COPD

More than 212 million people around the world have chronic obstructive pulmonary disease, according to a 2023 report published in eClinical Medicine. The umbrella term describes lung conditions that cause persistent and often progressive narrowing of the bronchial tubes. These are the tubes that carry air into and out of the lungs.

When the bronchial tubes become narrowed, airflow through the respiratory tract becomes restricted or blocked. This can lead to symptoms such as coughing, excess production of phlegm (a thick type of mucus produced in the airways), and dyspnea (shortness of breath). The vast majority of cases of COPD are caused by smoking, but the condition is also linked to exposure to other lung irritants.

How COPD affects the lungs

COPD can damage various sections of the bronchial tree. This consists of structures in the body that help move air from the trachea (or windpipe) down into the lungs and then back out again. These structures include:

• The bronchi, also known as the left and right bronchus, are the largest of the bronchial tubes.
• These branch off into thousands of smaller airway tubes called bronchioles.
• The bronchioles, in turn, form millions of tiny offshoots of their own called alveoli (or air sacs).
• Alveoli are surrounded by tiny blood vessels called capillaries and a network of arteries and veins.
• These small blood vessels allow oxygen (O2) to flow into the lungs while expelling carbon dioxide (CO2), a waste product in the form of gas.

COPD damages these bronchial tubes. One primary form of damage involves the bronchial tubes losing their natural elasticity, or the ability to expand and shrink back with each breath. As a result, the lungs may overinflate during breathing (leaving air trapped in them) and possibly burst. These changes can prevent the proper exchange of O2 and CO2 to and from the lungs, causing breathing and overall health issues.

The lung’s airways ordinarily help trap and rid the body of agents that can cause illness and infections, such as bacteria and viruses. When COPD damages the lungs, it thereby weakens this important piece of the immune system’s function.

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The two main types of COPD are emphysema and chronic bronchitis. People may experience symptoms of one of these conditions or a mix of both at the same time.

Chronic bronchitis

Bronchitis is a condition that causes inflammation and irritation of the bronchial tubes. This causes mucus to build up in the airways, making it harder to breathe. Frequent infections may also occur because the body’s ability to trap and expel infectious agents from the bronchial tubes is reduced.

This COPD condition is classified as chronic when it causes a productive cough that lasts for more than three months, with two or more bouts occurring within two consecutive years. (A productive cough, also known as a “wet” cough, is one that produces mucus or phlegm.) Because the main cause of chronic bronchitis is smoking tobacco, this cough is sometimes referred to as a smoker’s cough.

In addition to chronic coughing and feeling unwell overall (referred to as general malaise), other long-term bronchitis symptoms include:

• Chest pain, discomfort, or tightness, which may also be felt in the abdominal (stomach) muscles due to repeated and forceful coughing
• Shortness of breath, especially with physical activity
• Wheezing (a high-pitched whistling or rattling sound that occurs during breathing when air is partially blocked)

Emphysema

Emphysema progressively and permanently damages lung tissue, namely alveoli. The irreversible damage caused by this COPD type can cause alveoli to:

• Collapse or become narrow
• Stretch
• Overinflate

Over time, emphysema causes permanent enlargement of these air sacs. When the walls of multiple alveoli rupture, they can fuse together to form oversized air sacs with less elasticity due to the loss of elastic fibers that give structure and support to alveoli.

Damaged alveoli have a much harder time moving oxygen into the lungs during inhalation and removing CO2 out of them during exhalation. The lungs also overinflate, trapping and circulating stale air (including excess CO2) within them. These issues can lead to frequent breathlessness as a result.

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It may take years for COPD symptoms to develop and progress. The most common of these include:

• Chronic cough, which often involves coughing up phlegm, which may appear clear, yellow, green, or blood-tinged
• Breathlessness or dyspnea (shortness of breath) while performing daily activities and with other types of exertion
• Difficulty taking a deep breath
• Fatigue
• Wheezing or chest tightness

Early signs and symptoms of COPD

A mild cough that produces phlegm may be among the first COPD symptoms to develop. This productive cough can persist through the day, but it tends to be worse upon waking.

People with COPD may notice feeling short of breath when they’re exerting themselves or they may simply feel more tired in general. They may also wheeze or feel tightness in their chest on occasion.

In some early cases, people may experience COPD symptoms such as dyspnea and a productive cough only when they have a lung infection such as bronchitis or pneumonia. But during the early course of the disease, they may start to notice these lung infections occurring more often.

Worsening signs and symptoms of COPD

As COPD progresses, symptoms intensify, especially in people who haven’t quit smoking. Shortness of breath at rest or with exertion grows more severe and lung infections occur more frequently. In some instances, hospitalization may be needed to effectively treat a severe COPD flare-up.

For reasons that aren’t clear, severe weight loss may occur in about a third of people with severe COPD. Some experts suggest that shortness of breath makes it harder to eat. Other factors include inflammation along with low O2 and high CO2 levels, which consume more energy and calories than do healthy levels.

People with worsening COPD may also cough up blood. This is likely due to inflammation and irritation of the bronchial tubes. Coughing up blood may also be a sign of lung cancer, a condition that may co-occur alongside COPD.

Breathing slows down during sleep in people with COPD, which causes lower levels of oxygen but higher levels of CO2 in the blood. As a result, people may have headaches when they wake up.

COPD often occurs alongside obstructive sleep apnea (OSA), a sleep disorder that causes gaps in breathing along with drops in O2 and spikes in CO2 levels during sleep. When COPD and OSA occur together, the condition is referred to as an “overlap syndrome.” Together, these conditions can cause more significant dips in O2 during sleep.

The way people with COPD breathe may change as the disease progresses, especially those with emphysema. For instance, they may use a technique called pursed-lip breathing to help manage shortness of breath.

This involves slowly breathing in through the nose and breathing out through pursed or puckered lips at a slow and controlled rate. Pursed-lip breathing allows the airways to stay open longer and bronchial tubes to clear out stale air. That is, more O2 gets into the lungs while more CO2 gets out.

Some people with COPD prefer to use a maneuver that helps various respiratory muscles work more effectively. The maneuver involves standing over a table with the arms stretched out and palms or elbows placed on the surface of the table for support.

Overinflation of the lungs due to trapped air can cause the rib cage to permanently expand. Over time, a barrel chest may form, making it bulge and appear more rounded.

