Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a progressive condition that damages the lungs and makes breathing increasingly difficult over time. It is most often caused by long-term smoking or exposure to lung irritants.
COPD reduces airflow in the lungs. It can lead to ongoing shortness of breath, coughing, wheezing and other respiratory challenges.
COPD is the fourth leading cause of the death in the United States. It is the third leading cause of death in the world. While there is no cure, treatments and lifestyle changes can help slow its progression and improve quality of life.
What is COPD?
COPD is an umbrella term used to describe a series of progressive lung diseases characterized by difficulty breathing. The two primary COPD diseases are:
Emphysema
Emphysema results in damage to tiny air sacs in the lungs, which help move oxygen into the blood, become damaged. The air sacs lose their ability to stretch and some of their walls break down. This leaves fewer, larger sacs instead of many tiny ones. This damage can also destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny ones. This makes it harder for the lungs to move air in and out, so air can get trapped and breathing out becomes difficult.
Chronic bronchitis
Chronic bronchitis is a condition in which the bronchial tubes – the airways that carry air to the lungs – become constantly irritated and inflamed. This thickens the lining of the airways and triggers the production of excess mucus. It leads to a persistent cough, wheezing and shortness of breath.
Over time, tiny hair-like structures called cilia, which normally help clear mucus from the lungs, may get damaged or lost. Without healthy cilia, mucus builds up more easily. This can breathing even harder and increases the risk of lung infections.
Who develops COPD?
COPD prevalence in the United States varies among certain agencies and foundations. The U.S. Centers for Disease Control and Prevention (CDC) says that 16 million Americans have COPD. However, the nonprofit COPD Foundation estimates that 30 million Americans have COPD. Millions more may be undiagnosed or misdiagnosed with asthma – and not getting proper treatment.
Globally, the World Health Organization (WHO) estimates that more than 300 million people have COPD.
Most people with COPD develop the condition after the age of 40. Women are more likely to develop COPD than men. They also experience more COPD deaths, likely due to having smaller airways. Racial and ethnic minority groups tend to experience more severe COPD, in part due to limited access to medical care.
COPD usually occurs following years of exposure to something that irritates the lung. For most, it’s tobacco smoke from cigarettes. Another risk factor for developing COPD is exposure to lung irritants. These may include long-term exposure to air pollution, workplace chemical fumes or secondhand smoke.
If you smoke, then it’s critical that you quit smoking. Cigarette smoking can not only cause lung damage but also put you at higher risk for heart disease. Not smoking is the single most important thing you can do to slow the rate of lung function decline, regardless of COPD disease severity. Ask your healthcare provider about cigarette smoking cessation programs.
What are the symptoms of COPD?
- Increased shortness of breath
- Frequent coughing (with or without mucus) or chronic cough
- Increased breathlessness
- Wheezing
- Chest tightness
- Frequent colds
- Nose and throat infections
- Fatigue or tiredness
Late stages of COPD may include worsening of current symptoms as well as weight loss, muscle loss or an increased risk for depression or anxiety.
Is it COPD or asthma?
Asthma and COPD are two lung diseases that can make it hard to breathe. They share some symptoms – like coughing, wheezing, chest tightness, and shortness of breath – but they are not the same condition.
Asthma often starts in childhood or early adulthood. It happens when the airways swell and narrow, usually from things like allergies, exercise, or breathing in irritants. Asthma symptoms can come and go. With the right medicine and trigger control, people with asthma can often live active, healthy lives.
COPD usually develops later in life. The main cause is long-term smoking, but it can also come from breathing in dust, chemicals or air pollution for many years. COPD includes chronic bronchitis and emphysema. Unlike asthma, COPD slowly gets worse over time, and the lung damage cannot be reversed. Treatment can help manage symptoms, prevent flare-ups, and improve quality of life.
Knowing the difference matters. If you have breathing problems, talk with your doctor. The sooner you get the right diagnosis and treatment, the better you can protect your lungs and stay healthy.
How is COPD diagnosed?
A proper COPD diagnosis is key so people with the condition can get on a treatment plan right away. Doctors ask for your full health history, discuss your symptoms, and conduct a physical exam. Then they may conduct one of several lung function tests. These breathing tests may include:
Spirometry
A breathing test called spirometry gauges your body’s peak expiratory flow (PEF) rate. It measures how fast you can blow air out using maximum effort, your lung capacity and how well the lungs are working. Spirometry can also evaluate how well COPD treatment is working.
