Cytomegalovirus (CMV) is a very common viral infection that is usually "silent" and self-limited. CMV lies dormant in more than half of adults in the Untied States by age 40. However, the antibodies made by the body to defend itself against CMV may increase a person’s risk for coronary artery disease. In a recent study antibodies to CMV were the highest in women with coronary heart disease. More research is being done to understand the role between CMV and heart disease.


A recent study aimed at reducing a "first" heart attack through the use of a cholesterol-lowering drug got a surprise secondary benefit. The risk of type 2 diabetes was reduced by 30 percent. If this finding can be verified in other studies, this would add one more in a growing list of benefits to cholesterol lowering medications


Symptoms | Diagnosis | Treatment | Underwriting Comment

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is a term, which refers to a large group of lung diseases that interfere with normal breathing. It is estimated that 11% of the U.S. population has COPD and the incidence is increasing. Two major diseases of the lung are grouped under COPD: chronic bronchitis and emphysema.

Chronic bronchitis is a condition is which excessive airway mucus secretion leads to a persistent, productive cough. In chronic bronchitis, there also may be narrowing of the large and small airways making it more difficult to move air in and out of the lungs. An estimated 12.1 million Americans have chronic bronchitis.

Emphysema is chronic lung disease that affects the alveoli (air sacs) and/or the ends of the smallest bronchi (breathing tubes). The lung loses its elasticity and therefore these areas of the lungs become enlarged. The loss of elasticity limits airflow out of the lung. An estimated 2 million Americans have emphysema.


IMPORTANT NOTE:

  • There are 112, 584 deaths annually from chronic obstructive pulmonary disease
  • Although the causes of COPD are not fully understood, it is generally agreed that the most important cause is cigarette smoking. Causes such as air pollution and occupational exposures may play a role especially when combined with cigarette smoking. Heredity plays a role in some patient's emphysema.
  • It is well known that cancer and COPD are closely related. It has now been shown that patients with airflow obstruction have a higher incidence of cancer of the lung than those without obstruction.
  • COPD is the fourth leading cause of death in the United States.

The most common symptoms of chronic bronchitis include cough and sputum. After many years, the patient develops shortness of breath. Initially the patient appears normal, but as the lung involvement progresses, the lips and skin may appear blue (cyanosis), abnormal lung sounds develop and swelling of the feet and heart failure develop.

Patients with predominantly emphysema usually have shortness of breath initially and later develop cough and sputum during a respiratory infection or in the later stages of the illness. Initially the patients do not usually appear blue at rest but eventually appear underweight and visibly short of breath. The chest may increase in size from front to back (the so-called barrel chest) and lung sounds become diminished on physical examination.

 

Patient History
A thorough physical exam and a series of tests to diagnose chronic obstructive pulmonary disease would follow a patient history of:

1. A chronic productive cough for 6 months to 1 year.
2. Shortness of breath after other causes have been ruled out.

Blood studies.
In the early stages of COPD routine blood studies are normal. A later complication of COPD would be an elevated red blood cell count. The body adjusts to inadequate blood oxygen by increasing production of oxygen-carrying red blood cells. This is called secondary polycythemia.

Pulmonary Function Tests (see Medical Testing Tutor for further information on PFTs)
Pulmonary function tests (PFT's) are various tests used to determine characteristics and capabilities of the lungs.

  • Spirometry
    The most useful test in the management of obstructive pulmonary disease is Spirometry. This is done with the patient breathing into a tube connected to a recording machine. The patient takes a deep breath in and blows it out as quickly and completely as possible. Measuring the amount of air that can be forced out in one second (FEV1) and the amount of air that can be completely and forcibly exhaled (FVC) and measuring the ratio of the FEV1/FVC will give an excellent assessment of the amount of airway obstruction. In addition medications called bronchodilators are administered and the response of the lungs to the bronchodilators can help define the presence and extent of the disease.
  • Arterial Blood Gas (ABGs)
    An ABG is done from a sample of blood drawn from an artery. Blood drawn from an artery is blood leaving the lungs with a full load of oxygen. The blood gas machine measures the amount of oxygen and carbon dioxide (waste gas) in the arterial blood. This is another measure of how well the lungs are functioning in getting rid of the waste gas and delivering oxygen to the blood. Many times ABGs are used in more complicated cases of COPD to determine how much addition oxygen a patient needs.
  • Pulse Oximetry
    This is a non-invasive test involving placing a clip on the finger, earlobe or forehead to indirectly measure the amount of oxygen in the blood. It uses light waves to measure the oxygen levels in the blood. Its advantage is that it can be left in place to monitor levels at rest, during sleep and while walking.
  • Chest X-ray
    In the early stages of the disease, an x-ray of the chest may be normal. But in moderate to severe cases a reasonably accurate diagnosis of COPD can be made with the plain chest x-ray and C.T. (Computerized Axial Tomography) scanning. The most common appearances in the chest x-rays are hyperinflation of the lung, depressed diaphragms, loss of blood vessel markings, reduced size of the heart, the presence of bullae and sometime increased lung markings.

