Chronic obstructive pulmonary disease (COPD) is a term for damage to the lungs which makes breathing difficult. The main cause of COPD is long-term exposure to substances that irritate and damage the lungs; nearly all COPD in New Zealand is smoking-related. There is no cure for COPD, so prevention (ie, not smoking) is best. The term COPD includes emphysema, chronic bronchitis, certain types of bronchiectasis, and sometimes asthma.
Although often undiagnosed, COPD affects about 1 in 7 adults aged over 45 years (at least 200,000 New Zealanders) and is common in older age groups.
It is a common cause of hospitalisation, especially in winter, and is the 4th most common cause of death in NZ after cancer, heart diseaseand stroke.
The number of people with COPD is increasing due to high rates of smoking.
By the time someone develops symptoms of cough, wheeze and shortness of breath, over half their lungs are damaged beyond repair.
At any stage, quitting smoking is the most important step to treat COPD.
How does COPD affect the lungs
The lungs, the airways (bronchial tubes) and air sacs (alveoli) are elastic and stretchy. When you breathe in, each air sac fills up with air like a small balloon. When you breathe out, the air sacs deflate and the air goes out.
There are two main conditions that cause COPD – emphysema and chronic bronchitis.
Emphysema affects the air sacs, which are balloon-like spaces in the lungs. Over time the air sacs are slowly destroyed, which reduces air exchange in the lungs.
Chronic bronchitis affects the large and small airways, where they become inflamed, narrower and produce more mucus. making it harder to breath.
Most people with COPD have both these conditions.
What causes COPD?
Long-term exposure to substances that irritate and damage the lungs is the main cause of COPD.
In high and middle-income countries like New Zealand, tobacco smoke is the biggest risk factor.
In low-income countries, exposure to indoor air pollution (from open fires for cooking and heating), is a major cause.
Damage can also be caused by cannabis use, chemical fumes, recurrent chest infections or inherited factors (for example, alpha-1 anti-trypsin deficiency).
What are the symptoms of COPD?
A morning 'smokers cough' is often the first symptom of COPD. As the disease gets worse, coughing, mucus, wheezing, chest tightness and shortness of breath increase, and can be serious enough to limit daily activities.
Common symptoms of COPD include:
Cough with or without mucus or phlegm. Over time, the cough gets worse and occurs throughout the day.
Shortness of breath. At first, this happens only during exertion or exercise such as walking, but as the disease gets worse, breathing becomes difficult even at rest.
Getting chest infections more often.
What is a 'flare-up' of COPD?
COPD is a chronic (ongoing) disease. At times, it can suddenly get worse due to infections, air pollution or for other unknown reasons. This sudden worsening is called a flare-up or exacerbation, and if not managed well, it can result in a hospital stay. The effects can be lessened if you learn to recognise flare-ups, try to prevent them and help yourself get over them.
Signs you might have a flare-up:
more mucus (thicker and perhaps green/yellow)
sometimes swollen ankles.
You should ring your doctor or practice nurse if you think your condition is getting worse.
How is COPD diagnosed?
To diagnose COPD, a range of lung function tests (spirometry), imaging tests, and blood tests are used. Imaging tests such as X-rays are not so good at picking up COPD but may be used to rule out other possible causes of breathing problems.
Spirometry is the most commonly used test.
This test measures the amount of air you are able to breathe in and out and how quickly you are able to breathe air out.
Usually, when you have COPD, you will take longer to breathe all of your air out.
You can decide on the inhaler that suits you best by talking with your doctor or COPD educator. You may want to try a range of devices before choosing the one with which you are most comfortable. To get the most benefit from your inhaler you need to be using the correct technique and take it at the right time.
Walters JA, Tan DJ, White CJ, et al. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2014 Sep 1;9:CD001288. (Review) PMID: 25178099
Credits: Health Navigator. Reviewed By: Dr J Bycroft
Self care — what you can do to ease your symptoms
Chronic obstructive pulmonary disease (COPD) can affect many aspects of your life. However learning as much as you can about your condition, and getting the right help and support, can help you manage your condition and get the most out of life with COPD.
If you smoke, it is vital that you stop smoking. This is the only action that has been proven to slow the worsening of COPD. Quitting might also improve how your lungs work. If you smoke, your doctor or nurse can help you find ways to quit:
Quit card – a discount voucher for nicotine replacement patches, gum or lozenges.
Quitline – phone 0800 778 778 for free advice and support.
