Case 7-2023: A 70-Year-Old Man with Covid-19, Respiratory Failure ...

What A Pneumonia Infection Looks Like

Symptoms of 'Walking Pneumonia'

You may not even know you have it.

Pulmonary Embolism

Signs of this potentially fatal complication.

Persistent Cough?

When a cold becomes bronchitis.

What Is Pleurisy?

Causes behind painful breathing, fluid buildup.

What Are The Early Signs Of COPD?

Early signs of chronic obstructive pulmonary disease (COPD) include a chronic cough, increased mucus, and tiredness. Knowing which symptoms to look out for at home can help a person know when to visit a doctor for tests.

COPD is the term for a group of lung diseases that tend to worsen over time. Examples of these conditions include emphysema and chronic bronchitis.

COPD obstructs a person's airways, making it difficult to breathe. It is a progressive condition, meaning it tends to worsen over time. Without treatment, COPD can be life threatening.

According to the World Health Organization (WHO), the Global Burden of Disease Study estimated that COPD caused 3.23 million deaths worldwide in 2019. Additionally, health experts estimate around 16 million people in the United States have the disease.

This article describes the early signs and symptoms of COPD and how it gets worse. It also covers when to speak with a doctor.

The Global Initiative for Chronic Obstructive Lung Disease's COPD Gold Guidelines can help doctors assess whether a person has COPD according to the nature and degree of their symptoms, their history of symptom progression, and the presence of additional medical diagnoses that might cause or worsen their symptoms.

Additionally, the guidelines classify the severity of airflow limitation in COPD according to forced expiratory volume (FEV). FEV is how much air a person can push out of their lungs in 1 second during a spirometry test. The lower the value, the more breathing difficulties an individual has. Health experts grade the severity of airflow limitation using four categories:

However, the organization also recognizes that assessment of airflow limitation alone is not sufficient, as health experts now know COPD affects more than a person's ability to breathe. With this in mind, a full medical examination by a doctor can best determine whether an individual has COPD and the degree of the disease's severity.

In its early stages, COPD symptoms may be so mild that the individual does not notice them. The symptoms and severity of COPD can also vary from person to person.

However, because the disease is progressive, symptoms often worsen over time. The early signs and symptoms of COPD can include the below.

Chronic cough

A persistent or chronic cough is often one of the first symptoms of COPD. A person may experience a chesty cough that does not go away on its own.

Doctors generally consider a cough that lasts for longer than 8 weeks to be chronic.

Coughing is a protective mechanism that typically occurs in response to irritants, such as inhaled cigarette or tobacco smoke, getting into the lungs. Coughing also helps remove phlegm, or mucus, from the lungs.

However, if a person has an ongoing cough, this may signify a problem with their lungs.

Excess mucus production

Producing too much mucus can also be an early symptom of COPD. Mucus is essential for keeping the airways moist, and it also captures germs and irritants that get into the lungs.

When a person inhales an irritant, their body produces more mucus, which can lead to coughing. Smoking is a very common cause of excess mucus production and coughing.

Long-term exposure to irritants can damage the lungs and lead to COPD. Other lung irritants can include:

chemical fumes, such as those from paints and strong cleaning products

dust

pollution, including car exhaust fumes

perfumes, hairsprays, and other spray cosmetics

Shortness of breath and tiredness

The obstruction of the air passages can make it more difficult for a person to breathe, which can lead to shortness of breath, another common symptom of COPD.

At first, shortness of breath may only occur after exercise, but it can worsen over time. Some people cope with their breathing difficulties by becoming less active, which can lead to them becoming less physically fit.

A person with COPD needs to exert extra effort to breathe. This exertion can result in lower energy levels and feeling tired all the time.

Because their lungs are not functioning as well as they should, people with COPD are more likely to experience chest infections, including the common cold, flu, and pneumonia.

