Lung Health

What Is COPD? Symptoms and treatments of bronchitis and emphysema

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By UHN Staff • December 10, 2015

What Is COPD? Symptoms and treatments of bronchitis and emphysema

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Introduction

Chronic obstructive pulmonary disease is better known as COPD. It most commonly appears as two lung issues: emphysema and chronic bronchitis.

COPD signs and symptoms include shortness of breath, mucus-clogged airways and a persistent cough. Inhalers and supplemental oxygen can relieve symptoms of this chronic, irreversible condition.

Chronic lower respiratory diseases—including chronic obstructive pulmonary disease (COPD)—are the third-leading cause of death in the U.S. Even so, research has suggested that many people at risk of COPD are still unaware of the disease, and a 2014 survey carried out by the COPD Foundation indicated that many patients have reached a “severe” or “very severe” disease state by the time of diagnosis. The survey also suggested that COPD sufferers may need more education and better dialogue with their doctors to effectively manage potentially life-threatening COPD complications known as exacerbations (or flare-ups).

There is no cure for COPD, but treatment is available to make breathing easier and prolong life. In this brief guide, we’ll offer a COPD definition, explain emphysema symptoms and describe chronic bronchitis symptoms. How you manage symptoms will go along way toward preserving your lung function.

I. WHAT IS COPD?

The term chronic obstructive pulmonary disease (COPD) typically describes two conditions: emphysema and chronic bronchitis. Some people have just one of these, but most people with COPD have both. In order to understand their effects, it is necessary to understand how the lungs work to help provide oxygen to the heart and vital organs.

How the Lungs Work

Inside the lungs, there is a branching system of progressively smaller tubes (called bronchial tubes), at the end of which are air sacs (called alveoli). The alveoli have very thin walls, and are surrounded by capillaries (the smallest blood vessels). When you breathe in, oxygen and carbon dioxide travel through the bronchioles to the alveoli, and then pass through into the capillaries, where they are absorbed by red blood cells. This “oxygenated” blood travels to the heart, and then the rest of the body. At the same time, carbon dioxide from the blood in the capillaries passes into the alveoli, to be passed out of the body when you exhale. This exchange of gases—oxygen in, and carbon dioxide out—takes just fractions of a second. But the conditions that underpin COPD can prevent it from happening in the way it should.

What Is Emphysema?

The bronchioles and alveoli are normally very elastic, easily stretching and then returning to their original size during the process of breathing. But in emphysema, the thin walls between many of the alveoli are destroyed, and they (and the bronchioles that lead to them) are no longer able to return to their original shape during exhalation. Some of the airways collapse entirely, and this means that some alveoli don’t properly deflate. When airways collapse and alveoli are destroyed, air gets trapped in the lungs. This causes parts of the lung to become enlarged, or hyperinflated. Destruction of the alveoli also hampers the exchange of oxygen and carbon dioxide, and this leads to too little oxygen and too much carbon dioxide in the blood.

Chronic Bronchitis

Chronic bronchitis is caused by inflammation in the airways, and an increase in the production of mucus. The inflammation may be caused by inhaled tobacco smoke and other noxious particles, and/or by harmful foreign substances such as bacteria and viruses. Inflammation at the site of the threat brings disease-fighting cells to the area where they are needed. In the airways, the presence of harmful substances also increases the production of mucus. While mucus helps protect the lungs by trapping and removing potentially harmful substances before they travel too far into the airways, overproduction of mucus can hinder breathing.

Under normal circumstances, once the infection or foreign substance has been eliminated, any inflammation and excess mucus production subside. In people with COPD, the inflammation and excess mucus production do not completely subside, but instead persist. In addition, inhaled tobacco smoke can damage cilia: the tiny hair-like projections that normally help to sweep mucus out of the lungs, and expel toxic substances. Constant inflammation in the airways, along with an overabundance of mucus, narrow the bronchioles. This can cause difficulty breathing, and typically a chronic cough.

II. WHAT CAUSES COPD?

COPD generally occurs as a result of repeated exposure of the lungs and airways to irritants, most commonly smoke from cigarettes, cigars, and pipes.

