Chronic obstructive pulmonary disease (COPD) is a type of lung disease that involves damage or obstruction to the airways of the lungs, making it difficult to breathe. COPD is an overall term referring to a group of chronic lung conditions, most commonly including chronic bronchitis and emphysema, and possibly asthma or asthmatic bronchitis. While chronic bronchitis and emphysema may occur separately, it is common for patients to have both diseases at the same time.

Chronic bronchitis is characterized by an ongoing, mucus-producing cough that that occurs most days of the month, three months a year for two consecutive years or more. Constant coughing causes the bronchial tubes to become inflamed. Eventually, the airways become scarred. Long-term irritation also leads to the production of mucus, which further irritates and blocks the bronchial tubes. As a result, less oxygen is able to enter the airways.

In addition, the excessive mucus in the bronchial tubes provides an environment for disease-causing bacteria to grow. Therefore, lung infections are common complications of chronic bronchitis.

Emphysema is an incurable illness that occurs when the walls between the air sacs (alveoli) in the lungs lose their ability to stretch and recoil, causing shortness of breath (SOB).

The Centers for Disease Control (CDC) report that COPD affects up to 24 million Americans, and according to the American Lung Association, is the fourth leading cause of death in the United States. COPD patients typically die from complications, such as severe lung infections, heart problems, or lung cancers.

The main risk factor for COPD is smoking. Researchers estimate that smoking causes 80-90% of COPD deaths. According to the American Lung Association, female smokers are nearly 13 times more likely to die from COPD than females who have never smoked. Male smokers are nearly 12 times more likely to die from COPD than males who have never smoked.

There is currently no cure for COPD. Instead treatment focuses on reducing the symptoms and complications of the disease. Treatment varies, depending on the specific condition. It can range from medication and oxygen supplementation to transplant surgery. Bronchodilators are commonly used to relax the bronchi muscles in the lungs that can cause bronchospasms and restrict the airways.

CAUSES

Smoking: The single greatest risk factor for chronic obstructive pulmonary disease (COPD) is smoking. COPD is most likely to develop in cigarette smokers, but cigar and pipe smokers and marijuana smokers also are susceptible. The risk of COPD increases with the number of years and amount smoked.

Exposure to secondhand smoke, also known as passive or environmental tobacco smoke, also increases risk of developing COPD. Secondhand smoke is smoke that is inadvertently inhaled from someone else's cigarette, pipe, or cigar.

Age: Although the lung damage that occurs in emphysema develops gradually, most people with tobacco-related emphysema begin to experience symptoms of the disease between the ages of 50-60.

Exposure to pollution: An individual breathing fumes from certain chemicals, such as chlorine or pesticides, dust from grain, cotton, wood, or working around toxic fumes has an increased risk of developing COPD. Breathing indoor pollutants, such as fumes from heating fuel, as well as outdoor pollutants, such as car exhaust, increases the risk of COPD.

Heredity: A rare, inherited deficiency of the protein, alpha-1-antitrypsin (AAt), can cause emphysema, especially before age 50, and even earlier if the individual smokes.

Connective tissue disorders: Some conditions that affect connective tissue (provides body framework and support) are associated with emphysema. Connective tissues are the supporting tissues of the body, such as tendons, ligaments, bone, and cartilage. These conditions include cutis laxa (a rare disease that causes premature aging) and Marfan syndrome (a disorder that affects many different organs, especially the heart, eyes, skeleton and lungs).

SIGNS AND SYMPTOMS

General: Symptoms of chronic obstructive pulmonary disease (COPD) usually develop gradually over many years. They typically worsen over time. Some patients may suffer from either chronic bronchitis or emphysema, while other may have both diseases.

Patients who have had COPD for many years may develop bluish discoloration of the lips and nail beds (cyanosis). This occurs when there is not enough oxygen in the blood. Some patients may develop headaches in the morning because they are unable to remove carbon dioxide from the blood. Many people with COPD also experience weight loss because their body requires more energy to breathe than the average person.

Chronic bronchitis: Symptoms of chronic bronchitis include chronic cough, increased mucus that is yellow-greenish in color, frequent clearing of the throat, wheezing, and shortness of breath (SOB). Patients typically experience fatigue because the body has to work harder to get enough oxygen.