The shortage of oxygen in the blood can also lead to cyanosis, a condition that causes a bluish-purplish to whitish-grayish tint to the skin, lips, or nail beds. Although rare, clubbing of the fingers may also occur, which causes the tips of the fingers or toes to bulge and the nails to curve downward. This may also be a sign of lung cancer or another lung disorder.

Parts of the lung may also rupture as a result of COPD and cause a pneumothorax, also called a collapsed lung. When this occurs, air leaks from the lungs into the pleural space, the cavity between the lung and chest wall.

As the air builds up in this cavity, it becomes even harder to breathe as the affected lung can’t expand. Sudden, severe pain and shortness of breath occur, requiring emergency medical care to remove air from the pleural space.

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Health care providers (HCPs) around the world most often use the COPD staging system developed and updated by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). This organization issues international guidelines for COPD treatment and management. The GOLD staging system grades COPD severity based on:

• Spirometry test results (see below)
• Type and severity of COPD symptoms
• Frequency of COPD flare-ups (also called exacerbations, as symptoms tend to get worse during these periods)
• Presence of other chronic conditions co-occurring with COPD

Spirometry test for COPD

A spirometry test is the most common type of pulmonary function test (also known as a PFT or a lung function test). It measures the amount of air you can force out of your lungs in one second (also known as forced expiratory volume in one second, or FEV1). It also includes the maximum amount of air you can forcibly exhale from your lungs after taking the deepest breath you can (or forced vital capacity, or FVC).

Normal results are an FEV1/FVC ratio above 70 percent and FEV1 and FVC higher than 80 percent of the predicted value. (That would be the average result for people of the same age, height, and sex assigned at birth.) An FEV1/FVC ratio less than 70 percent can help confirm a COPD diagnosis, with additional values for the various stages of COPD as follows, per GOLD criteria:

Stage 1: Mild or early COPD

With mild COPD, spirometry test results will show an FEV1 of 80 percent or higher. During this early stage, many people experience few if any symptoms. Some may notice a lingering cough, which may be dry or slightly productive. They may also feel short of breath or easily winded with moderate-intensity activities such as walking briskly or walking uphill.

Stage 2: Moderate COPD

FEV1 will range between 50 and 79 percent once COPD moves into the moderate stage. People develop a persistent cough with an increase in phlegm (now usually a different color such as yellow or green), which is often worse when they first wake up.

They may feel short of breath, even with simple activities such as walking on flat ground. Wheezing, greater fatigue, and sleep issues may also develop.

Stage 3: Severe COPD

Once people reach this severe stage, FEV1 has dropped to between 30 and 49 percent of the normal range. COPD symptoms have gotten noticeably worse and flare-ups are likely occurring more often.

Severe shortness of breath and worsening symptoms such as wheezing and chest tightness or discomfort are likely to impact one’s ability to carry out their daily activities. Edema (swelling) in the legs, ankles, and feet may also occur.

Stage 4: Very severe or end-stage COPD

FEV1 is now less than 30 percent of the predicted value. COPD symptoms and flare-ups occur frequently and have gotten significantly worse and more persistent and may even become life-threatening. Breathing takes great effort and people experience frequent breathlessness, even while resting.

Crackles (also called rales) may be heard when people with COPD breathe. These abnormal lung sounds occur when small air bubbles pass through fluid blocking the airways.

A barrel chest may develop along with a fast heartbeat. Significant weight loss may occur and delirium and pulmonary hypertension (high blood pressure in the arteries between the lungs and the heart) may set in.

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COPD is usually caused by processes that narrow and damage the bronchial tubes. With chronic bronchitis, inflammation causes thickening and narrowing of the airways and increased mucus production, which also interfere with breathing.

With emphysema, the alveoli collapse, overexpand, or rupture, which impedes breathing by restricting the exchange of oxygen and carbon dioxide into and out of the lungs. These effects occur gradually, usually due to a combination of factors.

Smoking can cause COPD

Inhaling tobacco smoke either by actively smoking or being exposed to secondhand smoke can cause COPD, with smoking cigarettes being the main cause of COPD in the U.S. and worldwide. This is the case for both emphysema and chronic bronchitis. Smoking cigars, pipes, and other methods of smoking tobacco can also lead to COPD, but not as often as does smoking cigarettes.

It isn’t known whether smoking marijuana (cannabis) can also contribute to COPD, as research on this topic hasn’t provided a clear answer and in some cases has been contradictory. That said, marijuana smoke does contain many of the toxins, irritants, and cancer-causing chemicals that are found in tobacco smoke.

Exposure to other inhaled irritants may contribute to COPD

These include prolonged exposure to outdoor air pollution along with airborne toxins, chemicals, and air pollution inside the home, at work, or other settings. Examples of these include:

• Ammonia
• Carbon monoxide
• Fumes from asphalt, tar, and other vapors used for roadwork or roofing construction
• Fumes from diesel engines
• Fumes from metals used for welding, such as cadmium
• Mineral dusts from coal, asbestos, and silica
• Mold
• Organic dusts from wood and cotton and grain crop residue
• Pesticides, especially organophosphate and carbamate insecticides
• Smog
• Smoke from fires
• Sulfur dioxide

Early life events may contribute to COPD

Referred to as “childhood disadvantage factors” as noted in the 2023 GOLD report, various early life events can keep the lungs from fully developing and may affect lung function in utero or during childhood. These developmental issues can then impair lung health during the adult years.

These include early life factors such as:

• Smoking during pregnancy
• Poor growth of the fetus while in utero
• Low birth weight
• Premature birth
• Frequent or severe childhood respiratory infections
• Childhood asthma

Genetics may play a role in COPD development

Inheriting a genetic disorder called alpha-1 antitrypsin (AAT) deficiency may cause COPD. Also called alpha-1 antiprotease deficiency, people with this rare condition don’t produce enough of the AAT protein. Roughly 1 to 2 percent of COPD cases are attributed to this hereditary disorder.

AAT helps prevent an enzyme found in certain white blood cells called neutrophil elastase from damaging alveoli. In essence, the AAT protein helps protect the lungs when people breathe in toxins or irritating substances.

People with severe AAT deficiency tend to develop emphysema by early middle age, especially if they smoke tobacco. But the genetic disorder may also contribute to the development of COPD in people who have never smoked.