• Smoking: COPD most often affects people over age 40 who have smoked a pack of cigarettes a day for 10 or more years. Pipe and cigar smoking also can decrease lung function and increase the chance of COPD, even in people who have never smoked cigarettes. Recent research suggests that e-cigarettes also may be harmful to the lungs. Smokers who have a family history of COPD are at particularly high risk. For some people, exposure to secondhand smoke can cause respiratory symptoms and possibly COPD. One study found that exposure to secondhand smoke in childhood increases the risk for developing COPD in adulthood. People who have quit smoking are still at increased risk of eventually being diagnosed with COPD. But stopping smoking significantly reduces the chances of getting COPD as well as other serious lung, heart, and other diseases. Smokers with COPD who stop smoking slow the progression of their COPD. Smoking also increases the risk for lung cancer, and this risk declines when a person stops smoking and continues to decline the longer they go without smoking.
• Genetics: Not all smokers develop COPD. Therefore, experts believe that some combination of smoking and genetic factors may be at work in those who do get the disease. With the exception of the alpha-1 antitrypsin gene, the specific genes that may be involved in COPD are not known. However researchers have begun to identify possible candidates.
• Occupational exposures: Long-term exposure to various kinds of chemicals, fumes, and dust can also harm the lungs and cause COPD. The American Thoracic Society estimates that exposure to harmful inhalants in the workplace accounts for 10 to 20 percent of the symptoms or impairment of COPD.
• Air pollution: Whether outdoor air pollution from sources such as automobile, factory, and power plant emissions can cause COPD is uncertain, but there is some evidence that it damages lung function. A recent study found that people who lived near major roadways and were exposed over a long period of time to the tiny particles in automobile exhaust had an accelerated rate of decline in lung function. In addition to fine particulate matter, another type of outdoor air pollution is ozone. In the upper atmosphere, ozone protects against harmful ultraviolet radiation. But when present at ground level (where it may form when exhaust from tailpipes, coal-fired power plants and other sources mixes with oxygen), ozone is a pollutant. One study found that increased levels of ground-level ozone correlated with an increased risk of dying from respiratory illnesses, including COPD. For people who already have COPD, exposure to high levels of outdoor air pollution can exacerbate their condition. Indoor air pollution also can be a risk factor for COPD. Studies have found that exposure to wood smoke may increase COPD risk for smokers. In addition, people who already have COPD and are exposed to both types of smoke experience more frequent and severe symptoms.
• Alpha-1 antitrypsin deficiency: In a small number of people, COPD is caused by a hereditary disorder called alpha-1 antitrypsin deficiency. Alpha-1 antitrypsin is a protein that prevents an enzyme called neutrophil elastase from damaging the alveoli. People with alpha-1 antitrypsin deficiency lack this protein, and about 75 percent of adults with the deficiency develop COPD. People with this deficiency who smoke are at particularly high risk of developing severe lung disease, often at a relatively young age.

III. COPD SYMPTOMS

COPD can develop gradually over a long span of time, which often makes it difficult to diagnose until it is quite advanced. Because most people never use their full lung capacity, diminished lung function often is not noticed in the early stages of COPD. As the disease gets worse, people may become less active, not realizing that their lung function is compromised. They may be unaware of the extent of their limitations, and also unaware that these limitations are due to a lung disease. At some point—often at relatively low levels of exertion—the body will no longer be able to compensate, and symptoms become impossible to ignore.

Shortness of breath is the symptom that drives most people with undiagnosed COPD to see the doctor. At first, shortness of breath is only noticeable with exertion, but eventually breathlessness will hamper routine activities of living, like washing, dressing, and cooking. A chronic cough may at first be intermittent, but later may occur every day. For people with COPD, it is common to cough up small quantities of sputum. As the disease gets worse, the sputum may become thicker. Wheezing and chest tightness may or may not be present during day-to-day living, but often become very prominent when people with COPD catch a cold.

The frequency and severity of episodes of coughing and shortness of breath will increase as COPD worsens. Fatigue and weakness are common complaints. Weight loss may occur in the more advanced stages of the disease, along with morning headaches due to a build-up of carbon dioxide in the blood overnight.

Having a chronic cough and coughing up sputum when there is no identifiable reason, such as a cold or flu, is not normal. It is important to see a doctor during the early signs of lung disease, because effective treatments are available to assist with breathing and improve quality of life. In addition, if smokers learn that they have developed COPD or another lung disease early enough, they may be able to stop smoking before the disease becomes more serious.

COPD Prognosis

Having COPD can increase the risk for other health problems. For example, a person with COPD is more likely to catch a cold or the flu, and is more susceptible to getting pneumonia.

Very severe COPD may cause pulmonary hypertension, a type of high blood pressure that occurs in the lungs. It also appears to increase the risk for heart attack, stroke, and heart failure (a condition in which the ability of the heart to pump enough blood to the body is impaired). Heart function may be diminished in people with COPD, even if they have only mild symptoms.

COPD also takes a toll on mental health. Patients with COPD are more likely to be diagnosed with depression than healthy individuals, or those with a different chronic illness (diabetes, for example). `Older adults with COPD also appear to have an increased risk for a type of mental decline called mild cognitive impairment, which can develop into Alzheimer’s disease. Consult with your doctor or a mental health professional if you are feeling sad or think you might be depressed—help is available.

People with COPD also appear to be at increased risk for developing shingles, most likely because having COPD weakens the immune system. Shingles is a reactivation of the chicken pox virus that results in a painful rash, and it most often occurs in older adults and people with health conditions that impair their immune system.

IV. TESTING FOR COPD

In order to diagnose COPD, your doctor will perform a physical examination, take a detailed medical history, ask about any history of smoking (or current smoking habit) and other lifestyle issues, and perform pulmonary function tests, which measure the ability of the lungs to hold air, to move air in and out, and to move oxygen into the blood.

Spirometry

In a test called spirometry, the patient takes a deep breath in, and then exhales as hard and as long as possible into a hose connected to a machine called a spirometer. The spirometer can be used to take several types of measurements. Some common ones used in the diagnosis and management of obstructive lung diseases include:

• Forced vital capacity (FVC): The total amount of air that can forcibly be blown out after inhalation.
• Forced expiratory volume in 1 second (FEV1): The amount of air that can be blown out in one second.
• The ratio of FEV1 to FVC (FEV1/FVC): In healthy adults, this should be 75 to 80 percent.

Peak Expiratory Flow (PEF)

The speed of air moving out of the lungs at the beginning of an exhalation.
The values obtained from most pulmonary function tests are expressed in percentages, and are compared to values expected for a person of similar age, height, ethnicity, and gender who does not have any lung disease. For example, a spirometry reading may reveal a forced expiratory volume in 1 second (FEV1) of less than 80 percent of predicted for a person of the same age with no lung disease. Such a result indicates impaired lung function, possibly due to COPD or asthma.

