Chronic Obstructive Pulmonary Disease (COPD)

Overview

What Is It?

Chronic obstructive pulmonary disease (COPD) is a lung disorder that typically occurs in older adults with a history of smoking.

Chronic obstructive pulmonary disease (COPD) is a lung disorder that typically occurs in older adults with a history of smoking. It kills one person every four minutes in the United States and is one of the few causes of death that continues to increase. Today, more women than men have COPD, with an estimated 7 million women diagnosed with the disease. The prevalence of COPD is increasing among women while decreasing among men. Plus, more women than men die every year from the disease.

When you have COPD, your airways and the tiny air sacs in the lung (alveoli) are damaged by smoking or other inhaled particles and gases, which cause swelling, or inflammation. Eventually, this damages the lungs making it hard to breathe in and out and difficult for oxygen and carbon dioxide to pass through the air sacs.

Chronic obstructive pulmonary disease used to be described as chronic bronchitis or emphysema, but today we know that both conditions are forms of COPD. Asthma is a separate condition that also involves airflow limitation but affects people of all ages, while COPD typically affects those 40 and older. In addition, breathing issues in asthma can often be resolved with bronchodilator medication, while the airways with COPD may be only partially opened with medication.

It is possible, however, to have emphysema, bronchitis and asthma all at the same time.

According to the American Lung Association, an estimated 11 million Americans have been diagnosed with COPD, and an additional 24 million may have the disease and not know it.

Although the primary cause of COPD is cigarette smoking, about 20 percent of those diagnosed—one out of six people with the disease—have never smoked. Instead, they developed the condition from environmental exposures such as air pollution or work-related fumes, exhaust or dust. Other possible causes include low birth weight, fetal developmental issues, early childhood infections and genetic factors. Further, a genetic condition known as alpha-1 antitrypsin, or AAT deficiency has been linked to COPD.

Diagnosis

It is important that you get diagnosed as early in the disease as possible. While there is no cure for COPD, early and long-term treatment may improve symptoms, help you breathe better and reduce the risk of exacerbations (sudden worsening of your symptoms).

Unfortunately, studies find that doctors are not very good at diagnosing COPD in women because they have long considered it a "man's disease." If you think you might have COPD, ask your health care professional to test your lung function with spirometry.

Symptoms of COPD may include shortness of breath, particularly in the morning but eventually throughout the day. You may also have a cough and mucus production. Over time, your symptoms may worsen, particularly when exercising or climbing stairs, for example. You may notice that you've cut back on certain activities, because they make you too tired or cause shortness of breath or chest tightness. As the disease gets worse, these symptoms occur even when you're resting. Other symptoms may include fatigue and morning headaches.

COPD is marked by hyperinflation of the lungs, meaning you can't exhale all the air you've inhaled, so your lungs remain inflated like a balloon. This also interferes with how much air you can inhale, leading to the shortness of breath that is a primary symptom of the disease.

To diagnose COPD, your doctor will take a complete medical history and listen carefully to your lungs before ordering certain tests. These may include:

• Spirometry. This simple test uses a spirometer, which is a machine that checks how well your lungs function and displays the results on a graph. It measures two things:
  • Forced vital capacity (FVC), how much air you can exhale after taking in a deep breath.
  • Forced expiratory volume (FEV1), how much air you can exhale in one second.
  Your doctor will read the results, assess how well your lungs are working and determine if you have COPD. You are typically diagnosed with COPD if you have an FEV1/FVC ratio less than 70 percent and an FEV1 less than 80 percent of what would be "predicted" based on your age, gender, weight and other parameters.
  
  Spirometry is used not only to confirm your diagnosis, but also to track the progression of your disease over time.
• Other pulmonary tests. You may undergo other pulmonary tests, including one that measures your lung volume, and oximetry, in which a small sensor is clipped to your finger to measure the oxygen level in your blood.
• X-ray. Your doctor may order an X-ray to examine your lungs. However, X-rays are not very good at detecting COPD, so if your doctor does order one, ask why.
• CT scan. Although not required for a diagnosis, your doctor may order a CT scan, particularly to see if you have emphysema.
• Arterial blood gases. This test measures the amount of oxygen and carbon dioxide in your blood, as well as the acidity (pH) of your blood. As your COPD worsens, carbon dioxide builds up because you have a hard time exhaling.

