Chronic obstructive pulmonary disease (COPD) often refers to chronic bronchitis and emphysema. COPD is a complex, life-threatening disease that deteriorates the lungs over time. While there is no cure for COPD, there are certain lifestyle changes people can make to improve their symptoms and life expectancy. We asked Dr. Frank Sciurba, associate professor of medicine and education at the University of Pittsburgh School of Medicine and director of the Emphysema/COPD Research Center at UPMC, to explain what COPD patients and their families need to know.
Dr. Frank Sciurba of UPMC
What causes COPD?
COPD is a disease that, in this country, is primarily caused by cigarette smoking. What it involves is obstruction to expiration, so when you try to blow out air forcefully there is an obstruction and it takes longer. The consequence is that air stays trapped in the lungs so you can’t empty them and you’re breathing at a higher, less efficient, more uncomfortable lung volume.
So the two processes [chronic bronchitis and emphysema] caused by tobacco smoking include inflammation in the airway tubes with scarring and excessive mucous secretion, often associated with more cough and sputum production. The second process is the little air sacs at the end of the airways that transfer oxygen and carbon dioxide in and out of the blood system, the walls of those get destroyed. The consequence of that are several fold. One is that it can worsen the obstruction because those little air sacs also act like ropes to tether open the airways, so when those air sacs get destroyed the airways tend to collapse and increase the obstruction—and that is called emphysema. The other consequence is that as it gets worse and worse, the oxygen can’t transfer as efficiently.
What are some common symptoms?
Both processes can cause shortness of breath. At first, that shortness of breath occurs with activity. In fact, early on, patients may not even consciously begin to withdraw from their activities and may not even notice that they’re short of breath, especially if they’re still smoking. This is one of the problems with diagnosing COPD. People don’t even recognize that they have symptoms as they stop doing their activities. So then they’re not short of breath and often don’t even tell their doctors. Often activity limitation is the very first step in COPD. Since most people have both of these processes, often a patient with COPD will have symptoms of bronchitis and emphysema as the disease progresses.
How does one get tested for COPD?
Lung function testing and spirometry. The key test is spirometry that measures two important numbers: how much air you blow out from a deep breath and how much comes out in that first second. If the amount of air that comes out in that first second is less than 70 percent than all the air you can blow out, then you have obstruction. The doctor will use a bronchodilator—an inhaler—and if that number doesn’t reverse completely, that is called COPD. The severity of the COPD is based on how much air comes out in that first second relative to other people of your age, height, and gender.
Does COPD progress the same way in every individual?
COPD has many dimensions that can progress independently. For instance, some patients with very severe lung function abnormalities may not drop in their oxygen levels or they may not get as many exacerbations. While someone with mild lung function abnormality may get more flare-ups and lower oxygen levels. So the disease can progress uniquely in different individuals. But over time the longer you smoke, the older you are—and if you have a genetic predisposition or family history—you may be more inclined to get more severe lung function abnormalities and symptoms.
What are some common treatments?
Once someone is diagnosed, number one is quit smoking. It’s critical to get a flu shot every year. To get a pneumococcal vaccination every five years can decrease the risk of pneumonias. Exercise, pulmonary rehab at any stage is important to break that cycle of doing less and getting more short of breath. Exercise is very important. The first time it’s done, especially in patients with more moderate or severe disease, should be under a supervised situation because cardiac disease often occurs along with COPD and we want to make sure it’s safe for them.
As far as drug therapy, when patients have more moderate disease to severe disease, we want to start with a long acting maintenance inhaler rather than just a short-acting inhaler, which last four to six hours to relieve symptoms. In addition to more durable relief of symptoms, the maintenance inhalers also prevent the risk of ongoing decline in their lung function, prevent flare-ups, and really, in the end, likely prolong life. These maintenance inhalers which include various bronchodilators with or without an inhaled steroid are given every 12 to 24 hours. Patients with more severe disease will often be on both [long-acting and short-acting inhalers] for optimal symptom relief. The newer drugs coming out are going from 12 hours to once every 24 hours, which we do believe will improve compliance with the therapies and may overall improve their risk over time. Patients that drop their oxygen level do need supplemental oxygen therapy.
