Asthma and Allergy Center of Chicago, SC
WWW.ASTHMAALLERGYCHICAGO.COM
WWW.RESEARCH4HEALTH.COM
DISCLAIMER: 99% OF THIS DOCUMENT TEXT IS ORIGINAL. THE INFORMATION CONTAINED HEREIN IS ONLY FOR GENERAL
EDUCATION PURPOSES. WITHOUT PRIOR WRITTEN CONSENT, IT MAY NOT BE REPRODUCED, COPIED, OR RETRANSMITTED. NONE OF
THE INFORMATION IS INTENDED AS SPECIFIC RECOMMENDATIONS NOR INSTRUCTIONS FOR INDIVIDUAL MEDICAL CARE. CONSULT A
DOCTOR FOR MEDICAL CARE.
PERSPECTIVES IN COPD
©
IF YOU ANSWERED YES TO THREE OR MORE OF
THESE QUESTIONS…
1. DO YOU COUGH SEVERAL TIMES ON MOST DAYS?
Yes No
2. DO YOU BRING UP PHLEGM OR MUCUS ON MOST
DAYS?
Yes No
3. DO YOU GET OUT OF BREATH MORE EASILY THAN
OTHERS YOUR AGE?
Yes No
4. ARE YOU OLDER THAN AGE 40?
Yes No
5. ARE YOU A CURRENT SMOKER OR AN EX-SMOKER?
Yes No
2
YOU MAY HAVE COPDor, you know that you already do
This handout is intended to address some of the most basic facts and common questions about
COPD; it’s a starting point for you to understand what you have and what to do about it.
WHAT IS COPD?
COPD (C-O-P-D) refers to common chronic lung diseases that develop in people who have had
long term breathing exposure to environmental chemical or irritants.
Emphysema and Chronic Bronchitis are terms used to describe the most common forms of
COPD; most people with COPD have characteristics of both. In 2002, the Centers for Disease
Control (CDC) estimated that there were approximately 32 million people with COPD in the US.
You can obtain more current data and statistics about COPD in the US at: CDC COPD Data and
Statistics
Half of those people who have COPD don’t know it. For the other half who do know it, many
just try to ignore it, some seek medical care. Unfortunately, for many people who do seek
treatment, lack of adequate medical care may further contribute to impairment from COPD.
3
Now for a little BS (basic science)
When you breathe, air travels via your nose and mouth down through the airways into your
lungs. The airways are encircled by muscle strips (like rubber bands) and supported by
connective tissue (like the wires on a suspension bridge). It is in the smallest air sacs at the end
of the airways (the alveoli), where oxygen and carbon dioxide move between the airways and
your circulation.
COPD lungs are characterized by varying degrees of:
TISSUE DESTRUCTION OF THE ALVEOLI, AIRWAYS, AND SUPPORTING CONNECTIVE LUNG
SWELLING (“INFLAMMATION”) OF THE AIRWAY LINING
MUSCLE CONSTRICTION ("BRONCHOSPASM")
COPD involves a complex interaction between tissue destruction, inflammation,
bronchospasm, and mucus production. The lungs lose their stretchiness, stiffen or collapse, and
inflamed areas of the lung may produce mucus.
[from NHLBI]
4
Want to know a secret? Cigarette smoking is the leading
cause of COPD. What do you mean it's not a secret? Exposure to other environmental
irritants such as air pollution, chemical fumes or dust, and work-related chemicals also may
contribute to the development (or worsening) of COPD. Ok, want to know another secret?
The majority of people that smoke don’t develop COPD….what?
5
QUESTIONS...and some answers
I’ve smoked for years but feel fine, why should I care about COPD?
o Why? Because early detection and treatment can slow down or stop more
damage occurring to your lungs. If you wait until you have severe breathing
problems, irreversible damage likely has occurred but treatment can lessen the
effects.
My doctor has told me that my lungs sound clear, that means I don't have
COPD, right? SO, HOW DO I KNOW IF I HAVE COPD?
o Physical exam is the least sensitive way to determine if you have COPDit tells
you about as much as kicking a car's tires tells you about the engine .If you
have symptoms, you need to have some basic tests, one to look at how your
lungs function (how well air moves in and out), and other tests to look at the
lung structure.
o YOU NEED TO HAVE LUNG FUNCTION TESTS DONE TO DIAGNOSE COPD...
What is a lung function test?
o Lung function tests (pulmonary function tests) or “PFTs” are the terms used to
describe the breathing tests used to diagnose and to assess COPD lung damage.