Other symptoms of COPD include:

unintentional weight loss, according to an older 2013 study

swelling in the lower legs

itching

dry mouth

sexual problems

dizziness

bladder problems

bloating

drowsiness

fatigue

A person with a COPD diagnosis may experience flare-ups, which are also known as COPD exacerbations, when symptoms suddenly worsen. Triggers of COPD flare-ups can include chest infections and exposure to cigarette smoke and other lung irritants.

Exacerbations may begin as mild, but they can become very serious quickly without prompt medical care. Early warning signs of a COPD flare-up may include:

symptoms suddenly becoming more severe within days or even hours

coughing becoming stronger, more frequent, or different than usual

suddenly becoming out of breath and struggling to do things a person can normally do, such as walking or taking a shower

the color of the person's sputum — the thick mucus that comes from the lungs — changing from clear to a darker color

producing more sputum than usual

being more tired than usual

unusual insomnia, feeling or appearing confused to those around them, or having difficulty waking up, which can indicate high carbon dioxide levels — seek immediate medical attention

lower than usual oxygen levels according to pulse oximeter measurements

A person who experiences any of the above symptoms regularly should speak with a doctor. Anyone who experiences signs of COPD exacerbation should also consult their doctor as soon as possible.

Even if people are not sure they have COPD, a healthcare professional can usually distinguish between COPD and other diseases. Early diagnosis of COPD can allow individuals to receive treatment sooner, which can help slow the progression of the disease before it becomes severe or life threatening.

The most common cause of COPD is smoking cigarettes or other tobacco products. According to the National Heart, Lung, and Blood Institute, up to 75% of people with COPD either smoke or have smoked. However, long term exposure to other irritants or harmful fumes may also cause or contribute to the condition.

Genetics may also increase the risk of developing COPD. For example, people with a deficiency in a protein called alpha-1 antitrypsin may be more likely to develop the condition, especially if they smoke or have regular exposure to other lung irritants.

The signs and symptoms of COPD most often start in people aged 40 years or older.

Getting a COPD diagnosis begins with a medical exam. Doctors usually start by asking the individual about their symptoms and medical history, including whether or not they smoke and if they have had exposure to any lung irritants.

They may also perform a physical examination and check for wheezing or other signs of lung problems.

To confirm their diagnosis, a healthcare professional may order some tests, such as:

Spirometry: A person breathes into a tube that connects to a machine called a spirometer, which measures how well their lungs are working. To begin the test, the doctor may ask the individual to inhale into a bronchodilator, a type of medication that opens up the airways.

Chest X-ray or CT scan: These imaging tests allow a doctor to see inside a person's chest to check for signs of COPD or other medical conditions.

Blood tests: The doctor may order blood tests to check a person's oxygen levels or rule out other conditions that cause similar signs and symptoms to COPD.

COPD is a common condition. However, some people mistake its symptoms for the normal signs of aging, which can mean they do not get a diagnosis. Without treatment, COPD can become progressively worse over time.

COPD can be a significant cause of disability. An individual with severe COPD may struggle with day-to-day tasks, such as climbing a flight of stairs or standing for prolonged periods to cook a meal. Flare-ups and complications can also severely impact a person's health and quality of life.

There is no cure for COPD, but early diagnosis and treatment can greatly improve a person's outlook. Appropriate treatment and lifestyle changes can relieve symptoms and slow or halt the progression of the condition.

Treatment options include medications, oxygen therapy, and pulmonary rehabilitation. Lifestyle changes involve engaging in regular exercise, eating a nutritious diet, and stopping smoking.

When You Should Worry About RSV

For most people who get respiratory syncytial virus (RSV), the illness doesn't go beyond mild, cold-like symptoms that affect the upper respiratory tract, such as a runny nose, sore throat, cough, and a headache, according to the American Lung Association. The majority who are infected recover at home in a week or two at home just with rest, pain relievers (acetaminophen or ibuprofen), and plenty of fluids.

But when RSV gets into the lower respiratory tract, it can cause serious illness, straining the lungs and breathing passages. In certain vulnerable groups, the virus can be so damaging it requires emergency care in a hospital and may even prove to be deadly.