Emphysema: Shortness of breath (dyspnea), especially during activity, is one of the earliest symptoms of emphysema. As the disease progresses, shortness of breathe becomes constant, even during rest. An individual is likely to feel tired both because it is more difficult to breathe and because the body is getting less oxygen.

Other symptoms include distress resulting from the inability to get enough air, wheezing, chronic mucus production, exhaling through pursed (puckered) lips or grunting before exhaling, and needing to lean forward to breathe while sitting. Individuals with emphysema are often thin and have very pink skin. Individuals with advanced disease may have the characteristic barrel chests from the increase in lung size.

COMPLICATIONS

Death: Individuals with chronic obstructive pulmonary disease (COPD) may die from complications of the disease. Causes of death may include lung cancer, lack of blood flow and oxygen to the brain (stroke), respiratory failure, lung infections, and heart attack.

Heart problems: For unknown reasons, COPD increases risk of developing heart disease, including heart attacks. The heart may become enlarged because it is strained. COPD may cause high blood pressure in the arteries that bring blood to the lungs.

Infections: Patients with COPD may suffer from frequent infections, including the common cold, flu, and pneumonia. Lung infections make breathing even more difficult for COPD patients. Infections also cause even more irreversible damage to the lung tissue. Patients should talk to their healthcare providers about recommended vaccines. The flu shot is usually recommended in non-allergic COPD patients.

Lung cancer: Smokers with chronic bronchitis have a higher risk of developing lung cancer than smokers who do not have chronic bronchitis.

Quality of life: People with advanced emphysema are often incapacitated. They experience shortness of breath even when resting or sitting in a chair or bed. Patients should consult their healthcare providers if they experience feelings of sadness, low self-esteem, loss of pleasure, apathy, and sometimes, difficulty functioning for two weeks or longer, with no known underlying cause. These may be signs of depression.

DIAGNOSIS

Pulmonary function tests (PFTs): Pulmonary function tests (PFTs) can detect chronic obstructive pulmonary disease (COPD) before symptoms are seen. These noninvasive tests measure how much air the lungs can hold and the flow of air in and out of the lungs. They can also measure the amount of oxygen and carbon dioxide exchanged in the lungs. They include a spirometry test and lung volume test.

In a spirometry test, a person breathes into mouthpiece that is connected to an instrument called a spirometer. The spirometer records the amount and the rate of air that is breathed in and out over a specified time. Some of the test measurements are obtained by normal, quiet breathing, and other tests require forced inhalation or exhalation after a deep breath.

Lung volume measurement detects restrictive lung diseases. In this set of diseases, a person cannot inhale a normal volume of air. Restrictive lung diseases may be caused by inflammation or scarring of the lung tissue (interstitial lung disease) or by abnormalities of the muscles or skeleton of the chest wall.

Lung volume measurement can be performed in two ways. The most accurate way is for an individual to sit in a sealed, transparent box called a body plethysmograph. This box looks similar to a telephone booth. The patient then breathes in and out a mouthpiece while inside the plethysmograph. Changes in pressure inside the box allow determination of the lung volume. Lung volume can also be measured when an individual breathes nitrogen or helium gas through a tube for a specified period of time. The concentration of the gas in a chamber attached to the tube is measured, allowing estimation of the lung volume.

Chest X-ray: A chest X-ray may be performed to rule out other lung problems, such as lung cancer. Even in the advanced stages of emphysema, chest X-rays are often normal.

Blood tests: Arterial blood gases (ABGs) measure how well the lungs transfer oxygen to the bloodstream and how effectively they remove carbon dioxide from the bloodstream. A blood test for the alpha-1-antitrypsin (AAt) gene, which is found in some individuals with emphysema, may also be used.

Pulse oximetry: This test involves use of a small device that attaches to the fingertip to measure the amount of oxygen in the blood. To help determine whether or not the individual needs supplemental oxygen, the test may be performed at rest, during exercise, and overnight.

Sputum examination: A healthcare provider may take a sample of the patient's mucus (sputum) to help determine the cause of some lung problems. If disease-causing microorganisms (e.g. bacteria) are present, there is infection. If there is blood in the sputum, this may indicate lung damage or lung cancer.

Computerized tomography (CT) scan: A CT scan allows a healthcare professional to see the organs in two-dimensional images or "slices." Split-second computer processing creates these images as a series of very thin X-ray beams are passed through the body. A CT scan can detect emphysema sooner than an X-ray can, but it cannot assess the severity of emphysema as accurately as a pulmonary function test.

