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CUHK Health Exhibition 2024 Immaculate Heart Of Mary College QUIT SMOKING FOR YOUR LUNGS! THE EFFECT OF ACTIVE AND PASSIVE SMOKING ON THE PREVALENCE OF COPD IN HONG KONG CHENG...

CUHK Health Exhibition 2024 Immaculate Heart Of Mary College QUIT SMOKING FOR YOUR LUNGS! THE EFFECT OF ACTIVE AND PASSIVE SMOKING ON THE PREVALENCE OF COPD IN HONG KONG CHENG CHI YIU CHIANG PUI TUNG LAM HEI PING LI YIN TING CHOW MAN CHING YIP HONG CHING MENTOR: MS. WONG LEE I. Abstract Topic and Description Chronic Obstructive Pulmonary Disease (COPD) is a serious and life-threatening respiratory condition that worsens overtime, with both active and passive smoking as its primary cause. About 10,000 individuals in Hong Kong are affected with this health issue each year that is characterized by blockage or narrowing of the airways due to long-standing damage to the respiratory system brought on by breathing problems.Thus, this report introduces the causes, symptoms, treatments and prevention of COPD. Through explaining the details of COPD and promoting broader public awareness, this report aims to equip Hong Kong citizens with the requisite knowledge to mitigate the burgeoning health crisis. Rationale In recent years, chronic obstructive pulmonary disease (COPD) has emerged as a significant public health concern in Hong Kong. Due to the air pollution in the city such as smoking,secondhand smoke and urban development,numerous people are suffering from COPD. Unfortunately many individuals facing COPD tend to underestimate or ignore the seriousness of their condition. This attitude has put the people of Hong Kong at greater risk of the harmful effects of COPD. Given the seriousness of this issue, understanding of the medical principles and prevention of COPD is incredibly important. Therefore, it is necessary to reduce the growing COPD epidemic that threatens the health of Hong Kong citizens by educating the public and raising awareness. II. Description of Chronic Obstructive Pulmonary Disease A. Most common cause of COPD Different investigations show that smoking cigarettes is the most common cause of COPD. Previous studies show that about 75% of COPD patients have a smoking history. The chemicals and toxins in cigarette smoke can seriously damage the lungs.The smoke inflames the airways and makes them narrower and less flexible. This makes it much harder for the patient to breathe and increase the risk of developing COPD. The link between smoking and COPD is well known. Cigarette smoke contains over 7,000 chemicals, many of them are harmful to the lungs. These chemicals weaken human’s lungs to fight infections. Human’s lungs rely on the natural elasticity of the bronchial tubes and air sacs to force air out of your body. However, patients’ lungs lose their elasticity and cause over-expand due to COPD, which leaves some air trapped in their lungs when they exhale. In addition, it can cause inflammation, tissue damage, and the damage of the tiny air sacs in the lungs. As a consequence , this leads to the development of emphysema which causes destruction of the fragile walls and elastic fibers of the alveoli. Moreover, airways collapse when you exhale, impairing airflow out of your lungs. It is a key factor in developing COPD. Besides, secondhand smoke is one of the most common causes of COPD too. Being around secondhand smoke from burning cigarettes and exhaled smoke can also lead to COPD. Secondhand smoke has similar harmful chemicals as direct cigarette smoke and it can negatively impact the lungs of non-smokers. As the chemicals in secondhand smoke, such as carbon monoxide, tar, and nicotine can enter the lungs, it causes similar damage as in active smokers. Even non-smokers exposed to secondhand smoke can have impaired lung function and increase the risk of developing COPD. COPD is a lung disease with multiple causes while smoking is the most common cause of developing COPD. Secondhand smoke also plays important roles in developing COPD. Consequently, understanding these various causes is crucial for prevention, early detection and comprehensive management of this debilitating condition. B. Other causes of COPD In addition to the primary causes, various factors such as air pollution, gender, age, and genetic deficiencies in anti-protein enzymes contribute to the development of Chronic Obstructive Pulmonary Disease (COPD). B1. Gender Gender is the cause that can increase the risk of developing COPD.Biological differences may predispose women to a higher