c


c 
   c
is a disease state
characterized by airflow limitation that is not fully reversible. This newest
definition c
, provided by the Global Initiative for Chrnonic Obstructive
Lung Disease (GOLD), is a broad description that better explains this
disorder and its signs and symptoms (GOLD, World Health Organization
[WHO] & National Heart, Lung and Blood Institute [NHLBI], 2004). Although
previous definitions have include emphysema and chronic bronchitis under
the umbrella classification of c
, this was often confusing because
most patient with c
 present with over lapping signs and symptoms of
these two distinct disease processes.

c
 may include diseases that cause airflow obstruction (e.g.,

Emphysema, chronic bronchitis) or any combination of these disorders.
Other diseases as cystic fibrosis, bronchiectasis, and asthma that were
previously classified as types of chronic obstructive lung disease are now
classified as chronic pulmonary disorders. However, asthma is now
considered as a separate disorder and is classified as an abnormal airway
condition characterized primarily by reversible inflammation. c
 can co-
exist with asthma. Both of these diseases have the same major symptoms;
however, symptoms are generally more variable in asthma than in c
.

2 c
 is a progressive disease that makes it hard to breathe.

"Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy
substance), wheezing, shortness of breath, chest tightness, and other
symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have
COPD smoke or used to smoke. Long-term exposure to other lung irritants,
such as air pollution, chemical fumes, or dust, also may contribute to
COPD.


  
 

To understand COPD, it helps to understand how the lungs work. The air
that you breathe goes down your windpipe into tubes in your lungs called
bronchial tubes or airways.

Within the lungs, your bronchial tubes branch into thousands of smaller,
thinner tubes called bronchioles. These tubes end in bunches of tiny round
air sacs called alveoli (al-VEE-uhl-eye).

Small blood vessels called capillaries run through the walls of the air sacs.
When air reaches the air sacs, the oxygen in the air passes through the air
sac walls into the blood in the capillaries. At the same time, carbon dioxide
(a waste gas) moves from the capillaries into the air sacs. This process is
called gas exchange.

The airways and air sacs are elastic (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.

In COPD, less air flows in and out of the airways because of one or more of
the following:

2 The airways and air sacs lose their elastic quality.

2 The walls between many of the air sacs are destroyed.
2 The walls of the airways become thick and inflamed.
2 The airways make more mucus than usual, which tends to clog them.
¢ ! !"c

rigure 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. rigure
B shows lungs damaged by COPD. The inset image shows a detailed
cross-section of the damaged bronchioles and alveolar walls.

In the United States, the term "COPD" includes two main conditions²
emphysema (em-fi-SE-ma) and chronic bronchitis (bron-KI-tis). (Note: The
Diseases and Conditions Index article about bronchitis discusses both
acute and chronic bronchitis.)

In emphysema, the walls between many of the air sacs are damaged,
causing them to lose their shape and become floppy. This damage also
can destroy the walls of the air sacs, leading to fewer and larger air sacs
instead of many tiny ones. If this happens, the amount of gas exchange in
the lungs is reduced.

In chronic bronchitis, the lining of the airways is constantly irritated and

inflamed. This causes the lining to thicken. Lots of thick mucus forms in the
airways, making it hard to breathe.

Most people who have COPD have both emphysema and chronic
obstructive bronchitis. Thus, the general term "COPD" is more accurate.

 
COPD is a major cause of disability, and it's the fourth leading cause of
death in the United States. More than 12 million people are currently
diagnosed with COPD. Many more people may have the disease and not
even know it.

COPD develops slowly. Symptoms often worsen over time and can limit
your ability to do routine activities. Severe COPD may prevent you from
doing even basic activities like walking, cooking, or taking care of yourself.

Most of the time, COPD is diagnosed in middle-aged or older people. The

disease isn't passed from person to person²you can't catch it from
someone else.
COPD has no cure yet, and doctors don't know how to reverse the damage
to the airways and lungs. However, treatments and lifestyle changes can
help you feel better, stay more active, and slow the progress of the disease

¢#c


2 Chronic bronchitis
2 Chronic obstructive airway disease
2 Chronic obstructive lung disease
2 Emphysema

c$% &c


2 Most cases of COPD occur as a result of long-term exposure to lung

irritants that damage the lungs and the airways.
2 In the United States, the most common irritant that causes COPD is
cigarette smoke. Pipe, cigar, and other types of tobacco smoke also
can cause COPD, especially if the smoke is inhaled.
2 Breathing in secondhand smoke, air pollution, and chemical fumes or
dust from the environment or workplace also can contribute to COPD.
(Secondhand smoke is smoke in the air from other people smoking.)
2 In rare cases, a genetic condition called alpha-1 antitrypsin deficiency
may play a role in causing COPD. People who have this condition
have low levels of alpha-1 antitrypsin (AAT)²a protein made in the
liver.
2 Having a low level of the AAT protein can lead to lung damage and
COPD if you're exposed to smoke or other lung irritants. If you have
this condition and smoke, COPD can worsen very quickly.