TREATMENT

General: There is currently no cure for chronic obstructive pulmonary disease (COPD). Treatment focuses on reducing symptoms and preventing complications. Patients should take their medications exactly as prescribed to help prevent life-threatening complications, such as heart attack, from occurring. Patients should also tell their healthcare providers if they are taking any other drugs (prescription or over-the-counter), herbs, or supplements, because they may interact with treatment.

Smoking cessation: Smoking cigarettes may worsen symptoms of COPD. Therefore, Patients are encouraged to stop smoking. Nicotine replacement products, including the patch (Habitrol©, Nicoderm CQ©, Nicotrol©), chewing gum (Nicorette©), lozenges (Commit©), inhalers (Nicotrol Inhaler©), nasal sprays (Nicotrol NS©), and the antidepressant bupropion (Zyban©), may help patients quit smoking. These drugs work in part by continuing to release low levels of a brain chemical called dopamine. In this way, these smoking cessation medications decrease the craving for nicotine and reduce the signs and symptoms of withdrawal.

Varenicline (Chantix©) is a newer drug that works in a similar way. Chantix© stimulates the release of low levels of dopamine in the brain to help reduce the signs and symptoms of withdrawal. In addition, Chantix© blocks nicotine receptors in the brain. The U.S. Food and Drug Administration (FDA) has approved the course of Chantix© treatment for 12 weeks. Individuals who successfully quit smoking during Chantix© treatment may continue to use Chantix© for an additional 12 weeks to further increase the likelihood of long-term smoking cessation. Side effects of Chantix© include changes in taste, nausea, vomiting, gas, and insomnia (inability to sleep).

Bronchodilators: Medications called bronchodilators may help relieve coughing, shortness of breath, and difficulty breathing by opening constricted airways. Bronchodilators relax the muscles around the airways, making it easier to breath. Patients typically use an inhaler to take bronchodilators, but tablets are also available for some. Depending on the severity of the disease, a patient may need a short-acting bronchodilator before physical activities, a long-acting bronchodilator that is used every day, or both. Commonly prescribed bronchodilators include albuterol (Ventolin© or Proventil©), metaproterenol (Alupent©), terbutaline (Brethine©), theophylline (Theo-Dur© or Slo-bid©), and perbuterol (Maxair©).

Steroids: Steroids are used to prevent and reduce airway swelling, as well as decrease the amount of mucus in the lungs. Steroids may either be inhaled with an inhaler or taken by mouth. Examples of inhaled steroids include beclomethasone (Beclovent© or Vanceril©), budesonide (Pulmicort Respules©), flunisolide (Aerobid©), fluticasone (Flovent©), and triamcinolone (Azmacort©). Inhaled steroids seem to have fewer side effects than steroids that are taken by mouth. These drugs are typically used to treat moderate or severe COPD. Prolonged use of inhaled steroids may weaken the bones and increase the risk of cataracts, diabetes, and heart disease, including high blood pressure, high cholesterol levels, chest pain, and heart attack.

Commonly prescribed corticosteroids that are taken by mouth include prednisone (Prednisone Intensol©, Sterapred©, or Sterapred© DS), and triamcinolone (Aristocort©).

Liquid corticosteroids, such as Pediapred© or Prelone©, are available for children. These medications can be used short-term for severe symptoms, such as extreme shortness of breath.

Leukotriene modifiers: Leukotriene modifiers, such as zafirlukast (Accolate©) or montelukast (Singulair©), are a new type of long-term control medication. They help prevent airway inflammation and swelling. They also help decrease the amount of mucus in the lungs.

Supplemental oxygen: Patients who have extreme difficulty breathing may benefit from supplement oxygen. Various forms of oxygen are available, as well as different devices to deliver them to the lungs. A healthcare provider will help the patient set up oxygen for home use.

Lung transplant: Patients with severe emphysema may benefit from lung transplantations. Usually just one lung is transplanted because the survival rate has been proven to be higher for individuals with single-lung transplants than for individuals with double-lung transplants.

Surgery: In a procedure called lung volume reduction surgery (LVRS), surgeons remove small pieces of damaged lung tissue. The extra space that is created in the lungs after surgery appears to help the remaining lung tissue work more efficiently.

