Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a condition in which there is reduced airflow in the lungs. The disease develops and worsens over time. COPD is not reversible, but therapy can slow its progress, reduce symptoms, and improve quality of life.

Although patients can breathe in normally, changes in the small airways cause the tubes to narrow during expiration, making it hard to breathe out. In many patients with advanced COPD, the small sacs where oxygen and carbon dioxide are exchanged are destroyed, gradually depriving the body of enough oxygen.

COPD is associated with a set of breathing-related symptoms:

  • Being out of breath. At first when doing physical activities, but also at rest as lung function deteriorates.
  • Having a chronic cough.
  • Spitting or coughing mucus (phlegm).
  • Much worse breathing symptoms with anxiety.

The ability to exhale (breathe out) gets worse over time.

The lungs are located in the chest cavity and are responsible for breathing. The alveoli are small sacs where oxygen is exchanged in the lungs.

The two major diseases in the COPD category are emphysema and chronic bronchitis, both of which are covered in this report. Not all people with emphysema or chronic bronchitis have a diagnosis of COPD. There must be an obstructive airway component that cannot be reversed. The third, less common disease, is obstructive bronchiolitis, an inflammatory condition of the small airways. Asthma shares some of the same symptoms of COPD. But it is a very different disease. People can have asthma and COPD at the same time.

  • Inflammation of the bronchial tubes (from smoking and air pollution) causes the production of mucus, which clogs the airways and makes breathing difficult.
  • The mucus is cleared through coughing. Both constant coughing and inflammation can damage the bronchial tubes. The tubes swell and thicken, leaving less room for air flow.

Causes

Cigarette smoking is the most important cause of COPD. Cigarette smoking accounts for about 80% of COPD cases. Other causes, such as genetic syndromes (alpha-1 antitrypsin deficiency), exposure to pollutants such as dust, irritants and vapors, and asthma are also involved in the development of this disease.

People who smoke both tobacco and marijuana face nearly three times the risk of developing COPD compared to nonsmokers, although smoking marijuana alone does not seem to increase the risk. Researchers say there may be a synergistic effect, in which marijuana increases the susceptibility of the airways to the detrimental effects of tobacco smoke.

Breathing in secondhand smoke may also increase the risk for COPD, because the irritants from cigarette smoke get into the lungs.

Symptoms

The hallmark symptom of COPD is shortness of breath that gets worse over time. It is often accompanied by a phlegm-producing cough and episodes of wheezing. Symptoms may vary, however, or others may be present, depending on the disease involved. Many patients have symptoms of both chronic bronchitis and emphysema.

Typically, the first symptoms of emphysema occur in heavy smokers in their mid-50s:

  • The main early symptom is shortness of breath with light physical activity. Coughing is usually minor, and coughs produce little sputum (phlegm).
  • Late, severe symptoms include rapid, labored breathing, and persistent craving for air (air hunger), even during rest or after minimal physical activity.
  • Patients are often very thin (a wasted look called “cachexia”), have pinkish skin, and tend to breathe through pursed lips.
  • Involuntary weight loss and muscle wasting may occur, and can indicate a poor outlook.

Complications

COPD affects more than 6% of people in the United States. It is currently the third most common cause of death in the United States (behind heart disease and cancer), responsible for more than 100,000 deaths each year.

Although COPD has traditionally been considered a man’s disease, an increase in the rate of smoking in women has caused COPD to skyrocket in women. Women with COPD tend to fare worse than men. They are more likely to be hospitalized and to die from COPD. They also have more severe symptoms, greater depression, and a worse quality of life than men.

Women appear to be more susceptible to the effects of smoking and pollution, possibly because of hormones or other genetic differences. The good news is that women who stop smoking get their lung function back more quickly than men.

The leading cause of death from COPD is respiratory failure. However, people with mild-to-moderate COPD also tend to develop cardiovascular disease or lung cancer. This likely occurs from inflammation, which is involved in all three diseases.

Traditionally, doctors have measured the severity of COPD by the amount of air that a person can forcibly exhale in one second (FEV1). This amount decreases as COPD gets worse. However, COPD affects other systems and body parts, which provide clues about the severity of the disease. Many physicians use the BODE index to categorize COPD and predict the patients’ chances of survival. BODE stands for body mass index, degree of airflow obstruction, dyspnea (breathlessness), and exercise capacity as measured in a 6-minute walk test.

Acute exacerbations are episodes that occur when the airways suddenly become blocked and symptoms get worse. These events are associated with inflammation in the airways and are generally triggered by an infection in the airway or throughout the body.