Visit www.quit.org.nz – for free online Quit Coach, support, advice and information.
Have a COPD action plan
Ask your doctor or nurse to help you fill in a COPD action plan. An action plan is a written document that provides you with instructions and information on how to manage your COPD on a daily basis and also how to recognise and cope with worsening symptoms (exacerbations).
You can develop your COPD action plan with your healthcare provider and fit the plan to suit the severity of your COPD and your preferences. At each visit with your healthcare provider you can review the plan and make adjustments as needed. Here are two examples of COPD action plans, choose the one that suits you:
Regular exercise is important. When you exercise your muscles including your breathing muscles, they learn to do more work with less oxygen. Often when people try to exercise and become short of breath, they stop. However, the less active you are, the weaker your muscles become, making you even more short of breath.
Here are some tips for staying active
Choose an activity you enjoy such as walking or swimming and:
start with small amounts
begin at a comfortable pace – keep your breathing under control, so you can still talk if you wish
take as many rests as you need
go regularly and increase your time/distance as your fitness improves
aim for 30 minutes of exercise a day.
Before you start a new exercise regime talk to your doctor. They may recommend strategies like using a ‘bronchodilator’ inhaler before you exercise to help you breathe easier during exercise.
Improve the way you breathe
Correct breathing technique involves using the lower chest muscle (diaphragm) to take slow, deep breaths. Often with COPD, a habit of shallow breathing means only the top of the lungs fill with oxygen, adding to the feelings of breathlessness. Regular practicing of correct breathing technique will help you to breath more deeply and easily. Exercises can be taught by a physiotherapist or practice nurse. Learn breathing control Asthma Foundation (NZ).
Attend pulmonary rehabilitation
Pulmonary rehabilitation is a 4 to 12 week programme of education and exercise usually run by your local hospital. Ideally, everyone with COPD should attend as it has been shown to improve outcomes for people with COPD.¹
The programme is run in a group setting where you all learn more about:
quitting smoking and
nutrition and diet.
The aim of pulmonary rehabilitation is to help to reduce symptoms, increase day-to-day functioning and improve quality of life. Ask your doctor about attending a pulmonary rehabilitation programme or a generic self-management programme.
In addition to quitting smoking and the other factors mentioned above, the following measures are also helpful:
avoid a cold, damp home
avoid smoky or polluted situations
eat a healthy diet and get adequate rest
avoid contact with people with colds or influenza (the flu)
consider a MedicAlert bracelet
learn to manage stress and anxiety as they can make your breathing worse.
Having COPD increases your chances of getting chest infections. To help you lessen this, it is important to get vaccinated against influenza or the ‘flu’.
Because the flu virus strains change each year, it is very important that you get vaccinated each year to prevent getting sick over the winter. The flu vaccine is available every autumn and is free for people with COPD.
Another vaccine that lessens your chance of getting chest infections is the pneumococcal vaccine. It protects you against a bacteria that commonly causes chest infections. You can also get the pneumococcal vaccine (but this may not be free). Talk to your doctor or nurse about also having this vaccine.
for short-term use during a sudden flare up of your COPD symptoms.
Most COPD medication is available as a puffer (pump) or inhaler and may often be used with a spacer.
(also called rescue inhalers)
Reliever inhalers improve symptoms quickly because they deliver medication directly to your airways, causing the muscles of your airways to relax and open up. They usually start working within minutes and their effect lasts for a few hours.
The use of reliever medication will be different for different people:
People with mild symptoms use a reliever inhaler when required for breathlessness.
People with more severe COPD use a reliever inhaler regularly, up to 4 times a day.
You may also be given a reliever inhaler to use only when needed for breathlessness while you take a different inhaler regularly to prevent symptoms.
These are available as puffers or inhalers such as:
If the maintenance inhalers above don't fully control your symptoms, you can take a tablet called theophylline.
Theophylline causes the muscles of your airways to relax and open up. It also increases the strength of your diaphragm (the large muscle at the base of the chest used when breathing in) and speeds up how quickly you clear mucus and phlegm from your lungs.
While a useful medication, it is not used as much these days as it interacts with other medications or supplements and is toxic if the dose is too high. Blood tests can be used to help decide what dose you need to take.
Preventer medication (inhalers) help to reduce the number of flare-ups by lessening the inflammation that causes swelling and mucus productions in the airways. These inhalers are usually taken regularly, twice a day.