Bronchodilator Reversibility Testing

Another common diagnostic test is bronchodilator reversibility testing. For this test, the patient does a spirometry test, and then takes a type of drug called a bronchodilator before taking the spirometry test a second time. Bronchodilators open up narrowed airways by loosening the muscles surrounding the airways. If the spirometry test improves after taking a bronchodilator, this suggests that the patient has asthma rather than COPD, since asthma is often reversible. But for people with COPD, airflow will continue to be limited even after taking the drug.

Peak Flow Meter

A simpler device for measuring how quickly air can be expelled from the lungs is a peak flow meter. Using this handheld device, the person inhales deeply and then blows as hard as possible into the device. If the airways are narrow or blocked, the peak flow will drop below normal.

Measuring Lung Volume

Another type of pulmonary function test measures lung volume. In people with COPD, air often gets trapped in the lungs. Having too much air in the lungs can make the lungs overly inflated (hyperinflated). To determine whether this is happening, a physician may perform one of two tests to measure lung volume:

Body Plethysmograph

In this test, the patient sits in a sealed, clear box, and breathes into a mouthpiece connected to a measuring device. Lung volume is determined by changes in pressure inside the box.

Helium Dilution or Nitrogen Washout

This test involves breathing nitrogen or helium gas through a tube. The concentration of the gas in a chamber attached to the tube is measured to estimate the lung volume.

Diffusing Capacity of the Lung for Carbon Monoxide

The destruction of alveoli in people with emphysema can impair the normal exchange of oxygen and carbon dioxide. To estimate how well the lungs are able to move oxygen into the blood, a test called diffusing capacity of the lung for carbon monoxide (DLCO) may be performed. For this test, the patient inhales harmless gas that contains a small amount of carbon monoxide, holds his or her breath briefly, and then rapidly exhales into a tube. The exhaled gas is analyzed to determine how much carbon monoxide was absorbed by the lungs. This provides information about how quickly gas can move from the lungs into the bloodstream.

Impulse Oscillometry

This test uses sound waves to detect airway changes that indicate obstructive lung diseases such as asthma and COPD. The patient breathes normally into a device that generates vibrations and calculates resistance to breathing.

Chest X-ray

A chest X-ray generally cannot be used to diagnose obstructive lung disease, because only severe emphysema will be visible on a chest X-ray. However, your doctor may have you undergo a chest X-ray to see if your symptoms might be attributable to another condition, such as heart failure or another lung disease.

Computed Tomography

Computed tomography (CT) is another type of imaging study that may be used for some patients. During a CT scan, thin X-ray beams rotate around the patient, creating a series of two-dimensional images. A computer turns these images into a three-dimensional image of the lung (or other organ). This test is better at detecting emphysema than chronic bronchitis or asthma, but CT scanning is not generally used for an initial diagnosis of obstructive airway disease. It may be used to decide if a patient with COPD is a candidate for surgery, or to diagnose another lung disease called bronchiectasis.

Arterial Blood Gas Test

For patients with advanced COPD, an arterial blood gas test may be performed. This measures the amount of oxygen and carbon dioxide in the blood. It is used to determine if there is too little oxygen in the blood (a condition called hypoxemia), or to detect the presence of too much carbon dioxide (called hypercapnia).

V. DIAGNOSING COPD

A doctor should suspect COPD in anyone with a history of smoking or exposure to environmental irritants who has any of the characteristic symptoms of COPD (chronic cough, sputum production, and shortness of breath with exertion). Once diagnosed, COPD will be staged in order to work out a treatment plan.
COPD staging

COPD is divided into four stages: mild, moderate, severe, and very severe. These classifications are based on increasing severity of airflow restriction and symptoms. The spirometry reading for FEV1 is generally used to determine the severity classification.

• Stage I: Mild COPD. Spirometry shows mild limitation in airflow (FEV1 greater than 80 percent of predicted). Chronic cough and sputum production may be present. At this stage, the person is often unaware of impaired lung function.
• Stage II: Moderate COPD. Spirometry shows limitation in airflow that is worse than in mild COPD (FEV1 less than 80 percent but greater than 50 percent of predicted). Shortness of breath typically occurs with exertion. Cough and sputum production are more likely than in mild COPD. At this stage, the person may first become aware of a problem with breathing, and seek medical advice.
• Stage III: Severe COPD. Airflow limitation becomes progressively worse (FEV1 less than 50 percent but greater than 30 percent of predicted). Shortness of breath will increase, even with even a small amount of exertion, and the person will likely feel fatigued. Quality of life often diminishes.
• Stage IV: Very severe COPD. Airflow is severely compromised (FEV1 less than 30 percent of predicted or less than 50 percent of predicted, plus the person has chronic respiratory failure). This may lead to heart problems, such as heart failure. Quality of life is markedly impaired. Exacerbations of the disease may be life threatening.

Differences Between Asthma and COPD

One major difference between asthma and COPD relates to the reversibility of the condition. In COPD, the damage to the airways is not fully reversible—it is permanent, and gets progressively worse. The airway narrowing in asthma, on the other hand, is usually reversible. In addition, an asthma attack generally is sparked by a trigger, such as an allergic reaction, exposure to the cold, or exercise.

