Managing chronic Obstructive Pulmonary Disease (COPD)

Living with Emphysema and Bronchitis

Overview

Chronic obstructive pulmonary disease or COPD for short, is a chronic inflammatory lung disease that lead to obstructed ain and out of the lungs. COPD Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. It's most commonly caused by environmental factors, through chronic exposure to irritating gases or particulate, most often from cigarette smoke. People who develop COPD are at increased risk of developing heart disease, lung cancer from the shared risked factors.

The prevalence of COPD varies depending between countries and depends on factors such as smoking rates, air pollution levels, and access to healthcare. It's more common in low- and middle-income countries, where smoking prevalence is high and air pollution levels may be more elevated. In the United States, roughly 16 million people are currently diagnosed with COPD, but it's estimated that a further 16 million people have the disease but are undiagnosed. COPD becomes more common with advancing age, but it can affect people of all ages.

COPD is a significant public health issue which poses a considerable economic and quality of life burden. Efforts to prevent and manage the disease have a large impact on public health outcomes.

What are the types COPD?

Emphysema and chronic bronchitis are the two most common variants. They can occur together and vary in severity in individuals with COPD.

Chronic bronchitis is inflammation of the lining of the bronchial tubes. These carry air to and from the air sacs (alveoli) of the lungs where gas exchange taxes place. It's characterized by persistent coughing and mucus or sputum production.

Emphysema is a condition in which the alveoli, the terminus of the smallest air passages (bronchioles) of the lungs are damaged as a result of exposure to cigarette smoke and other irritating gases and particulate matter.

What’s the difference between COPD and asthma?   

With COPD, the airways have become permanently narrowed. There is a role for inhaled medication to help to open them up, but only to a slight extent.

With asthma, the narrowing of the airways is transitory. It often happens in response to a trigger; something inhaled that irritates the airways. Examples are dust, pollen or tobacco smoke. Inhaled medication can open the airways fully and relieve symptoms caused by tightness.

Symptoms of breathless, cough, wheeze or a tight chest that vary between days, or cause waking up in the night with symptoms, are more likely to indicate asthma.

However, the symptoms are similar and some people with asthma will eventually develop COPD in later life, and it can sometimes be difficult to distinguish between the two conditions, and some people have both COPD and asthma, which to say they have some temporary, reversible narrowing of the airways (asthma) on top of either permanent narrowing (chronic bronchitis) or damaged alveoli (emphysema).

Untreated COPD can be a disease that worsens over time; however, COPD is treatable. With good management, most people with COPD can attain good control of symptoms and quality of life, as well as reduction int the risk of associated conditions.

Symptoms

COPD symptoms often don't arise until significant amount of lung damage has taken place, and they tend to progressively worsen with time, particularly if environmental exposure continues.

Signs and symptoms of COPD may include:

Shortness of breath exacerbated by physical activities.

Wheezing

Chest tightness

Chronic cough that may produce mucus (sputum). It may be clear colour, white, yellow or greenish in appearance, which may indicate infection.

Frequent respiratory infections

Lack of energy

Unintended weight loss (in later stages)

Swelling around ankles, legs or feet.

People with COPD commonly experience more severe episodes or exacerbations, during which their symptoms become worse than the usual and this may continue for several days.

When to see a doctor

Consult a doctor if symptoms are not improving with treatment or getting worse, or there symptoms of an infection, such as fever or a change in sputum.

Immediate medical should be sought if patients feel short breath at rest or develop blueness of the lips or fingernail beds (cyanosis) or a rapid heartbeat, or if they feel drowsy.

Causes

The main cause of COPD in developed countries is tobacco smoking. In the developing world, COPD often occurs through exposure to fumes generated by burning fuel for cooking and heating in inadequately ventilated buildings.

Only a proportion of chronic smokers develop symptomatic COPD, although many smokers with long smoking histories have reduced respiratory function.

How the lungs are affected

Air travels down the windpipe (trachea) and into the lungs through two large tubes (bronchi). Inside the lungs, these tubes divide numerous times, a bit like the branches of a tree, into many smaller tubes (bronchioles) that terminate in clusters of tiny air sacs (alveoli).

The air sacs have very thin walls full of tiny blood vessels (capillaries). The oxygen in the inhaled air passes into these blood vessels to enter the bloodstream. Carbon dioxide — a gas that is a waste product of metabolism, travels in the opposite direction.

The lungs rely on the natural elasticity of the bronchial tubes and the alveoli to force air out. COPD causes them to lose their elasticity and over-expand, which leaves some the air trapped in the lungs, unable to escape during exhalation.

Emphysema

Causes of airway obstruction include:

In most people with COPD, the lung damage is caused by long-term cigarette smoking or other inhaled irritants. But there are likely numerous other factors at play in the development of COPD, such as a genetic predisposition to the disease, as not all smokers develop COPD.

Other irritants can cause COPD, including second-hand or passive smoke, pipe smoke, air pollution, and workplace exposure to dust, smoke or fumes.