Recurring lung infections may cause COPD

Recurring lung infections, especially if severe, are known to cause both of the main types of COPD, particularly chronic bronchitis. This includes repeated exposure to the flu virus (influenza types A and B) and bacterial infections caused by Staphylococcus, Streptococcus, Mycoplasma pneumonia, and Pseudomonas aeruginosa. Chronic gastroesophageal reflux disease can also contribute to the development of chronic bronchitis, although less frequently.

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Risk factors for COPD overlap with known causes of COPD. These include smoking tobacco, prolonged exposure to lung irritants, genetic mutations (such as those that lead to AAT deficiency), and childhood asthma.

Lung function may also be impaired in children who experience severe and/or repeated respiratory infections, raising the risk of COPD during adulthood. Chronic bronchial infection during adulthood, especially with Pseudomonas aeruginosa, may also accelerate FEV1 decline.

People with a history of chronic lung conditions such as asthma or cystic fibrosis are more prone to chronic bronchitis. The same goes for people who have had bronchiectasis, a condition that involves inflammation and thickening of the bronchi walls, which causes them to widen and become loose, scarred, and less able to clear out mucus. Having tuberculosis (TB) or HIV can also raise the risk for COPD.

Other known risk factors for COPD include:

Age: The risk for COPD goes up with age, with middle-to-older-aged adults most often affected.

Sex assigned at birth: Although COPD rates in people assigned male at birth (AMAB) and people assigned female at birth (AFAB) are roughly equal in developed countries, those AFAB tend to report more flare-ups, including shortness of breath, and worse health overall compared to people AMAB with similar disease severity and airflow restriction.

Socioeconomic status: Poverty is associated with a higher risk of COPD. This may be due to issues such as greater exposure to outdoor and household air pollutants, poor nutrition, more frequent infections, and other factors tied to low socioeconomic status.

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To help diagnose COPD, an HCP will discuss your symptoms and review your personal and family medical history. Considerations may include:

• Possible COPD symptoms such as a chronic, productive cough along with shortness of breath
• How these symptoms affect your daily life (such as having to modify activities or missing work and other important life events)
• Frequency of flare-ups, including when symptoms tend to get worse (such as when you’re around tobacco smoke or when the air quality is poor)
• Current or past smoking history
• Exposure to secondhand smoke, air pollution, and airborne toxins, chemicals, fumes, and dust
• History of severe or recurring respiratory infections, especially during childhood
• Personal and family history of chronic conditions that affect the lungs such as asthma or TB
• Family history of COPD or AAT deficiency
• Other health conditions you might have, including other types of lung disease, heart disease, anxiety, or depression

After going over your symptoms and medical history, your HCP will conduct a physical exam, which includes listening to your lungs and assessing your breathing. It also includes observing how much your chest moves when you breathe, if you use other muscles to help you breathe (such as your neck and shoulder muscles), and how long it takes for you to exhale.

They’ll also use a noninvasive device called a pulse oximeter to measure your oxygen saturation level (also known as O2 sats, which is how much oxygen your red blood cells are able to carry). The results can help determine how well your lungs are working. O2 sats tend to be low in people with COPD.

Your HCP will also give you a spirometry test before and after you inhale medicine called a bronchodilator (see below) to measure how much, how easily, and how fast you can blow air in and out of your lungs. This test also helps determine COPD severity and stage.

Other tests might include:

Alpha-1 antitrypsin testing

Your HCP may recommend you get a blood test to screen for AAT deficiency and to check the level of this protein in your body. This is likely the case if you have a closely related blood relative (such as a parent or sibling) who has COPD or this protein deficiency, or if you develop COPD symptoms at a young age.

Imaging tests

These might include a:

Chest X-ray (CXR): This imaging test uses electromagnetic radiation to create an image of the structures in your chest, including your heart and lungs. A CXR can detect lung abnormalities that may be associated with COPD. It can also help rule out other heart or lung conditions that may be causing or exacerbating your symptoms, such as heart failure or TB.

Your CXR results may be normal during the early stages of COPD but may show overinflation of the lungs as the disease becomes more advanced. If you have emphysema, the results of the test may show overinflation, blood vessel thinning, or bullae in the lungs. (Bullae are air-filled sacs, also called blebs or cysts.)

Chest computed tomography (CT) scan: This test uses X-ray and computer technology to create three-dimensional, cross-sectional images of the structures within your chest, including your heart, lungs, and blood vessels. The images may show areas of lung tissue destroyed by emphysema or airway inflammation typical of chronic bronchitis. A chest CT can help determine the extent of lung damage and severity of COPD.

Arterial blood gas (ABG) test

During this test, an HCP called a respiratory therapist collects a sample of blood from an artery, although it may be taken from a vein in some cases (called a venous blood gas). ABGs measure the amount of oxygen and carbon dioxide in your blood.

It can show how well the lungs are moving O2 into the lungs and pushing CO2 out of them. Consistently high CO2 levels tend to occur in the later stages of COPD.

Other tests

Your HCP may also conduct or order other lung function tests to see how well your lungs are working, such as:

Lung volume test: Also called body plethysmography, this test measures how much air you can hold in your lungs along with how much air remains after you exhale forcefully.

Diffusing capacity test: This test measures how well oxygen and other gasses move from your lungs to your bloodstream.

Exercise test: During this test, you’ll be asked to walk on a treadmill at your normal pace for several minutes to measure your aerobic capacity and to determine at what point during the activity you experience shortness of breath.

One commonly used exercise test is a six-minute walk test. This involves walking on a flat, indoor surface at your normal, comfortable pace for six minutes.

You’ll be asked to walk to a designated point, such as a chair or cone, before turning around and walking back to your starting point. You’ll keep walking back and forth for as long as you can within the six-minute window.

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Although COPD can’t be cured, there are treatment options to help you ease symptoms, support lung function, and breathe better. Knowing all the details about your condition—including which symptoms you have, how severe they feel, how often they occur, and whether they have changed over time—helps your HCP tailor the most effective COPD treatment plan.

This plan will likely include a mix of lifestyle changes to help you manage COPD and specific medical therapies for COPD, including pulmonary rehabilitation therapy, if symptoms persist. Surgery may be an option for very severe COPD.

