CHRONIC OBSTRUCTIVE PULMONARY DISEASE OVERVIEW

COPD, or chronic obstructive pulmonary disease, is a condition in which the airways in the lungs become damaged, making it increasingly difficult for air to pass in and out.

There are two major kinds of damage that can cause COPD:

• The airways in the lungs can become scarred and narrowed.


• The air sacs in the lung, where oxygen is absorbed into the blood and carbon dioxide is excreted, can become damaged.

When the damage is severe, it may become difficult to get enough oxygen into the blood and to get rid of excess carbon dioxide. These changes lead to shortness of breath and other symptoms.

Unfortunately, the symptoms of chronic obstructive pulmonary disease cannot be completely eliminated with treatment and the condition usually worsens over time. However, treatment can control symptoms and can sometimes slow the progression of the disease.

This article discusses treatment options for people with chronic obstructive pulmonary disease. Treatment of suddenly worsening symptoms, which often requires hospital treatment, is not discussed here. A review of the risk factors and diagnosis of COPD is also available. (See "Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)".)

CHRONIC OBSTRUCTIVE PULMONARY DISEASE MEDICATIONS

Bronchodilators — Medications that help open the airways, called bronchodilators, are a mainstay of treatment for chronic obstructive pulmonary disease. Bronchodilators help to keep airways open and possibly decrease secretions.

Bronchodilators are most commonly given in an inhaled form using a metered dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer. It is important to use the inhaler properly to deliver the correct dose of medication to the lungs. If you do not use the inhaler correctly, little or no medicine reaches the lungs. (See "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)".)

There are several types of bronchodilators that can be used alone or in combination. (See "Management of stable chronic obstructive pulmonary disease".)

• Short-acting beta agonists – Short-acting beta agonists, sometimes called rescue inhalers, can quickly relieve shortness of breath and can be used when needed. Examples of short-acting beta agonists include albuterol, levalbuterol, and pirbuterol.


• Short-acting anticholinergics – Short-acting anticholinergic medication (ipratropium, Atrovent) improves lung function and symptoms. If symptoms are mild and infrequent, short-acting anticholinergic medication may be recommended only when you need it. Or, if symptoms are more severe or more frequent, it may be recommended on a regular basis.


• Short-acting combination inhaler – A combination inhaler that contains albuterol and ipratropium (Combivent) is also available. Combination inhalers may be used just when needed or regularly, depending on the frequency and severity of your symptoms.

Long-acting treatments are often recommended for people who must use medication on a regular basis to control COPD symptoms.

• Long-acting beta agonists – Long-acting beta agonists may be recommended if your symptoms are not adequately controlled with other treatments. Examples of long-acting beta agonists include salmeterol, formoterol, and arformoterol.


• Long-acting anticholinergics – The long-acting anticholinergic medication, tiotropium (Spiriva), which is taken once daily, improves lung function while decreasing shortness of breath and flares of COPD symptoms. Aclidinium (Tudorza), a long-acting anticholinergic that is taken twice daily, also improves lung function. This type of medication may be recommended if your symptoms are not adequately controlled with other treatments, such as the short-acting bronchodilators.


• Theophylline – Theophylline in slow release form (eg, Theo-Dur, Slo-bid) is a long-acting bronchodilator that is taken in pill form. Theophylline is not commonly used, but may be beneficial to some people with more severe, but stable chronic obstructive pulmonary disease. The dose of theophylline must be monitored carefully by blood tests because of its potentially toxic effects.

Glucocorticoids — Glucocorticoids (also called steroids, although they are very different from muscle building steroids) are a class of medication that has anti-inflammatory properties. Glucocorticoids can be taken with an inhaler, as a pill, or as an injection. Inhaled glucocorticoids may be recommended if your symptoms are not completely controlled with bronchodilators and/or if you have frequent flares of chronic obstructive pulmonary disease.

Glucocorticoids taken in pill form are sometimes used for short term treatment (eg, for flares of COPD), but are not generally used long-term because of the risk of side effects.