risk of COPD. Although smoking is the leading cause, women's airways are generally smaller than men's, resulting in a greater concentration of tobacco smoke per unit area within their lungs. Consequently, women often exhibit less emphysema compared to men, but women have smaller lumen sizes and thicker airway walls which may make them more susceptible to airways disease like COPD. Moreover, the use of tobacco and exposure to biomass fuels among women is increasing. In 2017, 12.2% of women smoked, compared to 15.9% of men. Although a greater number of men smoke than women, COPD is more commonly seen in women. This suggests that women may exhibit heightened sensitivity to the detrimental effects of cigarette smoke, which increase the risk of developing COPD. B2. Age Advancing age is associated with a higher risk of COPD. As individuals age, lung function naturally declines, leading to decreased respiratory efficiency, vital capacity, and airflow. The elasticity of lung tissue decreases, impairing the lungs' ability to expand and contract effectively. However, aging alone is insufficient to precipitate COPD. Aging with other risk factors, such as smoking and exposure to industrial chemicals may increase the risk of developing COPD. Additionally, older adults are likely to have encountered harmful substances, such as tobacco smoke, for a long period, resulting in cumulative damage over time. Long term exposure to harmful substances may also cause chronic inflammation which is a key factor in the development of COPD. B3. Genetic deficiencies in Anti-protein Enzymes Genetic Deficiencies in Anti-protein Enzymes is one of the causes of COPD. Anti-protein enzymes are important in protecting lung tissue from damage caused by specific enzymes that degrade proteins. A deficiency in these protective enzymes can result in significant lung tissue damage, as excessive enzyme activity compromises the elastic fibers, leading to a loss of elasticity and structural integrity. Consequently, this increases the risk of developing COPD. Deficiencies in anti-protein enzymes may also provoke chronic inflammation, contributing to the progression of emphysema, a key component of COPD. Early genetic studies investigating familial links to COPD have revealed that about 1% of cases are due to alpha-1 antitrypsin (AAT) deficiency, a hereditary condition. This indicates that individuals with a family history of AAT deficiency possess a genetic predisposition to COPD. B4. Air pollution Air pollution represents a significant environmental risk factor for COPD. Inhaling pollutants such as nitrogen dioxide and sulfur dioxide from factories, power plants, wood burning, and wildfires can irritate and damage lung tissue. Long-term exposure to chemical dust and fumes is particularly harmful, as it may provoke inflammatory responses in the lungs, leading to structural changes over time. Additionally, pollutants can impair ciliary function, which is essential for clearing mucus and debris from the airways, increasing the likelihood of respiratory infections. C. Symptoms of Chronic Obstructive Pulmonary Disease COPD is often referred to as a set of progressive lung disorders marked by impaired airflow, alongside persistent breathing difficulties, arising from both emphysema and chronic bronchitis. When chronic bronchitis irritates the bronchial tubes (the airway that carries air to and from our lungs), swelling occurs and contributes to excess mucus production. The accumulation of mucus narrows the opening of the tubes, making it a stumbling block of a proper breathing activity since airflow is obstructed to pass though our body. Small, hair-like structures, namely cilia, would beat to sweep the mucus alongside bacteria out of the airways as a rule. Lamentably, the constant irritation of chronic bronchitis leaves the cilia an undesirable condition. With impaired cilia, mucus is not effectively cleared, blocking the bronchial tubes and aggravating breathing issues. It is of substantial importance for the air sacs to transport carbon dioxide and oxygen into and out of our body for human survival. Under normal circumstances, the alveoli expand and contract, facilitating the diffusion of gasses. However, a person diagnosed with Emphysema experiences the disintegration of the alveolar septa, compromising the elasticity of air sacs and impaired gas exchange. With the destruction of the walls of air sacs, one’s ability to inhale and exhale fully is hindered. Aside from that, a persistent, chesty cough that does not go away is another