Lifestyle changes

One of the most effective ways to stop COPD is to quit smoking tobacco. Doing so when COPD is mild or moderate can lessen lung damage and reduce symptoms, including shortness of breath, coughing, and mucus production.

Quitting smoking as soon as possible often leads to the best outcomes but quitting at any point has benefits. If you need help, work with your HCP to customize a smoking cessation plan for you.

In addition to quitting tobacco, limiting or avoiding exposure to risk factors that trigger or worsen COPD symptoms can also help prevent lung damage. These include airborne irritants such as secondhand smoke and indoor and outdoor air pollution.

Medications for COPD

Your HCP will prescribe COPD medications based on which symptoms you have and how severe they are, as well as which stage you’re in based on the results of spirometry and other lung function tests. These medicines might include one or more of the following:

Bronchodilators

Inhaled bronchodilators usually include both:

Short-acting (quick-relief) bronchodilators: Also referred to as rescue medicines, these provide rapid relief of COPD symptoms and are only taken when symptoms occur. They help you breathe easier by relaxing and opening up the airways.

Long-acting (controller) bronchodilators: These help provide extended relief of COPD symptoms by decreasing airway inflammation to keep the airways open longer. They’re taken every day or as prescribed by your HCP to help prevent symptoms, regardless of whether you’re currently experiencing symptoms.

Types of bronchodilators used to treat COPD include:

Beta-2 adrenergic agonists: These help relax the smooth muscles of the airway.

They include short-acting beta-adrenergics (SABAs) such as albuterol (also called salbutamol), levalbuterol, pirbuterol, and terbutaline. SABAs start to work within 5 to 20 minutes of inhalation, with effects lasting for four to six hours.

Long-acting beta-adrenergics (LABAs) such as arformoterol, formoterol, and salmeterol are used every 12 hours. Ultra-LABAs such as indacaterol, olodaterol, and vilanterol are used once every 24 hours.

LABAs also come in combination with long-acting anticholinergics. These include umeclidinium combined with vilanterol and olodaterol combined with tiotropium.

Anticholinergic/antimuscarinic antagonists: These help keep the airways open by keeping the bronchial tubes from constricting (narrowing).

Antimuscarinics are a subtype of anticholinergic drugs that specifically block muscarinic receptors for acetylcholine. Most anticholinergic drugs, including those used to treat COPD, are antimuscarinics.

Short-acting antimuscarinic agents (SAMAs) such as ipratropium and oxitropium provide rapid relief of COPD symptoms and are used only when symptoms occur, while long-acting antimuscarinic agents (LAMAs) like tiotropium are used for long-term control and prevention of symptoms.

Examples of anticholinergics/antimuscarinics prescribed for COPD include:

• Aclidinium
• Ipratropium
• Revefenacin
• Tiotropium
• Umeclidinium

Formulas that combine an anticholinergic with a beta-2 adrenergic are also available. For instance, the LAMA glycopyrrolate comes in a formula that includes the LABA formoterol or the ultra-LABA indacaterol.

Theophylline: Because of potential side effects (such as a rapid heart rate, headache, hyperactivity, nausea, nervousness, tremors, and trouble sleeping), this oral bronchodilator (taken as a pill) is only prescribed when other medicines don’t sufficiently relieve COPD symptoms or the cost of other medicines is an issue. A long-acting form of the drug is taken once or twice a day, which helps control shortness of breath, including during sleep.

The use of this drug dose is carefully controlled by your HCP. Routine tests are usually needed to monitor theophylline levels in the blood.

Corticosteroids

These are prescribed in the form of an inhaled corticosteroid (ICS) or an oral medicine. Corticosteroids help reduce airway inflammation and mucus production caused by COPD.

They’re usually reserved for treating moderate to severe COPD in people whose symptoms aren’t well controlled by other medicines or who continue to experience frequent flare-ups with their current treatment regimen.

Because ICS drugs are inhaled into the lungs, they usually cause fewer side effects compared to oral corticosteroids. But high ICS doses can cause side effects that affect the entire body, including raising the risk of infections such as pneumonia and making the bone disease osteoporosis worse. Examples of ICS drugs used to treat COPD include beclomethasone, budesonide, and fluticasone.

If needed, a short course of oral corticosteroids may be prescribed to help manage a COPD flare-up. In these cases, your HCP will likely prescribe the lowest effective dose for the shortest duration possible to help lower the risk of serious side effects.

Phosphodiesterase-4 inhibitors

Oral phosphodiesterase-4 (PDE4) inhibitors like roflumilast help expand the bronchial tubes by decreasing airway inflammation. For people with severe airflow obstruction whose symptoms haven’t improved with other treatments, PDE4 inhibitors may be added to the COPD treatment regimen to help reduce the risk of flare-ups.

Combination medicines

These include formulas that combine two or more medicines. These combination formulas help boost treatment effectiveness while simplifying the COPD treatment regimen. Examples of these combination therapies might include a LABA with an ICS or a SABA with a SAMA.

A formula that combines an ICS with a LABA plus a LAMA may also be considered. Known as triple inhaled therapy, this 3-in-1 COPD treatment may be prescribed for people with:

• Severe airflow obstruction
• More COPD symptoms, especially severe ones
• Eosinophil count of 100 or more cells per microliter of blood (eosinophils are a subtype of granulocytes, one of the main types of white blood cells)
• History of COPD exacerbations

Antibiotics and antivirals

COPD flare-ups may increase shortness of breath, coughing, and mucus production. These symptom exacerbations are often caused by a bacterial or viral infection, which are treated with an oral antibiotic or antiviral medicine in conjunction with a corticosteroid as needed.

Standard treatment of a bacterial infection may include an antibiotic such as amoxicillin/clavulanate, a macrolide (such as azithromycin or clarithromycin), or a second or third-generation cephalosporin (such as cefdinir, cefuroxime, or cefpodoxime). Trimethoprim/sulfamethoxazole may also be considered, but usually not as a first-line treatment, as it may not be as effective as other options.

Antibiotics such as levofloxacin may be prescribed for more severe infections in people whose symptoms haven’t improved with other antibiotics. They may also be used for people who are infected with bacteria, such as methicillin-resistant Staphylococcus aureus (also called MRSA), that are resistant to treatment with other antibiotics.