Doctors can simulate an asthma trigger with an inhaled drug called methacholine. This drug causes the airways to spasm, which will be detected on a test of breathing function (spirometry). A positive result of this test indicates asthma is probably the cause of the patient’s symptoms. However, this is not 100 percent accurate because a person with chronic bronchitis also may have a positive result on this test.

People with asthma (especially those who smoke) can develop a chronic cough, and could develop COPD. In some cases, it may not be possible to make a clear distinction between asthma and COPD. Current medical treatment guidelines state that for patients with both asthma and COPD, treatment should be similar to that for asthma. But each patient is different—therefore, treatment will likely be individualized.

VI. COPD TREATMENT

In people with COPD, the parts of the lungs damaged due to emphysema cannot be restored. Therefore, treatment is aimed at improving the function of the parts of the lungs that are still working, and reducing inflammation in the lungs. Ultimately, the goals of treatment are to relieve symptoms, prevent the disease from getting worse, improve the ability to exercise, prevent and treat complications, and prevent and treat flare-ups.

Drug Therapy for COPD

The mainstay of COPD treatment involves drugs called bronchodilators, which open the airways. Some people will also need anti-inflammatory drugs—your doctor will work with you to figure out the right drugs and combinations of drugs to relieve your symptoms.

While bronchodilators can be taken in different ways, the preferred method for delivering the drug in patients with obstructive airway disease is through inhalation, using an inhaler device. A drug delivered in this way quickly goes to the airway, where it is needed; moreover, there are generally fewer side effects with inhaled medications than there are with pills.

Types of Inhalers

Inhalers deliver bronchodilator or corticosteroid medication as a spray, mist, or fine powder. Three types of inhalers are available: a metered dose inhaler (MDI), a dry powder inhaler (DPI), and a nebulizer.

• • Metered dose inhalers: A metered dose inhaler (MDI) is a small, pressurized canister that contains medication with a mouthpiece and a metering valve.. The patient places his or her mouth over the mouthpiece, and then inhales slowly and deeply while pushing down on the top of the canister to deliver a precise dose of the medication. Once the medication is delivered, the patient must hold his or her breath for about 10 seconds before exhaling. Many people find it helpful to use a spacer device with their MDI to improve drug delivery. A spacer is a short tube that is placed between the mouthpiece of the inhaler and your mouth. The medicine enters the tube, and from there it can be inhaled more slowly and deeply, resulting in more effective delivery of the medication to the lungs.
  • Dry powder inhalers: Overall, DPIs tend to be somewhat easier to use, as they don’t require the coordination of taking a breath while actuating the device with your hand. To use a DPI, simply place your mouth tightly over the mouthpiece and inhale quickly. A DPI inhaler should not be shaken before use (like an MDI); nor are spacers used.
  • Nebulizers: Inhaled medications like bronchodilators and corticosteroids can also be delivered via a nebulizer. A nebulizer is a machine that turns a liquid form of a drug into a fine mist that is then inhaled through a mouthpiece or face mask. Nebulizers can be useful for those who have more severe lung disease, or have difficulty using MDIs or dry powder inhalers.
  • Bronchodilators: Almost every person suffering from COPD will be prescribed a short-acting bronchodilator (either a beta-agonist, an anticholinergic, or a combination of both; see sidebar, below) to use on an as-needed basis to relieve shortness of breath, coughing, wheezing, and other symptoms. Bronchodilators expand the airways, making it easier to breathe and therefore easier to go about daily life.

Beta-Agonists vs. Anticholinergics vs. Combination Drugs

Beta-agonists: Beta-agonists activate a receptor called the beta-2 receptor on muscles surrounding the bronchial tubes. This causes the muscles to relax, and the airway to dilate. Beta-agonists are available in short-acting and long-acting formulations. Short-acting beta-agonists include albuterol (Proventil HFA, Ventolin HFA, ProAir HFA), levalbuterol (Xopenex), and pirbuterol (Maxair Autohaler). These drugs start to work within minutes, and last about four to six hours. Long-acting beta-agonists include salmeterol (Serevent), formoterol (Foradil, Perforomist), arformoterol (Brovana), indacaterol (Arcapta Neohaler) and olodaterol (Striverdi Respimat) take longer to begin working (about 20 minutes), but last up to 24 hours.Most beta-agonists are taken in an inhaled form, but they are available as pills as well. The long-acting beta-agonists salmeterol, formoterol, and arformoterol are taken twice a day. Indacaterol and olodaterol are taken once a day. Possible beta-agonist side effects include headaches, nervousness, dizziness, and shakiness. If side effects occur, they often last only a short time and diminish or resolve completely once the medication is used regularly. If they persist, consult your doctor—a different medication or a lower dose may be prescribed.

Anticholinergics: Anticholinergics block a receptor in the lung to prevent constriction of the airways. This allows the airways to remain open. Short-acting anticholinergics include ipratropium (Atrovent), which starts to work within 15 minutes, and lasts for six to eight hours. Long-acting anticholinergics include tiotropium (Spiriva), and umeclidinium (Incruse Ellipta). These take about 20 minutes to start working, and last for 24 hours. Another long-acting anticholinergic drug, aclidinium (Tudorza Pressair), takes about 10 minutes to start working, and lasts 12 hours.Possible side effects of ipratropium are coughing, headaches, nausea, heartburn, diarrhea, urinary retention, and constipation, among others. Tiotropium can cause dry mouth, constipation, urinary retention, stomach pain, and other side effects. Possible side effects of umeclidinium include colds, infections in the upper respiratory tract (sinuses, ears), a cough, and joint pain. Aclidinium can cause fever, headache, muscle aches, sore throat, stuffy or runny nose, unusual tiredness, and other side effects. If these symptoms occur, they are generally not serious and should diminish or go away completely with ongoing use of the medication. If any side effect is severe or does not go away, a different medication may be needed.

