Chronic Obstructive Pulmonary Disease

What is COPD?
COPD (Chronic Obstructive Pulmonary Disease) is a general term which includes the conditions chronic bronchitisand emphysema.
· Chronic means persistent.
· Bronchitis is inflammation of the bronchi (the airways of the lungs).
· Emphysema is damage to the smaller airways and airsacs (alveoli) of the lungs.
· Pulmonary means ‘affecting the lungs’.
Chronic bronchitis or emphysema can cause obstruction (narrowing) of the airways. Chronic bronchitis and emphysema commonly occur together. The term COPD is used to describe airways which are narrowed due to chronic bronchitis, emphysema, or both.
How common is COPD?
COPD is common. About one million people in the UK have COPD. It mainly affects people over the age of 40. It accounts for more time off work than any other illness. A flare-up (exacerbation) of COPD is one of the commonest reasons for admission to hospital.
What causes COPD?
Smoking is the cause in the vast majority of cases. There is no doubt about this. The lining of the airways becomes inflamed and damaged by smoking. About 3 in 20 one-pack-per-day smokers, and 1 in 4 two-pack-per-day smokers develop COPD if they continue to smoke. Air pollution and polluted work conditions may cause some cases, or make the disease worse. However, people who have never smoked rarely develop COPD.
What are the symptoms of COPD?
· Cough is usually the first symptom to develop. It is productive with sputum (phlegm). It tends to come and go at first, and then gradually becomes more persistent (chronic). You may think of your cough as a ‘smokers cough’ in the early stages of the disease. It is when the breathlessness begins that people often become concerned.
· Breathlessness (‘short of breath’) and wheeze may occur only when you exert yourself at first, for example, when you climb stairs. These symptoms tend to become gradually worse over the years if you continue to smoke. Difficulty with breathing may eventually become quite distressing.
· Sputum – the damaged airways make a lot more mucus than normal. This forms sputum (phlegm). You tend to cough up a lot of sputum each day.
· Chest infections are more common if you have COPD. Wheezing with cough and breathlessness may become worse than usual if you have a chest infection. Sputum usually turns yellow or green during a chest infection.
What’s the difference between COPD and asthma?
Asthma and COPD cause similar symptoms. However, they are different diseases. Briefly:
· In COPD there is permanent damage to the airways. The narrowed airways are ‘fixed’, and so symptoms are chronic (persistent). Treatment to ‘open up the airways’ is limited.
· In asthma there is inflammation in the airways which causes muscles in the airways to constrict. This causes the airways to narrow. The symptoms tend to ‘come and go’, and vary in severity from time to time. Treatment to reduce inflammation and to ‘open up the airways’ usually works well.
Both asthma and COPD are common, and some people have both conditions.
Do I need any tests?
A test called spirometry is often done to confirm the diagnosis. This test measures how much air you can blow into a machine. A value is calculated from the amount of air that you can blow out in one second divided by the total amount of air that you blow out in one breath. A low value indicates that you have narrowed airways. A low value combined with the typical symptoms of COPD usually confirms the diagnosis.
What is the progression and outlook of COPD?
Symptoms typically begin in people aged over 40 who have smoked for 20 years or more. A ‘smokers cough’ tends to develop at first. Once symptoms start, if you continue to smoke, there is usually a gradual decline over several years. You tend to become more and more breathless. In time your mobility and general quality of life may become poor due to increasing breathing difficulties.

Chest infections tend to become more frequent as time goes by. A flare-up of of symptoms (an exacerbation) occurs from time to time, typically during a chest infection.

As the disease becomes more severe, not enough oxygen may get into the lungs through the narrowed airways. As a result, the amount of oxygen that gets into the bloodstream is less than normal. This can cause heart failure as the heart needs a good oxygen supply.

At least 25,000 people die each year in the UK from the end stages of COPD. Many of these people have several years of ill health and poor quality of life before they die. Chronic ill health and death due to COPD is preventable in most cases (see below).

How can the course of COPD be altered?
Stop smoking. This cannot be stressed enough. If you stop smoking at an early stage of the disease, it will make a huge difference. Any damage already done to your airways cannot be reversed, but stopping smoking prevents the disease from getting much worse. It is never too late to stop at any stage of the disease. Even if you have fairly advanced COPD, you are likely to benefit and prevent further progression of the disease.

Your cough may get worse for a while when you give up smoking. This often happens as the lining of the airways ‘come back to life’. Resist the temptation to start smoking again to ease the cough. An increase in cough after you stop smoking usually settles in a few weeks.

See your practice nurse or doctor if you have difficulty in stopping smoking. Help is available. For example, counselling, nicotine replacement therapy (nicotine gum etc), or other ‘anti-smoking’ medicines may help. See our separate leaflets on smoking and giving up smoking.

What are the treatments for COPD?
Stopping smoking is the most important treatment. No other treatment may be needed if the disease is in the early stage and symptoms are mild.

If symptoms become troublesome, one or more of the following treatments may be advised. Note: treatments do not cure COPD. Treatments aim to ease symptoms. Also, some treatments may prevent some flare-ups of symptoms. As a general rule, a trial of 1-3 months of a treatment will give an idea if it helps or not. A treatment may be continued after a trial if it helps, but may be stopped if it does not improve symptoms.