If you have a viral infection, your HCP may prescribe an antiviral medication. For instance, a flu infection may be treated with one of these antiviral medicines:

• Baloxavir marboxil
• Oseltamivir
• Peramivir
• Zanamivir

If you have COVID-19, your HCP may prescribe an antiviral medication such as:

• Nirmatrelvir with ritonavir
• Remdesivir
• Molnupiravir

Vaccines

COPD raises the risk of infection and complications from infectious respiratory diseases such as the flu, pneumonia, and COVID-19. To help protect you from these infections, your HCP may recommend you get vaccinated with the following:

• Annual flu vaccine
• Pneumonia vaccine
• COVID-19 vaccine

They may also recommend other adult vaccines as needed.

Oxygen therapy

Your HCP may recommend oxygen therapy if your oxygen saturation (blood O2 levels) is low at rest or during exertion or sleep. Low O2 sats can result in a higher than normal red blood cell (RBC) count. O2 therapy helps lower this high RBC count and ease shortness of breath.

Supplemental O2 is delivered through a face mask or a tube placed inside the nostrils called a nasal cannula. Various devices can be used to deliver oxygen, including:

• Battery-driven portable oxygen concentrators: These may be a good option when traveling on commercial airplanes.
• Compressed oxygen in small tanks: These allow people to travel for two to six hours outside of their homes.
• Electrically driven oxygen concentrators: These are plugged into electrical outlets to deliver O2.
• Liquid oxygen systems: This form of O2 therapy uses compressed and frozen O2. It consists of a stationary unit called a reservoir and a smaller, portable unit that’s filled from the reservoir as needed. The portable unit can provide supplemental O2 for several hours before needing to be refilled.

Some people may only need supplemental O2 when they sleep or exercise. Other people with advanced COPD may need to use it continuously.

Long-term O2 therapy helps extend the lives of people who have end-stage COPD and severely low O2 sats. In these cases, using supplemental O2 around the clock is best, but using it for at least 15 hours each day may also be beneficial.

Airway clearance therapy

This might start with deep breathing (also called diaphragmatic or belly breathing). Deep breathing expands the lungs, which may compel you to cough or huff (vigorously cough) out mucus.

Airway clearance may also involve the use of manual techniques and devices to prevent and clear mucus buildup in the airways. For instance, percussion (also called manual chest therapy) involves rhythmically clapping on the person’s chest with cupped hands to help dislodge and move excess mucus from the lungs to the larger airways, making it easier to cough or huff it out.

Vibration is similar to percussion, except flat hands are used to perform this technique. It involves gently shaking (vibrating) your ribs after you take a deep breath and blow the air out from your lungs. Various powered devices, such as electric percussors, can also help break up and clear excess mucus.

Postural drainage is often used alongside percussion to expel excess mucus from the airways. The technique uses gravity to move mucus away from the small airways and into the large airways, where it can be huffed and spit out.

A person with COPD would hold the body in various positions (such as lying on the back, sides, and stomach) for around five minutes each, making sure the chest is lower than the hips to facilitate mucus drainage. Each position helps drain a different lobe or segment of the lung.

An HCP such as a physical therapist or pulmonologist (medical doctor who specializes in diagnosing and treating respiratory conditions) can show you how to perform these therapies, including how to use a percussive device at home.

Noninvasive ventilation (NIV)

NIV delivers oxygen to the lungs without needing to be intubated (having a breathing tube placed in the trachea). It’s a form of noninvasive positive-pressure ventilation (NPPV), which uses a mechanical device to deliver a mixture of air and oxygen through the airways via a face mask.

Positive pressure means the pressure outside the lungs is greater than the pressure inside the lungs, which forces air into the lungs and helps keep the chest and lungs expanded so it’s easier to breathe. It also helps reduce hypercapnia (excessive retention of CO2).

A bilateral positive airway pressure (BiPAP) device can be used at home or the hospital. At home, a continuous positive airway pressure (CPAP) device can be used to provide a constant flow of pressurized air while you sleep. A CPAP may be especially helpful if you have sleep apnea in addition to COPD.

Pulmonary rehabilitation

Pulmonary rehabilitation is a supervised program that combines exercise training with nutritional, psychological, and smoking-cessation counseling (if needed). It also involves disease-management education, which may include using certain breathing techniques such as pursed-lip breathing, yoga breathing, or breathing with computer-aided feedback. Improving mental well-being is also an important part of pulmonary rehabilitation along with improving physical function.

Surgery

Surgery is often a last resort for people with severe COPD symptoms that haven’t improved with other treatments. Surgical options for COPD might include:

Endobronchial valve (EBV) implant

This is a minimally invasive procedure in which one-way valves are surgically implanted into the lung lobes that are most damaged. When you inhale, the valves close to keep air from getting into the treated lobe. When you exhale, the valves open to allow air and mucus to move out of the treated lobe.

The implant reduces the size of the overinflated lung within hours of placement. The pressure on the diaphragm also goes down as the size of the treated lung decreases, allowing for easier breathing.

Bullectomy

This surgery removes large bullae from the lungs, which may help improve breathing. These oversized air sacs form when hundreds of alveoli rupture and fuse together, trapping air inside them.

Lung volume reduction surgery (LVRS)

This surgery may be an option for people who have severe emphysema that affects the upper lung lobes. The goal is to remove about 30 percent of the most diseased lung tissue to improve exercise capacity and quality of life. LVRS also reduces the size of the diaphragm and allows the remaining lung sections to function more effectively—all of which can help you breathe better for at least several years.

Lung transplant

This may be an option for people with advanced COPD who have severe airflow obstruction and are younger than 65. A lung transplant may be considered for some people older than 65 if they don’t have other serious health conditions besides their lung disease.

Candidates include those who:

• Have had three or more severe flare-ups within the last year
• Have irreversible lung damage
• Are not a candidate for LVRS

Alpha-1 antitrypsin (AAT) replacement

If you have severe AAT deficiency, protein levels can be augmented with weekly intravenous (IV) AAT infusions.

Opioids

Your HCP may prescribe a short course of opioids to ease severe pain and coughing spells. But keep in mind that using opioids to suppress coughs can actually cause or worsen an infection.

Opioids also carry many risks and side effects (such as drowsiness and constipation) and a risk of opioid dependence or addiction if used regularly or improperly. If you opt to use these powerful medicines, be sure to discuss the risks and benefits with your HCP. It’s important to fully understand how to use opioids safely prior to taking them.