Once you are diagnosed, your doctor will classify your disease into one of four grades: mild (GOLD 1), moderate (GOLD 2), severe (GOLD 3), very severe (GOLD 4). The grade helps determine the best treatment regimen.

Exacerbations. Exacerbations are periodic flare-ups of COPD symptoms, such as cough, mucus production and shortness of breath. Although they tend to occur more frequently in patients with more severe disease, they can occur at any stage of the disease. They are marked by increased shortness of breath, greater difficulty trying to breathe out and higher levels of carbon dioxide because of reduced lung function. They typically lead to a change in your medication and may require hospitalization. A major goal of treatment is to reduce the risk of exacerbations.

Comorbidities. COPD doesn't just affect your lungs. The inflammation that accompanies the disease, coupled with the chronic, or long-term, oxygen deficiency, can contribute to numerous health problems that are more prevalent in people with COPD than in those without the disease. Among them are:

• depression
• diabetes
• heart disease
• high blood pressure
• infections
• lung cancer
• osteoporosis

Two of the most common comorbidities are depression, which affects up to 40 percent of those with COPD, and osteoporosis, which is significantly more common in those with COPD than in those without it. One 2014 study found that 67 percent of those with COPD had osteoporosis.

Treatment

The goals of treating COPD are to reduce your symptoms and risk of exacerbations, and improve your overall health and exercise tolerance.

COPD is treated with a combination of medication and nonmedical approaches. An important part of managing COPD, however, includes a good relationship and open communication with your doctor, and following your doctor's instructions.

Nonmedical treatments

• Smoking cessation. If you smoke, you must stop. Continuing to smoke will increase damage to your lungs and worsen your symptoms. Your best chance at success in quitting smoking is to enlist the help of your doctor and to find a support system, either in person, by phone or online. You may also need medication or a nicotine replacement product, like gum or a patch.
  
  You may experience some nicotine withdrawal symptoms, because nicotine can be quite addictive. These include sleeplessness, irritability, dizziness, headaches, increased appetite and weight gain. Be patient; symptoms usually peak within two to three days and disappear between a few days to several weeks after quitting.
• Pulmonary rehabilitation. This includes exercises to strengthen the muscles that help you breathe (your diaphragm), as well as regular exercise, such as walking. If there is no formal pulmonary rehabilitation program near you, you should try to walk at least 20 minutes a day or until you feel any breathlessness or other symptoms. Studies find that pulmonary rehabilitation programs can improve your ability to exercise, reduce shortness of breath, improve your quality of life and reduce the amount of medical services you use.
• Nutrition. About a third of people with severe COPD aren't able to eat enough and develop malnutrition. This may make your COPD worse and increase your risk of death. Talk to your doctor about whether you should take high-calorie nutritional supplements and, if needed, appetite stimulants. You also might consider:
  
  • Eating small, frequent meals with high-protein foods that are easy to fix, such as hard-boiled eggs, peanut butter, chicken breasts, cubes of cheese, cottage cheese and yogurt.
  • Resting before meals.
  • Taking vitamins (check with your doctor on the best options).
• Education. The more you know about your COPD, the better you may be able to manage it. It is important that you understand what triggers exacerbations, what medications you need and how to use them, how to reduce shortness of breath and how to recognize and treat complications. Education allows you to take a larger role in managing your COPD.

Types of Medications

Several types of medication are used to treat COPD symptoms. In some instances, you may be placed on more than one medication to control your symptoms.

The most commonly used medications are:

Bronchodilators. Bronchodilators work by relaxing your airways so you can breathe easier. They improve both lung function (which spirometry measures) and symptoms, can increase your exercise ability and can improve airflow. They may also reduce your risk of exacerbations and hospitalization.