Combination treatments — Combinations of short and long-acting bronchodilators, anticholinergics, and/or glucocorticoids are often used in people whose symptoms are not completely controlled with one medication.

Cough medicines — Cough medicines are not generally recommended for people with COPD because they have not been shown to improve COPD symptoms. Although cough can be a bothersome symptom, cough suppressants should be avoided since suppressing cough may increase the risk of developing an infection.

SUPPLEMENTAL THERAPIES FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Stop smoking — One of the MOST important treatments for chronic obstructive pulmonary disease is for current smokers to stop smoking. Studies of people with COPD show that the disease progresses more slowly after stopping smoking. Most people who stop smoking will cough less and produce less sputum, although this may take several months. A detailed discussion of ways to quit smoking is available separately. (See "Patient information: Quitting smoking (Beyond the Basics)".)

Oxygen — People with advanced chronic obstructive pulmonary disease can have low oxygen levels in the blood. This condition, known as hypoxemia, can occur even if the person does not feel short of breath or have other symptoms. The oxygen level can be measured with a device placed on the finger (pulse oximeter) or with a blood test (arterial blood gas). People with hypoxemia may be placed on oxygen therapy, which can improve survival and quality of life. (See "Use of oxygen in patients with hypercapnia".)

Some people with COPD who travel by air may be prone to hypoxemia during travel because of the changes in air pressure inside the plane. If a clinician determines that you are at risk for hypoxemia during a flight, in-flight oxygen can be prescribed. (See "Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)".)

Supplemental oxygen must never be used while smoking. Oxygen is explosive, and smoking while using oxygen can lead to severe burns. Fatal fires have occurred in people attempting to smoke while using oxygen.

Nutrition — More than 30 percent of people with severe COPD are not able to eat enough because of their symptoms (shortness of breath, fatigue). Unintended weight loss caused by shortness of breath usually occurs in people with more advanced lung disease. Not eating enough can lead to malnutrition, which can make symptoms worse and increase the likelihood of infection. (See "Nutritional support in advanced lung disease".)

To increase the number of calories you eat:

• Eat small, frequent meals with nutrient-dense foods (eg, eggs)


• Eat meals that require little preparation (eg, microwaveable)


• Rest before meals


• Take a daily multivitamin


• Nutritional supplements (liquids or bars) are also good sources of extra calories because they are easy to eat and require no preparation


• If you continue to lose weight, a prescription medication may be recommended to stimulate your appetite

Pulmonary rehabilitation — Pulmonary rehabilitation programs may include education, exercise training, social support, and instruction on breathing techniques that can ease symptoms of breathlessness. Pulmonary rehabilitation programs have been shown to improve a person's ability to exercise, enhance quality of life, and decrease the frequency of exacerbations of COPD. Even people with severe shortness of breath can benefit from a rehabilitation program. (See "Pulmonary rehabilitation in COPD".)

Surgery — Surgery, such as lung volume reduction surgery or lung transplantation, may be helpful in reducing symptoms in some patients with emphysema.

Lung volume reduction surgery — Lung volume reduction surgery involves removing the areas of lung that are most abnormal, which allows the remaining lung to expand and function more normally. (See "Lung volume reduction surgery in COPD".)

This procedure may be an option for people who have severe symptoms after trying all other routine therapies, including pulmonary rehabilitation. Not all patients will benefit from this surgery, and some may actually become worse. An imaging test, such as a CT scan, may be recommended to help determine if surgery is likely to be of benefit.

Lung transplantation — Lung transplantation may be considered in cases of severe chronic obstructive pulmonary disease. If successful, transplantation is likely to improve symptoms. However, lung transplantation has not yet been shown to prolong the life of people with COPD. (See "Lung transplantation: General guidelines for recipient selection".)

Other therapies — Other treatments for COPD are occasionally recommended, including: noninvasive ventilatory support (the use of a special mask and breathing machine to improve symptoms), anti-anxiety or anti-depressant medications, or morphine-like medications to reduce shortness of breath.

PREVENTION AND TREATMENT OF INFECTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE

People with chronic obstructive pulmonary disease are at risk for worsening symptoms as a result of respiratory infections. Avoiding these infections and treating them quickly if they occur are important parts of COPD therapy.