COPD action plan

A comprehensive treatment plan also includes your COPD action plan. This is a personalized strategy that describes steps to address symptoms depending on whether you’re feeling well or experiencing a flare-up.

It includes specific information about your treatments such as when, how much, and which medicines to take. It also provides guidance on when to contact your HCP and when to seek emergency medical care.

Your COPD action plan consists of three zones, which correspond to the type and severity of symptoms you’re experiencing. Recommended treatments vary based on which zone you’re in.

COPD green zone

Being in the green zone means you don’t have any COPD symptoms and your condition is well-controlled. In this zone, you’ll want to stick with your COPD treatment plan, which includes taking your long-acting controller medicines as prescribed by your HCP. If supplemental oxygen is part of your plan, keep using it as advised by your HCP, even on days when you feel well enough not to use it.

COPD yellow zone

If you’re in the yellow zone, this means you’re experiencing some COPD symptoms such as coughing, fatigue, and shortness of breath. Your cough may also be producing more phlegm, the color and consistency of which may have changed.

Follow the steps listed on your action plan for this zone, which likely includes using your short-acting (quick-relief) bronchodilator or starting a course of antibiotics or other medications as prescribed by your HCP. Call your HCP right away if your symptoms don’t improve with the treatments listed for this zone.

COPD red zone

Being in the red zone means you’re experiencing a severe flare-up with persistent and potentially life-threatening COPD symptoms such as:

• Chest pain
• Confusion
• Coughing up blood
• Cyanosis (bluish/grayish discoloration of the skin, lips, or nail beds)
• High fever and chills
• Racing heart rate
• Shortness of breath, even while resting
• Trouble sleeping due to breathlessness

Call 911 or get emergency medical care if you’re in the red zone and be sure to take further actions as advised by your HCP for this zone.

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Be sure to talk with your HCP if your COPD symptoms get worse, your treatment plan is no longer working effectively, or you have symptoms that point to an infection. Signs to watch out for include a fever or an increase in the amount of mucus produced, especially if it’s tinged with blood or if it changes to a yellow, green, brown, or rust color.

Get emergency medical care if you have potentially life-threatening symptoms as indicated by the information listed on the red zone of your COPD action plan. These may include:

• Chest pain
• Cyanosis
• Fast or irregular heartbeat that persists, even at rest
• Shortness of breath that persists, even after treatment with a short-acting (quick-relief) bronchodilator
• Trouble thinking or brain fog that persists

Emergency treatment of COPD exacerbations

This will depend on factors such as the type and severity of COPD symptoms and other conditions you have. In general, emergency care for COPD includes the use of inhaled bronchodilators and corticosteroids to open up the airways. IV antibiotics may also be given, depending on the type and severity of any infection that may be present.

Supplemental oxygen and the use of noninvasive ventilation interventions such as CPAP or BiPAP can also support breathing, if indicated and appropriate. In some severe cases, intubation may be needed to support breathing more effectively.

If these treatments fail to help, admission to a hospital critical care unit may be needed for further care.

What questions should you ask your healthcare provider?

Be sure to ask your HCP any questions you might have about COPD. These can help get the conversation started:

• What can I do to keep my COPD from getting worse?
• How do I lower my risk for a respiratory infection?
• What would you recommend to help me quit smoking?
• Which COPD symptoms indicate my condition is getting worse?
• When should I call you and when should I get emergency medical care?
• What should I do if my shortness of breath persists?
• Which COPD treatments, including medicines, would you recommend for me? What are the risks and benefits of these treatments? For which side effects should I call you?
• How, why, and when do I need to take my rescue (quick-relief) medicine?
• Do I need to use supplemental oxygen or a CPAP? If so, how often?
• Would you recommend I start pulmonary rehabilitation?
• What changes would you recommend I make at home or work?
• Which vaccines would you recommend I get?
• Which dietary and exercise changes would you recommend and why?
• How do I manage my COPD when I travel? Which medicines do I need to bring?
• Will I need to bring my oxygen to the airport or on the airplane?
• Who do I need to call if my COPD symptoms get worse while I’m traveling?
• What’s my prognosis? How can I improve my outlook?
• Are there any clinical trials for COPD you’d recommend for me?

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COPD can be associated with complications such as:

• Arrhythmia (irregular heartbeat)
• Anxiety and depression
• Debilitation
• Long-term need for oxygen therapy or noninvasive ventilation with a breathing machine and mask
• Lung cancer
• Osteoporosis (thinning and weakening of bones)
• Pneumonia
• Pneumothorax (collapsed lung)
• Pulmonary embolism (blockage of the arteries leading to the lungs)
• Pulmonary hypertension, which can lead to cor pulmonale (also called right-sided heart failure because the right side of the heart becomes too weak to pump enough blood to the lungs)
• Severe weight loss and malnutrition

COPD and lung cancer

COPD greatly increases the risk of lung cancer, according to multiple study reviews, including a 2022 analysis published in Frontiers in Oncology. Of the more than 829,000 people with COPD included in this analysis, approximately 5 percent of them developed lung cancer.

Many people with lung cancer also have COPD, although they may not know this since symptoms of lung cancer tend to overlap with those of COPD. These include symptoms such as:

• Chest pain or discomfort
• Cough that persists or gets worse, including one that produces mucus (often blood-tinged or rust-colored)
• Chronic or persistent lung infections such as bronchitis
• Dyspnea (shortness of breath)
• Fatigue
• Weight loss
• Wheezing

Although smoking tobacco is one of the main causes of lung cancer and COPD, having COPD can raise your risk of lung cancer, regardless of your smoking history. This may be due to factors such as:

• Genes: Some people may be more susceptible to the lung damage caused by COPD and lung cancer because of inherited gene mutations.
• Inflammation: Chronic lung inflammation can raise the risk for COPD and lung cancer.
• Lung damage: In addition to raising the risk of lung cancer, the damage to the lungs caused by COPD can accelerate the growth and spread of cancer cells.

Regardless of the cause, early diagnosis and treatment of COPD and lung cancer are key to improving quality of life, outcomes, and the chances of survival for both.