Combination drugs: For a person with mild COPD who has occasional symptoms, a short-acting bronchodilator alone may be sufficient to manage the condition. The physician may also prescribe two short-acting bronchodilators—a beta-agonist plus an anticholinergic—to use together. To simplify this regimen, some combinations of a short-acting beta-agonist plus a short-acting anticholinergic are available in one inhaler. The currently available combinations are albuterol plus ipratropium (Combivent Respimat), and fenoterol plus ipratropium (Duovent), although the latter is not available in the U.S.

Anti-inflammatory Drugs (corticosteroids)

Corticosteroids work by reducing swelling in the bronchial tubes. They can be taken in tablet, liquid, injected, or inhaled form. Corticosteroids do not work as quickly as bronchodilators—it can take up to a week to notice the effect. The pill form acts faster than the inhaled version, but corticosteroids in pill form are not recommended for long-term use in people with COPD due to potential side effects. Corticosteroids are recommended for people with moderate or severe COPD who do not get sufficient relief from bronchodilators, or experience frequent flare-ups.

• • • Inhaled corticosteroids: Most people with obstructive airway disease who take corticosteroids will use the inhaled form. Inhaled corticosteroids include triamcinolone (Azmacort), beclomethasone (Vanceril, Qvar, Beclovent), flunisolide (AeroBid, AeroBid-M), fluticasone (Flovent), and budesonide (Pulmicort). Using an inhaler device, the medication is delivered directly to the lungs. Very little medication travels through the bloodstream, which means there will be few side effects. In commonly used doses, inhaled steroids are safe to use over the long term, and they have been shown to reduce flare-ups. However, some studies have linked them to an increased risk for pneumonia. Other possible side effects are a sore throat, hoarse voice, and oral candidiasis (a yeast infection in the mouth). Candidiasis can be avoided by rinsing your mouth with water after each use of the inhaler, or by using a spacer.
    • Oral corticosteroids: Corticosteroids in pill form are generally reserved for treating acute exacerbations of COPD or asthma, and these drugs are generally only used for a short period of time (a few days to a few weeks). This is because in addition to reducing inflammation, corticosteroids have other effects on the body that can cause unwanted and sometimes severe consequences. Long-term use increases the risk for cataracts, bone thinning (osteoporosis), muscle weakness, hair loss, growth of facial hair in women, mood changes, and weight gain. A person who uses oral steroids for long periods of time may also be susceptible to developing high blood pressure and/or diabetes. Common corticosteroids taken in tablet form are prednisone (Deltasone) and prednisolone (Medrol).
    • Combination drugs: For people prescribed long-term use of both a long-acting bronchodilator and a corticosteroid, products are available that combine these two drugs in one inhaler. Combination products include formoterol plus budesonide (Symbicort), salmeterol plus fluticasone (Advair), formoterol plus mometasone (Dulera), and vilanterol plus fluticasone (Breo Ellipta).

Exacerbation Treatment

An exacerbation is a sudden flare-up of COPD symptoms beyond normal day-to-day variations. Increased breathlessness, along with wheezing, chest tightness, increased cough and sputum, a change in the color of sputum, and fever are common features of an exacerbation. Exacerbations may warrant either a short-term or long-term change in medication, and they sometimes require hospitalization.

Three types of medications often used to treat exacerbations are bronchodilators, corticosteroids, and antibiotics. When oral corticosteroids are used for an acute flare-up of symptoms, they will most likely be taken for five days. Another option is roflumilast (Daliresp), a once-a-day drug given to decrease the frequency of exacerbations or treat worsening symptoms in patients with severe COPD. The drug is indicated for people with chronic bronchitis, and is not intended to treat emphysema. Roflumilast works by a different mechanism than bronchodilators and anti-inflammatory drugs.

If an exacerbation is caused by a lung infection (which may be signaled by increased amounts of mucus production), antibiotics may be used.

VII. OTHER COPD TREATMENT APPROACHES

Along with drugs, other treatments are used to manage COPD. Some are as straightforward as getting immunized against influenza and pneumonia. Others are more complex—for example, younger adults who have emphysema as a result of a hereditary deficiency of alpha-1 antitrypsin may be treated with alpha-1 antitrypsin augmentation therapy.

• • • Immunizations: For people with obstructive airway diseases, influenza and some types of pneumonia can be very serious and potentially life threatening. It is extremely important that everyone with obstructive airway disease follow the recommended vaccination schedule, or their doctor’s advice. People with COPD should receive an influenza vaccination once a year. Flu season runs from November to March, and the ideal time to get a flu shot is in October or November. The pneumococcal vaccine protects against the bacteria that is the most common cause of pneumonia (Streptococcus pneumoniae), and is recommended for all COPD patients age 65 and older. It also may be given to patients with COPD who are younger than age 65 and have severe or very severe disease. Unlike the flu shot, which must be given every year in the fall, pneumococcal vaccination provides protection for at least five years. It can be given at any time of the year.
    • Alpha-1 antitrypsin therapy: Alpha-1 antitrypsin is a protein that circulates in the blood. Augmentation therapy uses a concentrated form of this protein, which has been removed from donated blood and purified. This therapy cannot reverse damage that has already been done to the lungs, but it may slow down the further decline of lung function.
    • Pulmonary rehabilitation: Pulmonary rehabilitation is a series of educational and structured exercises that allow people to make the most of the remaining capacity of their lungs. People with COPD who engage in these programs have less shortness of breath, an increased ability to exercise, better quality of life, and less frequent hospitalizations than similar COPD patients who do not participate in pulmonary rehabilitation. People with COPD tend to decrease their physical activity, since
      

