Chronic Obstructive Pulmonary Disease: Stages and Treatments
Before diagnosis, the doctor will prescribe a dose of at least one short-acting inhaled bronchodilator, a medication that relaxes the muscles in and around your airways, making breathing easier. If symptoms continue, the doctor will use spirometry, a test where an individual blows into a handheld device that records how much air they can blow in and out, in order to confirm the diagnosis.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system is used to classify the stages of COPD. The GOLD classification system can be used to characterize the severity of COPD and, in the past, has been used to formulate treatment plans and determine prognoses for the disease.
Using spirometry, the GOLD stages of COPD are defined by measuring how much air you can exhale from your lungs in one second. The measurement received from this test is known as the forced expiratory volume (FEV1).
Stage I COPD is defined by an FEV1 greater than or equal to 80 percent, which is considered mild obstruction.
At this stage, you may not have any symptoms, or at least not any symptoms that grab your attention. Despite that, there are a couple of signs and symptoms that may be present. These include:
- Cough: The cough can be intermittent to chronic. It can be dry or produce mucus that is clear, white, yellow, or green.
- Shortness of Breath: Also known as dyspnea. In this stage, this symptom is not necessarily evident or with minimal activity.
Stage II COPD is defined by an FEV1 between 50 percent and 80 percent. It is characterized by moderate obstruction.
At this stage, you will probably notice the following symptoms:
- Cough: You will probably notice a chronic cough — often referred to as a “smoker’s cough” — with an increase in mucus.
- Shortness of Breath: You will probably notice this symptom with lower levels of activity, even household chores may become challenging.
- Wheezing: This symptom will most likely be intermittent at this stage, especially when you exercise. When present, you may notice it getting harder to breathe.
- Fatigue: This symptom is minor/low-level at this stage, as your oxygen carrying capacity is being minimally affected.
Stage III COPD is defined by an FEV1 between 30 percent and 49 percent. It is characterized as severe obstruction.
Undoubtedly, all of the aforementioned symptoms will have increased. In addition, the following new symptoms may appear:
- Tightness of the chest;
- Shortness of breath at rest may be apparent, and/or;
- Frequent flares of the disease are more likely.
Stage IV COPD is defined by an FEV1 less than 30 percent and is characterized by very severe obstruction. This stage is often referred to as “end-stage” COPD.
Notable signs and symptoms include:
- Cyanosis: This symptom is characterized by a blue or gray discoloration of the lips and tips of the fingers and toes. It is due to a severe lack of oxygen in the distal extremities.
- Morning Headaches: This symptom is also a consequence of a lack of oxygen in the blood.
- Swelling in the Hands, Legs, and Feet: This symptom is most likely a consequence of declining heart function, which is secondary to the increased stress of pumping blood through the damaged lungs.
End-stage COPD, also known as Stage IV COPD, deserves special mention as it is a stressful time not only for the body but also for the mind. End-stage refers to the fact that this stage represents "the last phase in the course of a progressive disease." As a result, it may be compounded by significant complications.
Many with Stage IV of the disease equate it with imminent death or a period of grave disability before death, which is not always the case. As a result, palliative care becomes a huge part of living with end-stage COPD.
At this stage, everyday activities become very challenging mostly due to breathlessness. Therefore, you may notice your visits to the emergency department and hospitalizations becoming more frequent. Plus, you are more at risk of:
- Respiratory infections, such as pneumonia, colds, flu, and whooping cough;
- Heart problems, including heart attacks, heart failure, and abnormal heartbeats, and;
- Depression and/or anxiety.
Palliative care (also known as hospice care) is an integral part of care for those with end-stage COPD.
A great misconception is that this care is for imminent death. On the contrary, this type of care can be used to improve your quality of life, as its focus is providing you with more effective care.
Your health care team’s main objective is to ease your pain/discomfort and control or ease your symptoms. A personalized treatment plan that encompasses the optimization of your physical and mental well-being will be formulated and executed.
Currently, there is no known cure for COPD. The goals of COPD treatment include controlling symptoms, decreasing the risk of complications and exacerbations, and improving quality of life.
Quitting smoking is the foundation of any COPD treatment plan. Nicotine replacement is a good place to start and is available in the following forms: patches, gums, lozenges, nasal sprays, and inhalers.
Bupropion (Zyban) and varenicline (Chantix) are oral medications that are also commonly used for smoking cessation. Although they do not contain nicotine, they do help with nicotine cravings.
The following classes of medication are used to treat COPD:
- Short-acting bronchodilators, such as Albuterol (Ventolin), levalbuterol (Xopenex), and ipratropium (Atrovent);
- Long-acting bronchodilators, such as tiotropium (Spiriva), salmeterol (Serevent), and formoterol (Foradil);
- Inhaled steroids, including Budesonide (Pulmicort) and fluticasone (Flovent);
- Combination inhalers, such as Formoterol and budesonide (Symbicort) and salmeterol and fluticasone (Advair);
- Oral steroids, such as Prednisone, methylprednisolone (Medrol), and dexamethasone, and;
- Phosphodiesterase-4 inhibitors, such as Roflumilast (Daliresp).
Supplemental oxygen therapy and pulmonary rehabilitation are very helpful for those with moderate to very severe COPD.
Oxygen therapy has the potential to improve your quality of life and is the only therapy for COPD that has been shown to increase survival. On the other hand, pulmonary rehabilitation may decrease hospitalizations, increase participation in everyday activities, and improve quality of life for COPD patients.
As of late, there has been renewed interest in the use of natural, or alternative, treatments for COPD. This includes:
- Dietary Supplements and Herbal Remedies: Supplementation with vitamins C and E, which are antioxidants, may improve lung function in COPD patients. Eucalyptus oil may decrease breathlessness as well as loosen phlegm, which promotes clearance through coughing.
- Yoga: This discipline may reduce inflammation and improve lung function, breathing, and quality of life as well as help with depression, anxiety, and stress.
COPD Management Using GOLD
In the 2016 update of the GOLD guidelines, which not only take into consideration spirometry but also symptoms, the number of flares, and the number of hospitalizations, COPD patients are now classified in the following groups:
- Group A: Low risk and fewer symptoms.
- Group B: Low risk but more symptoms.
- Group C: High risk but fewer symptoms.
- Group D: High risk and more symptoms.
Examples of treatment considerations using this new Goldman group classification include:
- Group A: Short-acting bronchodilator as needed.
- Group B: Short-acting bronchodilator as needed along with long-acting bronchodilator(s) and pulmonary rehabilitation.
- Group C: Short-acting bronchodilator as needed along with long-acting bronchodilator(s), pulmonary rehabilitation, and inhaled glucocorticoids in the case of repeated flares.
- Group D: Short-acting bronchodilator as needed along with long-acting bronchodilator(s), pulmonary rehabilitation, inhaled glucocorticoids (in the case of repeated flares), and long-term oxygen therapy (if criteria met); also consider surgical options such as lung volume reduction surgery and lung transplantation.
Doctors have realized that COPD is not a “one-size-fits-all” disease, as FEV1 doesn’t give a complete picture of COPD. The recent reconsideration and update of the Goldman classification into groups provides a more complete picture of COPD.
With early diagnosis and treatment, people can live for many years, despite it being in the end-stage.
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