Last reviewed by Faculty of Harvard Medical School on January 24, 2013
By Harvey B. Simon, M.D.
Harvard Medical School
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. It's also the only disease among the top 10 killers that is seeing an increase in deaths each year. About 15 million Americans suffer from COPD. Men are affected about twice as often as women because male smokers have outnumbered female smokers.
COPD is not curable, but it is treatable. Lifestyle changes and medication can help people cope with chronic lung disease and live longer, fuller lives. But as you'll see, most cases of COPD can be prevented.
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What Is COPD?
COPD refers to chronic illnesses that block the flow of air and make breathing difficult. The two major forms of COPD are chronic bronchitis and emphysema. In both, narrowed air passages or bronchi make it hard to exhale. (Bronchi are wider during inhalation and narrow during exhalation.) Narrowed bronchi also cause asthma, but the narrowing is temporary and reversible. In COPD, it's permanent.
In chronic bronchitis, the mucous glands in the air passages are enlarged and produce too much mucous, which narrows the bronchi. In emphysema, the narrowing of the bronchi is caused by damage to the lung tissue and is more severe than in chronic bronchitis. Most patients with COPD have a mixture of chronic bronchitis and emphysema. Inflammation triggered by irritants that are inhaled also contributes to COPD. White blood cells try to fight off the irritation, but instead of controlling the damage caused by the irritant, they release chemicals that damage and eventually destroy lung tissue.
Smoking causes about 85% of COPD cases. Heavy smokers have the highest risk of developing COPD. Secondhand smoke and other inhaled toxins can cause COPD in some nonsmokers. In others, an inherited protein deficiency is to blame. But in some cases, no cause is apparent.
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What Are the Symptoms of COPD?
COPD starts gradually and progresses slowly over time. That's why the number of cases of COPD continues to increase years after many American men quit smoking.
At first, there are no symptoms. But little by little, symptoms appear, usually in middle age. A morning "smoker's cough" is often the first complaint. The cough gradually gets worse and occurs throughout the day. Next, shortness of breath develops. In the beginning, it only occurs during exercise, but as the disease progresses, breathing becomes a chore even at rest. Wheezing is another common symptom. Most patients also become tired and weak.
Patients with chronic bronchitis have a recurrent cough that brings up large amounts of thick, discolored phlegm almost every day for three months or longer. Over time, the lung disease puts a strain on the heart and men may develop cor pulmonale, a form of congestive heart failure. As a result, they accumulate fluid and gain weight. Their lips and skin may eventually turn bluish due to low blood oxygen levels.
Men with emphysema have a scant and dry cough, severe shortness of breath and they breathe faster than normal. Their skin stays pink and they dont retain fluid, but their appearance changes: they lose weight, their muscles tend to waste away, and they develop large, barrel-shaped chests.
Most patients with COPD have symptoms of both chronic bronchitis and emphysema. In addition to daily symptoms, most patients have two to three exacerbations each year. These are abrupt flares that are often triggered by lung infections. Symptoms get much worse and aggressive treatment is needed.
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How Is COPD Diagnosed?
The best way to diagnose COPD is with a simple, safe lung-function test, called the forced expiratory volume at one second (FEV1). It measures the amount of air you can breathe out with maximum effort in one second. Doctors can also use this test to check the results of treatment. X-rays, blood oxygen mearurements, and other tests may also help.
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People with COPD can take steps to control symptoms, and minimize complications and disability. The first rule is the most important: Avoid tobacco and secondhand smoke. This is a hard and fast rule. There are no exceptions.
Good nutrition is also important. A diet high in fruits, vegetables, and fish may actually help the lungs. There is no evidence that vitamin supplements help. In fact beta-carotene actually increases a male smoker's risk of lung cancer. Patients with chronic bronchitis and heart strain must avoid sodium (salt). Men with severe emphysema may benefit from high-calorie nutritional supplements. Drinking plenty of fluids will help keep phlegm loose and make it easy to clear out by coughing.
A program of low-to-moderate intensity exercise can help the muscles get the most from the oxygen that damaged lungs can deliver. Walking is best. Start with 5 just minutes of walking three to four times a day and build up to 45 minutes a day. Patients with severe COPD or heart disease may also need a structured pulmonary rehabilitation program, which can teach breathing exercises that strengthen chest muscles.
Preventing infection is essential. Be sure your flu and pneumonia shots are up to date. Keep your distance from folks with respiratory infections. Wash your hands carefully with an alcohol-based hand rub.
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Medications for COPD
Prescription medications can do a lot for patients with COPD. Your doctor will explain the benefits and possible side effects. Here is a summary of the major groups of medications.
- Bronchodilators - These relax the muscles in the walls of the bronchi, widening the tubes and easing the passage of air. The most popular short-acting bronchodilator is albuterol (Proventil). It is inhaled through a metered-dose inhaler (MDI) up to four times a day for quick relief of wheezing, coughing, or shortness of breath. Patients with mild COPD may need only a short-acting bronchodilator, but patients with more advanced disease also benefit from a long-acting bronchodilator. They help prevent symptoms rather than provide immediate relief. Salmeterol (Serevent) or formoterol (Foradil) can be inhaled twice a day as a spray or from a dry powder inhaler (DPI). Patients taking salmeterol or formoteral should continue using their short-acting albuterol MDI for that purpose.
- Anticholinergics - These are drugs that widen the bronchial tubes and reduce the amount of mucus without making it thick and difficult to bring up. They provide long-term control and are the most important medication for many men with COPD. The newer drug tiotropium (Spiriva) can be used just once a day, while ipratropium (Atrovent) requires more frequent use . Because anticholinergics and bronchodilators work in different ways, patients can benefit from using both types of drugs.
- Corticosteroids ("steroids") - These medications reduce inflammation in the bronchial tubes. Inhaled steroids can help many, but not all, patients with moderate-to-severe COPD. They are most effective for patients who are also taking long-acting bronchodilators. A combination of a steroid (fluticasone ) and a long-acting bronchodilator (salmeterol) is available for twice-a-day dry powder inhalation.
- Antibiotics - These can be critically important for flare-ups but are not helpful for maintenance therapy. Notify your doctor right away if your breathing becomes worse, if you develop a fever, or if your phlegm becomes thicker, discolored, or more plentiful.
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Does Oxygen Really Help?
People with COPD who have low blood oxygen levels can benefit greatly from long-term, round-the-clock oxygen therapy. At home, oxygen can be stored in cylinders or generated by machines called oxygen concentrators. Portable tanks can provide several hours of oxygen away from home. Oxygen therapy needs careful supervision by a physician. Because oxygen can be a fire hazard, patients and household members need to follow certain safety precautions.
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The Bottom Line
The average person will take some 600 million breaths during a lifetime. Most men can keep their lungs healthy simply by avoiding tobacco smoke and other harmful fumes. Early diagnosis and treatment can slow the damage, ward off complications, and improve the quality of life. New therapies are on the way, but simple prevention is the best treatment of all. And, after all, what's more important than preserving the breath of life?
Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.