Who Is Most Susceptible to Severe Illness?

According to the Centers for Disease Control and Prevention (CDC), those more likely to develop severe RSV infections are premature babies and infants, older adults, immunocompromised individuals, and people with chronic medical conditions, including chronic obstructive pulmonary disease (COPD) and chronic heart or lung disease.

Serious RSV cases can lead to bronchiolitis (an inflammation of the small airways in the lung) and pneumonia. Pneumonia causes the air sacs (alveoli) in the lungs to become inflamed and fill with fluid. This makes it harder to breathe and can become life-threatening.

Immunocompromised people with weakened immune systems may be at particularly high risk of pneumonia. These patients include those receiving treatment for cancer, transplant recipients, individuals who take drugs that suppress the immune system for diseases like Crohn's, lupus, or rheumatoid arthritis, and HIV patients.

"I saw pneumonia quite often in AIDS patients with RSV when I ran the HIV clinic at our county hospital in San Jose, California," says Dean Winslow, MD, an infectious-disease specialist and a professor of medicine at Stanford University in California.

Research has suggested that RSV not only increases the risk of viral pneumonia but bacterial pneumonia as well.

RSV Can Take an Enormous Toll on the Young and Old

In the fall of 2022, the United States experienced a dramatic rise in RSV-related hospitalizations. Federal data indicated that hospital admissions for RSV were 10 times higher than usual. At that time, beds at several pediatric hospitals were at or near capacity, and vulnerable seniors were also packing medical facilities.

Even in a typical year, RSV can take a serious toll on the young and old. The CDC estimates that RSV causes 58,000 to 80,000 hospitalizations among children younger than 5 years old, and 60,000 to 160,000 hospitalizations among adults 65 years and older.

The virus causes more fatalities among seniors than infants, leading to 6,000 to 10,000 deaths on average annually among those 65 and up, and 100 to 300 deaths among those under age 5, according to the CDC.

"Infants younger than six months often have more severe disease, probably because their immune systems haven't matured yet," says Dr. Winslow. "In older people, their immune systems are in decline. As people age, their cellular immune system — that's their lymphocytes and monocytes — doesn't work as efficiently, so all kinds of infections become more common."

He adds that older people often have underlying conditions, which can make them more susceptible to a variety of infections. At the same time, infections can worsen their underlying conditions. For example, the American Lung Association says RSV can trigger an asthma attack or exacerbate COPD.

For seniors living in nursing homes and other shared environments, infection risk goes up as RSV is very contagious, spreading through coughs, sneezes, and touch. RSV can survive hours on surfaces, and may be passed along through shared items, such as a salt shaker or pen.

Severe RSV Symptoms in Older Adults

The following symptoms may indicate that an adult is experiencing severe respiratory illness from RSV and requires prompt medical attention:

Wet, Worsening Cough Infection in the airways may cause the lungs to produce more phlegm and mucus. With RSV, the cough is often a wet cough or a "productive" cough because it is helping clear the lungs of mucus.

Afif El-Hasan, MD, a medical spokesperson for the American Lung Association, warns that a cough suppressant usually isn't a good idea with a wet cough.

"Let's say you're a 60-year-old and you're taking something like a codeine product to suppress the cough — then you're basically eliminating one of the natural defenses your body has of getting rid of infection, which is to cough up all of the mucus and all the secretions that are in the lungs and in the back of the throat," says Dr. El-Hasan. He suggests using an expectorant and a humidifier to make the cough more effective.

Fever Fever is the temporary increase in the body's temperature that means your immune system is fighting the infection. With adults, Mayo Clinic advises calling a healthcare provider if a temperature is 103 degrees F or higher.

Dehydration Watch for signs of loss of body fluids (dehydration), such as dry mouth, little to no urine output, sunken eyes, and extreme sleepiness.

