COPD: A burning respiratory disorder and its homoeopathic management

Abstract – COPD is a common progressive disorder of airway obstruction (FEV1 < 80% predicted; FEV1/FVC< 0.7) with little or no reversibility. Misbalance of the whole ecological environment, leading to atmospheric pollution and causes several respiratory diseases. Knowledge of past history helps the homoeopaths to know the sick man in a homoeopathic way.  It is also of utmost importance in remedy selection – to potency selection – to judge the susceptibility and as well as for the prognosis of the case.

Keywords –COPD, tobacco smoking, pulmonary function test, susceptibility, homoeopathy

Abbreviation-   COPD – chronic obstructive pulmonary disease, ABG- arterial blood gas, CXR- chest x-ray; ECG–electrocardiogram; RVH-right ventricular hypertrophy, AF-atrial fibrillation, PAH-pulmonary arterial hypertension, ECHO-echocardiogram, COLD- chronic obstructive lung disease, FEFR – forced expiratory flow rate, COAD- chronic obstructive airway disease; COLD – chronic obstructive lung disease, FEV1-forced expiratory volume in 1 sec; FVC-forced vital capacity ;TLC- total lung capacity, RV- residual volume ; DLCO- diffusion capacity for carbon monoxide

INTRODUCTION¹–

• COPD is a preventable and treatable disease characterised by persistent airflow limitation that is usually progressive, and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
• Related diagnosis includes CHRONIC BRONCITIS and EMPHYSEMA.
• The term COPD was introduced to bring together a variety of clinical syndromes associated with destruction of the lung and airflow obstruction.
• The term COAD and COLD are used as synonyms in different parts of the world.
• Prior to 1979, patients with these conditions were often classified in terms of symptoms (chronic bronchitis, chronic asthma). By pathological changes (emphysema) or physiological correlates (pink puffers, blue bloaters)
• COPD is a obstructive pattern respiratory disorder, during an obstruction in airways, there is decrease in expiratory flow which become more pronounced when expiration is more forceful.

PATHOPHYSIOLOGY^1,2,3,4–COPD has both pulmonary and systemic components.

Pulmonary component

Enlargement of mucous-secreting glands and increase in number of goblet cells, accompanied by an inflammatory cell infiltrate, result in increased sputum production leading to chronic bronchitis.

• Emphysema is defined pathologically as dilatation and destruction of the lung tissue distal to the terminal bronchiole.
•  Loss of elastic tissue, inflammation and fibrosis in airway closure , gas trapping, increase in residual volume and dynamic hyperinflation leading to changes in pulmonary and chest wall compliance, ultimately disturbance of ventilation leads to V/Q mismatching and hypoxemia.
• Unopposed action of Proteases and oxidants leading to destruction of alveoli and appearance of emphysema. ( EMPHYSEMA)

Systemic feature

• Muscular weakness reflecting deconditioning and cellular changes in skeletal muscles.
• Increased circulating inflammatory markers.
• Impaired salt and water excretion leading to peripheral oedema.
• Altered fat metabolism contributing to weight loss.
• Increase prevalence of osteoporosis.

ETIOLOGY⁴– Atmospheric pollution leads to Irritation as a result Stimulation of secretion and causes Mucous gland hyperplasia ——— chronic Bronchitis

• TOBACO SMOKING ——- metaplasia of epithelium—— loss of ciliated epithelium —- retention of secretion —— bacterial proliferation —– repeated attacks of acute bronchitis

INVESTIGATION^2,3–

PULMONARY FUNCTION TEST – (Most accurate test)

• OBSTRUCTIVE:
• FEV1, FVC, FEV1/ FVC – DECREASE (CHRONIC CASE)
• FEF rate decreased – Hallmark
• TLC, RV – Normal or Elevated
• DLCO – NORMAL; decrease in Emphysema
• Compliance- unchanged but increased in Emphysema

EXTRA EDGE –

• Best initial test = CXR- Increase AP diameter, air trapping and flat diaphragm
• Plethysmography will show increase RV
• ABG: TYPE II Respiratory failure occurs
• ECG – RVH, AF
• ECHO – RVH, PAH

Diagnostic point² –

• Should be suspected over the age of 40 yrs.
• Cough and associated sputum production usually the 1^st symptom.
• Persistent reduction in FEFR- MOST typical finding.
• Triad – Cough, sputum production and exertional dyspnea

Hallmark – airflow obstruction.

Chronic Bronchitis-

Cough and sputum for at least 3 consecutive months in a year for more than 2 successive years.

