Everything You Need to Know About COPD
Table of Contents
Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterized by increasing shortness of breath. COPD affects an estimated 32 million Americans, which makes it the third leading cause of death in this country.
Although asthma is considered by some to be a form of COPD, emphysema and chronic bronchitis are the two most common conditions mentioned under the umbrella of COPD. The most common cause of the disease is smoking, followed by long-term exposure to chemical irritants, and rarely the genetic condition called alpha-1 antitrypsin deficiency.
Signs and Symptoms
The early symptoms of COPD — such as occasional shortness of breath (especially after exertion), occasional cough, and fatigue — are mild and easily ignored. As the disease progresses, you may experience wheezing and chest tightness or chronic cough (sometimes referred to as “smoker’s cough) with or without excess mucus. With the progression of COPD even further, you may notice blue or gray discoloration of your lips or the beds of your fingernails, shortness of breath with little to no activity, frequent colds or respiratory infections, weight loss, and swelling in the ankles, feet, or legs.
These signs and symptoms are much more likely to progress and worsen with ongoing smoking, including exposure to secondhand smoke, or with ongoing occupational exposure to irritant chemicals/pollutants.
Emphysema is characterized by the destruction of the walls of air sacs (also known as alveoli). The destruction leads to air trapping in the lungs, making it harder to breathe.
Clinically, chronic bronchitis is defined as the presence of a chronic productive cough for three months during each of two consecutive years. Of course, the diagnosis of chronic bronchitis is made after excluding other causes of chronic cough. The chronic cough is usually accompanied by excess mucus and narrowing of the airways, making it harder to breathe.
While there are several well-established risk factors for the development of COPD, there is one that is the most significant of them all.
This risk factor is long-term cigarette smoking. In fact, about 90 percent of individuals diagnosed with the disease are smokers or former smokers. In simple terms, the longer you smoke (with consideration of number of packs of cigarettes and years), the greater your risk for COPD. However, only 20 to 30 percent of smokers will develop significant COPD. Smoking pipes, cigars, and even marijuana, as well as chronic exposure to secondhand smoke, may also increase your risk for COPD.
Other risk factors include:
- The combination of asthma and smoking;
- Chronic workplace exposure to volatile or irritant chemicals, dust, or fumes;
- Breathing in fumes from burning fuel for cooking and heating due to a poorly ventilated living situation, and;
- Being over the age of 40.
Finally, genetics can play a role in the development of COPD, as it is estimated that almost five percent of individuals diagnosed with the disease have alpha-1 antitrypsin deficiency, which is a rare genetic condition that can lead to lung and liver problems.
Screening and Prevention
Screening procedures for COPD are not overtly harmful, but they are costly in terms of time and expense. As a result, the United States Preventive Services Task Force currently recommends against screening for COPD in adults who do not have related symptoms. This recommendation does not apply to adults who present related symptoms, such as chronic cough, wheezing, or shortness of breath.
Considering COPD, unlike some other diseases, has clear risk factors/causes. Therefore, prevention is clear and straightforward.
Since the majority of COPD cases are directly related to cigarette smoking, the best way to prevent the disease is to never smoke. If you are a current smoker, you should quit now. However, this is easier said than done, as many smokers have had multiple unsuccessful attempts at smoking cessation. Nevertheless, keep trying to quit, as this is your best chance at preventing permanent damage to your lungs. You would also benefit from avoiding exposure to secondhand smoke.
Today, legislation has been passed making many environments — such as offices, restaurants, and bars — smoke-free. If you have occupational exposure to lung irritants, the best way to protect yourself is by using respiratory protective equipment. Lastly, consider advocacy demanding for clean air, as this is a way to not only protect yourself but also family and friends.
When to See a Doctor
Most individuals with COPD will go through periods where their disease is stable and other periods where it flares or worsens. You should see a doctor if you experience any of the following (as this may represent a flare of disease):
- An increase in shortness of breath and/or cough;
- Blue or gray discoloration of fingernails or lips (also known as cyanosis), which may indicate low levels of oxygen in the blood;
- An increase in phlegm production, with or without discoloration (e.g., white, yellow, green, or rust-colored);
- A fever greater than or equal to 101° F;
- Feeling dizzy, lightheaded, confused, or faint, and;
- A racing heart (also known as tachycardia).
Also, consider calling 911 or going to the emergency room if any of the above symptoms persist despite regular use of your prescription breathing medications.
COPD is commonly misdiagnosed. It is possible to experience some of the aforementioned symptoms without having COPD, as several other conditions — like asthma, congestive heart failure, and idiopathic pulmonary fibrosis — share similar signs and symptoms.
Since there is no single test for the diagnosis of COPD, the diagnosis is based on symptoms, a physical exam, and the results of diagnostic tests.
Visiting the Doctor
To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, and discuss any exposure you've had to lung irritants, especially cigarette smoke.