Besides infection, other factors that can trigger an exacerbation of COPD include:

  • Certain medications
  • Exposure to irritants in the air (air pollution)
  • Seasonal changes (hot weather)

Acute exacerbations include the following symptoms:

  • Increased phlegm
  • Thicker and darker phlegm
  • Shortness of breath (this is the most common and distressing acute symptom)

Nearly half of COPD patients report some limitation in daily activities. They may have trouble walking upstairs or carrying even small packages. Breathing becomes hard work. More than half of patients with COPD have difficulty sleeping (insomnia).

Those with COPD are more likely to have anxiety, depression, or another psychiatric disorder than people in the general population. Women with COPD are more susceptible to psychological problems than men.

If people with COPD become anxious or depressed, they may have a poorer outlook than people without emotional problems. Depression and anxiety are associated with an:

  • Increase in the frequency and length of exacerbations, as well as the number of hospitalizations
  • Increased risk of death in both those with stable COPD and in those with uncontrolled disease
  • Poor nutrition and exercise habits
  • Low compliance with medications and other medical care

Low oxygen levels also can impair mental function and short-term memory. Psychological therapy may be particularly helpful for people with COPD.

People with COPD often have poor nutrition. People with chronic bronchitis tend to be obese. People with emphysema tend to be underweight. Loss of weight and muscle mass is linked to a poor outcome in COPD. Good nutrition improves the ability to exercise, which in turn builds muscle strength and lung function. Obese people with COPD who lose weight tend to sleep better.

Over time, COPD causes low levels of oxygen (hypoxia) and high levels of carbon dioxide (hypercapnia) in the body. In order to boost oxygen delivery, the body compensates in a number of ways:

  • Blood vessels in the lung narrow. This leads to high blood pressure in the lungs (pulmonary hypertension).
  • More red blood cells are produced to increase the blood’s ability to carry oxygen.
  • The heart rate increases to pump more blood.
  • The breathing rate increases.

Eventually these activities can lead to very serious and even life-threatening conditions:

  • Abnormally high blood pressure in the lungs can cause a complication called cor pulmonale. The right ventricle of the heart enlarges, eventually leading to heart failure.
  • Chronic bronchitis is associated with a 50% higher risk of death from coronary artery disease, independent of the risks associated with smoking.
  • People with long-term and severe hypoxia and hypercapnia are at risk for acute respiratory failure, which can cause heart rhythm abnormalities or other life-threatening conditions.

Risk Factors

An estimated 64 million people around the world have COPD. In the United States, about 4.9 million people have emphysema, and 9.9 million have chronic bronchitis. Because emphysema and chronic bronchitis so often occur together, it is difficult to determine the number of emphysema patients versus those with chronic bronchitis. Many people, even if their symptoms are severe, regard their condition as a natural part of aging, or blame a lack of fitness, and do not get examined by a health care provider.

The main risk factors for COPD include:

  • Cigarette smoke
  • Age older than 40 years
  • Exposure to occupational dust and chemicals
  • Exposure to smoke from wood or other biomass fires
  • Exposure to indoor air pollution
  • Alpha-1 antitrypsin deficiency

Workers who are exposed for a long time to toxic chemicals (such as silica or cadmium), industrial smoke, dust, or other air pollutants are at increased risk for COPD. Such workers include:

  • Cooks
  • Furnace workers
  • Grain farmers
  • Miners
  • Women who cook over open fires
  • Railroad workers (from exposure to diesel exhaust)

Allergens are allergy-causing particles and organisms such as fungi, molds, and house dust. The connection between allergies, asthma, and COPD is the topic of much debate. Some physicians believe allergies and asthma are the early stages of COPD. Another school of thought says that COPD causes changes to the airways that produce asthma symptoms.

Although the exact connection is not known, people with hyperactive airways due to allergies or asthma are at increased risk for COPD. People with COPD who can control their airway problems with bronchodilators (the medication used in asthma) are less likely to die from COPD.

Diagnostic Tests

Despite the widespread incidence and seriousness of COPD, studies strongly suggest that it is underdiagnosed, especially in women. Some experts recommend that any adult smoker who complains of a daily cough should be screened for COPD. In one study, nearly half of patients over age 60 who regularly smoked had COPD. Anyone who has a chronic cough, increased phlegm production, or breathing difficulty that gets worse over time, should be checked for the disease.

The doctor will request a history that evaluates the patient’s risk factors. Risk factors include:

  • Past and present smoking
  • Exposure to industrial pollutants at work
  • Family history of alpha-1 antitrypsin deficiency
  • Low exercise capacity (such as trouble climbing stairs or difficulty walking for more than a certain distance)
  • History of asthma, allergy, sinusitis, or respiratory infections

Appearance

There are usually no changes in physical appearance in people with mild-to-moderate COPD. In advanced COPD, two classic appearances have been described: “pink puffer” and “blue bloater”. People with emphysema may be wasted and thin, with normal-colored pink skin. Those with chronic bronchitis may have bluish lips and fingers, be obese, and may have swollen feet and legs. Breathing may be rapid and shallow, done through pursed lips, and it may take longer to breathe out.