common symptom worthy-to-note. The coughing is often accompanied by the production of phlegm or mucus, which usually gets worse in the mornings as the mucus builds up overnight. As COPD progresses, the coughing can become more frequent and severe. The cough may worsen during COPD exacerbations, which are periods when symptoms deteriorate unexpectedly. During these times, the cough may produce more discolored mucus, indicating an infection or inflammation in the lungs. COPD symptoms rarely manifest until extensive lung damage has occurred, and they typically worsen with time, especially if smoking exposure persists. Also, the majority of patients do not exhibit any symptoms until they are in their late 40s or early 50s. Regrettably, during the first stages of COPD, people often post an neglectful attitude towards the disease as the first warning signs are so mild that they are often blamed to old age, for instance, feeling breathless with light exercises like walking down the stairs, or experiencing shortness of breath due to aging problems. As a consequence, a lot of people are unaware that they have fallen victim to COPD. III. Treatments of COPD Thanks to the well-developed healthcare system in Hong Kong, a multitude of effective treatments for COPD is available for the general public. Amidst the abundance of treatment choices, a patient with COPD and their family may find themselves confused due to their incompetent medical knowledge. Puzzled by the medical terminologies, patients and their families may grow weary of the search for the suitable treatment recommended by their doctors and choose to comply with a treatment that they cannot financially afford. Besides, not knowing the process of the procedure may increase patients’ fear thus adopting a negative attitude towards comparing their disease. Therefore, it is hoped that this essay will lessen the public’s concerns about treatments for COPD and will facilitate patients’ understanding of their medical services. In order to help the general public grasp a better picture of the treatment available, each treatment will be scrutinized to explain the advantages and shortcomings. At the end of the essay, an overall best treatment will be recommended. A. An introduction of different treatments A.1 medication treatments A 1.1 Beta2-agonists Beta2-agonists is a medication that is taken in the form of a nasal spray. It relaxes the smooth muscles in the airways that contract to constrict the bronchioles in patients with COPD. Contraction of bronchioles will increase the resistance of lungs thus leading to breathing difficulties or even slump the load on lung muscles. Therefore, it is vital to relax the bronchioles of COPD patients which can increase the circulation of air flow in and out of lungs to improve oxygen exchange and to relieve the overload of lung muscles. All beta2 agonists are available in inhaler form,like metered-dose inhalers. Taking the medication by inhalation will significantly reduce the drug’s side effects. Short-acting antimuscarinic agents (SABA), like SABAs is the short-acting beta2 agonists can maintain its effect for around 3-6 hours while long-acting antimuscarinic agents (LABA) (Andrea S Melani, 2015). Another beta2 agonist is LABAs which is a more long lasting medication that can last for at least 12 hours. As SABA has quick onset on effect, it is used to relieve bronchial asthma attacks on clinical and to provide an immediate relief for patients. Besides, LABAs are stereotypical used as maintenance therapy. (Anuj K. Agaewal & Avais Raja & Brandon D. Brown. , 2023) Still, there are some side effects of taking this medication. The main side effects of inhaling beta2 agonists include trembling (especially in the hands), nervous tension, headaches, suddenly noticeable heartbeats (palpitation) etc. Side effects like sudden tightening of the airways with some beta2 agonists inhalers are also included but are rare. (NHS, 2022) A 1.2 Tiotropium Tiotropium is a long acting antimuscarinic antagonist which can open the airways in the lungs with dosing once a day. As a cap for dry powder inhalation, adults should intake 18 mcg once daily via the inhaler device.There are two major types of Tiotropium, Spiriva Handihaler and Spiriva Respimat. The recommended dose of Spiriva Handihaler is two inhalations of the powder contents of one Spiriva capsule, once daily with the handihaler device. For administration of Spiriva Handihaler, a Spiriva capsule is placed into the center chamber of the Handihaler device. The Tiotropium