"' #c
(

The main risk factor for COPD is smoking. Most people who have
COPD smoke or used to smoke. People who have a family history of
COPD are more likely to develop the disease if they smoke.
Long-term exposure to other lung irritants also is a risk factor for COPD.
Examples of other lung irritants include secondhand smoke, air pollution,
and chemical fumes and dust from the environment or workplace.
(Secondhand smoke is smoke in the air from other people smoking.)

Most people who have COPD are at least 40 years old when symptoms
begin. Although uncommon, people younger than 40 can have COPD. ror
example, this may happen if a person has alpha-1 antitrypsin deficiency,


% &c



c' ¢c)' ¢c

Lung damage and inflammation

in the large airways results in chronic
bronchitis. Chronic bronchitis is
defined in clinical terms as a cough
with sputum production on most days
for 3 months of a year, for 2
consecutive years. In the airways of
the lung, the hallmark of chronic
bronchitris is an increased number (hyperplasia) and increased size
(hypertrophy) of the goblet cells and mucous glands of the airway. As a
result, there is more mucus than usual in the airways, contributing to
narrowing of the airways and causing a cough with sputum. Microscopically
there is infiltration of the airway walls with inflammatory cells. Inflammation
is followed by scarring and remodeling that thickens the walls and also
results in narrowing of the airways. As chronic bronchitis progresses, there
is squamous metaplasia (an abnormal change in the tissue lining the inside
of the airway) and fibrosis (further thickening and scarring of the airway
wall). The consequence of these changes is a limitation of airflow.

Patients with advanced c
 that have primarily chronic bronchitis rather

than emphysema were commonly referred to as ³blue bloaters´ because of
the bluish color of the skin and lips (cyanosis) seen in them. The hypoxia
and fluid retention leads to them being called ³Blue Bloaters.´

c$%)' ¢c

c*¢&% ¢

One of the most common symptoms of COPD is shortness of breath

(dyspnea). People with COPD commonly describe this as: ³My breathing
requires effort´, ³I feel out of breath´, or ³I can not get enough air in´. People
with COPD typically first notice dyspnea during vigorous exercise when the
demands on the lungs are greatest. Over the years, dyspnea tends to get
gradually worse so that it can occur during milder, everyday activities such
as housework. In the advanced stages of COPD, dyspnea can become so
bad that it occurs during rest and is constantly present. Other symptoms of
COPD are a persistent cough, sputum or mucus production, wheezing,
chest tightness, and tiredness. People with advanced (very severe) COPD
sometimes develop respiratory failure. When this happens, cyanosis, a
bluish discoloration of the lips caused by a lack of oxygen in the blood, can
occur. An excess of carbon dioxide in the blood can cause headaches,
drowsiness or twitching (asterixis). A complication of advanced COPD is
cor pulmonale, a strain on the heart due to the extra work required by the
heart to pump blood through the affected lungs. Symptoms of cor
pulmonale are peripheral edema, seen as swelling of the ankles, and
dyspnea.

¢ &c


There are a few signs of c
 that a healthcare worker may detect
although they can be seen in other diseases. Some people have c

and have none of these signs. Common signs are:

2 tachypnea, a rapid breathing rate

2 wheezing sounds or crackles in the lungs heard through a
stethoscope
2 breathing out taking a longer time than breathing in
2 enlargement of the chest, particularly the front-to-back distance
(hyperinflation)
2 active use of muscles in the neck to help with breathing
 2 breathing through pursed lips increased anteroposterior to lateral
ratio of the chest (i.e. barrel chest).

%*
%*

% is a chronic obstructive

pulmonary disease (COPD, as it is
otherwise known, formerly termed a
chronic obstructive lung disease). It is
often caused by exposure to toxic
chemicals, including long-term exposure to
tobacco smoke. Emphysema is
characterized by loss of elasticity
(increased pulmonary compliance) of the lung tissue caused by destruction
of structures feeding the alveoli, owing to the action of alpha 1 antitrypsin
deficiency. This causes the small airways to collapse during forced
exhalation, as alveolar collapsibility has decreased. As a result, airflow is
impeded and air becomes trapped in the lungs, in the same way as other
obstructive lung diseases. Symptoms include shortness of breath on
exertion, and an expanded chest. However, the constriction of air passages
isn¶t always immediately deadly, and treatment is available.

c*¢&% ¢
Signs of emphysema include pursed-lipped breathing, central cyanosis and
finger clubbing. The chest has hyper resonant percussion notes,
particularly just above the liver, and a difficult to palpate apex beat, both
due to hyperinflation. There may be decreased breath sounds and audible
expiratory wheeze. In advanced disease, there are signs of fluid overload
such as pitting peripheral edema. The face has a ruddy complexion if there
is a secondary polycythemia. Sufferers who retain carbon dioxide have
asterixis (metabolic flap) at the wrist.



¢ 
c+ c . 

2 These tests create pictures of the structures inside your chest, such as
your heart, lungs, and blood vessels. The pictures can show signs of
COPD. They also may show whether another condition, such as heart
failure, is causing your symptoms.

 !&  

2 measure how much air you can breathe in and out, how fast you can
breathe air out, and how well your lungs deliver oxygen to your blood.