• Increase PaC02 and decrease Pa02 (ventilation perfusion inequality)
• CHRONIC COUGH and muco-purulent sputum
• Blue bloaters
• Their respiratory centers are relatively insensitive to C02

Chest X –ray – increased interstitial markings (dirty lungs) (Chronic Bronchitis)

EMPHYSEMA³:

Emphysema is defined pathologically as dilatation  and destruction of the lung tissue distal to the terminal bronchiole.

• CLINICAL FINDING:
• Exertional dyspnoea ; cough rare, mucoid sputum; chest is very quiet
• Inspection: barrel-shaped chest
• Palpation: vocal fremitus diminished
• Pink puffer; tubular heart
• Typical chest findings –percussion- hyper-resonant; fremitus – decrease ; breath sounds – decrease; voice transmission – decrease; adventitutious sound- absent/ wheezing
• Hoover sign +
• Tripod position in COPD is the main decubitus.

NATURAL HISTORY OF COPD³–

The only three interventions that influence the natural history of COPD patients-

1. Cessation of smoking
2. Oxygen therapy chronically hypoxemic patients. If PaO2< 60 mm Hg/ oxygen saturation < 90% / if there are signs of right-sided heart failure / an elevated haematocrit. 3.
3. Lung volume reduction surgery (in selected patients with severe emphysema)

TABLE: GOLD criteria for COPD³ (severity reference)

GOLD Stage	Severity	Symptoms	Spirometry
0	At risk	Chronic cough , sputum	FEV1/FVC< 0.7(N), FEV1>- 80% (N)
I	Mild	With or without chronic cough/ sputum	FEV1/FVC<0.7 and FEV1>- 80%
II	Moderate	Same	FEV1/FVC<0.7 and FEV1 50-80%
III	Severe	Same	FEV1/FVC<0.7 and FEV1 50-80%
IV	Very severe	Same	FEV1/FVC<0.7 and FEV1 30%/ FEV1 <50% predicted with respiratory failure / signs of heart failure.

COMPLICATIONS OF COPD^1,2,3,4 –

• Acute exacerbation
• Polycythemia ( chronic bronchitis)
• Respiratory failure
• Cor pulmonale
• Pneumothorax (ruptured bullae) (In emphysema)
• Pulmonary artery hypertension (In chronic bronchitis)

SURVIVAL PREDICTION³–

BODE stands for – body mass index, airflow obstruction, dyspnoea, exercise capacity

HOMOEOPATHIC APPROACH^{5, 6, 7}:

According to homoeopathic principles it is not the disease that lead to the complications but it is the man whose susceptibility, miasmatic tendencies, constitutions, generalities etc. which will decide that what type of complications will occur in the suffering patients. All the complications are not seen in one patient and not at one time. In different patients, considering different factors, the different complication may occur.

MIASMATIC ANALYSIS-

PSORIC TAINT: Psora itself gives us no physiological change of structure – another miasm must be present in order to procure a physiological change in the structure or shape of a part or organ.

• Cough – dry, teasy, spasmodic and annoying; bronchial.
• Expectoration – scanty, tasteless
• Dyspnoea is often painful in PSORA OR pseudo-psora.
• The dropsies or the anasarcas of the PSORIC or PSEUDO-PSORA are always greater than SYCOTIC – they smother or down the patient before death takes place.

PSEUDO-PSORA- The curves and lines of chest are imperfect, the chest is often narrow, lacking not only width laterally, but in depth anterior-posteriorly,  the subclavicular spaces are hollow, or certain areas sunken or depressed; quite often one lung is larger than the other, or the action of one is accelerated and other lessened.

• They are the poor breathers, they have no desire to take a full respiration, seldom we find them diaphragmatic breathing ——- thus the lung never comes to its fullest expansion —– air cells are not brought into use.
• < on least exposure to cold; Voice coarse and croak-like, constant desire to hawk or clear throat – of viscid, scanty mucus.
• Cough – prolonged,< morning and when pt first lies down in evening; Expectoration purulent, or muco-purulent andin advanced cases, greenish yellow, offensive. Sometimes it smells offensive or it may be bloody.

SYPHILIS- Cough – one or two distinct barks like a dog.

SYPHILITIC –PSORIC- Chest wall narrow, may be more shallow than normal; even the action of the diaphragm is limited. Pumping power is so cramped that they are incapable of supplying sufficient oxygen for the body needs

SYCOSIS- Cough of sycosis has very little expectoration, usually of clear mucus; occasionally ropey and may also be of cottony in nature.