 

Treatment for chronic obstructive pulmonary disease depends on the severity of the disease. Most people are treated with medication.

Smoking Cessation
It has been proven that cessation of smoking is the single factor associated with improvement in the rate of decline of pulmonary function. Other preventive measures include avoidance of household or work place irritants and to participate in a general exercise and fitness program.

Medications

Broncholdilators
Patients with mild to severe COPD are usually treated with medications that have a bronchodiator effect on the bronchial tubes in the lungs. There are three types of bronchodilators that are used.

Anti-Inflammatories (Steriods)
Some patients with COPD have inflammatory changes in their bronchial walls of their lungs. Patients most likely to respond to anti-inflammatories are the same patients who have a significant response to bronchodilators. Steriods can be given in an inhaled or oral form. Steroids have many side effects and usually steroids in the oral form are given for only short "bursts" of time to avoid the majority of side effects. There is much less concern with side effects when using inhaled steroids.

Long-term oxygen therapy
This is used for patients in the later stages of COPD. The severity of the disease will determine if oxygen is needed only for activities such as walking and exercise, only at night or around the clock use.

Lung Reduction Surgery
Lung reduction surgery or thoracotomy for is a surgery that removes of parts of the lung that contain large bullae. The lung area that has a large bullae doesn't work well, and can press on other parts of lungs so the lung can't function normally. In these cases, dramatic improvement in lung function occurs after surgery.

Transplant Surgery
Lung transplantation for severe emphysema has been made possible by improved methods of immunosuppresion. 60% of all single lungs transplants are done for severe emphysema. Selection criteria include patients less than 60 years of age, life expectancy less than 2 years without transplant and progressive deterioration of lung status. Survival after transplantation has been reported as 77% at 2 years and 75% at 3 years. Thereafter, survival rates fall partly owing to rejection problems or infection and partly because of associated nonrespiratory conditions in elderly patients.

1) Does the client currently smoke cigarettes or cigars?

Any client with a documented history of either emphysema or chronic bronchitis and continues to smoke is almost always uninsurable for individual coverage. Clients who quit smoking have the possibility of stabilizing the loss of pulmonary function and a better medical outcome.

2) What medications is the client currently taking?

Mild COPD treatment may not include medications. The clients are encouraged to quit smoking and undergo pulmonary rehabilitation (i.e. cardiovascular exercise). Moderate COPD treatment includes various inhalers and oral medications. Again, the clients are encouraged to quit smoking and undergo a pulmonary rehabilitation program. Severe emphysema treatment includes medications and the addition of supplemental oxygen. Clients who use oxygen are universally uninsurable for individual coverage.

3) Does the client have any functional limitations as a result of COPD?

Functional limitations for clients with COPD involve shortness of breath with climbing stairs or walking a short distance. Clients who exhibit these kinds of functional limitations are generally uninsurable for individual coverage.

4) Does the client have a history of heart disease?

Many clients with pulmonary disease also have heart problems. Mild, well-controlled hypertension and mild to moderate COPD in a non-smoking client is insurable. Clients with more complicated heart disease (i.e. angina, myocardial infarction, etc.) and moderate emphysema are generally uninsurable for individual coverage.

5) Is the client currently involved in any form of pulmonary rehabilitation or undergone any lifestyle changes?

Lifestyle changes can have an enormous impact on the underwriting outcome for COPD cases. There are excellent medical studies that verify that mortality outcome is greatly improved with positive lifestyle changes such as quitting smoking and beginning an exercise program. It is important to document all lifestyle changes that would indicate a decrease in any pulmonary risk.

Coming in the February 2001 RiskTutor Online Newsletter:

Crohn's Disease

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