formulation is dispersed into the air stream when the patient inhales through the mouthpiece. For Spiriva Respimat, the recommended dose of it is two puffs ,once a day at the same time of day. For administration of Spiriva Respimat, the Spiriva Respimat cartridge should be inserted into the Spiriva Respimat inhaler to prepare the inhaler for first use. The Spiriva Respimat inhaler releases a mist of solution slowly and gently. The mist containing the medication is released by pressing the dose release button. However, there is still some adverse drug reaction. The most commonly reported adverse drug reaction was dry mouth. Dry mouth was usually mild and often resolved during continued treatment. Other reactions reported in individual patients and consistent with possible anticholinergic effects included pharyngitis, sinusitis, headache, constipation, depression, insomnia, and arthralgia. (Boehringer Ingelheim Pharmaceuticals, Inc.) A.2 Therapy treatments A 2.1 Oxygen therapy Oxygen therapy is a therapy treatment for hypoxemia caused by COPD. When the air sacs are exposed to irritation, it triggers an inflammatory reaction. The inflammatory reaction attracts various immune cells and they will release inflammatory chemicals.It will break down structural proteins in the connective tissue layer which give the tissue elasticity.The loss of elastin can make the lungs more compliant and lead to a breakdown of the septa. This causes a decrease of surface area that is available for gas exchange and the level of oxygen in the blood decreases which is called hypoxemia and it can cause many detrimental long-term effects, such as pulmonary hypertension and right ventricular failure. In Hong Kong, after the assessment by doctor and therapist ,patients with severe hypoxia will set up an oxygen concentrator at home. Compared with other oxygen supply devices, although the oxygen concentrator is larger, it is simple to use and does not require refill oxygen.Therefore, it is suitable for patients to use at home. Portable Oxygen Cylinders are usually prescribed together with stationary oxygen concentrators. (Medical Device DivisionDepartment of HealthRevised,2020) Portable Oxygen Concentrator is more convenient for carrying than other oxygen supply devices. However, it has a higher cost than that. Patients may not be able to afford it. 2.2 Pulmonary rehabilitation Pulmonary rehabilitation is a medical programme that helps patients with COPD breathe easier. It is usually a series of 2 to 3 weekly sessions lasting weeks or months. (National Heart, Lung, and Blood Institute, 2022) The rehabilitation includes breathing exercises like pursed lips breathing, yoga breathing and more. A six-minute walk test is usually conducted to measure how long a patient can walk for six minutes. Techniques to conserve energy in daily life are also taught. (Cleveland Clinic, 2024) Pulmonary rehabilitation has been shown to help patients gain strength,reduce symptoms of anxiety or depression and fatigue. Patients can easily conduct pulmonary rehabilitation exercises at home with resources from the Hong Kong government. (Hospital Authority) The success rate for pulmonary rehabilitation is 62% high. (Scott AS, Baltzan MA, Fox J, Wolkove N, 2010) Although pulmonary rehabilitation is cost effective and can easily be done, its effect may only serve to mildly relieve symptoms of COPD as it does not solve the root issue. In rare cases, unmonitored physical activities in the program can cause bone and muscle injuries. Most importantly, the rehabilitation program demands consistency and determination. A.3 Surgical treatments A 3.1 Bullectomy A bullectomy is a minimally invasive surgery that involves the surgical removal of bullae, which is a large pocket of air formed by stretching of the damaged alveolar walls, the epithelium of air sacs. Emphysema, a type of COPD, causes the breaking down of the alveolar walls. The damaged alveolar walls will stretch and form air-filled spaces in the lung called bullae. Having large obstructions in the airways, bullae can cause difficulties in exchanging oxygen and carbon dioxide during inhalation and exhalation in the alveoli,air sacs, as air can not move smoothly due to the obstructions. (Cleveland Clinic, 2023) This can cause difficulties in obtaining a regular amount of oxygen and expelling carbon dioxide in the lungs. Causing low levels of oxygen in blood (hypoxemia). In severe cases bullae can release air causing pneumothorax, the collapse of lungs. After the removal of bullae, patients may have