Alpha-1-antitrypsin deficiency

This is the cause in about 1% of people with COPD. This is a genetic disorder that causes low levels of a protein called alpha-1-antitrypsin (AAt). AAt is manufactured in the liver and released into the bloodstream to help protect the lungs. Alpha-1-antitrypsin deficiency can lead to liver or lung disease or both.

For adults with COPD related to AAt deficiency, treatment options include all those used for people with the more-common types of COPD. In addition, some people can be treated by taking the missing AAt protein, which may help to prevent further damage to the lungs.

Age: As people become older, the risk of developing COPD increases.

Respiratory infections: Repeated respiratory infections, such as pneumonia and bronchitis can damage the lungs and increase the risk of developing COPD.

Smoking is the most significant risk factor for COPD, particularly as it is preventable, and quitting smoking can slow down the progression of the disease.

Complications

COPD can cause many complications, including:

Respiratory infections. People with COPD are more prone to catch colds, the flu and pneumonia. Any respiratory infection can make it harder to breathe and may cause further damage to the lung.

Heart problems. For reasons that aren't fully understood, COPD can increase the risk of heart disease, including heart attacks and angina.

Lung cancer. People with COPD have a higher risk of developing lung cancer due to the increased exposure to environmental carcinogens.

High blood pressure in lung blood vessels. COPD may cause raised blood pressure in the blood vessels that bring blood to the lungs (pulmonary hypertension).

Depression. Difficulty breathing can prevent people from carrying out the activities that the enjoy. And dealing with the consequences of illness can contribute to the development of depression.

Prevention

Unlike some diseases, COPD often has a defined cause and a clear means of prevention and slowing its progression. Most cases are directly related to cigarette smoking, and the best way to prevent COPD is to avoid smoking or quit immediately, which is easier said than done, but plenty of assistance is available through tobacco cessation programs. Also, avoiding second-hand smoke exposure whenever possible

Occupational exposure to chemical, fumes and dusts is another risk factor for COPD. It is important to reduce occupational exposure by wearing the most suitable protective equipment.

Some useful steps to help prevent complications associated with COPD:

Quitting smoking also reduces the risk of heart disease and lung cancer.

Getting regular flu and pneumococcal pneumonia vaccine reduces the risk of infections.

Consult the doctor if feeling, sad or helpless or experiencing depression.

Diagnosis

COPD is commonly misdiagnosed. Many people with COPD are not diagnosed until the disease is advanced.

Diagnosis is based on review of COPD signs and symptoms, assessing family and medical history, and exposure to lung irritants, in particular smoking.

Diagnosis requires tests including:

Lung (pulmonary) function tests. These tests measure the amount of air that patients are able to inhale and exhale, and whether the lungs deliver enough oxygen to the blood. The most common test is spirometry. This involves measuring much air the lungs can hold and how fast the air is blown out of the lungs. Other tests include measurement of lung volumes and diffusion capacity, walk tests, and pulse oximetry.

Chest X-ray. A chest X-ray can show emphysema, other lung problems or signs of heart failure.

CT scan. A CT scan of the lungs detect emphysema and screen for lung cancer.

Arterial blood gas analysis. This blood test measures how effectively the lungs are bringing oxygen into the blood and removing carbon dioxide.

Laboratory tests. Lab tests may be used to determine the presence of the genetic disorder alpha-1-antitrypsin deficiency, which may be the cause of COPD in some patients, particularly in younger patients and those with a family history of COPD.

Treatment

Many people with COPD have only mild disease for which little treatment is required other than smoking cessation. For more advanced stages of disease, effective treatment is available that can control symptoms, slow progression, or reduce the risk of complications and exacerbations, and improve quality of life.

Quitting smoking

The most essential step in any treatment plan for COPD is to quit all smoking. Stopping smoking can keep COPD from getting worse and reducing your ability to breathe. But quitting smoking isn't easy. And this task may seem particularly daunting if you've tried to quit and have been unsuccessful.

Medications

There are several different types of medications that are used to treat COPD.

Bronchodilators

Bronchodilators usually come in inhalers — they relax the muscles around your airways to widen the passage and reduce obstruction. This can treat coughing and shortness of breath and make breathing more comfortable. Some people need a short-acting bronchodilator before activities, whilst others require long-acting bronchodilators for every day use.

Examples of short-acting bronchodilators include:

Ipratropium (Atrovent HFA)

Albuterol (ProAir HFA, Ventolin HFA, others)

Levalbuterol (Xopenex)

Examples of long-acting bronchodilators include:

Arformoterol (Brovana)

Aclidinium (Tudorza Pressair)

Formoterol (Perforomist)

Indacaterol (Arcapta Neoinhaler)

Salmeterol (Serevent)

Tiotropium (Spiriva)

Umeclidinium (Incruse Ellipta)

Inhaled steroids

Inhaled corticosteroids can reduce airway inflammation and help prevent exacerbations. Side effects can include oral infections and bruising. These medications are useful for those with frequent exacerbations of COPD.

