Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have trouble breathing in and out. This is referred to as airflow obstruction.
Breathing difficulties are caused by long-term damage to the lungs, usually because of smoking.
How common is COPD?
COPD is one of the most common respiratory diseases in Ireland. It usually affects people over the age of 35.
Around 110,000 people in Ireland have been diagnosed with COPD, but it is thought that there are about 2 00,000 people living with the disease who have not been diagnosed. This is because many people who develop the symptoms of COPD do not get medical help because they often dismiss their symptoms as a 'smoker's cough'.
COPD affects more men than women. However, according to the Irish Thoracic Society, rates of COPD in women are increasing.
The main cause of COPD is smoking. The likelihood of developing COPD increases the more you smoke and the longer you've been smoking.
The effects of COPD
People with COPD have trouble breathing in and out, known as airflow obstruction. Their lungs become inflamed due to irritation, usually from cigarette smoke.
Over many years, the inflammation leads to permanent changes in the lung. The walls of the airways get thicker in response to the inflammation and more mucus is produced. Damage to the delicate walls of the air sacs in the lungs means the lungs lose their normal elasticity. It becomes much harder to breathe, especially when you exert yourself. The changes in the lungs cause the symptoms of breathlessness, cough and phlegm associated with COPD.
Although any damage that has already occurred to your lungs cannot be reversed, you can prevent COPD from developing or getting worse by making lifestyle changes.
Treatment for COPD usually involves relieving the symptoms, for example by using an inhaler to make breathing easier.
Although COPD causes about 1,500 deaths a year in Ireland, severe COPD can be prevented by making changes to your lifestyle.
Damage to the lungs caused by smoking will gradually build up, so you may not notice the symptoms of chronic obstructive pulmonary disease (COPD) at first. However, they can get worse over time.
COPD does not usually become noticeable until after the age of 35. See your GP if you have the following symptoms:
- increasing breathlessness when exercising or moving around
- a persistent cough with phlegm that never seems to go away
- frequent chest infections, particularly in winter
If you have COPD, the airways of the lungs become inflamed and narrowed. As the air sacs get permanently damaged, it will become increasingly difficult to breathe in and out.
The symptoms of COPD are often worse in the winter, and it is common to have two or more flare-ups a year. A flare-up is when your symptoms are particularly bad. This is one of the most common reasons for people being admitted to hospital in Ireland.
While there is currently no cure for COPD, the sooner the condition is diagnosed and appropriate treatment begins, the less chance there is of severe lung damage.
Several factors increase your risk of developing chronic obstructive pulmonary disease (COPD).
Risk factors you can change
You can change some of the things that make COPD more likely.
Smoking is the main cause of COPD. At least four out of five people who develop the disease are or have been smokers. The lining of the airways becomes inflamed and permanently damaged by smoking. This damage cannot be reversed. Around 10-25% of smokers develop COPD.
Exposure to other people's smoke increases the risk of COPD.
Fumes and dust
Exposure to certain types of dust and chemicals at work, including grains, isocyanates, cadmium and coal, has been linked to the development of COPD, even in people who do not smoke. The risk of COPD is higher if you breathe in dust or fumes in the workplace and you smoke.
According to some research, air pollution may be an additional risk factor for COPD. However, at the moment it is not conclusive and research is continuing.
Risk factors you cannot change
There are a few factors for COPD that you cannot change.
Having a brother or sister with severe COPD
A research study has shown that smokers who have brothers and sisters with severe COPD are at greater risk of developing the condition than smokers who do not.
Having a genetic tendency to COPD
There is a rare genetic tendency to develop COPD called alpha-1-antitrypsin deficiency. This causes COPD in a small number of people (about 1%). Alpha-1-antitrypsin is a protein that protects your lungs. Without it, the lungs can be damaged by other enzymes that occur naturally in the body.
People who have an alpha-1-antitrypsin deficiency usually develop COPD at a younger age, often under 35.