Preventer medication is a combination of a corticosteroid plus a long-acting bronchodilator in a single inhaler.
If your COPD symptoms become severe or you experience a sudden worsening in your symptoms, see your doctor.
Anti-inflammatory (or steroid) tablets such as prednisone may be prescribed as a short course for one or two weeks if you have a bad flare-up. They work best if taken as soon as the flare-up starts, so your doctor may give you some tablets to keep at home in case you have a flare-up.
If your symptoms are due to a bacterial chest infection, then your doctor may prescribe a short course of antibiotics.
Knowing what to do when you first get sick and when to start taking steroid tablets can make a big difference to getting better faster and staying out of hospital. Ask your doctor or nurse for a COPD Management Plan.
Most COPD medication is available as inhalers, which come in different shapes and sizes, such as:
You can decide on the inhaler that suits you best by talking with your doctor or asthma educator. You may want to try a range of devices before choosing the one with which you are most comfortable. To get the most benefit from your inhaler you need to be using the correct technique and take it at the right time. Read more about inhalers.
Spacers (for use with inhalers)
A spacer is a clear plastic tube with a mouthpiece or mask at one end and a hole for your inhaler at the other. A spacer is attached to the end of your inhaler to make it easier to use. It also makes the medication in the inhaler more effective because more of it is able to get into your lungs.
Spacers are good if you have trouble working your inhaler or when you get so breathless that you have trouble breathing in the medication from your inhaler. Talk to your doctor or pharmacist about how to get a free spacer, and make sure they show you how to use it correctly. Read more about spacers
A nebuliser is a machine that turns liquid medicine into a fine mist which you can breathe easily into your lungs. The machine has a mouthpiece or face mask which you use to breathe in the medicine for between 3 and 10 minutes.
Nebulisers may be used to help you take your reliever medication when your COPD is so bad that you can’t use your inhaler as you usually do. Read more about nebulisers.
Many people think oxygen is given to treat shortness of breath. This is not the case. Being short of breath does not mean you are short of oxygen. If your body has low oxygen levels for long periods it can put a strain on your heart and lead to heart problems. Oxygen is given to prevent strain on the heart.
The tubes from the machine that deliver oxygen to your lungs are very long so you can move around your home while connected. Portable oxygen tanks are also available. It is vital not to smoke while you are taking oxygen, because of the high risk of fire.
Your doctor will decide whether you need oxygen. If your doctor thinks that your oxygen levels are low they will arrange for you to have a special blood test. You will need to be seen by a specialist respiratory doctor as well.
Figure A shows the location of the lungs and airways in the body. The inset image shows a detailed cross-section of the bronchioles and alveoli. Figure B shows lungs damaged by COPD. The inset image shows a detailed cross-section of the damaged bronchioles and alveolar walls. (Image from the National Heart Lung and Blood Institute, public domain image)
COPD has a major impact on quality of life, particularly as the disease progresses to the severe stage. Quality of life is also affected by poor mobility and social isolation.
Co-morbidities are common with COPD patients having higher risk of also developing heart disease, stroke, lung cancer and pneumonia. Many also develop anxiety and/or depression and patients should be screened for these at least once a year and as needed.
One of the most effective treatments for COPD is encouraging your patients to attend a pulmonary rehabilitation programme. Rates of referral are low in NZ and represents a lost opportunity to improve patient outcomes.
The COPD Prescribing Tool (BPAC)
Based on the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD 2016), the COPD prescribing tool provides pharmacological treatment options for patients with COPD based on symptom severity. The tool comprises four patient categories, A, B, C or D which corresponds to the severity of the patient’s symptoms. Read more about the COPD prescribing tool.
COPD & Asthma Fundamentals "The most up-to-date Asthma & COPD Fundamentals course available in New Zealand. The course aligns the latest research with specific information for the New Zealand context, such as recently funded medications, treating Māori and Pacific peoples, and best practice health literacy. The course aligns with the latest NZ asthma guidelines." It includes two half day workshops covering the key aspects of COPD and asthma pathophysiology, management and practice. Delivered by The Asthma & Respiratory Foundation (NZ).
Non-pharmacological-management of COPD – Fiona Horwood Goodfellow Unit, 2017. "Dr Fiona Horwood talks about non-pharmacological management of Chronic Obstructive Pulmonary Disease. Fiona is Clinical Head for General Medicine and a Respiratory Physician at Counties Manukau DHB."