This is important because the more exacerbations you have, the higher your risk of future exacerbations. They may also hasten disease progression, leading to worse lung function more quickly. Thus, bronchodilators are a standard type of COPD treatment. All are inhaled, although they may be delivered via different types of inhalers. Long-acting bronchodilators are convenient and more effective at maintaining symptom relief than short-acting therapies.

Inhaled glucocorticoids (also known as inhaled corticosteroids, or ICS)

These drugs may help reduce inflammation from COPD and may reduce exacerbations. They are never used as solo therapy for COPD and are always prescribed in conjunction with a long-acting bronchodilator, sometimes two, in people with more severe COPD, significant symptoms or repeated exacerbations. They are used to treat asthma. Potential side effects of ICS include thrush, hoarse voice and bruising.

Phosphodiesterase-4 (PDE-4) inhibitor

This class of drug reduces inflammation and may increase airway relaxation. Roflumilast, a type of PDE-4 inhibitor, may be used to reduce exacerbations for those with severe or very severe COPD. PDE-4 inhibitors have more adverse effects than inhaled medications for COPD and aren't recommended for people who are underweight. Caution is advised for use in people with depression.

Inhalers. Most medications for COPD are delivered via inhalers.
There are four main types of inhalers:

• Metered dose inhaler (MDI). With these inhalers, you insert an aerosol canister of medication at the end of a small tube, press down on the canister and breathe in deeply. MDI requires coordination between your hand and breath, and you must be able to take a deep breath. There are breath-activated MDIs, which are triggered when you breathe in and may be easier to use.
• Dry powder inhaler. With these inhalers, you insert a specific dose of the medication into the device, put the mouthpiece between your lips and breathe in deeply. They are portable and easy to use, but any exposure to moisture can ruin the medicine because it's a dry powder. You also have to be able to breathe in deeply to get the right dose of medicine.
• Nebulizer. With a nebulizer, the medicine is automatically sent through a mouthpiece. You breathe in through the mouthpiece to get the medicine into your lungs, and out through your nose. For some people, a nebulizer may be the easiest delivery system to use, but it is bulky and requires more time than other types of inhalers.

It is important that you work with your health care professional to find the right inhaler for you and to become comfortable with how it works. If you don't like the one you're using, ask about switching. Many inhalers are very effective, but the key is to find one that works for you and that you can use properly. Things such as your age, eyesight and other medical conditions can all affect your ability to use the medicine. Remember: the medication only works if it gets into your lungs.

Vaccinations. Any kind of lung infection, including a cold, can lead to a COPD exacerbation. You can't prevent all such infections, but you can protect yourself against pneumococcal pneumonia and the flu with vaccines. So make sure you get a flu vaccine every year. If you are 65 or older, or you have COPD, you should consider getting a pneumococcal polysaccharide (pneumonia) vaccine.

Rarely Used Medications

There are other medications that were once frequently used to treat COPD but are now usually only prescribed in limited circumstances. These drugs include: systemic glucorticoids, which are sometimes used for short-term treatment of exacerbations; mucus-thinning agents, which may benefit people with certain COPD symptoms, but are not widely recommended; and antibiotic therapy, which may be used on a short-term basis to treat bacterial infections but is usually not needed long-term if your COPD is well-controlled.

Other Treatments

• Oxygen. As your condition worsens, you may require supplemental oxygen therapy to help you breathe. Long-term oxygen therapy is only recommended for people in the advanced stages of COPD who have low oxygen levels in the blood.
• Surgery. Some people with severe COPD may qualify for surgery.
  • Lung volume reduction surgery. This type of surgery is performed in people with severe hyperinflation of the lung, in which too much air remains in the lungs. The surgeon removes part of your lung to reduce the hyperinflation to improve your lung function. Less invasive therapies that reduce hyperinflation using the bronchoscope—coils and one-way valves—are being studied.
  • Lung transplant surgery. Also reserved for those with the most severe stage of COPD. Although it can reduce your symptoms, there is no evidence that lung transplant prolongs your life.