If you are concerned about the health of your lungs and have symptoms that could be chronic obstructive pulmonary disease (COPD), see your GP as soon as you can. Being diagnosed early means you will receive appropriate advice, help and treatment to stop or slow the progression of COPD.
To find out if you have COPD, your doctor will ask you about your symptoms and how long you have had them, and whether you smoke or have smoked in the past. They will examine you and listen to your chest using a stethoscope. Your doctor will also check how well your lungs are working with a lung function test called spirometery.
To assess how well your lungs work, a breathing test called spirometry is carried out. You will be asked to breathe into a machine called a spirometer.
The spirometer takes two measurements: the volume of air you can breathe out in one second (called the forced expiratory volume in one second or FEV1) and the total amount of air you breathe out (called the forced vital capacity or FVC).
You may be asked to breathe out a few times to get a consistent reading.
The readings are compared with normal measurements for your age, which can show if your airways are obstructed.
You will have other tests as well as spirometry. Often, these other tests will help the doctor rule out other conditions that cause similar symptoms.
A chest X-ray will show whether you have another lung condition which may be causing symptoms, such as lung cancer.
A blood test will show whether your symptoms could be due to anaemia, as this can also cause breathlessness.
Some people may need more tests. The tests may confirm the diagnosis or indicate the severity of your COPD. This will help you and your doctor plan your treatment.
Peak flow test
To confirm that you have COPD and not asthma, your doctor might ask you to take regular measurements of your breathing using a peak flow meter, at different times over several days. The peak flow meter measures how fast you can breathe out.
Blood oxygen level
The level of oxygen in your blood is measured using a pulse oximeter, which looks like a peg and is attached to the finger. If you have low levels of oxygen, you may need an assessment to see whether extra oxygen would help you.
Blood test for alpha-1-antitrypsin deficiency
If the condition runs in your family or you developed the symptoms of COPD under the age of 35 and have never smoked, you will probably have a blood test to see if you are alpha-1-antitrypsin deficient.
Some people may need a CT scan. This provides more information than an X-ray and can be useful in diagnosing other lung diseases or assessing any changes to your lungs because of COPD.
Other breathing tests
If your symptoms seem worse than would be expected from your spirometry results, your doctor may decide you need more detailed lung function tests. You may be referred to a hospital specialist for these tests.
You may have an electrocardiogram (ECG) or an echocardiogram to investigate whether your heart has been affected by COPD.
The doctor may take a sample of phlegm to check whether it has been infected.
- Blood test
- During a blood test, a sample of blood is taken from a vein using a needle so it can be examined in a laboratory.
- An X-ray is a painless way of producing pictures of inside the body using radiation.
If you have trouble breathing
Middle-aged smokers and ex-smokers who have a persistent chesty cough (especially in the morning), breathlessness on slight exertion or persistent coughs and colds in the winter should see their GP or practice nurse for a simple breathing test. Although COPD cannot be reversed, the sooner it is identified and treated, the better.
Stopping smoking is the main way for people with COPD to help themselves feel better and the only proven way to reduce the rate of the decline in lung function in people with COPD.
Stopping smoking at an early stage of the disease makes a huge difference. Any damage already done to the airways cannot be reversed, but giving up smoking prevents it from getting worse.
If COPD is in the early stage and symptoms are mild, no other treatments may be needed. But it is never too late to stop smoking. Even people with fairly advanced COPD are likely to benefit from quitting, which may prevent further damage to the airways.
Research has shown that you are up to four times more likely to give up smoking successfully if you use support along with stop-smoking medicines such as tablets, patches or gum. Ask your doctor about this or go to the www.quit.ie website.
If an inhaler is prescribed for you, your GP, practice nurse or pharmacist can explain how to use it. They will check that you are using it properly. Most people learn to use an inhaler successfully, but if you are having problems, a spacer or a different type of inhaler device may help you take your medicines correctly. A spacer is a device that increases the amount of medication that reaches the lungs.