The person will be asked to cough and produce phlegm, if possible.

Chest Examination 

The physician will next perform a simple examination of the chest area with a stethoscope to listen for:

  • Crepitations or rales, a noise resembling a paper bag being rumpled
  • Reduced or distant breath sounds
  • Signs of pulmonary hypertension
  • Wheezing or gurgling sounds

Other findings may include:

  • Breathlessness when the patient lies flat
  • Increased pressure in the veins

The best tests for diagnosing COPD and seeing how well it responds to treatment are pulmonary function tests. The gold-standard test for people with respiratory symptoms such as shortness of breath is spirometry. Spirometry test  measures the volume and force of air as it is exhaled from the lungs. It measures airway obstruction, it can identify COPD early, and the results are standardized. So they are always consistent. Because it is easy and reliable, spirometry is an effective method to help health professionals diagnose COPD early, when it is most treatable.

Pulse Oximetry Test 

A safe and painless test for measuring oxygen in the blood is called pulse oximetry, which involves placing a probe on the finger or ear lobe. The probe emits two different lights. The amount of each light the blood absorbs is related to how much oxygen the red blood cells carry. However, this test measures only oxygen in the blood and not carbon dioxide. Results should be taken together with other tests to determine the need for medication or oxygen therapy.

Chest X-Rays 

Chest x-rays are often performed. But they are not very useful for detecting early COPD. By the time an x-ray reveals COPD, the patient is already well aware of the condition. However, x-rays can look for tumors, infections, and other lung problems.

Typical signs of COPD on x-ray include the following:

  • Abnormally large amounts of air in the lung.
  • A flattened diaphragm.
  • A smaller heart (if the person has heart failure, the heart becomes enlarged and there may not be signs of over-inflated lungs).
  • Exaggerated lung inflation in upper areas.
  • Larger amounts of air in the lower lungs in people with emphysema related to alpha-1 antitrypsin deficiency.

Chest x-rays are rarely useful for diagnosing chronic bronchitis, although they sometimes show mild scarring and thickened airway walls.

Computed Tomography 

Computed tomography (CT) scans can accurately assess the severity of COPD and may be used to determine the size of the air pockets (bullae) in the lungs. The location of the bullae can have implications for therapy of emphysema.

The American Cancer Society, the American Lung Association, the National Comprehensive Cancer Network, and the U.S. Preventive Services Task Force now recommend that annual low-dose CT screening for lung cancer should be offered to current and former smokers who:

  • Are between the ages of 55 to 80 years
  • Have smoked a total of at least 30 pack years
  • Still smoke or have quit within the past 15 years
  • Have no history of lung cancer

It is important to note that screening CT scans produce many false-positive results. This means that many people have suspicious findings on a CT scan that do not turn out to be cancer after a lung biopsy is done. The CT scan can also detect incidental abnormalities like emphysema.

Treatment

The appropriate medications for COPD depend on its stage of severity, which is determined by the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has proposed a staging strategy that is widely accepted. GOLD categorizes COPD severity as follows:

  • Stage I: Smoker’s cough, little or no shortness of breath, no other symptoms of COPD, FEV1 greater than 80% of predicted.
  • Stage II: Shortness of breath on exertion, sputum-producing cough, some symptoms of COPD, FEV1 50% to 80% of predicted.
  • Stage III: Shortness of breath on mild exertion, FEV1 30% to 50% of predicted.
  • Stage IV: Shortness of breath on mild exertion, right heart failure, bluish skin, nails, and lips (cyanosis), FEV1 less than 30% of predicted.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has proposed a group-based management system in which patients are classified according to the symptoms, GOLD stage, number of exacerbations per year, requirements for hospitalization, and other clinical scales, into 4 groups (ABCD groups) with different treatment recommendations. Quitting smoking, vaccinations (flu and pneumococcal), and physical activity are recommended for all groups. Short-acting bronchodilators may also be used in all groups as needed. Further group recommendations for therapy include:

  • Group A – low risk, less symptoms – Any short-acting bronchodilator may be used as necessary.
  • Group B – low risk, more symptoms – Long-acting bronchodilators, either anticholinergic (antimuscarinic) or beta-adrenergic agonist.
  • Group C – high risk, less symptoms – Inhaled corticosteroids and long-acting anticholinergic (antimuscarinic) alone or long-acting beta-adrenergic agonists, pulmonary rehabilitation.
  • Group D – high risk, more symptoms – Multiple drug therapy and individual management are required, including inhaled corticosteroids and other drugs, long-term oxygen therapy, and pulmonary rehabilitation. Surgical options are considered.