Either Spirometry or Complete PFTs (which includes spirometry with gas
diffusion and lung volume testing) should be done for all COPD patients.
o All doctors who manage COPD patients should have spirometers in their office for
testing. Portable plastic peak flow meters are NOT an acceptable substitute for
either spirometry or complete PFTs for the diagnosis or the assessment of COPD.
o Lung function testing is recommended for anyone who has symptoms.
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What other tests do I need
o A screening Chest CT (CAT scan) may show structural or other lung problems not
visible on a regular chest x-ray. In milder cases of COPD, chest x-rays or CT scans
may appear normal.
o Thyroid hormone tests, a complete blood count, and an oxygen level should also
be performed as a minimum part of testing (at rest, and maybe while walking).
Does COPD ever go away?
o Does the IRS ever take a holiday? Chronic” means that the condition is long-
term; COPD cannot be cured and it does not magically disappear. You can (and
most likely do) try to ignore COPD but it does not ignore you. Like electricity (or
the IRS), COPD does not think, it just does what it does.
o The goal is to keep COPD from ruining your life. Uncontrolled, COPD prevents or
interferes with routine daily activities: bathing, walking, having conversations,
sleeping, sexual activity. COPD affects your entire body, your entire life, not
just your lungs.
Why should I stop smoking if I already have COPD?
o Really? If you continue to smoke, you will lose lung function faster than is normal
for someone your age. By stopping, this rapid decline in lung function will level
off to the normal rate for your age (you'll see on the graph on page 8...don't look
yet). Well, this may be not be entirely true for all COPD sufferers but who is
willing to take that risk? Small changes in lung function can make a big
difference in your life: the difference between being able to walk up a flight of
stairs, go to the store, walk down the block, sleep…
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TREATMENT
THE GOAL OF COPD TREATMENT IS TO RETURN YOU TO AS MUCH OF YOUR
NORMAL LIFE AS POSSIBLE. COPD TREATMENT SHOULD HELP TO:
REDUCE DAILY SYMPTOMS
REDUCE THE FREQUENCY OF ACUTE ATTACKS
IMPROVE YOUR ABILITY TO DO ROUTINE ACTIVITIES
WITH MINIMAL RESTRICTIONS
1
st
things first....Just in case you’ve been living in a bunker forty feet
underground without any contact with the world for the past 100 years....You need to
stop smoking immediatelyNO IFS, ANDS….NOR ANYMORE BUTTS.
8
OK, now take a look at the graph below....it shows that heavy smokers ("susceptible smoker")
have a much faster loss of lung function vs non-smokers (the susceptible smoker curve is much
steeper). Look closely, you'll see that when you stop smoking, it halts the negative effects of
smoking on the rate of lung function decline (the "stopped smoking" curves go back up). In
other words, the benefits from stopping begin when you quit.
If that's not enough to get you to consider stopping smoking, how about a really gross picture
of smokers vs non-smokers lungs? Good thing you’ve got skin and bones cover up your lungs.
LUNG FUNCTION
AGE
[Fletcher , et al Br med J.1977]
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Medications
Hmm, let’s see. Go to a doctor, get a prescription for an inhaler, get better. Simple, right? Uh,
read on... Truth in fact, most non-specialist doctors fail to recognize COPD until patients are
really symptomatic and impaired. Moreover, most non-specialists just don’t understand which
COPD medications to prescribe for their patients, or even understand how…well, just read on.
One of the problems complicating treatment is that if you don't use an inhaler properly, you
won't get the full dose of medicine into your lungs. Meaning, your inhaler won't seem to help
you that much. Let's just say that there are some healthcare providers out there that don’t
understand how to properly use inhalers (or how to properly instruct patients how to use
inhalers)…it's just a bit embarrassing. Let’s just blame inhaler users, it’s much easier.
Some Common Inhaler Devices
It sounds silly but consider this: if you put gasoline into the back seat of a car
does it work as well as if you put it in the gas tank? Misuse of COPD inhalers (“bad technique”)
is the most common reason people don't respond to their medications. There are distinct
advantages and disadvantages for different inhalation devices; devices need to be matched to
each individual patient to obtain the best results from treatment.
>>>> KEEP CALM and READ ON >>>>
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Inhaled medications for COPD fall into two basic categories:
1. BRONCHODILATORS and
2. CORTICOSTEROIDS ("STEROIDS")
1. BRONCHODILATORS
Bronchodilators are the primary initial therapy for COPD treatment. Bronchodilators act by
relieving the tightening or constriction ("bronchospasm") of the smooth muscle around the
outside of the lung tubes. Pay attention...There are two types of bronchodilator medications:
1. Beta-Agonists and 2. Anticholinergics
Both classes of medication act to relieve "bronchospasm" in COPD. Depending upon the
severity of your COPD, you may use one, or a combination of bronchodilators. For people with
more severe COPD, using an inhaler with a combination of both types of bronchodilators works
better than using an inhaler with only one.