less difficulty breathing as oxygen can get into the blood through the lungs better. A bullectomy is most suitable for young people with large bullae that are concentrated in one area. The procedure has a mortality rate of 7.3%. (Palla A, Desideri M, Rossi G, Bardi G, Mazzantini D, Mussi A, Giuntini C, 2005). A bullectomy is a treatment for COPD whose effects are more long-lasting and is suitable for patients with fatal bullae. However, a bullectomy generally requires a recovery time of about four weeks. Even though a bullectomy is a minimally invasive surgery, it still carries risks including excessive bleeding and infection. Not to mention the cost of a surgery. A minimally invasive surgery costs about HKD 59k - 72k. (Hospital Authority, 2024) A 3.2 Lung Volume Reduction Surgery (LVRS) Lung Volume Reduction Surgery is a surgical procedure that removes the damaged lungs to allow the inhaled air only to reach the healthy parts of the lungs. This means that more oxygen can reach the bloodstream as the inhaled air with more oxygen will not be trapped in the damaged part of the lungs. After the surgery, the patient can breathe more efficiently and his quality of life will be improved. In the lungs of a patient with COPD, hypertrophy (thickening of smooth muscle layers around the airway) and hypoplasia (increased cell production in lung tissues) will occur.(Cleveland Clinic, 2024) Other than that, due to the exposure of chemicals and irritants from smoking, the mucus production in bronchioles will increase and cilla will be shortened. All of this results in the obstructed and narrow bronchioles which eventually lead to air trapping. Air trapping is the condition where air cannot be fully exhaled in the lungs. With this, inhalation becomes inefficient as inhaled air may reach the damaged parts of lungs. The damaged parts of lungs cannot absorb oxygen as well as the healthy part of lungs. With this surgery, inhaled air reaches the healthy part of lungs thus allowing more oxygen to enter the bloodstream. After the surgery, patients are expected to have a better quality of life, improved lung function and improved ability to exercise. However, surgery comes with risks. Patients may risk having pneumothorax (a collapsed lung), air leaking along a suture line and more. LVRS carries a mortality rate of 3%-5%. (American Lung Association)​​A lung reduction surgery costs around HKD 72,050 - 88,300. (Hospital Authority) 3.3 Lung Transplant A lung transplant is a surgical procedure that replaces a diseased lung with a healthy lung from a deceased donor. When other treatment options are exhausted, a lung transplant may be considered. In the lungs of a patient with COPD, the air sacs have lost their elasticity causing air to be trapped. The bronchioles are constricted by the build up of tissues and mucus. (​​Saetta M, Turato G, Maestrelli P, Mapp CE, Fabbri LM, 2001) Other than this, the septa,the alveolar walls, may break down, decreasing the surface area for oxygen to enter the bloodstream. Overall, this may cause difficulty breathing due to air trapping, hypoxemia and more. In severe cases, patients may need to rely on a mechanical ventilator. A lung transplant can increase the patient’s life expectancy from 4 to 6 years. Besides, patients’ quality of life will be greatly better as the lung’s function will be restored. Patients may enjoy a normal life because of the reduced need for supplemental oxygen. However, donor lungs are scarce because of an ongoing donor shortage. Only two pairs of lungs were donated in Hong Kong in 2023. The highest number of lungs donated in Hong Kong is 13 in 2015 and 2021. However, the number of people who are waiting for lungs is 21 as of August 2024. (Department of Health, 2022). The cost of a lung transplant is around 110,600 - 471,700. The success rate of a lung transplant is 50-60%. Therefore, the chances of a successful lung transplant is very scarce. A.4 Quit smoking Quitting smoking is a treatment recommended by most doctors when the patient’s cause of COPD stems from chemicals from cigarette smoke. As smoking is the leading cause of COPD, quitting smoking can greatly alleviate the symptoms of COPD or avoid the condition of patients with COPD from worsening. When patients stop being exposed to chemicals in cigarette smoke, it has been shown that symptoms of COPD will decrease greatly. Owing to smoking being the trigger for a majority of people suffering from lung diseases like COPD.