Stopping Smoking 

Stopping smoking is the first and most important step in treating COPD and slowing its progression. Quitting smoking decreases symptoms of breathlessness and cough, as well as the risk for heart disease, likely due to decreased inflammation.

Diet 

Good nutrition is always important. Dietary issues become critical in late COPD, when breathing is difficult. Many people with COPD lose muscle tone and body mass and appear to waste away. This may be due to the extreme effort it takes to breathe, which rapidly consumes calories. Some people find it difficult to stop the effort of breathing long enough to chew food. A nutritionist can find the right foods and design meal plans to help COPD patients be as healthy as possible. There is not strong evidence to support the use of nutritional supplements in patients with COPD.

Medications 

Medications that relax the bronchial muscles and open up the airways are an important part of treating COPD. Opening up the airways is called bronchodilation. Bronchodilators do not change the overall course of the disease. However, these medications help improve breathlessness, the ability to exercise, and quality of life.

There are two common types of bronchodilators used, both of which are almost always prescribed as an inhaler medicine:

  • Anticholinergics
  • Beta-2-agonists

When your symptoms do not occur very often and your COPD is not severe, you may use a bronchodilator medicine only as needed for your symptoms. The effects of the inhaled medicine lasts a few hours. This type of inhaler medicine is called short acting.

As symptoms become more frequent or COPD becomes more severe, inhalers will likely be needed every day. These inhalers are called long-acting drugs and you only need to use them once or twice a day, depending on which one is prescribed. It is important to use these inhalers every day whether or not your symptoms are present.

Inhaled corticosteroids (ICS) may be added to bronchodilator inhalers just described for patients with more severe COPD and more frequent exacerbations. Side effects include oral infections and hoarseness. However, regular use of inhaled corticosteroids for people who experience frequent exacerbations may be tried, as they can decrease their frequency.

Supplemental Oxygen is an important part of COPD therapy. It can:

  • Improve exercise endurance
  • Improve quality of life and mental outlook
  • Improve sleep
  • Reduce breathlessness
  • Reduce pulmonary hypertension
  • Improve survival

Supplemental oxygen affects all of these factors, along with the lungs’ ability to exchange carbon dioxide for oxygen. There is some evidence that supplemental oxygen may also reduce heart problems in people with COPD.

Pulmonary Rehabilitation 

Pulmonary rehabilitation is a proven method of relieving shortness of breath (dyspnea), reducing hospitalizations and disability from COPD, increasing exercise capacity, and improving mental and physical quality of life, although there is no proof that it improves survival. This treatment is recommended for people with stable chronic lung disease who are affected by respiratory symptoms. Although pulmonary rehabilitation doesn’t improve lung function, it strengthens muscles and improves other body systems to minimize the effects of lung dysfunction. While once considered mainly for those with severe disease, it has been shown to be effective in helping people with less severe disease as well.

Many hospitals offer these programs, which are led by a team of health professionals. Pulmonary rehabilitation can also be done in the home or community. The treatment is tailored to individual patients. But it usually includes:

  • Breathing training
  • Disease education
  • Exercise (interval, strength, upper limb, endurance and resistance training)
  • Nutritional advice
  • Psychological assessment

People are usually assessed at the beginning and end of the program. Programs generally last 6 to 12 weeks. But longer programs appear to provide more long-term benefits.

Exercise 

Exercise is important for maintaining strength and endurance, both of which are greatly affected by COPD. Weight-bearing exercises are important for maintaining quality of life and the ability to live independently. For the greatest benefit, programs should combine low- and high-intensity exercise with strength and endurance training. Home-based exercise programs can also help people with COPD. Receiving supplemental oxygen during rehabilitative exercise may improve patients’ endurance. There is no evidence that inspiratory muscle training (training the muscles used to breathe in) is effective during pulmonary rehabilitation.

Surgery 

When a patient no longer responds to medications, surgery becomes a possible option. Choices include:

  • Bullectomy
  • Lung transplantation
  • Lung volume reduction surgery (LVRS)

Treating COPD in Older Adults

Older adults are at greater risk for complications or death from COPD, and their treatment needs to be tailored accordingly. Treatment in this group includes short- and long-acting bronchodilators, vaccines, and quitting smoking.

The goal of COPD treatment, in addition to providing symptom relief, is to prevent exacerbations. Each exacerbation causes lung function to decline. Bringing lung function back to its pre-exacerbation state can take 6 months. When exacerbations are frequent, lung function may never return to normal, and the patient’s condition spirals downward.

Exacerbations are most commonly caused by bacterial or viral infections, or by air pollution. The cause is never identified in about one third of patients.