There are both "short-acting" and "long-acting" forms of each types of medication:
Common SHORT ACTING BETA-AGONIST inhalers include: AlbuterolHFA (ProAirHFA,
VentolinHFA, ProventilHFA), XopenexHFA
Common LONG-ACTING BETA-AGONIST inhalers include: Foradil, Servent, Arcapta, Vilanterol,
Striverdi.
Common SHORT-ACTING ANTICHOLINERGIC inhalers include: Atrovent. There is also a
combination product of Atrovent plus Albuterol, which is called: CombiventHFA.
Common LONG-ACTING ANTICHOLINERGICS inhalers include: Spiriva, Tudorza, Seebri, and
Incruse.
KEEP READING>>>
Normal Bronchospasm
[Wikipedia]
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Common single-inhaler combinations of both LONG-ACTING ANTICHOLINERGIC/LONG-ACTING
BETA-AGONIST (also termed LABA/LAMA inhalers) include: Stiolto, Anoro, Bevespi,
Utibron.
2. CORTICOSTEROIDS ("steroids")
Corticosteroids relieve tissue "inflammation"; inflammation refers to the processes of swelling
and redness of the inside lining of the airways. There are "systemic steroids" which you take by
mouth, intravenously, or by injection, and, "inhaled steroids" taken via inhaler or nebulizer.
Systemic steroids are commonly used for treatment of acute severe COPD attacks. Common
systemic steroids include: Prednisone, Medrol. Risks of systemic steroids include: high blood
pressure, cataracts, avascular necrosis, skin thinning, fractures, muscle wasting, etc...everything
that makes news headlines these days. The long-term side effects are not commonly
associated with short-term use; however, the long-term side effects tend to prevent systemic
steroid daily use for most patients.
Inhaled Corticosteroids. To date, studies have demonstrated benefit of some inhaled steroids
used alone and in combination with a long-acting bronchodilator limited only to reducing
exacerbation rates (how often severe, acute COPD attacks occur) only among specific
populations of patients with moderate-severe COPD (people with severe airway obstruction on
lung function tests, who ALSO have experienced multiple acute COPD episodes over the previous
12 months which required treatment with either antibiotics or systemic steroids). In reality, less
than 1-in-5 people on current COPD treatment meet these criteria for inhaled steroid
treatment.
There remains significant controversy regarding the routine use of inhaled steroids in most
people with COPD. The major concern relates to the increased risks for pneumonia occurring
in people who take these medications as preventive therapy. Ask your doctor to review the
current recommendations and your individual risks and benefits of using inhaled steroids.
12
Inhaled steroid medications are available in combinations with long-acting beta-agonists
(examples: Advair, Symbicort, Dulera, Breo), and as single agents (examples: Flovent, Pulmicort,
Asmanex, Alvesco, QVAR).
In the future, there may be many more combinations of the various classes of these inhaled
medications, including “triple therapy” (single inhalers containing LAMA +LABA + inhaled
steroid).
Other Stuff
1. Oxygen
There are specific defined criteria by which your doctor may determine whether using oxygen
may help your breathing and the rest of your body. If you get easily winded or get short of
breath with activities, you should have your oxygen level checked while resting, and with
activity; some people may need to have it checked during sleep.
Some COPD patients may need extra oxygen all the time, or just some of the time to help them:
Perform routine tasks
Be more alert
Sleep better
Live longer
2. Theophyllines
Years ago, theophyllines were widely prescribed for COPD. They act as weak bronchodilators,
and have some other alleged benefits. Due to numerous side effects and medication inter-
actions, theophyllines have a very limited role in current COPD treatment. Common brand
names include: Theodur, Uniphyl, Theo-24.
3. Phosphodiesterase 4 (PDE4) Inhibitors
This class of medications initially were held to have high promise in reducing exacerbations and
possibly altering the underlying disease itself. Unfortunately, in actual use they provide
marginal benefits for even the most severe COPD sufferers and side effects tend to be common,
especially abdominal pain, cramping, etc. Common names include: Daliresp, Ariflo.
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4. Mucolytics
These agents are intended to break down mucus. Their use has steadily declined with
improvements in other medications. They do not improve lung function or alter the course of
COPD but may have some benefit in reducing exacerbations in patients with chronic bronchitis.