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One of the most effective ways to prevent COPD is to quit smoking tobacco or never start. If you need help quitting, be sure to talk with your HCP about smoking cessation programs and products that can help you quit for good. This might entail joining an online or in-person smoking cessation support group and asking for help from your friends and loved ones as you strive toward your quit goal.

If you have young children who live with you, make a concerted effort to ensure they’re not exposed to tobacco smoke. Young children are more vulnerable to the adverse effects of tobacco smoke because they breathe at a faster rate and have lungs that are not as fully developed as adults.

Exposure to secondhand and thirdhand tobacco smoke can be harmful to anyone, especially young children and those with compromised lungs such as people with COPD.

Thirdhand smoke refers to the contamination that tobacco leaves behind after the smoke has cleared. Many of the toxic substances found in tobacco smoke (including nicotine and heavy metals such as arsenic, cyanide, and lead) can cling to skin, fur, and indoor surfaces such as walls, ceilings, carpets, and fabrics. These substances can make their way back into the air (called re-emission) where they react with other chemicals to form new and potentially harmful compounds that can linger and affect lung health.

In addition to tobacco smoke, try to limit or avoid exposure to other irritants or toxins that affect the lungs such as air pollution, along with chemical fumes and dust.

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This can vary, depending on factors such as which COPD stage you’re in, whether you’ve quit smoking and avoid other lung irritants, and whether you follow your treatment plan. Airflow obstruction and COPD symptoms such as shortness of breath tend to be progressive, meaning they get worse over time. But taking actions such as quitting tobacco, especially in the earlier stages of COPD when symptoms are mild, can make a considerable difference in your outcome and quality of life.

Many people with COPD are able to manage their conditions well enough to live healthily and happily for many years. People with co-occurring conditions (such as heart failure, lung cancer, and pulmonary hypertension) tend to have worse outcomes. For instance, the quality of life is often poorer while the risk of death is usually higher in people who have both COPD and asthma.

People with advanced COPD often need substantial help with medical care and activities of daily living such as cooking, eating, grooming, bathing, and other forms of personal hygiene. Respiratory failure and complications from co-occurring conditions such as heart failure, lung cancer, pneumothorax, and pulmonary embolism may contribute to higher rates of death in people with COPD.

Severe flare-ups in people with end-stage COPD may require intubation and mechanical ventilation to continue breathing. In some cases, prolonged mechanical ventilation is needed.

Palliative and end-of-life care

Many people experiencing severe illness decide that they do not want to remain dependent on a ventilator to live. If you have considered these issues, you may want to prepare an advance healthcare directive (AHCD). These are legal documents that communicate your preferences for certain treatments in the event you can no longer make medical decisions for yourself.

It also allows you to select a health care proxy. The person you appoint as your proxy can make health care decisions on your behalf based on your AHCD and known wishes. An HCP can help you prepare your AHCD.

Palliative care may be an option during any COPD stage, although many people choose to exercise this option as they near the end of life. It aims to ease the physical and emotional symptoms of COPD, including pain and stress.

Palliative care may also involve hospice care at home or at a hospice facility when treatments to prolong your life are no longer a viable option. Your AHCD, palliative care, and hospice care allow you to live the rest of your life on your terms in a manner that’s most comfortable for you.

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The day-to-day challenges of living with COPD, especially as the disease progresses, can sometimes feel daunting. But following your treatment plan, maintaining regular visits with your HCP, and incorporating some healthy habits in your daily routine can help you maintain an active lifestyle with COPD. These tips and resources from the American Lung Association may help:

Manage activities and conserve energy

Conserve energy by simplifying your tasks. These five Ps can help:

Pace: Move slowly and steadily instead of rushing. Take breaks and rest between activities. Don’t wait until you feel fatigued to rest, as doing so can make it harder for you to recover afterward.

Plan: Space out your activities. Plan your day in advance, making sure not to do too many tasks that require you to use a great deal of energy.

Position: Sit and stand upright to help expand your breathing capacity. Don’t stand in the same position for too long, though, as this can increase fatigue. Bear in mind that bending or reaching repeatedly within a short amount of time can also leave you feeling short of breath and more tired.

Prioritize: In addition to planning your daily activities, it’s also important to prioritize which ones truly need to get done each day and which ones can be completed at a later date. In some cases, you may be able to delegate or ask for help completing activities.

Pursed-lip breathing: Inhale through your nose and then take at least twice as long to exhale the air out through pursed or puckered lips. By using this breathing technique, you’ll use less breaths while keeping your airways open for longer periods. The more you practice this way of breathing the more natural it can feel.

Activities of daily living (ADLs) and instrumental ADLs (IADLs)

ADLs include basic self-care tasks that you need to perform each day, such as bathing, dressing, grooming, eating, and walking. IADLs (such as shopping, preparing meals, housekeeping, and managing your medicines) often consume more energy. Careful planning of these activities is often essential.

The five Ps can help you complete your ADLs and IADLs without feeling completely drained of energy. But as COPD progresses, you may find that you need more help. Let your family and friends know which activities they can help you with. Also consider talking with your HCP about the challenges you’re facing with completing ADLs or IADLs.

They can refer you to a pulmonary rehabilitation program where you’ll learn how to manage these more effectively. They may also refer you to an occupational therapist (OT) who will assess your living situation and share ways to help you manage these activities more efficiently.

Your HCP or OT can also refer you to a social worker or appropriate agencies in your community who can provide assistance with ADLs and IADLs and let you know which services are covered by your insurance plan. You can also contact the American Lung Association directly at 1-800-LUNGUSA or join the Living With COPD online support community for more information on these resources.

Get active

Although it may seem counterintuitive, it’s important to stay physically active on a regular basis when you have COPD as much as you can. Start by talking with your HCP. Along with providing guidance on the types and amounts of activities that would be best for you, they can help you determine exercise goals that are safe and practical.

By enrolling in a pulmonary rehabilitation program, you can also learn how to exercise safely and effectively with COPD. You may also want to consult with a certified personal trainer or clinical exercise physiologist with expertise training and developing exercise programs for people who have health conditions such as COPD.