Pulmonary rehabilitation program: A key part of COPD treatment involves a pulmonary rehabilitation program, which combines education, exercise training, and behavioral intervention to help restore the individual with emphysema to the highest possible level of independent living.

INTEGRATIVE THERAPIES

Good scientific evidence:

Boswellia: Boswellia has been proposed as a potential therapy for asthma. Future studies are needed to assess the long-term efficacy and safety of boswellia and to compare the efficacy of boswellia to standard therapies. Boswellia should not be used for the relief of acute asthma exacerbations. Boswellia is generally believed to be safe when used as directed, although safety and toxicity have not been well studied in humans. Avoid if allergic to boswellia. Avoid with a history of stomach ulcers or stomach acid reflux disease (GERD). Use cautiously if taking lipid-soluble medications, agents metabolized by the liver's cytochrome P450 enzymes, or sedatives. Use cautiously with impaired liver function or liver damage or lung disorders. Use cautiously in children. Avoid if pregnant due to potential abortifacient effects or if breastfeeding.

Buteyko breathing technique: The Buteyko breathing technique (BBT) consists of breathing techniques, relaxation exercises, and asthma education. The technique aims to reduce hyperventilation. Studies have shown reduced use of rescue inhalers among patients receiving BBT. Improvements in other measures of asthma severity have not been shown. Additional study is warranted.

BBT is generally considered safe. Avoid with asthma that changes suddenly ("brittle asthma"). BBT may interact with asthma medications and should be used with caution when decreasing asthma medication. Asthma should be treated by a qualified healthcare professional and patients should always carry a rescue inhaler. Avoid if pregnant or breastfeeding.

Choline: Choline is possibly effective when taken orally for asthma. Choline supplements seem to decrease the severity of symptoms, number of symptomatic days and the need to use bronchodilators in asthma patients. There is some evidence that higher doses of 3 grams daily might be more effective than lower doses of 1.5 grams daily. Choline is generally regarded as safe and appears to be well-tolerated. Avoid if allergic/hypersensitive to choline, lecithin, or phosphatidylcholine. Use cautiously with kidney or liver disorders or trimethylaminuria. Use cautiously with a history of depression. If pregnant or breastfeeding it seems generally safe to consume choline within the recommended adequate intake (AI) parameters; supplementation outside of dietary intake is usually not necessary if a healthy diet is consumed.

Coleus: There is a lack of sufficient data to recommend for or against the use of coleus in the treatment of bronchial asthma. Preliminary data appears to be promising. However, larger, randomized, controlled trials are needed to confirm the safety and efficacy of coleus in bronchial asthma. Coleus is generally regarded as safe, as very few reports have documented adverse effects. However, only a few short-term trials have assessed its safety in a small sample size of patients. Avoid if allergic to Coleus forskohlii and related species or with bleeding disorders. Avoid if pregnant or breastfeeding.

Ephedra: Ephedra contains the chemicals ephedrine and pseudoephedrine, which are bronchodilators (expand the airways to assist in easier breathing). It has been used and studied to treat asthma and chronic obstructive pulmonary disease, such as asthmatic bronchoconstriction, in both children and adults. Other treatments such as beta-agonist inhalers (for example, albuterol) are more commonly recommended due to safety concerns with ephedra or ephedrine. However, the U.S. Food and Drug Administration (FDA) has collected thousands of reports of serious toxicity linked to ephedra (including over 100 deaths). Ephedra products are banned from dietary supplements because of serious health risks, including heart attack, heart damage, breathing difficulties and fluid retention in the lungs. Avoid ephedra if pregnant or breastfeeding.

Psychotherapy: Family psychotherapy may slightly improve wheezing and thoracic gas volume for asthma in children, according to several studies.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Pycnogenol: Pycnogenol© is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster spp. atlantica), which is grown in coastal south-west France. Pycnogenol may offer clinical benefit to both children and adults with asthma. Additional study is needed before a conclusion can be made. Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

Yoga: Multiple human studies report benefits of yoga (such as breathing exercises), when added to other treatments for mild-to-moderate asthma (such as standard drug therapy, diet, or massage). Better research is needed before a firm conclusion can be drawn.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Unclear or conflicting scientific evidence:

Acupressure, shiatsu: Preliminary research suggests that acupressure may be of benefit in improving quality of life in asthma. Further well-designed studies are needed before firm conclusions can be drawn. A combination of acupressure and massage may reduce dyspnea (labored breathing) and anxiety in patients with chronic obstructive pulmonary disease (COPD) who use prolonged mechanical ventilatory support. Further study of acupressure alone is needed before a recommendation can be made. A small study of patients undergoing pulmonary rehabilitation reported acupressure to be beneficial for decreasing dyspnea. Larger, well-designed studies are needed before clear conclusions can be drawn.