Short acting bronchodilator inhalers
An inhaler with a bronchodilator medicine is often prescribed. These relax the muscles in the airways (bronchi) to open them up (dilate them) as wide as possible. They include:
· Beta agonist inhalers. For example, salbutamol and terbutaline.
· Antimuscarinic inhalers. For example, ipratropium.
These inhalers work well for some people, but not so well in others. Typically, symptoms of wheeze and breathlessness improve within 5-15 minutes with a beta agonist inhaler, and within 30-40 minutes with an antimuscarinic inhaler. The effect from both types typically lasts for 3-6 hours. Some people with mild or intermittent symptoms only need an inhaler ‘as required’ for when breathlessness or wheeze occur. Some people need to use an inhaler regularly. The beta agonist and antimuscarinic inhalers work in different ways. Using two, one of each type, may help some people better than one type alone.
Long acting bronchodilator inhalers
These include the beta agonists called formoterol and salmeterol, and the antimuscarinic called tiotropium. They work in a similar way to the short acting inhalers, but each dose lasts at least 12 hours. One may be an option if symptoms remain troublesome despite taking a short acting bronchodilator.

Sometimes a combination of a short acting and a long acting inhaler is used. Sometimes a combination of both types of long acting inhaler is used. This is mainly used for people with more severe symptoms, or for people who have frequent flare-ups of symptoms.

Steroid inhaler
A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups (exacerbations) of symptoms. Steroids reduce inflammation. There are several brands of steroid inhaler. A steroid inhaler may not have much effect on your ‘usual’ symptoms, but may help to prevent flare-ups.
Bronchodilator tablets
These contain medicines such as theophylline that ‘open the airways’. Side-effects are quite common and inhalers are usually better. However, some people find inhalers difficult to use, and tablets are an alternative. They may also be added in to the above treatments in severe cases.
Steroid tablets
A short course of steroid tablets is sometimes prescribed if you have a bad flare-up of wheeze and breathlessness (often during a chest infection). They help by reducing the extra inflammation in the airways caused by infections. Taking steroid tablets long-term is not usually advised due to the serious side-effects which can develop.
Mucolytic medicines
A mucolytic medicine such as carbocisteine or mecysteine makes the sputum less thick and easier to cough up. This may also have a knock-on effect of making it less easy for bacteria (germs) to infect the mucus and cause chest infections. The number of flare-ups of symptoms (exacerbations) tends to be less in people who take a mucolytic. It needs to be taken regularly, and is most likely to help if you have moderate or severe COPD and have frequent or bad flare-ups.
A short course of antibiotics is commonly prescribed if you have a chest infection, or if you have a flare-up of symptoms which may be triggered by a chest infection.
This may help some people with severe symptoms. It does not help in all cases. A specialist usually does some breathing tests to assess whether oxygen will help. If found to help, oxygen needs to be taken for at least 15-20 hours a day to be of benefit. Normally, you will only be considered for oxygen if you do not smoke. There is a serious fire risk when using oxygen if you smoke.
This is an option in a very small number of cases. For example, removing a section of lung that has become useless may improve symptoms. Lung transplantation is being studied, but is not a realistic option in most cases.
Treatment of flare-ups (exacerbations) of symptoms
If you have a flare-up of symptoms, you may be advised to increase the dose of your usual treatments, and/or to add in some other treatments for the duration of the flare-up. For example, an increase in the dose of your usual inhaler or perhaps adding in another inhaler type for the duration of the flare-up. Also, commonly, a short course of antibiotics and/or steroid tablets are used as part of the treatment for a flare-up of symptoms.

If you have frequent flare-ups then your doctor may advise on a ‘self-management plan’. This is a written plan of action agreed by you and your doctor on what to do as soon as possible after a flare-up starts to develop. For example, you may be given advice on how to increase the dose of your inhalers when needed. You may also be given some steroid tablets and/or antibiotics to have ‘on standby’ so that you can start these as soon as possible when a flare-up first develops.

What can I do to help?
Get immunised
Two immunisations are advised.
· A yearly ‘flu jab’ each autumn protects against possible influenza and any chest infection that may develop due to this.
· Immunisation against pneumococcus (a germ that can cause serious chest infections). This is a ‘one off’ injection and not yearly like the ‘flu jab’.
Try to do some regular exercise
Studies have shown that people with COPD who exercise regularly tend to improve their breathing, ease symptoms, and have a better quality of life.

Any regular exercise or physical activity is good. However, ideally the activity that you do should make you at least a little out of breath, and be for at least 20-30 minutes, at least 4-5 times a week. If you are able, a daily brisk walk is a good start if you are not used to exercise. But, if possible, try to increase the level of activity over time.

Try to lose weight if you are overweight
Carrying extra weight can make breathlessness worse.
COPD and flying
If you have COPD and plan to fly then you should see your GP well in advance for a ‘fitness to fly’ assessment. Some people with COPD need oxygen when flying, as altitude can decrease the oxygen in your bloodstream.
In summary
· COPD is usually caused by smoking.
· Symptoms usually become worse if you continue to smoke.
· Symptoms are unlikely to get much worse if you stop smoking.
· Treatment with inhalers often eases symptoms, but no treatment can reverse the damage to the airways.
· A flare-up of symptoms, often during a chest infection, may be helped by increasing the dose of usual treatments. This may be combined with a short course of steroid tablets and/or antibiotics.