Treatment of exacerbations commonly includes the following measures:

Oxygen 

Supplemental oxygen with controlled oxygen therapy and noninvasive positive pressure ventilation.

Bronchodilators 

Inhaled anticholinergics or short-acting beta-2-agonists may be used. In this situation nebulized forms are frequently used. Theophylline is not recommended, because it provides very little benefit and carries a risk of serious side effects.

Corticosteroids 

Corticosteroid medications may be given either through a vein (intravenously) or by mouth (orally), for up to 2 weeks. While 14 day treatment is common, a 5 day course may be just as effective in keeping people from having another attack for at least 6 months.

Antibiotics 

These may be used if there are signs of infection, such as fever or yellow or green phlegm.

Pulmonary rehabilitation 

For some people, initiating pulmonary rehabilitation after an acute attack can also be effective in reducing hospitalization and improving symptoms.

Medications

Anticholinergic medications relax the bronchial muscles and open up the airways.

Brands and Benefits 

Anticholinergics used for COPD include short-acting ipratropium (Atrovent) and long-acting such as tiotropium (Spiriva) or umeclidinium (Incruse) or glucopyrrolate (Lonhala and Seebri) and aclidinium (Tudorza). They are considered standard maintenance medications for COPD.

Long-acting anticholinergic medications are also being given along with inhaled corticosteroids and long-acting beta-agonists. Although the combination may not reduce the number of exacerbations, it improves lung function and quality of life, and it reduces hospitalizations. For people who experience frequent symptoms of COPD, current guidelines support long-acting anti-cholinergic or beta-agonist inhaler as primary therapy for COPD, supplemented by regular use of inhaled corticosteroids.

Anticholinergic inhalers are also available as a single inhaler or combined with a beta-agonist.

  • Combivent contains both ipratropium and the common short acting beta-2-agonist albuterol.
  • Anoro Ellipta and Stiolti Respirmat, combined anticholinergic and long-acting beta-2-agonists have been approved for once daily use.
  • Recently a once daily combination of inhaled steroid, anticholinergic, and long-acting-beta-2 agonist has been approved (Trelegy Ellipta).

Side Effects

Anticholinergics have few severe side effects, and they are less likely to interfere with sleep than the other standard inhaled medications. Side effects include mild cough and dry mouth. Anticholinergics should be used cautiously in people with glaucoma or an enlarged prostate. Some studies have linked the long-acting anticholinergic tiotropium with an increased risk for heart problems, but other studies are reassuring. More research is needed.

Beta-2-Agonists

When anticholinergics are no longer enough — and sometimes in place of an anticholinergic medication — health care providers will prescribe a beta-2-agonist. GOLD guidelines recommend that all patients with COPD stages II to IV take a long-acting beta-2-agonist. 

Short-Acting Beta-2-agonists 

For people whose symptoms come and go, such as with exertion, short-acting bronchodilators are recommended. Albuterol (Proventil, Ventolin, ProAir) is the standard short-acting beta-2-agonist. Others include:

  • Fenoterol
  • Levalbuterol hydrochloride (Xopenex)
  • Levalbuterol tartrate (Xopenex HFA)
  • Pirbuterol (Maxair)

There is no evidence that one beta-2-agonist is better than another. Newer beta-2-agonists, including levalbuterol (Xopenex), have more specific actions than the older medications. Most are inhaled and are effective for 3 to 6 hours.

Long-Acting Beta-2-Agonists 

Long-acting bronchodilators are more effective than short-acting bronchodilators for patients with more significant long-term symptoms. Long-acting beta-2-agonists salmeterol (Serevent) and formoterol (Foradil) are proving to be particularly effective as long-term maintenance therapy for COPD. Newer ones include indacaterol (Arcapta) and olodaterol (Striverdi). They reduce exacerbations by 20% to 25%, they may help prevent bacteria from building up on the airways, and they may offer real improvements in lung function. A nebulized formulation of formoterol is also available for the treatment of COPD.

Some inhalers combine a long-acting beta-2-agonist and a corticosteroid (such as Advair, Seretide, Breo, Dulera and Symbicort). Combining a corticosteroid and long-acting beta-2-agonist reduces exacerbations and improves lung function slightly, but it may increase the risk of pneumonia. Large, long-term studies are needed to assess efficacy and safety over time.

Side Effects 

Side effects of both long- and short-acting beta-2-agonists include anxiety, tremor, restlessness, and headaches. People may experience fast and irregular heartbeats. A physician should be notified immediately if such side effects occur, particularly in people with existing heart conditions. Such people face an increased risk of sudden death from heart-related causes. This risk is higher with medications taken by mouth or through nebulizers, but there have also been reports of heart attacks and chest pain (angina) in some people using inhaled beta-2-agonists.