When used for increased mucus production during exacerbations, they may have some benefit
in reducing symptoms. Common names include: Mucomyst.
5. Expectorants
These agents allegedly act to make mucus less sticky and easier to cough up. There is little data
to indicate that they actually do anything in COPD. Common names include: Mucinex.
6. Research Stuff
Current medications temporarily improve lung function and daily, reduce symptoms and the
frequency of exacerbations...but...there are no current medications which alter the underlying
disease processes of COPD.
All COPD sufferers should consider participating in clinical research trials designed to evaluate
the benefit and risks of investigational medications for improving the care and lives of people
living with COPD.
www.Research4Health.com
"RESEARCH STUFF" ISTHE HOPE FOR THE FUTURE
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What About?
1. Pulmonary Rehab
Learning to do more with less can go a long way towards helping you to lessen the effects that
COPD has on your daily life. Pulmonary rehab programs may include: monitored exercise,
education and nutrition programs, and counseling.
Rehab programs have been shown to increase survival rates (i.e. reduce death) among COPD
patients.
The graph below shows that for every 100-foot increase in exercise performance, estimated
survival was increased by approximately 11%. (From Bowen et al. Chest. 2000)
2. Surgery
In a limited number of COPD patients, some surgical procedures can improve symptoms and
lung function. Some procedures include: lung volume reduction surgery, "bullectomy", and
lung transplantation. Speak with your lung specialist regarding these procedures.
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3. Vaccinations
Ok, do we really have to tell you every year that you should get a flu shot? Do think that you
feel crappy now? Just ignore the advice and see how much fun it is to get another severe
respiratory illness on top of COPD... not to mention, the other risks and complications from the
flu.
And... by the way, talk to your doctor about a "pneumococcal" pneumonia vaccines (two
different ones)...Just another bug that could kill you if you catch it....Believe it or not, vaccines
do actually help more than just kids.
Treatment of Acute Exacerbations
Every COPD sufferer will have episodic worsening (i.e. "exacerbations"). Colds are the most
common triggers but other environmental irritants (cold weather, dust, etc.) can cause similar
problems. Every one catches colds but for many people with severe COPD, a simple cold could
be a life-threatening event. You should discuss with your doctor ahead of time what you should
do when (not, if) you have an exacerbation.
Signs of worsening COPD may include:
• More breathless or wheezy than usual
• Change in amount and/or color of sputum
• Need to use inhalers more than usual
• Reduced energy for daily activities
• Loss of appetite
• Increasing tiredness, fatigue, and/or poor sleep
• Cough – new or increased
You should discuss with your doctor what to do when you have any changes in your health
related to your COPD.
16
Here is a plan (modified from the Canadian Thoracic Society) about what to
do if you have changes in your COPD:
WHAT TO DO IF YOUR COPD WORSENS
1) If your SPUTUM becomes more yellowish/greenish
Start: 1. Antibiotic _______________ Dose:____ #pills:___ Frequency:___ #days:___
NOTE: if repeating antibiotics within 3 months, then:
Instead, Start: Antibiotic _____________ Dose:____ #pills:___ Frequency:___ #days:___
2) If you are more SHORT OF BREATH or coughing up more mucus than usual,
take an additional ____ puffs of ____________ up to a maximum of ____ times per day
a. If your do not improve, or if you need to use additional rescue more than twice within 12
hours, then immediately begin:
Start: Prednisone, Dose:____ # pills:___ at once, repeat in 4 hours, then 2 pills once daily
until no need for additional rescue inhaler more than your usual for at least 2 days.
Notify Dr. _____________ if not off prednisone within 7 days. (may be taken with antibiotics)
--- NOTE---
If you do not improve before bedtime, or if your symptoms worsen, contact your doctor or
go to the emergency room
If you become extremely short of breath, confused, or drowsy, call 911
Notify your doctor of any worsening or if you symptoms are not significantly better within
48 hours.
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DON'T FORGET
It's about learning how to do more with what you've got.
Ignored and untreated COPD will continue to ruin the quality of your
life..and the lives of those with whom share your life.
Discuss with your doctor which medications are best for your COPD;
routinely have lung function tests to monitor your disease
Learn how to properly use inhalers; stop wasting medicine and get the
best results with the best inhaler technique
A well-tuned engine performs better than a poorly tuned one; a
supervised rehab program can help you get in better shape
Do we have to say it again? STOP SMOKING...
Have a plan for what to do when you get sick or when your COPD worsens