(MedlinePlus, 2023) Gas mixture generated by smoking is proved to contain about 4500 components, for instance, carbon monoxide, nicotine, oxidants which most of them are harmful to our health. These components were considered as the principal factor driving the pathogenesis of COPD or even lung cancer. When exposed to cigarette smoke in the long-term, the lung barrier arouses protective responses and DNA repair will occur to restrain these changes which are the faults leading to the progression of COPD. (Biomed Res Int, 2019) Nonetheless, quitting smoking is an effective way to lower the risk of COPD and it is totally free which only needs determination. It is the best way to protect everyone either the smoker itself or people breathing secondhand smoke (SHS). According to the results of the studies, SHS exposure was associated with an increased risk of COPD, especially in women or individuals with a long exposure. Thereby, here are some ways to quit smoking like medicines, nicotine replacement therapy and having stop-smoking classes. (Mount Sinai, 2023) The above indicates that no matter first-hand smoke or secondhand smoke are harmful to us and will higher the risk of getting COPD. Thus, the best thing to do to protect your lungs and keep your COPD symptoms from getting worse is to quit smoking. B. Comparison between different treatments The following are the treatments which are premier treatments after comparing in different aspects to strike a balance between the cost and effects. Nevertheless, it is reminded that these are just suggestions and patients need to make a suitable decision based on their actual situation according to the doctor’s instructions. B1. In odds of succession B1.1 Medication Treatments In the two medication therapy for COPD proposed, Beta2-agonists and Tiotropium, they both have different benefits and drawbacks in different situations. However, Beta-2 Agonists have both short acting drugs like Ventolin Inhaler and long acting drugs like Serevent Inhaler which can get a higher odds of succession due to it being generic. B1.2 Therapy Treatments In the two therapy treatments proposed, oxygen therapy and pulmonary rehabilitation, they both serve different patients with different severity of COPD. However, pulmonary rehabilitation is considered to have a higher odds of succession due to its flexibility for patients. Patients, no matter their stage of COPD, can enjoy the benefits of pulmonary therapy. B1.3 Surgical Treatments In the three surgical treatments for COPD proposed in this essay, lung volume reduction surgery carries the lowest mortality rate which is 3-5%. While a bullectomy and a lung transplant carries a mortality and success rate of 7.3% and 50-60% respectively. B2. In fees B2.1 Medication Treatment Beta2 Agonist (SABA) — ventolin inhaler(Salbutamol) (100mcg) $40 B2.2 Therapy Treatments Although the two therapy treatments, oxygen therapy and pulmonary rehabilitation, are meant for COPD patients in different stages, pulmonary rehabilitation is more cost-efficient. As breathing exercises can simply be conducted at home. B2.3 Surgical Treatments In the three surgical treatments for COPD proposed in this essay, bullectomy costs the least at HKD 59k - 72k. While a lung volume reduction surgery and lung transplant costs around HKD 72k - 88k and 110k- 471k. B3. In avaliability B3.1 Medication Treatment B3.2 Therapy Treatments As a result of the sophisticated healthcare system of Hong Kong, both therapy treatments, oxygen therapy and pulmonary rehabilitation are widely available to the public. Other than that the Hong Kong government provides subsidies for patients to rent oxygen concentrators. Free pulmonary rehabilitation exercises are also available on the Hospital Authority website. B3.3 Surgical Treatments Among the three surgical procedures, bullectomy, LVRS and lung transplant. Lung transplant is the least available. As the number of lungs donated each year is gravely scarce. The number of lungs donated in 2023 is only 2. Moreover, the highest pairs of lungs donated in Hong Kong in a year is only 13 in 2015 and 2021. IV. Conclusion There are several treatments to ease or even completely cure COPD, but they usually require a high cost and their success rate is not 100%. Therefore, it is highly recommended that quitting smoking is the most effective way to mitigate COPD or prevent suffering from it. Not to mention, COPD is not the only disease which is led by smoking. This implies that the drawbacks of smoking outweigh the benefits which influence our respiratory system. As a result, please quit smoking for the sake of your lungs.