      COPD rehabilitation involves steadily improving lung function. Here a COPD patient uses an “incentive spirometer” as a training device to build lung function.

      shortness of breath makes exertion more and more difficult. Decreased activity can start a vicious cycle of progressive deconditioning, and this leads to worsening of symptoms and more breathlessness, with less and less physical activity. Pulmonary rehabilitation is aimed at breaking that cycle through several core components, including aerobic, strength and flexibility training, breathing exercises, advice on controlling irritants and allergens, and help with smoking cessation if necessary. There are many pulmonary rehabilitation programs around the country. Your physician can most likely refer you to one; alternately, contact the American Lung Association (www.lungusa.org) or the American Association for Cardiovascular and Pulmonary Rehabilitation (www.aacvpr.org), which has a searchable online directory of pulmonary rehabilitation programs. Health insurance may or may not cover pulmonary rehabilitation: You’ll need to check with your insurance carrier. The guidelines for Medicare coverage of pulmonary rehabilitation vary from state to state—check with your physician or pulmonary rehabilitation provider to obtain the guidelines in your state.

    • Oxygen therapy: People with severe COPD may have low levels of oxygen in their blood, a condition called hypoxemia. This may cause increased difficulty breathing, and further impair the ability to exercise. Low oxygen levels may also cause fatigue, memory loss, headaches in the morning, depression, and confusion. Oxygen therapy can help patients with hypoxemia, but it usually is given only to patients with very severe (stage IV) COPD. For these people, long-term use of supplemental oxygen for more than 15 hours each day can prolong life and improve quality of life. Oxygen therapy also may reduce shortness of breath during exertion, which makes it easier to perform basic daily activities. Supplemental oxygen may be used continuously (24 hours) or periodically, such as only during exercise or overnight. The primary goal of using supplemental oxygen is to ensure adequate delivery of oxygen to preserve the function of vital organs.
    • Lung volume reduction surgery: Selected patients with advanced COPD may be candidates for this procedure, which removes the parts of the lung that are most heavily damaged by emphysema. The destruction of alveoli in people with emphysema causes air to get trapped in the lungs, and as a result, the lungs become enlarged (hyperinflated). Enlarged lungs can crowd the chest cavity and flatten the diaphragm, making it more difficult to breathe. Removing these hyperinflated portions of the lungs has the effect of improving lung function and quality of life. The surgery won’t cure emphysema, but it may help to relieve symptoms and may prolong life in some patients. However the surgery only helps a minority of patients with emphysema. For this reason, it is very important that patients who are considering lung volume reduction are carefully evaluated by a surgeon who is experienced in this highly specialized surgery. Medicare covers traditional lung volume reduction surgery for people who meet certain criteria, and requires that anyone contemplating the surgery first complete a certified pulmonary rehabilitation program.
    • Lung transplantation: Lung transplantation may be considered for patients with severe COPD who are otherwise healthy. This procedure is generally reserved for people who have end-stage lung disease, but no other significant health problems. The criteria generally include an FEV1 less than 20 percent of what would be predicted for someone without lung disease, as well as very low oxygen levels, or very high carbon dioxide levels. For patients with emphysema, either one or both lungs may be transplanted. The procedure generally results in improved lung function and better quality of life. However, there are risks involved in the surgery, and lung transplant recipients must take drugs to suppress their immune system for the remainder of their lives. These drugs are necessary to prevent the body from rejecting the new organ.

VIII. LUNG HEALTH: SELF-HELP STRATEGIES

In addition to taking prescribed medications, people with COPD can take steps to improve their health and possibly slow down the damage caused by the disease. For people who are current smokers, quitting the habit is vital. People with COPD should also reduce their exposure to secondhand smoke, and other lung irritants. In addition, eating a healthful diet, exercising regularly, using special breathing techniques, and even staying cool can have important benefits: One study found that high indoor and outdoor temperatures were linked to more symptoms, while being in hot indoor environments also worsened lung function.

Smoking Cessation

Stopping smoking is an essential step for preventing and treating COPD—but as just about anyone who has quit smoking or tried to quit smoking can attest, this advice is easy to give but not so easy to accomplish. About 70 percent of adult smokers report that they want to quit completely, but very few people succeed in permanently quitting on their first attempt. Quitting smoking requires, first and foremost, motivation. But it also requires understanding what you’re up against and getting the right type of help.

Nicotine Addiction

Nicotine is an addictive substance that acts on regions of the brain that produce pleasurable effects, and it produces these effects very quickly. Nicotine is carried in cigarette smoke into the lungs, where it is absorbed from the alveoli into the bloodstream. From there, it reaches the brain within about seven seconds—an extremely efficient mode of drug delivery. It also clears from the brain very quickly. In the brain, nicotine causes the release of brain chemicals called neurotransmitters. The primary neurotransmitter released from nicotine intake is dopamine, which is believed to be linked to the region of the brain responsible for pleasurable feelings, such as those connected with food and sex. Other neurotransmitters released when nicotine binds to nicotinic receptors produce effects that also reinforce tobacco use. These include improved memory and attention, reduced anxiety and stress, relaxation, improved mood, and appetite suppression.