Short-acting bronchodilator inhalers
Short-acting bronchodilator inhalers deliver a small dose of medicine directly to your lungs, causing the muscles in your airways to relax and open up. They also prevent hyperinflation (over expansion) of your lungs.
There are two types of short-acting bronchodilator inhaler:
- beta-2 agonist inhalers, such as indacterol, salbutamol and formoterol
- antimuscarinic inhalers, such as ipratropium
The inhaler should be used when you feel breathless and this should relieve the symptoms.
Long-acting bronchodilator inhalers
If a short-acting bronchodilator inhaler does not help relieve your symptoms, your GP may recommend a long-acting bronchodilator inhaler. This works in a similar way to a short-acting bronchodilator, but each dose lasts for at least 12 hours.
There are two types of long-acting bronchodilator inhalers:
- beta-2 agonist inhalers, such as salmeterol and formoterol
- antimuscarinic inhalers, such as tiotropium
Steroid inhalers, also called corticosteroid inhalers, work by reducing the inflammation in your airways.
If you are still getting breathless or having flare-ups even when taking long-acting bronchodilator inhalers, your GP may suggest including a steroid inhaler as part of your treatment. Most people with COPD will be prescribed a steroid inhaler as part of a combination inhaler.
If you are getting breathless or having flare-ups when using a combination of inhalers, your GP may prescribe theophylline tablets. Theophylline causes the muscles of your airways to relax and open up.
When you have been taking theophylline tablets regularly, you will need to give a blood sample. This is to measure the amount of theophylline in your blood and help your GP prescribe the appropriate dose of tablet. This will allow you to get the correct dose of theophylline while reducing the likelihood of side effects.
Due to the risk of potential side effects, such as increased heart rate and headaches, other medicines, such as a bronchodilator inhaler, are usually tried before theophylline.
Mucolytic tablets or capsules
Mucolytics, such as carbocisteine, make the mucus and phlegm in your throat thinner and easier to cough up. They are particularly beneficial for people with a persistent cough with lots of thick phlegm or who have frequent or bad flare-ups.
Antibiotics and steroid tablets
If you have a chest infection, your GP may prescribe a short course of antibiotics.
Steroid tablets may also be prescribed as a short course if you have a bad flare-up. They work best if they are taken as the flare-up starts, so your GP may give you a course to keep at home. Occasionally, you may have to take a longer course of steroid tablets. Your GP will give you the lowest effective dose and monitor you for side effects. Side effects are not usual if steroid tablets are given for less than three weeks.
Other types of treatment
A nebuliser can be used for severe cases of COPD if other inhaler devices have not worked effectively. A nebuliser is a machine that administers medicine through a mouthpiece or a face mask. The medicine is in a liquid form and is converted into a fine mist. This enables a large dose of medicine to be taken in one go.
You can usually choose whether to use the nebuliser with a mouthpiece or a facemask. Your GP will advise you on how to use the nebuliser correctly.
Before you start this treatment, your GP or COPD specialist will test to make sure that the nebuliser is suitable for you.
Long-term oxygen therapy
If the oxygen level in your blood is low, you may need to take oxygen through nasal tubes, also called a nasal cannula, or through a mask. Oxygen is not a treatment for breathlessness, but it is needed for some patients with persistently low oxygen levels in the blood.
Your GP or nurse may do a test called pulse oximetry, which checks the levels of oxygen in your blood. You will probably be referred for more detailed assessment at the hospital to see whether you might benefit from long-term oxygen therapy.
Oxygen must be taken for at least 15 hours a day. The tubes from the machine are long so you will be able to move around your home while you are connected. Portable oxygen tanks are available if you need to use oxygen away from home.
Do not smoke when you are using oxygen. The increased level of oxygen that is produced is highly flammable, and a lit cigarette could trigger a fire or an explosion.
Non-invasive ventilation (NIV)
Non-invasive ventilation (NIV) helps a person breathe artificially. You may receive it if you are taken to hospital because of a flare-up. You may be referred to a specialist centre to see if you are suitable for NIV. It works by pushing air into your lungs through a mask covering the nose or face.