Chest X-ray
A chest X-ray is a fast and painless imaging test that takes pictures of the lungs and airways. It can be done in the doctor’s office, clinic or hospital. Chest X-rays can show signs of lung damage from COPD. They may reveal enlarged lungs caused by emphysema, thickened bronchial walls from chronic bronchitis, and overinflation of the lungs.
Chest X-rays are often used along with breathing tests (spirometry) and patient history to help doctors confirm a COPD diagnosis. Doctors may also use chest X-rays to see how well certain treatments are working. They may also check for complications after procedures or surgeries.
Chest computer tomography (CT) scan
A CT scan is a chest imaging test conducted in a medical imaging facility or hospital. It is a special type of X-ray that takes detailed pictures of your lungs and the inside of your chest. It gives doctors a detailed look at how much lung damage is present and where it is located.
For people with COPD, a CT scan can show important changes in the lungs that regular chest X-rays might miss. It can reveal signs of emphysema, thickened airways due to chronic bronchitis, trapping of air in the lungs, and other conditions like lung nodules or scarring.
Arterial blood gas test
This type of blood test measures the levels of oxygen and carbon dioxide in your blood. The blood test is taken from an artery (usually the wrist) instead of a vein. This is usually done in a doctor’s office or a hospital. To confirm a COPD diagnosis, it is done in conjunction with breathing tests (spirometry) and imaging (X-rays or CT scans).
For people with COPD, the test can help doctors see how well the lungs are moving oxygen into the blood and removing carbon dioxide. Signs that may indicate COPD include low oxygen levels, high carbon dioxide levels or changes in blood acidity. The test provides insight into how severe the lung disease is and how well the lungs are working.
What are the treatments for COPD?
COPD disease control is essential. Several different types of medications are used for treating COPD. Some medications are delivered by metered-dose or dry powder inhalers. Others are delivered through a nebulizer. Nebulizers are electric or battery-operated devices that turn liquid medicine into a fine mist that can be inhaled via a mouthpiece or face mask. Other medications may be taken as oral medications.
Biologic medications are available to treat a type of COPD that is affected by high levels of eosinophils. Eosinophils are a type of white blood cell. A high eosinophil count can trigger lung and airway inflammation.
Medications for COPD:
- Bronchodilators relax and open the airways to relieve COPD symptoms.
- Controller medications (anti-inflammatory) are used to reduce and prevent lung inflammation.
- Combination inhaler medications combine more than one type of COPD medication in one device.
- PPhosphodiesterase-4 and phosphodiesterase-3/4 (PDE-4 and PDE-3/4) inhibitors block enzymes that cause inflammation.
- Biologics that treat COPD with high levels of eosinophils in the blood
In addition, antibiotics may be prescribed to respiratory infections that can worsen COPD.
Always use your COPD medication as prescribed. Do not stop using the medication even when you are symptom-free and feeling well.
Bronchodilators
Bronchodilators relax tight muscles in the airways and relieve symptoms such as coughing, wheezing and shortness of breath. Bronchodilators can be both short-acting or long-acting.
What are the different types of bronchodilators for asthma?
- Short-acting beta-agonist bronchodilators (quick relief). You may sometimes hear these referred to as short-acting beta-agonists, or SABA. These include albuterol and levalbuterol. When using these quick-relief medications, COPD symptom relief starts almost immediately and lasts 3-6 hours. This is the medicine you should use if you are experiencing a sudden onset of COPD symptoms. You may also be advised to use it prior to activities that may expose you to COPD triggers.
- Long-acting beta-agonist bronchodilators. You may also hear these referred to as long-acting beta-agonists, or LABA. These include arformoterol, formoterol, olodaterol, salmeterol and vilanterol. Taken daily, LABA medications relieve symptoms for between 12-24 hours. This is the medication to use to prevent airway inflammation and keep COPD symptoms under daily control.
- Short-acting muscarinic antagonist (SAMA). These medications are also called anticholinergics. SAMA medications provide relief from symptoms for 6-8 hours. They are designed to relax and open the airways and clear mucus from the lungs. The primary SAMA medication is ipratropium bromide.