With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported, according to scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

Acupuncture: Some research suggests acupuncture may help prevent exercise-induced asthma and that it may reduce the perceived level of breathlessness associated with asthma or emphysema. However, reviewers agree that the available studies are small, poorly designed, and insufficient for making recommendations. A few studies have found no support for the use of acupuncture for asthma. Overall there is insufficient evidence on which to base recommendations for acupuncture to treat breathlessness in chronic obstructive pulmonary disease (COPD).

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures, with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. There is currently not enough scientific evidence to make a strong recommendation for the use of the Alexander technique in chronic asthma patients. More study is needed in this area. There is a lack of high-quality research describing the effect of the Alexander technique on respiration. No serious side effects have been reported with use of the Alexander technique. It has been suggested that the technique may be less effective with learning disabilities or mental illnesses. The Alexander technique has been used safely in pregnant women.

Applied kinesiology: Applied Kinesiology (AK) is an assessment technique that uses muscle strength testing with the aim to identify nutritional deficiencies and health problems. It is based on the concept that weakness in certain muscles corresponds to specific disease states or body imbalances. Study results are mixed in regards to bronchial asthma. Further research is needed before conclusions can be drawn. Applied kinesiology techniques in themselves are harmless. However, medical conditions should not be treated with AK alone, and should not delay appropriate medical treatment.

Aromatherapy: Early evidence suggests that aromatherapy may aid mucus clearance in chronic obstructive pulmonary disease (COPD). More studies are needed before conclusions about this application of aromatherapy can be made. Essential oils should be administered in a carrier oil to avoid toxicity. Avoid if history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

Ayurveda: There is early evidence that daily supplementation with gum resin of Boswellia serrata, known in Ayurveda as Salai guggal, may reduce dyspnea (shortness of breath), rhonchi, and the number of attacks in bronchial asthma. Another herb, Devadaru (Cedrus deodara), may have antispasmodic effects and reduce symptoms in bronchial asthma, particularly for patients with shorter histories of asthma and lower frequencies of attacks. Further research is needed in this area before a recommendation can be made.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before use of any herbs or supplements. Use guggul cautiously with peptic ulcer disease. Avoid sour food, alcohol, and heavy exercise. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag, and avoid amlaki (Emblica officinalis) at bedtime. Avoid Terminalia hebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.

PREVENTION

Smoking cessation: The primary cause of chronic obstructive pulmonary disease (COPD) is smoking. Patients who do not smoke are less likely to develop COPD than patients who do.

Patients who have COPD should not smoke. Smoking cigarettes may worsen symptoms of COPD.

Avoidance of respiratory infections: Avoid being around crowds during the cold and flu season (colder months). Washing the hands frequently, along with carrying a small bottle of hand sanitizer, helps keep viruses and bacteria away. Touching the nose or rubbing the eyes increases a patient's risk of developing viral or bacterial infections. Patients should talk to their healthcare providers about recommended vaccines.

Control breathing: Patients should talk to their healthcare providers or respiratory therapists to about breathing techniques that may help manage symptoms. Therapists may recommend relaxation exercises that may make it easier to breath. These breathing techniques may also help reduce symptoms of anxiety or distress, which occur in patients who have difficulty breathing.

Drink fluids: With COPD, mucus tends to collect in the air passages and can be difficult to clear. Drinking plenty of fluids, such as water or 100% fruit juices, help to keep secretions thin and easy to bring up.

Eat healthy foods: A healthy diet may help COPD patients maintain their strength and improve energy. Patients who are underweight should talk to their healthcare providers to determine whether or not they need nutritional supplements.

Regular exercise: Regular exercise can significantly increase the capacity for physical activity. Simple breathing techniques (deep breathing) may also help.

Visit the doctor: Patients should visit regularly visit their healthcare providers to have their lung function monitored.

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