Pulmonary rehabilitation programmes
Pulmonary rehabilitation is a programme of exercise and education designed to help people with chronic lung problems. It can increase your exercise capacity, mobility and self-confidence.
Pulmonary rehabilitation is based on a programme of physical exercise training tailored to your needs. It usually involves walking or cycling, and arm and strength-building exercises. It also includes education about your disease for you and your family, dietary assessment and advice, and psychological, social and behavioural changes designed to help you cope better. A rehabilitation programme is provided by a multidisciplinary team, which includes respiratory nurse specialists, physiotherapists and dietitians.
Pulmonary rehabilitation takes place in a group and the course usually lasts for about six weeks. During the course, you will learn more about your COPD and how to control your symptoms. Pulmonary rehabilitation can greatly improve your quality of life.
Lung surgery may be an option for some people with certain types of COPD. This may involve removing a section of the lung that's no longer working, called lung volume reduction surgery (LVRS), to give the remaining lung more room to work. Surgery works best in people who have disease that is worse in the upper lobes of their lungs.
Most people who have this surgery should do better than people not having surgery for at least three years. However, about one person in four gets no benefit from the operation, and about one person in twenty dies during or shortly after surgery.
Lung transplantation is a realistic option for only a very small number people with COPD. It is a high-risk operation and you will need to take anti-rejection medication for the rest of your life.
Treating a flare-up
A flare-up is when your symptoms are particularly bad. If you have a flare-up of your COPD symptoms, you may be advised to increase the dose of the treatments you usually take. For example, you may need to increase the dose of your inhalers or tablets. Some people may need to use a spacer or a nebuliser for their inhaled therapy.
You may also need to take extra treatments during the flare-up, such as adding a further inhaler or tablet to what you usually take. It is common to take a short course of antibiotics or steroid tablets during a flare-up.
Some people need to go into hospital for more intensive treatment during a flare-up. Other people are treated with 'hospital at home' schemes, where experienced health professionals come to their home regularly. Your healthcare team will recommend the type of care that is best for you.
Research has shown that 'hospital at home' works as well as hospital admission in improving people's condition, and that people with COPD prefer it.
If you are having a very bad flare-up, you may have to go into hospital.
In hospital, you are likely to receive oxygen, antibiotics (if necessary) and a nebuliser to help ease your symptoms.
People with COPD who have severe breathing difficulties during a flare-up and who are admitted to hospital may need non-invasive ventilation (NIV) through a mask to help them breathe more easily. In the most severe cases, admission to an intensive care unit for treatment with an artificial breathing machine (ventilator) may be necessary.
Everyone should see or talk to a healthcare professional after they have recovered from a flare-up, to check on their current condition and review their treatment options. It may take up to three months to complete your recovery and your cough and phlegm may take a few weeks to settle, even after any infection has been treated.
If you have frequent flare-ups, you may be given a self-management plan by your healthcare team. This is a written plan of action, agreed by you and your doctor, for what to do as soon as a flare-up develops. For example, it may contain advice on how to increase the dose of inhalers.
Some patients may be given steroid tablets or antibiotics to have 'on standby' so that they can start taking them as soon as a flare-up starts.
Your doctor may also arrange for emergency appointments or telephone prescriptions when you have a flare-up.
Give up smoking
Smoking is by far the biggest risk factor for COPD. If you smoke, stopping is the single most effective way to reduce your risk of getting the condition.
If you already have COPD, stopping smoking can halt its progression and reduce your risk of dying from it.
Research has shown that you are up to four times more likely to succeed in giving up smoking if you use support along with stop-smoking medicines such as patches or gum. Ask your doctor about this, discuss it with your phramacist or log on to www.quit.ie, call the National Smokers Quitline at 1850 201 203 or join our facebook page www.facebook.com/hsequit for further advice and help.
Also avoid exposure to tobacco smoke as much as possible.
