Chronic Obstructive Pulmonary Disease (COPD)
By Jillian Foglesong Stabile, MD
The term COPD is one you’ve probably heard many times. There are lots of ads for different medications on television and in magazines. But what is COPD? What causes it, and how is it treated? We’ll be discussing some of the basics of COPD, its diagnosis, and treatment.
COPD is a combination of lung conditions such as chronic bronchitis and emphysema. These conditions cause respiratory symptoms such as cough, excessive sputum production, and shortness of breath. It is caused by air getting trapped in the lungs making it more difficult for air to flow in and out. COPD is persistent and generally worsens over time.
Types of COPD
The 2 most common types of COPD are emphysema and chronic bronchitis.
Emphysema is a type of COPD that affects the alveoli, which is the air space at the very end of the lungs. On x-ray, this type of COPD may show up as “blebs,” which is the enlargement of the alveoli. Picture emphysema like an overfilled bubble with no elasticity in the walls.
Chronic bronchitis is long-term inflammation of the bronchi, which are the breathing tubes in the airways. The inflammation causes increased mucus. This makes people more likely to get lung infections.
Causes of COPD
COPD is most commonly caused by smoking. Other toxic particles, such as pollution, can also contribute. COPD can also be more likely in people with abnormal lung development or genetic conditions such as α1-antitrypsin deficiency.
Who gets COPD?
COPD is more common in
- Current or former smokers
- People >65
- American Indians, Alaskan Natives, and multiracial people
- People who are not working (unemployed, retired, or disabled)
- People with less education
- People with asthma
- People who are divorced, widowed, or separated
Women and COPD
COPD is becoming more commonly diagnosed in women. Women are more likely to be diagnosed later than men and may be more vulnerable to the effects of tobacco and other toxins. Women who smoke tend to get COPD at younger ages than their male counterparts.
Symptoms of COPD
Early in the course of COPD, many people don’t have any symptoms or may only have mild symptoms. As COPD gets worse, cough, wheezing, shortness of breath, and chest tightness are common. If these symptoms sound like other conditions, such as asthma or the common cold, you’re right. The symptoms associated with COPD are common in other diseases and conditions as well. People with COPD are also prone to lung infections, lung cancer, heart problems, weak muscles, and bones, depression, and anxiety.
Diagnosis of COPD
COPD is generally diagnosed with forced spirometry or pulmonary function testing. This testing is performed in your primary care doctor’s office or with a specialist. The testing involves breathing into a machine forcefully to measure the volume of your lungs, along with other measurements. You’ll typically do a breathing treatment and then repeat the testing.
Part of the definition of COPD involves how reversible the obstruction is, which is determined by response to the breathing treatment. Your doctor will use the results of this testing to determine the degree of disease and also help determine what type of treatment might be beneficial for your condition.
COPD exacerbation is a flair of COPD. Patients have worsening of their symptoms. Exacerbations are associated with shortness of breath, airway and body inflammation, and overinflated lungs. Usually, exacerbations start with a bacterial or viral respiratory infection. Exacerbations frequently cause hospitalization and are a major cause of morbidity and mortality. Patients who have exacerbations may be slow to return to their pre-exacerbation level of function, and some never get back to their baseline.
Causes of COPD Exacerbation
As mentioned above, exacerbations are mostly caused by viruses or bacteria. Most of the time, we don’t know the exact cause of the symptoms. In hospitalized patients, when patients have been cultured, the most commonly identified organisms are
- Coronavirus (not necessarily covid)
- Respiratory syncytial virus (RSV)
Pollution is also a potential cause of COPD exacerbation. Patients who have respiratory illnesses should consider staying indoors when pollen or pollutant counts are high.
Treatment for COPD
Treatment for COPD falls broadly into 2 categories. Treatment for COPD and treatment of exacerbations. Many classes of medication can be used in the case of COPD, that we’ll discuss broadly in this section.
General Treatment for COPD
General guidelines for COPD treatment include, first and foremost, stopping smoking. There are many resources out there for patients that want to quit smoking. Smoking cessation is difficult but doable. Talk to your healthcare provider about options and resources to quit smoking. Avoid secondhand tobacco smoke and other air pollutants. Stay away from people that are sick.