Many smokers come to depend on smoking to reliably produce these effects. However, because nicotine levels don’t stay elevated in the blood for very long, the effects are short-lived and more cigarettes are needed to achieve them.
Upon quitting, many smokers report withdrawal symptoms, such as depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, and increased appetite or weight gain. These are relieved with smoking, making it especially difficult to quit.

The physiologic addiction to nicotine is only part of the story: There also is a large psychological and behavioral component. Smoking becomes a habit, and as such, smokers often associate smoking with certain activities or moods. For example, some people smoke a cigarette after a meal or with a drink, when they feel stressed, or to perk themselves up when they feel down. Smokers also come to associate the pleasurable effects of smoking with the ritual of smoking. They may enjoy just holding a cigarette, the act of lighting it, or the smell and taste of the smoke.

For some people age 65 and older, Medicare Part B will cover smoking cessation counseling. The coverage is limited to those who smoke and have a disease or adverse health effects linked to tobacco use. Two smoking cessation attempts are allowed each year; for each attempt Medicare will pay for up to four counseling sessions.

Breaking the smoking habit will most likely require coming up with new problem-solving and stress-reducing techniques to replace smoking. For example, it can be helpful to identify situations or activities that increase your risk for smoking, and discuss new types of coping skills with a counselor or fellow smokers who are quitting. Also try to minimize time spent with smokers, to reduce temptation.

Medications That Can Help

To address the nicotine addiction, several types of pharmacologic therapies are available to relieve withdrawal symptoms. Many of these products are nicotine replacement therapies. These are available in skin patches, gums, lozenges, inhalers, and a nasal spray. The patch, gum, and lozenges can be obtained without a prescription. Nicotine gum is not chewed like regular gum—in order for the nicotine to be absorbed, the gum must be chewed a few times, and then placed and held between the cheek and gum.

The nicotine patch maintains a steady blood level of nicotine, which avoids the ups and downs of nicotine levels during smoking, and disrupts the “crave and reward” cycle. A step-down program is usually recommended when using the nicotine patch. This program starts with a higher dose (21 mg/day), which is reduced to a moderate dose (14 mg/day), and finally a low dose (7 mg/day).
E-cigarettes contain nicotine, and some smokers switch to these vapor-producing devices to help them quit tobacco cigarettes. While the effectiveness of nicotine replacement therapies such as the gum and patch are established; e-cigarettes are still being studied as an aid to quitting. One recent study found that smokers who used e-cigarettes were actually less likely to quit smoking than those who never used them.

Another drug that is sometimes used for smoking cessation is bupropion (Zyban), which requires a doctor’s prescription. Zyban has been shown to help eliminate withdrawal symptoms, but it appears that the drug works best when used in conjunction with one of the nicotine replacement therapies.
Varenicline (Chantix) is another drug available by prescription only. It works by binding to some of the nicotinic receptors, which blocks nicotine from binding to these receptors. This results in a reduction in the craving for nicotine, and decreases the pleasurable effects of smoking. Studies have shown the drug to be generally effective at helping people to quit smoking; however, some people who take the drug experience severe changes in mood and behavior. The manufacturer advises stopping the drug and contacting a healthcare provider immediately if agitation, depressed mood, changes in behavior, or suicidal thoughts or behavior occur.

Health Benefits of Smoking Cessation

Some of the benefits of quitting occur relatively quickly—for example, within 20 minutes of your last cigarette, your heart rate drops; while the carbon monoxide level in your blood drops to normal after about 12 hours. By two to three months after your last cigarette, your lung function begins to improve, and your heart attack risk begins to fall. Within one to two years, the risk for heart disease decreases. The risk for developing cancer also declines with the number of years of smoking cessation.

Eat Right

For people with COPD, difficulty breathing may make it difficult to eat properly, creating a downward cycle that can lead to malnourishment and even greater breathing problems. Malnutrition can worsen lung function and also compromise the immune system, rendering a person with COPD susceptible to infections and other illnesses.

It is extremely important for people with COPD to consume the recommended number of calories, and try to maintain a healthy weight. If you are underweight, it means your body has fewer stores of energy to draw from. Being overweight also can be problematic, since carrying extra weight means the heart has to work harder, which makes breathing more difficult.

A well-balanced diet that provides an adequate number of calories is necessary for good health. The recommended caloric intake varies by age and level of activity. For example, women age 51 and older who are relatively sedentary need about 1,600 calories per day—this rises to 1,800 calories for moderately active women in this age group, and 2,000-2,2000 for those who are active. For men, the numbers are 2,000, 2,200-2,400, and 2,400-2,600 respectively.

Keep in mind that people with COPD expend extra energy in the simple act of breathing. For a person with COPD, the act of breathing may burn 10 times as many calories as it does for someone without lung disease. This means that even more calories may be required to maintain proper weight.
Foods to prioritize: The U.S. Department of Agriculture (USDA) has established sound nutrition guidelines (visit www.mypyramid.gov to view these). You might also consider consulting a registered dietitian who specializes in COPD and can work with you to develop an individualized food plan.