People with COPD who exercise or keep active regularly have improved breathing, less severe symptoms and a better quality of life.
For most people with COPD who are disabled by their breathlessness, a structured programme of pulmonary rehabilitation provided by experienced healthcare professionals does the most good. Getting breathless is unpleasant but it isn't harmful. Every patient should exercise as much as they can, however limited that may be, twice a day. Even chair-bound people can do some arm and upper-body movements.
Research shows that pulmonary rehabilitation improves exercise tolerance, breathlessness and health-related quality of life. It results in people seeing doctors less often and spending less time in hospital.
Maintain a healthy weight
Carrying extra weight can make breathlessness worse. Therefore, it is good a good idea to lose some weight if you are overweight. This can be difficult because the breathlessness caused by COPD can make it hard to exercise.
However, some people with COPD find that they lose weight because they use up so much energy breathing. Eating food that is high in protein and taking in enough calories is important to maintain a healthy weight.
Research has shown that people with COPD who are underweight will have fewer COPD symptoms if they increase their weight.
There are various breathing techniques that some people find helpful for breathlessness. These include breathing control, which involves breathing gently, using the least effort, with the shoulders supported. This can help when people with COPD feel short of breath.
Breathing techniques for people who are more active include:
- relaxed, slow deep breathing
- breathing through pursed lips, as if whistling
- breathing out hard when doing an activity that needs a big effort
- paced breathing, using a rhythm in time with the activity, such as climbing stairs
Talk to others
If you have questions, your GP or nurse may be able to reassure you. You may find it helpful to talk to a trained counsellor or psychologist, or someone at a specialist helpline. Your GP surgery will have information on these. Some people find it helpful to talk to other people who have COPD, either at a local support group or in an internet chat room.
Relationships and sex
Relationships with friends and family
Having a chronic illness such as COPD can put a strain on any relationship. Difficulty breathing and coughing can make people with COPD feel very tired and depressed. It is also inevitable that their spouse, partner or carer will feel anxious or frustrated about their breathing problems. It is important to talk about your worries together.
Being open about how you feel and what your family and friends can do to help may put them at ease. But do not feel shy about telling them that you need some time to yourself, if that is what you want.
Your sex life
As COPD progresses, the increasing breathlessness can make it difficult to take part in activities. The breathlessness may occur during sexual activity, which may mean that your sex life can suffer. But it may not all be due to COPD. Some sexual changes happen as we get older. Slower erections and delayed orgasms are normal in middle and later life.
Communicate with your partner and stay open-minded. Explore what you both like sexually. Simply touching, being touched and being close to someone helps a person feel loved and special.
If you have chronic obstructive pulmonary disease (COPD) and you are planning to fly, go to your GP for a fitness-to-fly assessment. This involves checking your breathing using spirometry and measuring your oxygen levels.
Before travelling, remember to pack all your medication, such as inhalers, in your hand luggage.
If you are using oxygen therapy, tell your travel operator and airline before you book your holiday, as you may need to get a medical form from your GP. If you are using long-term oxygen therapy, arrange to take an adequate oxygen supply with you abroad.
End of life care
COPD is a serious condition. At least 1,500 people die each year from the end stages of COPD. As with other conditions that cannot be reversed or cured, it is important to receive good care at the end of life. Talking about this and planning it in advance can be helpful. This is called palliative care. It can be difficult to talk about dying with your doctor and, particularly, with family and friends, but many people find that it helps. Support is also available for your family and friends.
It may be helpful to discuss which symptoms you may have as you become more seriously ill, and the treatments that are available to reduce these.
As COPD progresses, your doctor should work with you to establish a clear management plan based on your and your carer's wishes. This will include whether you would prefer to go to hospital, a hospice or be looked after at home as you become more ill.
You may want to discuss drawing up an advance decision, also called a living will, which sets out your wishes for treatment if you become too ill to be consulted. This might include whether you want to be resuscitated if you stop breathing, and whether you want artificial ventilation to be continued.