Avoiding respiratory infections can help you avoid exacerbations. Get your recommended vaccines. Influenza “flu” vaccine is recommended yearly. Other vaccines that may be recommended for you include the pneumococcal “pneumonia” vaccine and the SARS-CoV2 “covid” vaccine. Talk with your healthcare provider about what vaccinations are recommended for your specific health needs.
Pulmonary rehabilitation is a program that helps you learn about COPD and learn to increase your awareness of your breathing. Classes can occur individually or in groups. You learn breathing techniques to improve shortness of breath and to exercise your lungs to improve your ability to exercise your body and improve your lung function. To find a pulmonary rehabilitation program, talk to your healthcare provider about resources in your area.
Medication for COPD Exacerbation
When you’re experiencing an exacerbation, the first thing that your healthcare provider will do is evaluate whether you need to be hospitalized. Patients who are in respiratory distress require hospitalization to stabilize them and reduce the risk of death. Most patients who have a COPD exacerbation do not require hospitalization. Your healthcare provider (or the urgent care or emergency room) may get labs and or x-rays to determine if you have developed pneumonia which increases your risk of hospitalization and complications from the exacerbation.
If you don’t require hospitalization, the medications used to treat an exacerbation most commonly include systemic steroids, bronchodilators, and antibiotics.
Bronchodilators such as Albuterol are used to open your airways to improve breathing in the short term. These can be administered by nebulizer or by metered dose inhaler. Some of the bronchodilators may be combined with an anticholinergic medication such as ipratropium and can be used to open the airways and decrease secretions.
Steroids are used to decrease inflammation in the lungs. They can be administered in oral or IV forms. The IV forms of steroids are administered in hospitalized patients and only rarely in outpatients in very specialized cases. Steroids have been shown to decrease the rate of treatment failure, shorten hospital stays in hospitalized patients and prevent hospitalizations in outpatients, and improve low oxygen levels. They may also increase the time between exacerbations, thereby decreasing the frequency of exacerbations.
About half of the patients with COPD exacerbation have increased bacteria concentrations in their lungs. Since we don’t always know what organism causes COPD exacerbation, it is common to start antibiotics to treat patients with exacerbation. Studies have shown that antibiotics decrease the risk of treatment failure and death in moderate to severe exacerbations.
Patients who require supplemental oxygen (and don’t use it at home) usually require hospitalization. Supplemental oxygen is used for patients who have low blood oxygen levels. It’s a supportive measure and is not treating the underlying inflammation or infection.
Medication for Patients with COPD without Exacerbation
There are many types of medication used to treat COPD when you don’t have an exacerbation.
Long-acting bronchodilators (LABAs) are one of the most common treatments for stable COPD patients because they decrease shortness of breath and improve quality of life. They also decrease the number of exacerbations. These medications can be found alone or in combination with other medications for COPD.
Long-acting muscarinic antagonists
Long-acting muscarinic antagonists (LAMAs) are more effective than LABAs at reducing exacerbations and hospitalizations. They are used in monotherapy or in combination with other medications.
Inhaled corticosteroids (ICS) are typically not used as monotherapy. These medications can increase the risk of thrush, hoarseness, or pneumonia and are used in combination with other therapies in more severe cases of COPD.
Phoshodiesterase-4 inhibitors such as Roflumilast or theophylline are used in severe cases of COPD. We don’t know exactly how they work, but studies have shown that it may slightly decrease the number of exacerbations in select patients.
Supplemental oxygen is used in patients who have chronic difficulty maintaining their oxygen saturation. To qualify for supplemental oxygen at home, you generally need to be in a chronic stable state and have oxygen levels below 88% either at rest or with exercise. Usually, you have to have levels that improve with supplemental oxygen.
COPD is a chronic and treatable disease. There is no cure currently, but there are a variety of treatment options available that can improve your quality of life and help you live longer. If you or a loved one has been diagnosed with COPD, talk to your healthcare provider about treatment options that will work best for you.
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Dr. Foglesong Stabile is a board-certified Family Physician who enjoys full scope Family Medicine, including obstetrics, women’s health, and endoscopy, as well as caring for children and adults of all ages. She also teaches the family medicine clerkship for Pacific Northwest University of Health Sciences.