The main test for COPD is spirometry (spi-ROM-eh-tre). Other lung

function tests, such as a lung diffusion capacity test, also may be used.
(ror more information, go to "Types of Lung runction Tests.")



2 During this painless test, a technician will ask you to take a deep breath
in. Then, you'll blow as hard as you can into a tube connected to a small
machine. The machine is called a spirometer.

The machine measures how much air you breathe out. It also measures
how fast you can blow air out.


!,

2 This blood test measures the oxygen level in your blood using a sample
of blood taken from an artery. The test can help find out how severe
your COPD is and whether you may need oxygen therapy

Spirometry can detect COPD long before its symptoms appear. Doctors
also may use the results from this test to find out how severe your COPD is
and to help set your treatment goals.

The test results also may help find out whether another condition, such as
asthma or heart failure, is causing your symptoms


'%*%¢
O

 
 
 


2 Relieving your symptoms

2 Slowing the progress of the disease
2 Improving your exercise tolerance (your ability to stay active)
2 Preventing and treating complications
2 Improving your overall health

* 
) 

Bronchodilators relax the muscles around your airways. This helps open
your airways and makes breathing easier.

Depending on how severe your disease is, your doctor may prescribe
short-acting or long-acting bronchodilators. Short-acting bronchodilators
last about 4 to 6 hours and should be used only when needed. Long-acting
bronchodilators last about 12 hours or more and are used every day.

Most bronchodilators are taken using a device called an inhaler. This

device allows the medicine to go right to your lungs. Not all inhalers are
used the same way. Ask your health care team to show you the correct
way to use your inhaler.

If your COPD is mild, your doctor may only prescribe a short-acting inhaled
bronchodilator. In this case, you may only use the medicine when
symptoms occur.

If your COPD is moderate or severe, your doctor may prescribe regular

treatment with short- and long-acting bronchodilators.


   

Inhaled steroids are used to treat people whose COPD symptoms flare up
or worsen. These medicines may reduce airway inflammation.

Your doctor may ask you to try inhaled steroids for a trial period of 6 weeks
to 3 months to see whether the medicine helps relieve your breathing
problems.

- 

& 

The flu (influenza) can cause serious problems for people who have
COPD. rlu shots can reduce your risk of the flu. Talk with your doctor
about getting a yearly flu shot.

   - 

This vaccine lowers your risk of pneumococcal pneumonia (nu-MO-ne-ah)

and its complications. People who have COPD are at higher risk of
pneumonia than people who don't have COPD. Talk with your doctor about
whether you should get this vaccine.

'


Pulmonary rehabilitation, or rehab, is a medically supervised program that

helps improve the health and well-being of people who have lung problems.

Rehab may include an exercise program, disease management training,

and nutritional and psychological counseling. The program's goal is to help
you stay more active and carry out your daily activities.

Your rehab team may include doctors, nurses, physical therapists,

respiratory therapists, exercise specialists, and dietitians. These health
professionals work together and with you to create a program that meets
your needs.
 +!

If you have severe COPD and low levels of oxygen in your blood, oxygen
therapy can help you breathe better. ror this treatment, you're given
oxygen through nasal prongs or a mask.

You may need extra oxygen all the time or just sometimes. ror some
people who have severe COPD, using extra oxygen for most of the day can
help them:

2 Do tasks or activities, while having fewer symptoms

2 Protect their hearts and other organs from damage
2 Sleep more during the night and improve alertness during the day
2 Live longer

 !

In rare cases, surgery may benefit some people who have COPD. Surgery
usually is a last resort for people who have severe symptoms that have not
improved from taking medicines.

Surgeries for people who have COPD that's mainly related to emphysema
include bullectomy (bul-EK-to-me) and lung volume reduction surgery
(LVRS). A lung transplant may be done for people who have very severe
COPD.

)  

When the walls of the air sacs are destroyed, larger air spaces called
bullae form. These air spaces can become so large that they interfere with
breathing. In a bullectomy, doctors remove one or more very large bullae
from the lungs.

 !- '  !

In LVRS, surgeons remove damaged tissue from the lungs. This helps the
lungs work better. In carefully selected patients, LVRS can improve
breathing and quality of life.
 !

A lung transplant may benefit some people who have very severe COPD.
During a lung transplant, your damaged lung is removed and replaced with
a healthy lung from a deceased donor.

A lung transplant can improve your lung function and quality of life.
However, lung transplants have a high risk of complications. These include
infections and death due to the body rejecting the transplanted lung.

If you have very severe COPD, talk with your doctor about whether a lung
transplant is an option. Discuss with your doctor the benefits and risks of
this type of surgery.

*!
There is currently no cure for COPD; however, COPD is both a preventable
and treatable disease. Clinical practice guidelines for the management of
COPD are available from the Global Initiative for Chronic Obstructive Lung
Disease (GOLD),[40] a collaboration that includes the World Health
Organization and the U.S. National Heart, Lung, and Blood Institute. The
major current directions of COPD management are to assess and monitor
the disease, reduce the risk factors, manage stable COPD, prevent and
treat acute exacerbations and manage comorbidity.[3]