At your doctor’s visit, be sure to mention all of your symptoms and how long they have been present. In addition, tell your doctor if:
- You are a current smoker, have smoked in the past, or never smoked;
- You are exposed to dust or chemical vapors/fumes on the job;
- You are exposed to chronic secondhand smoke;
- You have a family history of COPD;
- You have asthma or another active respiratory condition, and;
- You take over the counter or prescription medications.
During the physical examination, your doctor will use a stethoscope to listen to your lungs as you breathe, checking for wheezing or other signs of lung abnormalities. Based on all of the above information, your doctor may order several tests to confirm the suspicion of COPD.
The most commonly used test to confirm a diagnosis of COPD is spirometry (also known as pulmonary function tests). This test measures the amount of air you can breathe in and out of your lungs. Your doctor may ask you to inhale a bronchodilator, which is a type of medication that opens up the airways, prior to the commencement of lung testing.
Spirometry is noninvasive, simple, and painless. It can be used to detect even very mild lung disease as well as to monitor the progression of disease and response to treatment.
In addition to spirometry, your doctor may order imaging studies, such as a chest X-ray (CXR) and/or a computed tomography (CT) scan.
A CXR can show signs of emphysema and can be used to exclude other lung problems, such as pneumonia, heart failure, and tumors.
A CT scan of the chest can provide a more detailed examination of the lungs, blood vessels, and heart. This test is also painless, but a dye may have to be injected into a vein in your arm to obtain clearer images. The CT can also be used for surgical planning in the event surgery for COPD is recommended.
Although there are no blood-based tests to definitively diagnose COPD, blood tests may be used as complementary clues to the diagnosis or to assess the severity of disease during exacerbations (flares).
One of the more commonly used blood tests is the arterial blood gas (ABG) analysis/test. The ABG test measures levels of oxygen, carbon dioxide, and other important parameters in your blood. ABG analysis provides the best clues as to the acuteness and severity of disease exacerbation.
Other blood tests may be needed to monitor levels of sodium, potassium, calcium, and magnesium, as patients with COPD may have alterations in the levels of these important electrolytes. They may also be used to exclude other diagnoses not related to COPD.
For instance, drugs such as diuretics (“water pills”), ß-blockers, and theophylline can lead to low potassium levels. Additionally, alpha-1 antitrypsin levels should be measured in all patients younger than 40 years old diagnosed with COPD, with a family history of emphysema at an early age (younger than 45 years old at diagnosis), or patients having changes consistent with emphysema with no smoking history.
The four stages of COPD are classified based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) system. The system was devised in 1997 by the National Heart, Lung, and Blood Institute, National Institutes of Health, and the World Health Organization. The GOLD classification is used for determining the severity of COPD and helping to design a treatment plan and prognosis.
Using spirometry, the GOLD stages are defined by measuring the volume of air that can be forced out in one second after taking a deep breath, which is known as the FEV1. The results are:
- Stage I (mild obstruction) is defined by an FEV1 greater than or equal to 80 percent;
- Stage II (moderate obstruction) is defined by an FEV1 between 50 and 80 percent;
- Stage III (severe obstruction) is defined by an FEV1 between 30 and 49 percent, and;
- Stage IV (very severe obstruction) is defined by an FEV1 less than 30 percent.
Unfortunately, as COPD progresses, you’re more susceptible to a multitude of complications.
Respiratory infections, such as pneumonia, colds, flu, and whooping cough, are more likely in individuals with COPD. Therefore, doctors recommend annual flu vaccination as well as vaccination against pneumococcal pneumonia.
If you have COPD, you are at increased risk for heart problems, including heart attacks and abnormal heartbeats called arrhythmias. The reasons for this observation are not fully understood, but some propose that low oxygen levels in blood lead to narrowing of the arteries and high blood pressure.
This chronic disease has also been found to be associated with increasing your chances of a collapsed lung (also known as a pneumothorax), diabetes, and thinning bones (also known as osteoporosis).
Additionally, compared to adults without COPD, those with the disease are more likely to:
- Have lung cancer, which is probably directly related to smoking;
- Develop depression and/or anxiety;
- Develop sleep problems, such as sleep apnea;
- Have activity limitations, such as difficulty walking or climbing stairs;
- Be unable to work;
- Need special equipment, such as portable oxygen tanks;
- Not engage in social activities and be confined to their homes;
- Have increased confusion or memory loss;
- Have more emergency room visits or overnight hospital stays;
- Have other chronic diseases, such as arthritis, heart failure, or asthma, or;
- Report fair or poor health status.
There is no cure for COPD, but early treatment/intervention can change the course of the disease. The goals of therapy for COPD are three-fold. They are controlling your symptoms, reducing your risk of complications and exacerbations, and improving your quality of life. Your health care team may include a primary care physician, lung specialist, and physical and respiratory therapists. The major areas of treatment include smoking cessation, medication, lung therapies, and surgery.
The most important part of any treatment plan for COPD is to quit smoking. For some, this is easier said than done.