Loss of Effectiveness and Overdose 

All long-acting beta-2-agonists come with a boxed warning about an increased risk of asthma-related deaths, but there is no clear evidence that people who have COPD without asthma are at increased risk.

There has been some concern that short-acting beta-2-agonists may become less effective when taken regularly over time. A major concern is that people who perceive beta-2-agonists as being less effective may overuse them. Overdose can be serious and, in rare cases, even life threatening, particularly in people with heart disease or asthma.

Corticosteroids

Corticosteroids are powerful anti-inflammatory drugs.

Oral Corticosteroids 

Oral corticosteroids are reserved for treating COPD exacerbations, and research finds that they are better than inhaled corticosteroids for this purpose. They speed the time to recovery and reduce the length of the hospital stay, but they do not reduce mortality or affect the long-term progression of the disease. They shouldn’t be regularly used for stable disease because of the increased risk of side effects.

Oral corticosteroids are recommended for the initial treatment of people who are hospitalized for COPD exacerbations, yet research finds that most people are given IV steroids instead.

Inhaled Corticosteroids 

Inhaled corticosteroids (ICS) are the mainstay of asthma therapy. However, their primary use in COPD is to treat exacerbations, rather than for long-term maintenance. Side effects include oral infections and hoarseness.

A review of evidence has shown that both long-acting beta-agonists (LABA) and inhaled corticosteroids (ICS) yield similar benefits for COPD patients when used as individual therapies. However, long-acting beta-agonists are slightly better at improving lung function, and ICS are slightly more effective at improving quality of life, but increase the risk of pneumonia. Therefore, current guidelines support long-acting beta-agonists as primary therapy, supplemented by regular use of corticosteroids for people who experience frequent exacerbations.

Methylxanthines (primarily slow-release theophylline) are also bronchodilators, which relax the airways of the lungs. These drugs are used in people with more severe exacerbations that do not respond completely to corticosteroids, oxygen, or antibiotics.

These drugs do not significantly improve lung function, symptoms, or overall outcomes when used for acute exacerbations. Some experts believe that the modest benefits do not outweigh the risk for toxic side effects from these drugs. Side effects are generally related to the amount of theophylline in the blood. At high doses, side effects can include nausea, anxiety, headaches, insomnia, vomiting, irregular heartbeat, tremors, and seizures.

Many COPD drugs are inhaled using metered dose inhalers, dry powder inhalers, or nebulizers.

Metered-Dose Inhaler 

The standard device for delivering COPD medication is the metered-dose inhaler (MDI). This device allows precise doses to be delivered directly to the lungs. A holding chamber, or spacer, improves delivery by giving the patient more time to inhale the medication.

Breath-Activated Dry Powder Inhalers 

Dry powder inhalers (DPIs) deliver a powdered form of the drug directly into the lungs. DPIs are as effective as MDIs and are easier to manage, especially for older adults. Humidity or extreme temperatures can affect DPI performance, so these devices should not be stored in humid places (such as bathroom cabinets) or in locations with high temperatures (such as car glove compartments during the summer months).

Other Handheld Inhalers 

Respimat delivers a fine-mist spray that is created by forcing the liquid medication through nozzles. It does not use any propellant.

Nebulizers 

A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. Nebulizers are often used in hospitals or when the patient cannot use an inhaler.

This metered-dose inhaler is a quick way of administering medicine directly into the bronchial passageways to promote clearer breathing.

Medicines That Loosen Lung Secretions 

People with persistent coughing and phlegm often use medications that loosen secretions and help move them out of the lungs.

Expectorants 

Expectorants, such as guaifenesin (found in common cough remedies), stimulate the flow of fluid in the airways and help move secretions using the motion of cilia (the hair-like structures in the lung) and coughing. Expectorants have not been shown to benefit people with COPD.

Mucolytics 

Mucolytics contain ingredients that make thick phlegm more watery and easier to cough up. Although mucolytics are not generally recommended for people with COPD, there is some evidence that they may reduce exacerbations by a small amount in some patient with moderate-to-severe COPD who take these medications throughout the winter. The most effective mucolytic is stopping smoking. Anticholinergics appear to decrease the production of mucus. Beta-2-agonists and theophylline improve mucus clearance.

Oxygen-Replacement Therapy 

Lung function may eventually worsen to the point that patients need supplemental oxygen delivered through portable or stationary tanks.

Your doctor will monitor the oxygen levels in your blood. This may be done when resting, when being active, or at night while you sleep.

Continuous Therapy

Continuous oxygen therapy (more than 15 hours a day) for COPD and emphysema has been proven to prolong survival in certain people. It also improves alertness, motor speed, and hand strength. Continuous oxygen therapy is usually recommended for people with:

  • Lung oxygen level below 55 mm Hg (or an arterial oxygen saturation at or below 88%) while resting.
  • Lung oxygen level below 60 mm Hg (or whose arterial blood oxygen saturation is 89%) while resting, plus right heart failure or an abnormal increase in red blood cells.