Shortness of Breath and Wheezing This is a major sign of trouble. Mayo Clinic advises paying close attention to breathing to determine if emergency care is needed. When the lungs can't hold as much air because they are swelling or have mucus buildup, a person with RSV typically experiences shortness of breath.

If the infection gets deep in the lower respiratory tract, the small airways entering the lungs may get inflamed and cause wheezing. Wheezing — a high-pitched noise produced when exhaling — is usually a sign of extreme physical distress. Rapid or shallow breathing also signals major trouble.

Sometimes a person struggling to breathe will want to sit up rather than lie down in order to make breathing easier.

Bluish Tint to Skin Seek out emergency medical care immediately if this symptom appears. "When you're not oxygenating the blood like you should, you can get blue around the mouth and in the nail beds," says El-Hasan. An oximeter, an inexpensive home device that clips on the finger, can quickly gauge a person's oxygen levels.

Severe RSV Symptoms in Infants

In addition to some of the same symptoms that adults have, infants can have distinctive signs that indicate they are in severe RSV-related distress and require immediate medical attention.

Struggling to Breathe The Mayo Clinic urges parents to look for chest muscles and skin pulling inward with each breath. This can be a sign that the child has a severe infection.

"Because they have very small airways, infants [especially those who are less than 6 months old] can have a serious, deep infection in the lungs," says Ana Weil, MD, assistant professor with the Center of Emerging and Re-Emerging Infections at the University of Washington's department of medicine in Seattle. The risk of severe illness grows as the tiny airways become inflamed and narrower.

Poor Feeding Because very sick babies are struggling to breathe, they may also struggle to eat or drink. Fast or effortful breathing may cause them to aspirate (inhale) milk, for example, sending it into their lungs.

Excessive Sleepiness With an infant, El-Hasan, who is also a pediatrician with the Southern California Medical Group in San Juan Capistrano, advises parents to be on the alert for extreme lethargy. "It could be an urgent situation if the child is excessively tired or becoming weaker," he says. A baby who is in discomfort may also become overly fussy.

Fever As with adults, a high temperature is a danger sign for young ones. Mayo Clinic says that parents should call a healthcare provider if a child younger than 3 months old has a rectal temperature of 100.4 degrees F or higher, or a child between 3 and 24 months old has a rectal temperature higher than 102 degrees F or higher.

Treatments When Symptoms Get Extreme

In the most extreme circumstances, an infected person may require additional oxygen, or IV fluids (if they can't eat or drink enough), or intubation (have a breathing tube inserted through the mouth and down to the airway) with mechanical ventilation (a machine to help a person breathe), according to the CDC. In most of these cases, hospitalization only lasts a few days.

Infants and young children with severe pneumonia caused by RSV may be prescribed ribavirin (Virazole), administered via inhalation or pill.

How to Prevent Severe RSV Disease

Children at high risk for RSV, such as those who were born prematurely or have certain heart or lung diseases, may receive an injection of palivizumab (Synagis), a monoclonal antibody designed to prevent severe illness by helping the immune system to slow or stop the spread of the virus. It is not used to treat the symptoms of RSV disease once a child already has the virus.

Vaccines for RSV are another important tool for staving off worrisome disease. On May 3, the U.S. Food and Drug Administration approved the world's first RSV vaccine, for adults 60 and up. The shot, manufactured by the global biopharmaceutical company GSK (GlaxoSmithKline) will be marketed as Arexvy.

Additional vaccines for older adults as well as vaccines to protect infants are expected to be available in the very near future.

"We can save lives and prevent complications and prevent hospitalizations by using these vaccines going forward," says Dr. Weil.

In addition to getting immunized, the CDC encourages the public to take these measures to help limit the spread of this highly contagious illness, especially if you have any symptoms:

Wash your hands often with soap and water for at least 20 seconds.

Cover your coughs and sneezes with a tissue or your upper shirt sleeve, not your hands.

Avoid close contact, such as kissing, shaking hands, and sharing cups and eating utensils, with others.

Clean frequently touched surfaces such as doorknobs and mobile devices.

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