Many start with nicotine replacement that is available in many forms, including over-the-counter solutions — such as patches, gums, and lozenges — and prescription medication — like nasal sprays and inhalers. Also, oral medication — such as bupropion (Zyban) and varenicline (Chantix) — is commonly used for smoking cessation.
Plus, it is a good idea to avoid secondhand smoke and protect yourself against workplace exposures, if applicable.
Medication used to treat COPD include short- and long-acting bronchodilators, inhaled steroids, combination (bronchodilator plus steroid) inhalers, oral steroids, phosphodiesterase-4 inhibitors, and theophylline.
Bronchodilators relax the muscles in and around your airways, making breathing easier as well as helping relieve cough and shortness of breath. Examples of short-acting bronchodilators include albuterol (ProAir and Ventolin), levalbuterol (Xopenex), and ipratropium (Atrovent). Tiotropium (Spiriva), salmeterol (Serevent), and formoterol (Foradil) are examples of long-acting bronchodilators. Depending on the severity of your disease, you may have to use both types of bronchodilators.
Inhaled steroids reduce inflammation in the airways. They are very useful in those with severe symptoms and/or frequent flares and may help to prevent flares in the future. Budesonide (Pulmicort) and fluticasone (Flovent) and are examples of inhaled steroids.
At times, your doctor may deem a combination inhaler is appropriate in your treatment plan. Formoterol and budesonide (Symbicort) and salmeterol and fluticasone (Advair) are examples of combination inhalers.
Short courses (from five days to no more than two weeks) of oral steroids may be appropriate for individuals with moderate to severe exacerbations of their COPD. Due to their serious side effects (e.g., weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection), the long-term use of steroids is highly discouraged.
Roflumilast (Daliresp), a phosphodiesterase-4 inhibitor, is a newer agent for those with severe symptoms of COPD, especially those of chronic bronchitis, that has a dual action of fighting inflammation and relaxing airways.
Theophylline is an older and inexpensive COPD medication that help improve breathing and prevent flares. A low dose is recommended, as its side effects (nausea, headache, and fast heartbeat) are dose-related.
For those with moderate to severe COPD, additional lung therapies may include supplemental oxygen therapy and pulmonary rehabilitation. Some people will need supplemental oxygen only during activities or while sleeping, while others will need it all the time.
Oxygen therapy can improve your quality of life and is the only COPD therapy proven to prolong survival.
Pulmonary rehabilitation programs combine education, exercise training, and nutrition and psychological counseling. These programs may shorten your hospitalizations, increase your ability to participate in everyday activities, and improve your quality of life.
Lung surgery may be considered for those with severe COPD that are not responding to conventional treatments. Your surgical options include:
- Lung volume reduction surgery: Entails removing small wedges of damaged lung tissue from the upper lung zones to allow for more efficient function of the remaining healthier lung tissue.
- Bullectomy: Removes bullae (large air spaces) from the lungs to help improve airflow.
- Lung transplantation: May be an option for those who meet certain criteria.
COPD Management Using GOLD
With the emergence of the GOLD classification, many doctors have begun to simplify the management of COPD based on the following approaches:
- Stage I: Short-acting bronchodilator as needed.
- Stage II: Short-acting bronchodilator as needed along with long-acting bronchodilator(s) and pulmonary rehabilitation.
- Stage III: Short-acting bronchodilator as needed along with long-acting bronchodilator(s), pulmonary rehabilitation, and inhaled glucocorticoids in the case of repeated flares.
- Stage IV: 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.
Living with COPD
What to Avoid
If you are living with COPD, it requires lifelong disease management. As such, it is important to avoid:
- Stressors to your lungs, which can cause the progression of the disease and/or flares, and;
- Smoking and exposure to secondhand smoke, chemical fumes, air pollution, and/or excessive dust.
Regular exercise can help improve your overall strength and endurance and strengthen your breathing muscles. If you are considering embarking on an exercise regimen, it is best to consult your doctor who should be able to refer you to a pulmonary rehabilitation program.
There is no specific diet for COPD, but, in general, you should eat a variety of nutritious foods and drink plenty of water. The nutritious foods should provide a boost to your immune system, while the water will thin any excess mucus, making it easier to cough up and out.
You should limit caffeinated beverages, as they may interact with some COPD medications. Excess salt should also be avoided, as it can cause water retention, which could make breathing more difficult.
If you're overweight, losing weight can significantly help your breathing.
Dealing with Flares
As the symptoms of COPD wax and wane, you should be prepared for flares. Therefore, you should carry your emergency contact information with you and post it on your refrigerator. Also, you should carry a list of all your medications and their current doses.
To lower your risk of respiratory infections — which could contribute to flares — ask your doctor if you should get vaccines to protect you from the flu, pneumonia, and pertussis.
Lastly, see your doctor regularly, even if you are feeling fine.
COPD is a progressive and currently incurable disease, but with the right diagnosis and treatment, people can live for many years with the disease and a respectable quality of life. This underscores the fact that early diagnosis of COPD can help slow the progression of the disease before it becomes severe or life-threatening.