• A great deal of coughing is required to raise it, hence prolonged teasing cough.
• Cough often in early autumn or winter. Often the troubles begin with coryza- much sneezing with profuse watery flow from nose
• Expectoration in summer time usually free but always taking cold in the head on least exposure to cold air or dampness. They cannot as a rule breathe through the nose.
• Fish brine odour characteristic of sycotic taint. ( Roberts)
• Patient, as a rule, is fleshy and puffy, their obesity often lies at the bottom of their dysponea and they are constantly gaining flesh
• Frequently face blue, sycotic and apt to be venous congestion or rather stagnation.

HOMOEOPATHIC THERPEUTICS:

1. Ammonium carbonicum^8,9,10,11– Mucous membranes of the respiratory organs are specially affected. Roughness and hoarseness, with difficulty of speech. Bronchitis of the aged. Copious bronchial secretion, with great difficulty of expectoration and bronchial dilatation. Numerous coarse rattles and yet he experiences no necessity to clear his chest. Cough in the morning or at night, < after eating, talking, in the open air, and on lying down, followed by exhaustion. with slimy sputum and specks of blood and continuing till summer heat prevails, <3 to 4 A.M.
2. Antimonium arsenicosum^8,9– Found useful in emphysema with excessive dyspnea and cough, much mucous secretion. Worse on eating and lying down.
3. Antimonium tartaricum^8,9,10,11– Bronchitis of infants and old people; profuse mucus with feeble expulsive power; rattling of phlegm in chest, with increased irritability to cough; unequal breathing. sudden and alarming symptoms of suffocation, Cough and dysponea better lying on right side.
4. Aralia racemosa^8,9– This is a remedy for asthmatic conditions, with cough aggravated on lying down. Dry wheezing respiration, sense of impending suffocation, and rapidly increasing dyspnea. Spasmodic cough < after first sleep, with tickling in throat.
5. Arsenicum album^8,9,10,11-After suppressed coryza and coexistence of emphysema and cardiac affections. Chronic bronchitis of the aged. Dry cough from more or less extensive emphysema and consecutive pulmonary congestions. Difficulty of breathing continues during the interval upon coughing, and returns periodically, especially at night; aggravation after eating and in the afternoon; emaciation; < about and after midnight, from lying down, from drinking cold water, from mental excitement.
6. Aspidosperma quebracho⁸-The digitalis of the lung. Removes temporary obstruction to the oxidation of the blood by stimulating respiratory centers, increasing oxidation and exertion of carbonic acid. It stimulates the respiratory centers and increases the oxygen in the blood. “Want of breath” during exertion is the guiding symptoms.
7. Blatta orientalis^8,9-Remedy for asthma, especially when associated with bronchitis and phthisis where there in much dyspnea. It is suited specially to corpulent people < in rainy weather. Indicated after arsenic when this is insufficient.
8. Calcarea carbonicum^8,9,10,11– Long continued painless hoarseness. Chronic bronchitis, complicated with emphysema; bronchial dilatation with the characteristic fetid sputa, yellow; cough dry, violent, even spasmodic, with tickling in throat, causing stitching headache, especially evenings, in bed, or during night when sleeping, raising only after great and long efforts scanty,
9. Causticum^8,9,10,11-Morning hoarseness with pain in chest; aphonia. Violent racking cough, especially at night, with pain in the throat and head, but he is obliged to swallow the sputum; sputum comes up apparently with cough, but it cannot be spit out. Greasy taste of the sputa; cough immediately relieved by a cold drink; spurting of urine with the cough.
10. Coccus cacti^8,9,10,11– Constant hawking from enlarge uvula; fatigue of the vocal organs, even after speaking without exertion. Chronic bronchitis, complicated with gravel; cough with expectoration of a large quantity of viscid, albuminous mucus; cough worse when waking in the morning, clear, dry and barking. Regular paroxysms of violent tickling, racking cough, ending in vomiting or raising much clear, ropy mucus.
11. Drosera rotundifolia^8,9,10,11– Bronchitis of old age, in connection with emphysema or bronchiectasis; Cough very deep and hoarse; worse, after midnight; prolonged, periodical fits of rapid, incessant, deep barking or choking cough; yellow expectoration, with bleeding from nose and mouth; retching. Harassing and titillating cough in children- not at all through the day, but commences as soon as the head touches the pillow at night.
12. Grindelia robusta^8,9,10,11-An efficacious remedy for wheezing and oppression in bronchitis patient. Chronic bronchitis and bronchorrhea, with tough white, mucus, expectoration, difficulty to detach, accumulation of mucus in the bronchioles; patient feels that expectoration bring relief. Cough with profuse tenacious expectoration, which relives..
13. Hepar sulphuris^8,9,10,11– a rattling, chocking, moist cough, depending on an organic or catarrhal basis; <towards morning and after eating; fatiguing, hollow cough as soon as he uncovers any part of his body. Weakness and much rattling in chest. Cough with abundant expectoration of mucus. Bronchitis.
14. Hydrastis canadensis⁸-Bronchial catarrh, later stages. Bronchitis in old, with great debility, loss of appetite, cachectic state, great weakness; chronic cough, accompanied by febrile paroxysms evenings and night, and excessive prostration; Hemorrhagic or catarrhal process. Sputa thick, yellow, tenacious expectoration. Feels suffocating when lying on left side.
15. Kalium bichromicum^8,9,10,11-Respiration oppressed; wakens 2 a.m. sensation of choking on lying down. Bronchitis oscillating between acute and torpid inveterate bronchitis, Cough resonant, whistling, with nausea and expectoration of thick mucus; whistling; loud rattling in chest; “stuffing” cough, with pain in chest and expectoration of yellow or yellowish green tough mucus, <in winter or during chilly summers, he must sit up in bed to breath, > by bending forward and bringing up the stringy mucus.
16. Kalium carbonicum^8,9,10,11– Dry, hard cough with stitching pains and dryness of pharynx, dry membrane in the trachea, which cannot be detached; slimy, salty, tenacious expectoration; cough evening and < after 3 a.m., from eating and drinking, Bronchitis, whole chest is very sensitive.
17. Medorrhinum^8,9,11-Much oppression of breathing; afternoon about 5 p.m.; sense of constriction. Dyspnoea; cannot exhale. Cough >lying on face, lying on stomach. Terrible, painful cough, as if larynx would be torn to pieces and as if mucus membrane was torn off, with profuse discharge of viscid greyish mucus, mixed with blood.
18. Natrum sulphuricum^8,9-Dyspnea, during damp weather, must hold chest when coughing. Humid asthma; rattling in chest, at 4 and 5 a.m. cough, with thick ropy, greenish expectoration; gradually >by rest. If he coughs while standing, he feels a sharp stich in left side of chest, with shortness of breath.
19. Phosphorus^8,9,10,11-Subacute attacks of bronchitis in emaciated, cachectic, young overgrown invalids; broncho-pulmonary catarrhs from dilation or fatty degeneration of the heart.. Cough from tickling in throat; worse, cold air, reading, laughing, talking, from going from warm room into cold air. Sputa rusty, blood- colored, or purulent. Worse lying upon left side; in cold room.
20. Psorinum^8,9– Asthma, with dyspnea; worse, sitting up; better, lying down and keeping arms spread wide apart. Dry, hard cough, with great weakness in chest. Feeling of ulceration under sternum. Pain in chest; better, lying down. Cough returns every winter, from suppressed eruption.
21. Sepia officinalis^8,9,10,11-Dry, fatigue cough, apparently coming from stomach. Roughness and soreness of larynx and throat. Hoarseness with coryza. Dyspnea, worse, after sleep; better rapid motion. Cough in morning, with profuse expectoration, tasting salty. Aggravation by cold, damp weather. Amelioration by exertion of body.

