Stephanie Fsadni learns that women are more prone to breathing problems than men. Respiratory consultant Josef Micallef explains why they are more predisposed to suffer from asthma, lung cancer and chronic obstructive pulmonary disease (COPD).

Women are more prone to respiratory problems than men due to a number of physiological factors. “A woman on average has a smaller body size and hence a smaller thorax (chest) than a male. This means that females have smaller airways, as well as smaller total lung capacity overall,” says respiratory consultant Josef Micallef.

“This has implications on exercise endurance, which is visibly seen in athletes. Females may report respiratory symptoms earlier than males. Also, they will show more symptoms compared to a male with the same lung condition.”

The most common condition that affects females much more than males is asthma and this is on the increase everywhere, including Malta.

Another condition that is becoming more common is chronic obstructive pulmonary disease (COPD), which closely follows local smoking trends.

“This increase is inevitably linked to the increasing numbers of lung cancer diagnosed in females, particularly the adenocarcinoma subtype,” the consultant says.

There are also rare lung conditions, which are more common in females including pulmonary hypertension and orphan lung diseases.

Not every person with asthma suffers from the same symptoms.Not every person with asthma suffers from the same symptoms.

Asthma

Locally we have a high prevalence of asthma, affecting 10 per cent of the population. Genetic factors play an important role, with asthma affecting various members of the same family.

Smoking, occupation, pollution and other environmental or home allergens contribute significantly to the development of respiratory conditions.

“House dust mite and cockroaches are definitely linked to asthma. Pets including cats, horses, dogs and birds are also potential allergens,” Micallef points out.

He says that certain endemic plants and trees could play a role in triggering asthma attacks and traffic and industrial emissions (particulate matter) do not help.

“I do believe locally wind plays an important role. High wind speeds are common on an island, which will blow allergens into the respiratory tract of the asthmatic causing cough, wheeze and sometimes shortness of breath,” he adds.

Micallef also mentions obesity as another important factor linked to increased asthma. The use of certain medications like aspirin, NSAIDs (anti-inflammatory, painkillers) and beta blockers (used to treat hypertension and heart conditions) are also known to cause asthma.

Asthma onset has no age: it can start in childhood or in adulthood.

“The peaks are in children, then in middle-aged females at around age 50 to 55 years. The prevalence of asthma in adults aged 65 or older is estimated at four to eight per cent of the population worldwide,” Micallef continues.

In the long term, untreated asthma tends to worsen with increasing age. Adult onset asthma, especially in the elderly, is associated with severe asthma, which is sometimes difficult to treat with ‘conventional’ inhalers.

Allergy plays the most important role in all age groups but menopause,diet and obesity may also be implicated.

There is also a small group of patients who suffer from occupational asthma (work-related asthma).

“Locally, carpenters and construction workers are most frequently symptomatic.”

Asthma is a chronic condition and even though common hearsay is that it goes away, facts show otherwise. Many adolescents improve but a good number develop symptoms again in adulthood.

Micallef is “rather concerned” about one particular issue.

“The patient often underestimates asthma severity and, unfortunately, we continue to have yearly deaths everywhere in the world, including Malta. Mortality is higher in females.”

Smoking and lung cancer

The local smoking rate in females is around 15 per cent while that of males is 24 per cent. This means an average below 20 per cent, which is one of the lowest in Europe.

“Smoking has however increased over the years among females. Locally, young females are smoking more compared to previous generations, starting in their teens and continuing into adulthood. They claim to stop during pregnancy but most continue to smoke after,” asserts Micallef.

He says that many females are attracted to ‘lighter cigarettes’ which tend to cause more peripheral lung tumours, especially adeno-carcinoma. This tumour has more than doubled over the past 10 years. This cancer is also more common in passive or second-hand smoking.

The patient often underestimates asthma severity and, unfortunately, we continue to have yearly deaths everywhere in the world, including Malta. Mortality is higher in females

“This reflects and follows the general trend in the Western world. Smoking is considered to be a way of socialising and being trendy. Peer pressure does not help. It is believed that smoking makes one calmer during times of stress, yet it is very addictive. Many females also think it will suppress their appetite to avoid weight gain. However, no one realises at what expense,” laments Micallef.

Second-hand smoke and third-hand smoke are also a risk for lung cancer, which remains the most common cause of cancer-related deaths.

Children are most at risk of second-hand smoke, which refers to exposure to a mixture of gases and fine particles, most commonly cigarettes, cigars and pipes, toxic chemicals in the environment as well as smoke exhaled by smokers. This happens mostly in homes and at the workplace.

“Second-hand smoke is definitely a risk factor for developing lung cancer though it is not as high as smoking, which increases the risk by about 25 per cent,” claims Micallef.

Third-hand smoking refers to residual nicotine and other toxic chemicals that ‘stick’ to surfaces, such as hair, skin, carpets, furniture, toys, etc. Smoking at a window is another contributor.

“Again we know this is harmful and can lead to lung cancer. This has led to an anti-smoking campaign even locally, banning smoking in public places, including Mater Dei Hospital.”

The introduction of e-cigarettes has raised concern among the World Health Organisation and respiratory and cancer societies.

“No one is sure about the potential health risks to e-cigarette smokers as well as those around them. These are likely to be less toxic than conventional cigarettes, but they have been banned in pregnancy.

“We are very concerned that use of e-cigarettes among adolescents might lead to more smoking when they grow older. Definitive studies are needed to assess risk and benefit. This is going to be difficult with about 500 brands and 8,000 flavours on the market.”

COPD

Smoking is the main cause of chronic obstructive pulmonary disease (COPD), a progressive disease which results in the blockage of damaged lung airways. It is the fourth leading cause of death and is on the increase among females.

Women are more breathless in view of smaller airways and decreased lung capacity. Symptoms include cough, daily mucus production and progressive breathlessness. It also leads to recurrent attacks of breathlessness with copious sputum production, which resembles a chest infection.

“COPD affects anyone with a history of smoking usually above the age of 40. Most will just complain they have a ‘smoker’s cough’, however, this disease is progressive. They are initially breathless on exercise, then progressively even on walking and then, finally, most of the time. This reflects progressive lung damage and airway inflammation, which is irreversible,” states Micallef.

Stopping smoking is the only way to prevent COPD. Once the disease is diagnosed, the lungs and breathing will continue to get worse. However, the process is much slower if one stops smoking compared to those who continue to do so.

“Most smokers will admit that smoking is harmful for their health. It is difficult to quit smoking but I believe everyone can do it. One may need professional help to stop and this is easily available.

“I will continue to advise, encourage and support patients to quit at every consultation, as I firmly believe in this. It is never too late to quit.

“I am sure we will all live longer and healthier together in a smoke-free world.”

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