- Long-acting muscarinic antagonist (LAMA). These are longer lasting anticholinergics, providing relief for 12-24 hours. They are taken daily. LAMA medications include aclidinium bromide, tiotropium and umeclidinium.
Controller medications
Controller medications are typically corticosteroids, which can be taken by inhaler or tablet. They are anti-inflammatory medications, meaning they help reduce airway inflammation and swelling. This helps prevent COPD flares before they can start. They can also help reduce mucus.
After using an anti-inflammatory medication, it takes time for airway swelling to subside and the mucus to clear out of the airways. Keep using the medication as directed, even if you don’t feel anything happening right away.
What are different types of controller medications for COPD?
- Inhaled corticosteroids can reduce and prevent airway inflammation and swelling. They are not typically prescribed just for COPD. Doctors usually prescribe them as part of a combination with a LABA and/or LAMA.
- Oral corticosteroids (OCS) are pills used to treat acute COPD flares. They are usually prescribed only for short periods of time (5-7 days). Taken as prescribed, they gradually reduce COPD symptoms and open the airways.
The dosage of OCS is 10 times the dose of inhaled corticosteroids. As a result, there is an increased risk of side effects with OCS. The side effects may include weight gain, insomnia, headaches, and easy bruising of the skin. There is also a risk of mental health problems, including moodiness and depression.
If taking OCS long-term, side effects can be even more problematic. These may include eye problems, onset of diabetes, increased risk of infections and thinning bones. Patients should talk with their doctor about the risks vs. benefits of long-term oral corticosteroid use.
Note: When you hear the term “steroids” in respiratory care, it refers to corticosteroids. These are NOT related in any way to the anabolic steroids used illegally in body building.
Combination medications
Combination medications combine two or even three medications into one inhaler. The devices may contain an anti-inflammatory inhaled corticosteroid, a SABA, LABA and/or LAMA.
What are different types of combination medications for COPD?
- Inhaled corticosteroids and LABA combinations. These are taken on a daily basis to reduce airway inflammation and relieve COPD symptoms. Most are taken once every 12 hours. One is taken once a day. These medication combos include budesonide/formoterol, fluticasone/salmeterol and fluticasone/vilanterol.
- Inhaled corticosteroid, LABA and LAMA combinations. These 3-in-1 inhalers treat COPD on multiple fronts. They are taken daily to relieve airway inflammation, open airways and relieve COPD symptoms. These inhalers include fluticasone/umeclidinium/vilanterol and budesonide/glycopyrrolate/formoterol.
- Inhaled LABA and LAMA combinations. These are taken daily to relax and open up breathing passages and relieve symptoms. These medication combos include umeclidinium/vilanterol, tiotropium/olodaterol, aclidinium bromide/formoterol, and glycopyrrolate/formoterol. The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report recommends LABA and/or LAMA as an optimal first-line treatment option for most patients with COPD, regardless of exacerbation risk.
- Inhaled SABA and SAMA. These medications relax and open up the airways to promote easier breathing. They also can widen airways and reduce mucus. The combination is intended to help relieve symptoms within 15 minutes after a dose. It can be taken up to four times per day. The combination is ipratropium bromide and albuterol.
Phosphodiesterase-4 and 3/4 (PDE-4 and PDE-3/4) inhibitors
A PDE-4 inhibitor is approved for COPD associated with chronic bronchitis. The drug can help control lung inflammation and reduce flare-ups. It blocks the PDE-4 enzyme, which plays a role in the body’s immune and inflammatory cells. By inhibiting the enzyme, PDE-4 inhibitors helps control inflammation and reduce mucus. It is an oral medication that comes in a tablet form called roflumilast.
A PDE-3/4 inhibitor is also approved for COPD. The drug aims to help control inflammation and reduce flare-ups. It blocks two different enzymes, a PDE-3 and PDE-4. The PDE-3 causes airway muscles to relax and widen while the PDE-4 controls inflammation and reduce mucus. It comes as an ampule and is taken using a nebulizer. The drug name is ensifentrine.
Biologics
Biologic medications focus on treating the source of symptoms rather than the symptoms themselves. They target the cell pathways and proteins that cause inflammation in the body, stopping symptoms before they can start.
Two biologic medications are approved for COPD: dupilumab (Dupixent®) and mepolizumab (Nucala®).