The USDA recommends consuming foods and beverages that are rich in nutrients and come from the basic food groups. Try to avoid foods with little nutritional value that supply only empty calories. The diet should emphasize fruits, vegetables, whole grains, and dairy products. The diet should also include protein from lean meats, poultry, and fish, along with beans, eggs, and nuts. Try to limit the amount of saturated fats, trans fats, cholesterol, salt (sodium), and sugar. Sodium is particularly problematic because it can cause fluid retention, which can interfere with breathing.

Drink plenty of fluids, which help to thin mucus and thus make it easier to cough up. Try for six to eight glasses (eight fluid ounces each) per day. Water, milk, and fruit juice are the best sources, but coffee, tea, and soft drinks also count.

Exercise Regularly

People at all stages of COPD experience a decline in their ability to engage in physical activity over time as the disease worsens. But while it may seem difficult to exercise when breathing is a problem, a program of regular exercise can actually improve lung function. It also keeps muscles strong, and improves overall health. A recent study of people with COPD found that those who got no exercise at all were less able to be physically active and had weaker muscle strength compared to people who were at least somewhat physically active.

If you feel daunted by the idea of exercising, keep in mind that the level of exertion required is relative to your health and ability. You don’t need to be an athlete to benefit from exercise—in fact you should begin by having a discussion with your doctor to determine the most appropriate type of exercise and level of intensity.

If you’ve been in a pulmonary rehabilitation program, continue the exercises on your own after finishing the program. If you haven’t been in one of these programs, be sure to increase your physical activity slowly from your present level. Walking and swimming are good ways to get exercise without overexerting yourself. Try to walk a little farther and for longer periods each day. Try to work up to 20 to 30 minutes of physical activity three to five times a week. The key is to do it on a regular basis (daily, or at least several times each week). Research has shown that increasing physical activity decreases hospitalizations due to flare-ups of COPD. One study found that people with COPD who engaged in any regular exercise were about one-third less likely to be readmitted to the hospital within 30 days of being discharged. The benefit was greatest for those who exercised 150 minutes or more a week.

Before beginning an exercise, warm up your muscles by doing some stretches. If walking is your chosen activity, start at a slow pace and gradually walk faster. It may help to walk or exercise with friends, making it a social occasion. Be sure to go at your own pace, and don’t compare yourself to anyone else. Keep a diary to record your exercise goals and track your progress. Breathing techniques, such as pursed-lip breathing and diaphragmatic breathing, may help to make the most of every breath you take. Talk to your physician or respiratory therapist about these techniques to find out if they might be useful for you.

Diaphragmatic Breathing

This makes more efficient use of the diaphragm (a dome-shaped muscle in the abdomen, which is involved in the mechanical process of breathing). In people with COPD, the diaphragm and other muscles involved in breathing can weaken. Using a diaphragmatic breathing technique can help to strengthen these muscles, slow down your breathing rate, increase your blood oxygen levels, and allow you to use less effort to breathe. Here’s how:

• Lie comfortably on your back.
• Place one hand on your upper chest and one on your stomach.
• Breathe normally for a minute, and notice whether your chest or stomach rises with each intake of breath. If your chest expands, try to focus on breathing with your diaphragm (which would cause your stomach to rise).
• Inhale slowly through your nose.
• Slowly exhale through pursed lips.
• Rest and repeat. Continue for five to 10 minutes.

Breathe Clean Air

Keep the air in your home as clear of irritants as possible. For example:
Don’t smoke, and don’t allow anyone else to smoke in the house.
Keep all fumes and strong smells out. If you must have painting done, stay out of the house until it is finished. Avoid smoke from wood fires.

Also avoid outdoor air pollutants as much as you can, by staying indoors when outdoor air quality is poor. If you have to go outdoors, refrain from strenuous activity. The American Lung Association provides information about air quality on the website www.stateoftheair.org. A “State of the Air” app is available for smartphones and tablets, to check ozone and particulate pollution.
Travel comfortably: Having a chronic lung disease such as COPD may require making special arrangements for traveling, especially travel by airplane. Those who require oxygen therapy will first need to obtain permission to fly from their physician. They must also notify the airline well in advance of travel, to arrange for use of oxygen during the flight.

Some people who don’t require oxygen therapy at home may need supplemental oxygen while flying, since changes in air pressure that occur in an aircraft may cause a flare-up of symptoms.
Always discuss air travel plans with your physician. Lung function tests will likely be needed to determine whether supplemental oxygen will be required. The doctor will also need to provide a letter to the airline. During the flight, the oxygen will be provided by the airline (there will likely be a fee for this service). Passengers are not allowed to bring their own oxygen canisters on board an airplane, but some airlines will allow patients to use their own portable concentrators during flights. Empty cylinders and equipment likely are allowed only as checked baggage.

Information about which airlines allow use of oxygen on flights, along with their policies, is available from the Airline Oxygen Council of America (www.airlineoxygencouncil.org).

Relax and take care of yourself

Anxiety, stress, and fatigue are common in everyday life and can lead to health problems even for otherwise healthy people. For people with COPD, they can exacerbate the condition, leading to worsened lung function, infections, and other health problems. It’s vital to know your limits. Take the time you need for everyday tasks, and rest when you are tired. Even something as simple as choosing clothes that are easy to put on and take off can make things easier. Also stay away from crowds during flu season, even if you’ve been vaccinated against flu.

Coping with COPD may feel overwhelming at times. Sharing your feelings and concerns with loved ones, and asking for their help may ease some of the burden. Joining a support group for people with COPD may be even more helpful. The American Lung Association (The American Lung Association) is a worthy resource for finding a local support group.