REPERTORIAL APPROACH¹²

• S.R. PATHAK ( A CONCISE REPERTORY OF HOMOEOPATHIC MEDICINES)

CHEST – Emphysema: Am-c; Ant-t; Ars; Coca; Grind; Hep; Lach; Lob; Senega

BRONCHITIS: Ant-t; Ars;  Bry; Calc; Dros; Fer-p; Hep; Hyds;  Ip; Lyco; Nat-s; Pho; Pul; Sang; Senec; SIL; Stan; Stic; Sul.

ASTHMA ( BRONCHIAL): Aco ; Amb; Arg-n; ARS; Ars-io; Cup; Ip; Kali-ar; Kali-c; Kali-n; Lach; Lob; Merc-i-r; Nux-v; PUL; Samb; Sil; SPO; Stan; Stram; Sul; Tab; Terb; Thu; Tub; Visc

CONCLUSION: In this era the frequency and tendency of disease like COPD increasing day by day, due to- sensitive mental state,  anxiety, allergic traits, suppressed skin disorder, pollution ,smoking , heredity, effect of urbanisation, etc. The changing pattern of the diseases also we found frequently, but we are believing in symptom similarity, and this is the sole indication of choice of remedy, along with management according to symptoms or condition of the patient.

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About Author:

Dr RUP NANDI, BHMS (HONS.), MD (HOM.); HMO; KASHIPUR BPHC; GOVT OF W.B

Prof. (Dr) Rajat Chatterjee, PhD, MD (Hom.), Principal The Calcutta Homoeopathic Medical College and Hospital

Dr Aditi Paul; BHMS; MD (Hom); Homoeopathic Medical Officer; RAGHUNATHPUR BPHC, GOVT. OF W.B