Both are indicated for adults with inadequately controlled COPD with an eosinophilic phenotype. This means dupilumab and mepolizumab are prescribed to COPD patients with high levels of eosinophils, a type of white blood cell that can trigger airway inflammation. The medications can help patients gain better control of their COPD symptoms.
Biologics are given as an injection under the skin every 2-4 weeks (depending on the medication). The first dose is always administered in the doctor’s office or clinic. After that, patients have the option of taking the biologic in a doctor’s office or clinic or self-administering it at home using an injectable pen.
Antibiotics
Antibiotics are used to treat a respiratory infection (such as acute bronchitis or pneumonia) that can make COPD worse. People with COPD tend to have more respiratory infections.
Important: Be sure to talk with your doctor about the potential for side effects of COPD medications, particularly oral corticosteroids and PDE-4 and PDE-3/4 inhibitors.
Additional treatments for COPD:
- Oxygen therapy may be used if a person’s oxygen level is too low.
- Pulmonary rehabilitation is a whole-body approach treatment of COPD.
- Surgical interventions are usually a last resort for people who have severe COPD symptoms that have not improved with taking medicines.
Oxygen Therapy
Some people with COPD may need extra oxygen to help improve their daily breathing. Many different types of devices are available, including portable units.
Oxygen therapy is a treatment that delivers oxygen for people to breathe. Oxygen therapy can be delivered from tubes resting in the nose, a face mask, or a tube placed in the trachea (windpipe). People may need oxygen therapy if the blood oxygen levels become too low.
Some people with COPD on extra oxygen will only need it while sleeping or during certain activities. Others may need it all the time.
Oxygen therapy is generally safe. Side effects may include a dry or bloody nose, tiredness and morning headaches. Oxygen poses a fire risk, so you should never smoke or use flammable materials when using it.
Pulmonary Rehabilitation
Pulmonary rehabilitation (or pulmonary rehab) is a supervised whole-body approach to COPD care. It includes COPD education, exercise training, nutrition counseling, health education, breathing techniques, and more. Pulmonary rehab is also used for other chronic obstructive lung disease conditions.
Benefits of pulmonary rehab include:
- reduce risk of COPD flares and shorten hospital stays
- make it easier to manage routine activities, work, and outings or social activities
- reduce symptoms of anxiety or depression
- improve quality of life
Surgical Interventions
- Bullectomy removes one or more very large bullae from the lungs. Bullae are larger air spaces that form when the walls of the air sacs are destroyed. These air spaces can become so large that they interfere with breathing.
- One-way endobronchial valves can be implanted in one of your bronchial tubes. These valves allow air to exit the damaged or diseased parts of the lung, but not re-enter.
- Lung volume reduction surgery removes damaged tissue from the lungs and helps the lungs work better.
- A lung transplant is surgery to remove a diseased lung and replace it with a healthy lung. Lung transplants are used to extend the lifespan for people who have severe or advanced chronic lung conditions that do not respond to other treatments.
What is Asthma-COPD Overlap (ACO)?
It’s possible for people to have both COPD and asthma at the same time. This is called Asthma-COPD Overlap, or ACO. Delayed diagnosis is common with ACO.
People with ACO may have:
- long-term airway inflammation and progressive lung damage seen in COPD; and
- airway hyper-reactivity and flare-ups common in asthma.
ACO treatment involves aggressive medication. It may include inhaled corticosteroids and/or a combination of medications that include a long-acting beta-agonist and muscarinic antagonist. Treatment may also include reducing exposure to triggers.
If asthma or COPD symptoms worsen or persist, request a lung function test from your doctor.
Does asthma lead to COPD?
Asthma by itself does not lead to COPD. But a person whose lungs are damaged by poorly controlled asthma and continued exposure to irritants such as tobacco smoke is at increased risk of developing COPD.
Patient Resources
Here are some additional organizations that offer COPD patient education and resources:
Trusted Messengers (TM) is Allergy & Asthma Network’s award-winning community outreach program.
Reviewed by:
William E. Berger, MD, FACAAI, is a board-certified allergist and immunologist who serves as Medical Director and a member of the Board of Directors with Allergy & Asthma Network. He is a Distinguished Fellow and Past President (2002-03) of the American College of Allergy, Asthma & Immunology (ACAAI).
