Pregunta general: ¿De qué forma se logra un aprendizaje significativo cuando se integran interacciones positivas entre el docente y sus alumnos dentro de

1.4.1

Undiagnosed, Early and Subclinical COPD

Typically, individuals with COPD present with obvious symptoms of airflow limitation including chronic cough, breathlessness and wheezing. These symptoms are related to the various contributions of airways disease and emphysema that reduce the ability to move air in and out of the lungs and participate in gas exchange. However there are many ex- and current-smokers who experience respiratory symptoms and may or may not have airflow limitation consistent with COPD and never receive treatment for a pulmonary condition. Ex- and current-smokers are most likely to encounter pulmonary function testing or be referred to a respirologist by a primary care provider only when pulmonary symptoms start to alter their exercise capacity and drastically impact their quality of life. A study in the province of Ontario, Canada reported that up to 75% of ex- and current-smokers had impaired lung function consistent with COPD but had not previously sought medical help for respiratory illness; (9) this may have reflected the fact that most of these individuals could still carry-out day-to-day activities. Unfortunately, other studies (48, 49) have recognized that COPD underdiagnosis is common in other countries as well. There are several reasons COPD might go undiagnosed and untreated in the general population. First, since lung function decline is a chronic process, it can take decades before obvious symptoms present. At the same time, many ex- and current- smokers often attribute impaired lung function to normal aging and not an indicator of respiratory illness. Second, certain individuals may be ‘protected’ from being diagnosed with airflow limitation because of anatomical or comorbid conditions that prevent them from performing diagnostic pulmonary function tests (to be discussed in section 1.4.2). Lastly, as was previously mentioned in section1.2.2, the small airways are the major site of airflow obstruction in COPD, but these airways only account for a fraction of overall airway resistance. Given this, it has been speculated that disease processes can occur in the small airways or the ‘silent zones’ over very long timeframes without having a noticeable influence on lung function (16). Therefore it is likely that small airways

disease can accumulate without detection until a critical point is reached and overall lung function starts to decline rapidly.

1.4.2

Airflow Limitation in Obese and Overweight Individuals

Obesity, defined as a body mass index (BMI) greater than 30kg/m2,and being overweight is a biomarker for dyspnea which is one of the major and predominant symptoms of COPD (50). Therefore, breathlessness in overweight individuals might be directly related to their obesity or a manifestation of an underlying and untreated lung condition such as COPD. High BMI is associated with a decrease in functional residual capacity (FRC) and total lung capacity (TLC) due to the increase in adipose tissue in the thoracic trunk of affected individuals (51). The smaller lung capacity combined with increased adipose deposits cause impaired movement of the diaphragm, and reduced chest wall compliance and ultimately both the forced expiratory volume in one second (FEV1) and

forced vital capacity (FVC) decrease. It has also been reported that the decrease in FVC is more severe than FEV1, leading to a subsequent increase in FEV1/FVC in these

individuals (52, 53). Therefore overweight and obese individuals might be ‘protected’ from developing airflow limitation based on the FEV1/FVC ratio due to extrapulmonary

or anatomical impairment (50). As a result, many overweight individuals may go untreated due to the absence of a COPD diagnosis (on spirometry) even though they may experience dyspnea that is attributable to airflow limitation and not solely a symptom associated with being overweight. These individuals may make up a large percentage of people with ‘undiagnosed’ or very early or mild COPD. At the same time, it is difficult to know for sure if the symptoms these subjects experience are secondary only to obesity or directly related to impaired lung function – this is postulated to be the primary reason obese or overweight individuals do not seek further treatment from a respirologist beyond the primary care setting.

1.4.3

Identifying Individuals Susceptible to Developing COPD

The Fletcher and Peto curve (Figure 1–5) that describes the natural history of COPD popularized the concept that both smokers and non-smokers alike, reach and maintain

maximum lung function during the first half of adulthood before lung function starts to decline (54). Fletcher and Peto suggested that while both smokers and non-smokers experience a decline in lung function, smokers decline much more rapidly and develop airflow obstruction due to their rapidly declining trajectory. The concept of rapid declining lung function in smokers has been confirmed more recently but the rate of change in lung function over time is now known to be highly variable (55). Recently, the seminal findings of Fletcher and Peto were extended when it was suggested that there exists another group of individuals who develop COPD aside from ‘rapid decliners’. These individuals attain a low maximal lung function in adulthood and subsequently experience a rate of decline of lung function that is normal (similar to what is observed in non-smokers). This study found that among COPD patients, approximately half experienced a rapid-decline in lung function leading to airflow limitation while the other half reached a low maximal lung function before declining at a normal rate (56). This was an exciting finding because it suggested that lung function at young ages and maximally attained lung function in adulthood might serve as important biomarkers related to the development of COPD.

At the same time, it is clear that identifying which ‘trajectory’ an individual follows may not be enough to identify who will develop COPD. Many ex- and current-smokers have an ‘early’ or subclinical form of COPD that does not satisfy the criteria for a COPD diagnosis based on lung function or pulmonary symptoms. Disease might accumulate ‘silently’ (16) in the small airways (13) of the peripheral lung for many years without any symptomatic or lung function indications making it difficult to identify which trajectory an individual might follow (rapid decliner, normal decliner etc.). The identification of early and subclinical COPD in individuals who smoke or who have smoked has many benefits with respect to treatment planning and lifestyle change recommendations. Concomitant with the objectives of any COPD treatment plan, which are to reduce recurrent respiratory symptoms and prevent exacerbation episodes, the identification of very early forms of the disease can help individuals and their health care team put together a targeted therapy strategy to achieve the most optimal outcome for a certain individual at the onset of disease.

Unfortunately, as discussed in section 1.4.1, many smokers develop respiratory symptoms over the span of several years but may not consider them significant enough to seek help from a primary care provider who could help kickstart a treatment plan. In this way COPD progression may continue for decades before treatment begins at which point it may be in the severe and debilitating stages and be very difficult to manage. Furthermore, as will be described in more detail in section 1.5, conventional and gold- standard pulmonary function tests for assessing lung function and diagnosing COPD do not fully characterize small changes in lung function that might indicate very early or subclinical disease progression. Therefore the combination of very few individuals visiting the primary care setting along with poor characterization of small changes by gold-standard tools for diagnosing COPD makes the identification, treatment and longitudinal monitoring of COPD from the earliest stages extremely difficult in clinical practice.

Figure 1–5. Lung function decline over time in never-smokers, current-smokers

and individuals who quit smoking. Adapted from ‘The Natural History of Chronic

Airflow Obstruction’ (54) and ‘Lung-Function Trajectories Leading to Chronic Obstructive Pulmonary Disease’ (56).

In the next section I will describe the methodology for measuring pulmonary function and diagnosing COPD. An overview of these methods will highlight the inherent drawbacks of these conventional breathing tests for characterizing the early and subclinical forms of COPD – another potential reason the prevalence of unerdiagnosis and undertreatment of COPD is so high.