A few tips to keep in mind when working out:

• Start slowly and pace yourself, gradually building up your strength, pace, and endurance.
• Take breaks as needed.
• Take slow, paced breaths (which can include pursed-lip breathing), making sure to exhale through the most challenging parts of the exercise.
• If you use supplemental oxygen, work with your HCP to adjust your O2 flow rate for physical activity, which will likely differ from the flow rate you use while resting.
• Refrain from working out if you’re experiencing a severe or persistent COPD flare-up (including increased shortness of breath), are out of oxygen, or feel dizzy, faint, weak, unsteady, sick (especially if you have a fever or an infection), or if you are experiencing chest pain.

Mind your mental and emotional health

The challenges of living with COPD can affect your mood, thoughts, and feelings. It can also contribute to or worsen mental and emotional health issues such as stress and depression. It may even lead to anxiety and panic attacks.

Many people with COPD feel sad, anxious, and fearful at times. If these feelings persist or if they start to interfere with your ability to keep up with your daily activities, it’s important to reach out for help. Know that you are not alone.

When you’re in need of mental and emotional support, try to:

Reach out to your HCP. Along with listening to what you’re feeling and helping you identify effective coping strategies, your HCP can refer you to a licensed mental health provider for individual or group counseling and other therapies.

Request help from people you trust. Whether it’s a family member, close friend, spiritual advisor, or member of your COPD care team, don’t be afraid to ask for help and support. Simply having someone who can listen to you when you’re feeling alone, overwhelmed, or in need of reassurance and comfort can help. Consider opening up and letting them in when you’re in need of a compassionate ear.

Use healthy coping strategies. Find the stress-management techniques that work best for you, whether that’s coloring like you did as a child, practicing positive thinking, sipping on a warm cup of tea, turning on your favorite tunes, or trying other ways to cope with stress that help you relax while lifting your spirits. Letting the tears flow from time to time may also help you feel less burdened, as can finding opportunities to laugh. 

Connect with others. Consider joining an in-person or online support group for people living with COPD. In addition to finding helpful tips and resources, you may find that connecting with others who share similar experiences can be a source of comfort and hope.

Diet recommendations for people with COPD

People with COPD burn more calories when they breathe than do people without the condition, so it may make sense for them to eat more calorie-dense foods. Ounce for ounce of food, a diet higher in fats and lower in carbohydrates provides more calories and can thereby help boost a person’s energy levels.

But eating healthy with COPD entails more than just cutting carbs and upping your intake of fats. What you eat and don’t eat makes a difference. It’s also important to focus on foods that nourish the body but won’t make you bloated, as this can make it harder to breathe.

A registered dietitian nutritionist (RDN) can help you customize an eating plan that factors in your food preferences, daily energy needs, and special dietary needs and conditions you might have in addition to COPD. They can also let you know how much and which type of macronutrients (protein, fats, and carbohydrates) and micronutrients (vitamins and minerals) you’ll need each day to meet your energy needs and to maintain a healthy weight.

Your HCP can refer you to an RDN in your area or to one who offers telehealth consultations, if that’s your preference. You can also visit the Academy of Nutrition and Dietetics website for a listing of RDNs by location, specialty, language, and insurance and payment options.

These COPD-friendly eating tips may also help:

Practice portion control

Eating to the point of feeling stuffed can make it harder to breathe. Therefore, minding your portions and eating smaller meals and snacks might be a better option for keeping the bloat and breathlessness in check.

Slow your eating pace

If you tend to feel short of breath when you eat, take small bites and chew your food thoroughly before taking the next bite. You can also try putting your eating utensils down between bites to slow down your pace.

Also, be sure you're sitting upright for meals and not slouching, which allows your chest and diaphragm to expand more fully while breathing. Drinking water at the end of your meal versus in between bites may also help reduce bloating and feeling too full too fast, which can worsen shortness of breath.

Fuel with fats

Opt for monounsaturated and polyunsaturated fats, which are liquid at room temperature. Good sources of these healthy fats come from plants and other whole foods such as avocados, nuts, and seeds, as well as fatty fish like salmon.

Avoid foods with trans fats and limit foods with saturated fats such as butter, hydrogenated vegetable oils, lard, shortening, pastries, and fried foods. These often require more effort to digest, which can result in bloating. They also raise cholesterol levels.

Remember that overdoing it on fatty foods can lead to weight gain, and carrying excess weight can make it harder to breathe. While eating healthy fats can be a part of a smart diet for COPD, it’s important to be mindful of your intake if you need to manage your weight.

Power up with protein

Select lean sources of protein such as lean cuts of meat, skinless poultry, fish, eggs, beans, peas, nuts, and skim or low-fat milk, cheese, and yogurt.

Curb the carbs

This doesn’t mean eliminating all carbs. It’s a matter of knowing how much of this macronutrient to eat each day and choosing carbs wisely, which an RDN or your HCP can help you figure out. Focus on complex carbs high in fiber to aid digestion, such as whole grain breads, rice, and pasta, as well as fresh fruits and vegetables.

Opt for fresh fruits and veggies that are less likely to cause bloating such as berries, carrots, cucumbers, grapes, leafy greens, and pineapple. Some fruits and veggies that are more likely to cause indigestion and bloating include fruits such as apples, apricots, watermelon, and peaches, as well as veggies such as broccoli, Brussels sprouts, cabbage, cauliflower, and kale. (These fruits and veggies are packed with nutrients, so feel free to keep eating them if they don’t cause you indigestion and bloating.)

Hydrate with healthy fluids

Unless otherwise advised by your HCP or RDN, hydrate well throughout your day with healthy fluids to thin out mucus, which can make it easier to cough out. It’s usually best to stick with water or herbal teas, as these aren’t likely to cause digestive issues such as nausea and bloating. Infusing your water with berries or cucumbers works, too.

Limit or avoid alcoholic and caffeinated beverages as these can make your COPD symptoms feel worse and may interact with some COPD medications. Check with your HCP to see if this is the case for your medicines. Also limit or avoid sugary drinks such as soda, which are often high in simple carbs and can increase bloating.

Supplement if advised

Check with your HCP to see if you need to boost your vitamin and mineral intake. Using corticosteroids over the long term may affect your bone density (also called bone mass).

But before adding a calcium, multivitamin, or other dietary supplement to your eating plan, ask your HCP if any are needed. In some cases, your HCP may need to check your nutrient levels with a blood test to see if you have a deficiency that requires the use of supplements.

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• 5 Resources for COPD Patients and Caregivers
• How Being Overweight Affects COPD
• Lifestyle Changes That Can Help You Manage COPD