Examples of inhaled steroids include:

Budesonide (Pulmicort Flexhaler)

Fluticasone (Flovent HFA)

Combination inhalers

Some medications combine bronchodilators and inhaled steroids. Examples of these combination inhalers include:

Fluticasone and vilanterol (Breo Ellipta)

Fluticasone, umeclidinium and vilanterol (Trelegy Ellipta)

Formoterol and budesonide (Symbicort)

Salmeterol and fluticasone (Advair HFA, AirDuo Digihaler, others)

Combination inhalers that include more than one type of bronchodilator also are available. Examples of these include:

Aclidinium and formoterol (Duaklir Pressair)

Albuterol and ipratropium (Combivent Respimat)

Formoterol and glycopyrrolate (Bevespi Aerosphere)

Glycopyrrolate and indacaterol (Utibron)

Olodaterol and tiotropium (Stiolto Respimat)

Umeclidinium and vilanterol (Anoro Ellipta)

Oral steroids

For more severe flare ups of COPD becomes more severe, short courses of oral corticosteroids may prevent worsening of COPD. However, long-term use of corticosteroids can have serious side effects, such as, osteoporosis, cataracts weight gain, diabetes and an increased risk of infection.

Phosphodiesterase-4 inhibitors

Approved for severe COPD and symptoms of chronic bronchitis, roflumilast (Daliresp), is a phosphodiesterase-4 inhibitor. It decreases airway inflammation and relaxes the airways. Common side effects include weight loss and diarrhoea.

Theophylline

When other treatment has been ineffective, theophylline (Elixophyllin, Theo-24, Theochron), may help improve breathing and prevent episodes of worsening COPD. Side effects are dose dependent and include, fast heartbeat, nausea, headache and tremor. The blood levels of the medication need to be monitored.

Antibiotics

Respiratory infections can aggravate COPD symptoms. Antibiotics can help to treat episodes of worsening COPD, but they aren't generally used for prevention as side effects and antibiotic resistance may limit their effectiveness.

Lung therapies

Additional therapies for more severe COPD:

Oxygen therapy. If there isn't enough oxygen in the blood, supplemental oxygen is required. There are several oxygen delivery devices, including lightweight, portable units that can be carried around. Some people require oxygen only during activities or during sleep. Others may require oxygen all the time. Oxygen therapy can improve quality of life and is proven to extend life.

Pulmonary rehabilitation program. These programs combine exercise, education, smoking cessation, nutrition advice and counselling. These programmes have been demonstrated to reduce readmission to hospital, increase activity and improve your quality of life.

In-home non-invasive ventilation therapy

A non-invasive ventilation therapy machine which uses positive airways pressure with a mask (BiPAP) helps to improve breathing and reduces retention of carbon dioxide (hypercapnia) that can lead to acute respiratory failure and hospitalization.

Managing exacerbations

Exacerbations can be triggered by respiratory infection, air pollution or other causes of inflammation. Prompt medical help should be sought if there is an increase in coughing or if breathing has become harder.

Exacerbations may require additional medications (such as antibiotics or steroids), or supplemental oxygen. Once symptoms improve, other measures to prevent future exacerbations should be considered, such as quitting smoking, inhaled steroids, long-acting bronchodilators, getting the annual flu vaccine, and avoiding air pollution.

Surgery

Surgery is an option for severe emphysema. Surgical options include:

Lung volume reduction surgery. Removing small wedges of damaged lung tissue from the upper lungs can creates extra space in the chest cavity so that the remaining healthier lung tissue can expand and the diaphragm works more efficiently.

Endoscopic lung volume reduction: this is a less invasive procedure. A small one-way endobronchial valve is placed in the lung, permitting the most damaged lobe to shrink so that healthier parts of the lung have more space to expand into.

Lung transplant. Transplantation can improve the ability to breathe and to be active. However, it's a major operation that has significant risks, such as organ rejection, and requires take lifelong immune-suppressing medications.

Bullectomy. Large air spaces (bullae) form in the lungs when the air sacs (alveoli) are destroyed and combine. These bullae can become large and result in breathing problems. In a bullectomy, bullae are removed from the lungs to improve repiration.

Lifestyle and home remedies

These steps can slow the damage to the lungs and improve wellbeing:

Control of breathing. A respiratory therapist can teach techniques for breathing more efficiently throughout the day, involving breathing positions, and energy conservation and relaxation techniques that can be used when feeling short of breath.

Clear your airways. Mucus can collect in the air passages and be difficult to clear. Controlled coughing, drinking good amounts of water and the use of a humidifier can be helpful.

Exercise regularly. Regular exercise can improve the strength and stamina of the respiratory muscles.

Eat healthy foods. A healthy diet can promote strength. Being over and underweight are both detrimental to respiratory effort.

Avoid smoke (active and passive) and air pollution.

Have regular check up and take flu and pneumonia vaccines regularly.

Coping and support

Living with COPD can be a challenge —Some activities may have to be reduced or modified and may impact on friends and family.

Psychological support is available and some patients may benefit from counselling or medication if you they feel depressed or overwhelmed.

References

1) Chronic Obstructive Pulmonary Disease

2) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019