included may not be right for everyone with COPD.
- Bronchodilators: This medication opens up airways in your lungs, making it easier to breathe. You may be prescribed more than one bronchodilator to treat COPD. 2 main types of bronchodilators are Beta-2 agonists (Ventolin, Cricanyl, Serevent) and Anticholinergics (Atrovent, Spiriva, Tudorza).
- Rapid-Onset Bronchodilators: These are quick relief versions that work to start relieving symptoms within minutes. Typically, quick relief medications come in a blue puffer. They are short acting and last 4-6 hours. The Ventolin and Bricanyl inhalers are the most common. Long-acting medications like Oxeze are also available. These can work to provide relief for up to 12 hours.
- Slow-Onset Bronchodilators: These options take longer to act. Some last 4-6 hours (Atrovent) and some last up to 12 hours (Serevent), while other slow-onset bronchodilators last 24 hours (Spiriva).
- Pill Bronchodilators: Xanthines or theophyllines (such as Uniphyl or Theodur) are slow-onset bronchodilator pills, that work differently than the inhalers listed above. They have serious side effects and drug interactions, including food and other medicines. For this the reason, they are not commonly used. When they are used, it is usually in combination with other bronchodilators.
- Combination Inhalers (combine bronchodilator and a corticosteroid): This option is used mainly in moderate to severe COPD cases. They are used to treat and prevent COPD exacerbations or flare-ups. They combine a bronchodilator to relieve the shortness of breath and an inhaled corticosteroid to lessen swelling in the airways. Some combination medicines for COPD are Advair (combine fluticasone with salmeterol), Breo TM (fluticasone furoate combined with vilanterol trifenatate), and Symbicort (combine budesonide with formoterol fumarate). Combination meds are ‘preventers’ and need to be taken daily, typically twice per day. These will help over time but do not help provide immediate relief.
- Corticosteroid Pills: Prednisone is a popular option for this type of medicine. They have more side effects than inhaled corticosteroids that are used in combination medication. These pills can be used for short periods of time and are typically limited to use when there is a flare-up. They may need to be taken on a regular basis if a physician deems inhalers alone are insufficient treatment.
- Antibiotics: Flare-ups can be caused by viral infections, like the flu for example, or bacterial infections, such as bacterial pneumonia. If it is a bacterial infection causing the flare up, it can be treated with antibiotics. If the cause is viral, antibiotics won’t work.
- Flu and Pneumonia Shots: Vaccines can help protect against some strains of flu and pneumonia. Vaccines can lower the chances of getting a flare-up and reduce the chances of needing hospital care. Flu shots are administered annually, whereas the pneumonia shots are required every 5-10 years.
- Supplemental Oxygen: In severe COPD, it can be extremely difficult to get enough oxygen from natural air. Low oxygen levels can make people feel increasingly short of breath and tired. Oxygen inhalation may be used to relieve these issues. When oxygen is used, people must continue to take their other medications. Oxygen only helps those with very low blood oxygen levels (hypoxemia) or temporary lung damage from infections (i.e. pneumonia). Oxygen offers a few benefits, including: improving the way a person feels and thinks; decreasing shortness of breath; aiding in easier exercise; and preventing heart strain caused by low levels of oxygen.
Pulmonary rehab is one treatment option that establishes a specialized exercise program for people with a long-term lung disease like COPD. These programs include sessions on quitting smoking, breathing control, and energy management. There may also be a component on medication education that offers more details on when to use specific medications and how to use them properly. The focus for this treatment is on improving exercising ability and improving the overall quality of life.
This invasive treatment option may be possible for someone with very advanced COPD. Candidates for a transplant no longer smoke and won’t live long unless they have a transplant. If an individual qualifies, they will be put on a wait list for a donation. Transplants may include either one or both lungs. If the transplant is completed, the person will be required to take anti-rejection medications (immunosuppressants) for the rest of their lives.
The following environmental triggers can make COPD symptoms worse and even cause flare ups that require medical treatment. Those with COPD must try their best to avoid the following:
- Air pollution, smog
- Second-hand smoke
- Strong fumes, perfume, scented products (i.e. paint, perfume, cleaning products)
- Cold air
- Hot and humid air
We’ll have more information connecting this foundational understanding of COPD to what underwriters need to know in their role in our next post!
COPD Diagnosis Treatment, COPD Definition, COPD Definition II, COPD Definition III, COPD Definition IV, Stages of Chronic Obstructive Pulmonary Disease, COPD Prognosis, COPD Life Expectancy and Prognosis, COPD Life Expectancy II, COPD Risk Factors, COPD Symptoms and Causes, COPD Signs and Symptoms, Reinsurance Manual (Swiss Re)