Pulse oximetry is a method used to measure the oxygen level (or oxygen saturation) in the blood. The device measures oxygen in peripheral tissues (such as the finger, earlobe, or nose) as a general indicator. Oxygen saturation should always be above 95%, although in those with long-standing respiratory disease, it may be lower.

Supplemental oxygen may also benefit patients with moderately low blood oxygen levels, but more research needs to be done to confirm this.

Ideally, people should receive enough oxygen to keep the oxygen level at 65 mm Hg, but no less than 60 mm Hg, or at an oxygen saturation level of at least 90%. People may need extra oxygen flow during sleep or physical activity.

Almost half of people improve enough in 1 month to stop continuous treatment, although these people should be observed closely. COPD often gets worse, and people need to restart oxygen therapy. Some people get worse in spite of treatment, although it is not possible to predict who is at risk for oxygen therapy failure. The addition of nitric oxide, a gas that widens blood vessels, may offer additional benefits.

Intermittent Oxygen

People with less severe COPD who are not on permanent oxygen maintenance may need supplemental oxygen during specific circumstances:

  • People whose oxygen level drops below 55 mm Hg (or an arterial oxygen saturation at or below 88%) only while exercising may benefit from supplemental oxygen during physical activity. Supplemental oxygen may improve endurance, and it enhances the delivery of oxygen to the muscles while they are working.
  • People whose oxygen level drops below 55 mm Hg (or an arterial oxygen saturation at or below 88%) during sleep may need oxygen at night. Such patients usually experience fitful, poor-quality sleep. This type of oxygen therapy does not appear to affect survival or prolong the time until patients need continuous oxygen therapy.

Precautions 

Supplemental oxygen is a fire hazard, and some hotels and residences do not allow its use. No one should smoke near an oxygen tank, and tanks should be stored safely, secured to a wall and away from heaters and furnaces.

Lifestyle Changes

Quitting smoking is the first and most essential step in treating COPD and slowing its progress. In many people who quit early, lung function stabilizes and eventually declines to about the rate of nonsmokers in the same age group. In some people, lung function may even improve slightly after quitting. As COPD progresses, quitting smoking can slow the rate of decline; however, lost lung function is never fully recovered.

Most people who smoke try to quit an average of seven times before they are successful. Using a combination of smoking cessation aids improves the likelihood of quitting. These include nicotine replacement products (such as patches, gum, nasal spray, and lozenges), counseling, and prescription medications such as bupropion (Zyban) and varenicline (Chantix).

Good Hygiene

People should wash their hands with ordinary soap before eating and after going outside the home. Antibacterial soaps add little protection, particularly against viruses.

Vaccines

Two important vaccinations are recommended to protect against respiratory infection.

  • Seasonal influenza vaccination. People with COPD should be vaccinated against influenza each year at least 6 weeks before flu season begins. Flu shots appear to help reduce exacerbations of COPD during flu season.
  • Pneumococcal vaccine. The adult-type pneumococcal vaccine protects against 23 types of pneumococcus, a common cause of pneumonia. Everyone with COPD should have this vaccine at least once. People who had their first shot more than 5 years previously may benefit from a booster vaccine. Adults at high risk should also receive the PVC13 pneumococcal vaccine that was initially approved for children. The vaccine remains effective for years. Flu and pneumococcal vaccines can be given at the same time without increasing side effects.

Pursed-Lip Breathing

A technique called pursed-lip breathing can help improve a patient’s lung function before starting activities or doing a strenuous task, such as heavy lifting. Pursed-lip breathing helps change pressure in the airways and prevents the small airways from collapsing. To use this technique:

  • First, inhale through the nose, moving the abdominal muscles outward so that the diaphragm lowers and the lungs fill with air.
  • Exhale through the mouth with the lips pursed, making a hissing sound.
  • Take twice as long breathing out as you did breathing in, so that there is pressure in the windpipe and chest, and trapped air is forced out.

Holding Breath and Coughing

A simple technique is to inhale deeply and slowly, hold the breath for 5 to 10 seconds, then cough while breathing out.

Breathing exercises have been shown to improve functional exercise capacity and tolerance. The exercises do not seem to reduce other symptoms such as shortness of breath, or improve quality of life.

Fluids and Humidity

People with congestion and heavy phlegm should drink plenty of fluids and keep their homes humidified.

Chest Therapy

Chest therapy involves breathing in rhythmically for three to four deep breaths, then coughing to produce phlegm. Tapping the chest may also help loosen and bring up phlegm in people who produce a lot of it. Avoid chest therapy during an acute exacerbation of COPD.