Vaccines — Everyone with chronic obstructive pulmonary disease should have a pneumococcal vaccination, which helps prevent a type of pneumonia. (See "Patient information: Pneumonia prevention (Beyond the Basics)".)

People with COPD should also get an annual flu shot before flu season, generally in the late fall or early winter. For patients who get the flu, antiviral medications may be prescribed. (See "Patient information: Influenza prevention (Beyond the Basics)".)

Antibiotics — Antibiotics are of some benefit in people with a bacterial respiratory infection who have worsening COPD symptoms. However, most respiratory infections are caused by viruses, which will not improve with antibiotic treatment. (See "Management of acute exacerbations of chronic obstructive pulmonary disease".)

Continuous use of antibiotics to prevent infection is not currently recommended.

PROGNOSIS

Although chronic obstructive pulmonary disease usually worsens over time, it is difficult to predict how quickly this will occur. A number of factors play a role in the severity of COPD symptoms, including whether you continue to smoke, are underweight, have underlying medical problems, and how your lungs function during exercise. People with COPD who have less severe symptoms, are a healthy weight, and do not smoke tend to live longer.

The BODE index is an example of an index that clinicians use to predict survival and to guide the timing of lung transplantation. It uses a combination of body mass index (BMI), severity of airflow obstruction on spirometry, degree of shortness of breath with exertion, and distance walked in six minutes. (See "Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions".)

END OF LIFE DECISIONS IN COPD

Although discussions about death and dying can be uncomfortable for patients, family members, and healthcare providers, the subject is important, especially for people with severe chronic illnesses. Not everyone with COPD will die as a result of their disease. However, discussions about what you want at the end of your life should occur well before you become seriously ill. This is particularly important for people with COPD, who are at risk for being placed on a ventilator (breathing machine) when they are very ill.

Important questions to consider include:

• Who do I want to make medical decisions for me if I cannot communicate?


• Are there specific treatments that I do or do not want at the end of my life?

Certain legal documents, called a healthcare proxy and living will, are used to communicate your preferences. The document you need depends upon where you live. In the United States, state-specific documents can be downloaded from the internet (such as www.caringinfo.org) and do not require a lawyer.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (The Basics)

Patient information: Medicines for chronic obstructive pulmonary disease (COPD) (The Basics)

Patient information: Chronic bronchitis (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Chronic obstructive pulmonary disease (COPD), including emphysema (Beyond the Basics)

Patient information: Asthma inhaler techniques in adults (Beyond the Basics)

Patient information: Quitting smoking (Beyond the Basics)

Patient information: Supplemental oxygen on commercial airlines (Beyond the Basics)

Patient information: Pneumonia prevention (Beyond the Basics)

Patient information: Influenza prevention (Beyond the Basics)

 

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Bullectomy for giant bullae in COPD

Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging

Chronic obstructive pulmonary disease: Risk factors and risk reduction

Management of infection in acute exacerbations of chronic obstructive pulmonary disease

Dynamic hyperinflation in patients with COPD

Lung volume reduction surgery in COPD

Management of acute exacerbations of chronic obstructive pulmonary disease

Management of stable chronic obstructive pulmonary disease

Mechanical ventilation in acute respiratory failure complicating COPD

Chronic obstructive pulmonary disease: Prognostic factors and comorbid conditions

Pulmonary rehabilitation in COPD

Use of oxygen in patients with hypercapnia

Nutritional support in advanced lung disease

Lung transplantation: General guidelines for recipient selection



The following organizations also provide reliable health information.

• National Library of Medicine

(www.nlm.nih.gov/medlineplus/copdchronicobstructivepulmonarydisease.html, available in Spanish)

• National Heart, Lung, and Blood Institute

(www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html)

• American Lung Association

(www.lungusa.org)

• Alpha-1 Foundation

(www.alphaone.org)

Patient Support — There are a number of online forums where patients can find information and support from other people with similar conditions.

• About.com COPD Forum

(http://copd.about.com/forum)

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