How does exercise help someone with COPD?
So exercise—while it doesn’t necessarily improve lung function right away—by improving the muscle strength and cardiovascular conditioning, it could allow you to do more activity with fewer symptoms. When your body is more efficient and in better condition you don’t have to breathe as much. We’ve also noticed that patients who participate in pulmonary rehab programs are less inclined to get chest flare-ups and less inclined to be admitted to the hospital. Breaking this inactivity cycle and getting folks back to better activity levels is really an important component in the treatment of COPD.
Can you talk more about pulmonary rehab?
So, unfortunately, there aren’t as many programs out there as there needs to be to help patients. But if you look in most areas, you will find a program. A good program deals with multiple factors. First of all, they educate and make sure people are using their inhalers, using their oxygen right if they need to. They can connect people with smoking cessation programs. They can refer people for nutritional counseling if they’re obese or are malnourished.
But the most important components of pulmonary rehab are related to strength and endurance training. Often we’ll do upper and lower extremity flexibility and strength training. Often we’ll do treadmill or bicycle endurance training. Generally we work up to 20 to 40 minutes three to four times per week in a rehab program. In general, we like to train people so that once they leave the rehab program they are comfortable continuing a maintenance program in their own homes or environments. So a good rehab program will always take into account what type of equipment or walking surfaces they have available to them in their own environment because six weeks is not enough. It’s got to be a lifetime change in doing activity and staying active to maintain their level of functioning and minimizing their symptoms.
What are the biggest concerns from a doctor’s standpoint of treating COPD?
One of the big issues is when we prescribe the medications patients have to be educated to understand the impact of the medications. The majority of patients, when it’s examined, don’t fully comply with the medications. Or when they are getting the prescriptions, sometimes they’re not using the inhalers properly. So I think education both in making patients understand that sometimes inhalers don’t make you feel better immediately, but they can prevent flare-ups and possible decline in your lung function, so it’s important to use them regularly. Then a doctor should, when the patient comes to the office, on an intermittent basis, actually watch their patients use their inhalers and make sure they’re using them properly. Because it’s common to not have good technique. When your technique is not ideal, you’re not going to get the drug delivery and you’re not going to get the benefits from the inhaler medications.
What triggers a COPD flare-up?
About one-third of the cases we don’t have a good explanation. Viruses and other bacteria are very common. But in general when someone has a flare-up it’s because bacteria in their lungs decide to get more active or they get exposed to new strains of bacteria that can take off. We treat them with antibiotics. In some cases environmental irritants may be a factor.
Any lifestyle changes you would recommend?
In general, try to eat healthier. If you’re overweight, get your weight back in line because being overweight just adds to the burden of exercise and activity. If you’re underweight, then nutritional supplementation may be appropriate. In general avoid irritants, especially if you have overlapping allergies. Stay away from people who have colds. Stopping smoking is really critical and avoiding particularly pollutant days. Most importantly, I think, is that patients need to actually live life. They need to exercise; they need to go out there and not be afraid. Unless you have overlapping heart disease or other conditions, activity and going out there and living life will not result in further harm. It will improve your overall well-being and probably prolong life.
What can people do to help their doctor treat them to the best of their ability?
Be honest with your doctor. Tell them whether you’re smoking or not smoking, whether you’re willing to quit smoking, whether you’re complying with the medications because they need to understand that in order to fully guide whether the medication is successful. Ultimately, the doctor can point you in a certain direction, but it’s up to the patient. Motivated patients who do pulmonary rehab and comply with the medications are the ones who do well. It is a lot of work for the patients and they have to work and team up with the doctor and do their part.