When coughing to produce mucus, another method is to lean forward and “huff” repeatedly. Take relaxed breaths, and then huff again. Avoid forceful coughing, if possible.

COPD is not simply a lung condition, but a disease that causes wasting of the muscles and bones. So certain physical exercises may be very helpful.

Strengthening Exercises for the Limbs

Exercising and strengthening the muscles in the arms and legs helps some patients improve their endurance and reduce breathlessness. These exercises may also help with everyday activities, like climbing stairs and standing up from a chair. Exercising only one leg at a time (for example, pedaling a stationary bicycle with one leg instead of two) might benefit people who are usually too out-of-breath to exercise, and help them increase their exercise capacity.

Walking

Walking is the best exercise for people with emphysema. In studies of lung rehabilitation, regular exercise increased walking distance and improved breathing. People should try to walk three or four times a day for 5 to 15 minutes each time. Devices that assist with breathing may reduce the breathlessness that occurs during exercise.

Yoga and Eastern Practices

Yoga and tai chi, two practices that use deep breathing and meditation techniques, may be particularly beneficial for COPD patients. Research is underway to determine whether yoga is helpful for COPD patients.

Because many people with chronic bronchitis are obese and many with emphysema are underweight, nutrition assessment is an important part of COPD treatment. Not getting enough of foods that are rich in vitamins A, C, and E, and having a lack of fruits and vegetables can contribute to the development of the disease.

Protein and Fats

People with body wasting (cachexia) lack enough protein. Although most healthy diets emphasize proteins from fish, poultry, and lean meat, these people may benefit from foods with a higher-than-average fat content. (People should still prefer healthy fats, however, such as those found in olive oil and oily fish.)

Fruits, Vegetables, and Whole Grains

Healthy foods are as important for lung function as they are for general health. Specific foods that may be important for healthy lungs are those that contain antioxidants (fresh, deep green and yellow-orange fruits and vegetables), selenium (fish, nuts, red meat, grains, eggs, chicken, liver, and garlic), plant chemicals called flavonoids (apples, onions), and magnesium (green leafy vegetables, nuts, whole grains, milk, and meats). One study found that, compared to a Mediterranean diet, which is high in fruits, vegetables, and whole grains, a Western diet high in red meat and simple carbohydrates increased the risk for COPD fivefold.

Vitamin supplements are not helpful, and they may be very harmful for smokers.

Acupuncture 

A trial of COPD patients showed that acupuncture (along with standard medication) helped reduce shortness of breath on exertion in patients with COPD. More research is necessary to assess acupuncture as a treatment option.

Air Travel 

People with COPD must take extra precautions when traveling by plane. High altitudes may worsen breathing problems and reduce blood oxygen. Air travel can almost always be managed. But additional pre-assessment medical testing, planning, and expense may be required. It is best to discuss the following with your physician before flight travel:

  • Current control of symptoms
  • Previous travel experience
  • Time since the last episode of COPD symptoms

People may need to arrange for some services in advance, such as in-flight oxygen or wheelchairs and they may need to notify the airline of certain medications, ventilators or continuous positive airway pressure (CPAP) machines. COPD patients may consider obtaining a frequent traveler’s medical card (FREMEC).

People with COPD are at high risk for depression and anxiety, which can impair their outlook on life. Depression often gets worse as people with COPD need to limit their activities and social interactions. Psychological counseling and social support are important for helping people improve their emotional state, cope with daily stresses, and maintain their independence and social relationships.

As much as possible, patients should avoid exposure to airborne irritants, including:

  • Aerosol products
  • Hair sprays
  • Insecticides
  • Paint sprayers
  • Smoke from wood fires

To minimize the amount of contaminants in the home:

  • Avoid exposure to pollen, pet dander, house dust, and mold.
  • Eliminate molds and mildew from household water damage.
  • Have furnaces and chimneys inspected and cleaned periodically.
  • Make sure wood-burning stoves or fireplaces are well ventilated and meet the Environmental Protection Agency’s safety standards. Burn only pressed wood products labeled “exterior grade,” because they contain the fewest pollutants.
  • Ventilate by keeping windows open (weather permitting), using exhaust fans for stoves and vents for furnaces, and keeping fireplace flues open.

Surgical Procedures

Surgery, as a last resort, may help some people with very severe COPD. Coverage for such procedures varies among insurance carriers. A major drawback is that people must be in good enough health to undergo major surgery. By the time COPD is advanced, however, this is usually not the case. As a result, surgery cannot help most COPD patients.

The three available surgical options that are appropriate for some people with COPD are lung transplantation, lung-volume reduction surgery, and bullectomy.