Prevention

The best way to prevent COPD is to never smoke or stop smoking and avoid secondhand smoke. Also avoid exposure to toxic fumes or gases in your home, environment and workplace.

Facts to Know

1. Chronic obstructive pulmonary disease (COPD) causes one death every four minutes in the United States and is one of the few causes of death that continues to increase.
2. According to the Centers for Disease Control and Prevention (CDC) an estimated 15 million Americans have been diagnosed with COPD. More than 50% of adults with low pulmonary function were not aware that they had COPD; therefore, the actual number may actually be higher.
3. The prevalence of COPD remains higher in women than men, based on 2015 data from the CDC.
4. When you have COPD, your airways and the tiny air sacs in the lung (alveoli) are damaged by smoking or other inhaled particles and gases, which cause swelling, or inflammation. Eventually, this damages the lungs making it hard to breathe in and out and difficult for oxygen and carbon dioxide to pass through the air sacs.
5. Chronic obstructive pulmonary disease used to be described as chronic bronchitis or emphysema, but today we know that both conditions are part of COPD.
6. Although the primary cause of COPD is cigarette smoking, about 20 percent of those diagnosed have never smoked. Instead, they developed the condition from environmental exposure such as air pollution or work-related toxins. Other causes include your genetic makeup, being small at birth and a history of respiratory infections in childhood.
7. Early diagnosis and treatment of COPD is desirable to managing the disease.
8. Symptoms of COPD include shortness of breath, particularly in the morning but eventually throughout the day. You may also cough and have mucus production.
9. COPD is diagnosed with pulmonary function tests like spirometry; sometimes with X-rays or a CT scan.
10. Treatment for COPD includes medications and lifestyle changes, as well as pulmonary rehabilitation.

Questions to Ask

Review the following Questions to Ask about COPD so you're prepared to discuss this important health issue with your health care professional.

1. Why do you think I developed COPD?
2. How would you grade my COPD?
3. What treatment do you recommend? Is that what national guidelines recommend?
4. Would I need to take treatment every day?
5. What side effects might occur with this medication?
6. How do I use the inhaler?
7. What if I can't use an inhaler?
8. What lifestyle changes should I make?
9. Can you help me quit smoking?
10. Can I exercise?
11. How can I prevent exacerbations?
12. Do I need a pneumonia vaccine?
13. Do I need a flu shot?

Key Q&A

Lifestyle Tips

1. Quit smoking.
   If you smoke, you must stop. Continuing to smoke will increase damage to your lungs and worsen your symptoms. Your best chance at success in quitting smoking is to enlist the help of your doctor and to find a support system, either in person, by phone or online. You may need medication or a nicotine replacement product, like gum or a patch.You may experience nicotine withdrawal symptoms, because nicotine can be quite addictive. These include sleeplessness, irritability, dizziness, headaches, increased appetite and weight gain. Be patient; symptoms usually peak within two to three days and disappear between a few days to several weeks after quitting.
2. Avoid exposure to air pollution and other lung irritants.
   This means staying away from anyone who smokes, staying indoors on days when the air quality if poor, avoiding interstates and other areas of high traffic and avoiding exposure to occupational hazards, such as chemical agents and fumes.
3. Exercise every day.
   A good way to get started is with a pulmonary rehabilitation program. This includes exercises to strengthen the muscles that help you breathe, as well as regular exercise, such as walking. If there is no formal pulmonary rehabilitation program near you, try walking at least 20 minutes a day or until you feel any breathlessness or other symptoms. Studies find that pulmonary rehabilitation programs can improve your ability to exercise, reduce shortness of breath, improve your quality of life and reduce the amount of medical services you use.
4. Take your medication as directed.
   If you have any problems taking your medicine, including difficulties with the inhaler or side effects, tell your health care professional. Your doctor can adjust the dose, switch you to a different medication or inhaler and arrange for you to get education on appropriate use of the medication.
5. Develop a partnership with your health care team to manage your COPD.
   Studies find that the better your communication with your health care team, the better you'll do in managing your COPD.

