Courteney MacKuen, MD MPH
Alyson J. McGregor MD MA
Case Overview:
Chronic Obstructive Pulmonary Disease (COPD) includes aspects of emphysema and chronic bronchitis and is a major cause of mortality and morbidity. In 2008 it became the third leading cause of mortality in the United States with an estimated 6.5 percent prevalence. 6 Historically thought as male predominant, this trend has changed and, since 2008, the annual age adjusted prevalence has become significantly higher in women. 6 Despite this, women are under-diagnosed as compared to men presenting with similar symptoms. 3 In addition, women are reported to exhibit differences in the degree of symptom severity, as well as differences in prognosis. 4 It is important for physicians to be aware of the sex differences in this common disease.
Patient Profile:
Name – BH
Age – 53 years
Sex – Female
Medical History:
- Non –Insulin Dependent Diabetes (NIDDM)
- Chronic Obstructive Pulmonary Disease (COPD)
- Hypertension
- Depression
Social History:
- Cigarette smoking (40 pack year history)
- Social Drinker
Prescribed Medication:
- Citalopram 10 mg once a day
- Combivent (Ipratroprium/albuterol) 2 puffs four times a day
- Spiriva (Tiotroprium) 2 puffs once a day
- Lisinopril 10 mg once a day
Presenting Complaint:
BH presented to the Emergency Department with increasing shortness of breath. She has been in her usual state of health until three days ago when she started to have increasing cough. She has also noted that her shortness of breath is much worse when walking short distances. She denies any fevers but endorses an increase in yellow sputum production.
Physical Exam:
Vital signs: Blood Pressure 158/96, Heart Rate 102, Respiratory Rate 25, pO2 91%, Temperature 37 degrees
On exam, BH was alert and in moderate respiratory distress. Her lung exam was significant for diffuse wheezing bilaterally. She became short of breath when she repositioned herself on the bed for the exam. She had no edema in lower extremities, and no Jugular-Venous Distention. She was tachycardic, but her heart sounds were normal with normal S1 and S2 sounds, no murmurs, rubs, or gallops. Her tympanic membranes were clear and no erythema was noted in posterior pharynx. The rest of her exam was unremarkable.
ED Course
BH was placed on supplemental oxygen at 4 L/min by nasal cannula. She was treated with oral prednisone 60 mg and three nebulized albuterol/ipratroprium treatments over one hour. After receiving these interventions she was reevaluated and the pO2 found to be 98% on 4L/min of O2. Chest x-ray showed hyperinflated lungs without evidence of consolidation or infiltrate. Oxygen per nasal cannula was decreased to 2L/min and she maintained a pO2 of 96% saturation. BH was admitted to the hospital. She received smoking cessation counseling and an additional 60 mg of prednisone each day for the next consecutive two days. On day three of hospitalization she had an O2 saturation of 95% on room air with only minimal scattered wheezes, she was discharged with a 10-day course of steroid taper.