Organizations and Support

For information and support on COPD, please see the recommended organizations, books and Spanish-language resources listed below.

Alpha-1 Association and Foundation
Website: https://www.alpha1.org
3300 Ponce de Leon Blvd.
Coral Gables, Florida 33134
Main: 305-567-9888 Toll Free: 877- 2-CURE-A1 or 877-228-7321
Fax: 305-567-1317
See more at: https://www.alpha1.org/What-is-the-Alpha-1-Foundation/Contact-Us#sthash.IfIEDNOg.dpuf
Email: info@alpha1.org

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)
Website: https://www.aacvpr.org
Address: 330 N. Wabash Ave., Suite 2000
Chicago, IL 60611
Phone: 312-321-5146
Email: aacvpr@aacvpr.org

American Association for Respiratory Care (AARC)
Website: https://www.aarc.org
Address: 9425 N. MacArthur Blvd., Suite 100
Irving, TX 75063
Phone: 972-243-2272
Email: info@aarc.org

American College of Chest Physicians
Website: https://www.chestnet.org
CHEST Global Headquarters
Address: 2595 Patriot Boulevard
Glenview, Illinois 60026
Phone: 224-521-9800 or 800-343-2227 (toll-free in the United States)
Fax: 224-521-9801

American Lung Association
Website: https://www.lung.org
Address: 55 W. Wacker Drive, Suite 1150
Chicago, IL 60601
Phone: 1-800-LUNGUSA or 1-800-548-8252
Email: info@lung.org

American Thoracic Society
Website: https://www.thoracic.org
Address: 25 Broadway
New York, NY 10004
Phone: 212-315-8600
Email: atsinfo@thoracic.org

COPD Foundation
Website: https://www.copdfoundation.org
Address: 20 F Street NW, Suite 200-A
Washington, DC 20001
Phone: 1-866-316-COPD or 1-866-316-2673
Email: info@copdfoundation.org

COPD Learn More, Breathe Better
Website: https://www.nhlbi.nih.gov/health/public/lung/copd/index.htm
Address: NHLBI Health Information Center, Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

International Society for Heart and Lung Transplantation
Website: https://www.ishlt.org
Address: 14673 Midway Road, Suite 200
Addison, Texas 75001
Phone: 972-490-9495
Email: ishlt@ishlt.org

National Heart, Lung and Blood Institute Information Center
Website: https://www.nhlbi.nih.gov
Address: NHLBI Health Information Center, Attention: Website
P.O. Box 30105
Bethesda, MD 20824
Phone: 301-592-8573
Email: nhlbiinfo@nhlbi.nih.gov

National Hospice and Palliative Care Organization
Website: https://www.nhpco.org
Address: 1731 King Street, Suite 100
Alexandria, VA 22314
Phone: 703-837-1500

National Jewish Health
Website: https://www.nationaljewish.org
Address: 1400 Jackson St.
Denver, CO 80206
Hotline: 1-877-225-5654 (Lung Line)

Second Wind Lung Transplant Association, Inc.
Website: https://www.2ndwind.org
Hotline: 1-888-855-9463

Books

Life and Breath
by Neil Schachter, MD

Live Your Life with COPD: 52 Weeks of Health, Happiness and Hope
by Jane M. Martin, BA, LRT, CRT

Spanish-language resources

American Lung Association
Website: https://www.lung.org/espanol/
Address: 55 W. Wacker Drive, Suite 1150
Chicago, IL 60601
Phone: 1-800-LUNGUSA or 1-800-548-8252
Email: info@lung.org

National Jewish Health
Website: https://www.nationaljewish.org/healthinfo/espanol/
Address: 1400 Jackson St.
Denver, CO 80206
Hotline: 1-877-225-5654 (Lung Line)