Discussion
Differences in Development of COPD. There is a considerable body of literature to determine the differing effects of smoking in men compared to women. Several large studies have shown that women who smoke are more susceptible to COPD with equivalent pack-years to men.5,15 However, other studies have shown no difference between genders with respect to the effect of smoking on lung disease. 1,14 Approximately 20% of patients who develop COPD are non-smokers, with the majority of these being women.3 This suggests that women’s lungs may be more susceptible to causative factors of COPD. 3 One theory postulated by many is that women have smaller caliber peripheral airways making them more susceptible to airflow obstruction. 9 In a large study of both men and women with COPD, pulmonary histology of peripheral airways found women to have smaller airway lumens with disproportionally thicker walls. 10
Differences in Diagnosing COPD. Not only do differences exist in the development of COPD, but there is also evidence that women are less likely than men to be diagnosed with COPD. In a study in which primary care physicians were given identical presentations of COPD in men and women, men were diagnosed significantly more often than women. 3 In addition, the use of spirometry (a quantitative diagnostic tool) is speculated to more accurately diagnose women.2,8
Difference in symptoms. Differences are seen in self-reported symptoms between men and women. Women report more dyspnea compared to men despite similar results on spirometry. 9,10,13 In addition to more dyspnea, women had a difference in functional status, experiencing shorter walk times, despite similar standard assessments of lung function.13
Differences in outcomes. There is conflicting data on long term outcomes, including mortality, between men and women with COPD. Older studies speculate an increased mortality in women compared to men when presenting to the ED with COPD.12 In contrast, one study comparing women and men with the same level of lung function showed equal mortality rates.11 Yet another study of sex differences in mortality shows that there may actually be a significant protective effect of female sex among those with COPD.13 More recently, Ford et al published a study showing that men’s mortality rate is decreasing while women’s mortality rate is increasing.7
Some of these sex differences may be dependent on the diagnosis. Jordan et al asserts that quantitative diagnosis using spirometry, as opposed to qualitative diagnosis, can erase many of the sex differences noted in COPD. 8
Conclusion
There are significant sex and gender differences in the diagnosis, symptoms and mortality in COPD. Critical areas of consideration are those in symptomatology, with women reporting increased dyspnea. Despite this, there is a trend to under diagnose COPD in women as compared to men. Since COPD represents such a large burden of disease with increased prevalence in women, awareness of these differences by physicians can have a potentially significant impact on future morbidity and mortality.
References
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2. Carlone et al . Health and social impacts of COPD and the problem of under-diagnosis.
Multidiscip Respir Med. 2014 Dec 6;9(1):63
3. Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis
of COPD. Chest. 2001; 119: 1691–5.
4. C. G. Cote,1 K. R. Chapman Diagnosis and treatment considerations for women with COPD. Int J Clin Pract. March 2009, 63, 3, 486–493
5. Chen Y, Horne SL, Dosman JA. Increased susceptibility to lung dysfunction in female smokers. Am Rev Respir Dis. 1991;143:1224–30
6. Ford ES, Croft JB, Mannino DM, Wheaton AG, Zhang X, Giles WH
COPD surveillance–United States, 1999-2011. Chest. 2013 Jul;144(1):284-305
7. Ford ES. Trends in mortality from chronic obstructive pulmonary disease among adults in the United States. Chest. 2014 Nov 20.
8. Jordan RE, Miller MR, Lam KB, Cheng KK, Marsh J, Adab P. Sex, susceptibility to smoking and chronic obstructive pulmonary disease: the effect of different diagnostic criteria. Analysis of the Health Survey for England. Thorax. 2012 Jul;67(7):600-5
9. Langhammer A, Johnsen R, Gulsvik A et al. Sex differences in
lung vulnerability to tobacco smoking. Eur Respir J 2003; 21:
1017–23
10. Martinez Fernando J. Sex Differences in Severe Pulmonary Emphysema.
Am J Respir Crit Care Med. 2007. Vol 176. pp 243–252, 2007
11. Ringbaek T., Seersholm N. and Viskum, K. Standardised mortality rates in females and males with COPD and asthma. Eur Respir J. 2005; 25: 891–895
12. Sunyer J, Anto JM, Mcfarlane D, et al. Sex differences in mortality of people who visited emergency rooms for asthma and chronic obstructive pulmonary disease. Am J
Respir Crit Care Med. 1998; 158: 851–856.
13. de Torres, J.P. et al. Sex differences in mortality in patients with COPD. Eur Respir J. 2009; 33: 528–535
14. Vollmer WM, Enright PL, Pedula KL et al. Race and gender differences in the effects of smoking on lung function. Chest 2000; 117: 764–72.
15. Xu X, Li B, Wang L. Gender difference in smoking effects on adult pulmonary function. Eur Respir J. 1994;7:477–83.
Key Words: Case Study, COPD, In This Case
