COPD (chronic obstructive pulmonary disease)

Description

The abbreviation COPD stands for chronic obstructive pulmonary disease. It is a chronic disease of the lungs caused by inflamed and, similar to asthma, permanently narrowed airways. In contrast to asthma, the airways cannot be completely widened with the help of medication, but only partially.

COPD develops from chronic bronchitis and/or emphysema (lung swelling) with symptoms such as sputum, chronic cough or shortness of breath.

The most common cause is smoking. About 90% of all patients are (former) smokers. For long-time smokers, the risk of developing the disease is 20%, which should not be underestimated.

Among the most frequent causes of death, COPD ranks 4th. Worldwide, approximately 210 million people suffer from the disease and about 5 million die from it every year.

The tendency is increasing, because within the next years more and more people will probably smoke.

Among all those affected, men are more likely to be affected than women.

Chronic bronchitis is the basis for COPD. The cilia, which are normally responsible for transporting mucus and dirt out of the lungs, become paralyzed. This is compounded by excessive mucus production by the lungs. Symptoms such as frequent coughing and sputum production occur. If the cause of chronic bronchitis is eliminated at this time (such as smoking), there is a good chance that all changes will return to normal.

If this is not the case, chronic obstructive pulmonary disease may develop over time. The cilia are completely destroyed and the bronchial mucosa thickens, narrowing the airways.

At a later stage, the mucous membrane of the bronchial tubes recedes, this is called atrophy (tissue atrophy).

This in turn causes the wall of the alveoli to thin out, become unstable (especially during exhalation) and collapse. Once this happens, there is no turning back, and breathlessness and poor performance result.

COPD can worsen if the alveolar septa (walls of the air sacs) are destroyed, causing the lungs to lose elasticity and become over-inflated, similar to a balloon. Experts refer to this as emphysema.

The undisputed main cause of COPD is tobacco smoking. The manifestation and development of the disease depends to a large extent on how much and how long the person has been smoking. It should not be forgotten that passive smoking also damages the lungs.

Apart from smoking, the risk of disease is increased by general air pollution and frequent respiratory infections in childhood. Recent studies have also shown that living next to a busy road, and thus having significant exposure to particulate matter, is also linked to the development of disease.

Another factor is the work environment. Those exposed to high levels of air pollution, such as miners, are more likely to become ill.

The rarest causes of COPD are congenital defects. These can include a lack of antibodies (antibody deficiency syndrome) or an enzyme deficiency, e.g. alpha-1-antitrypsin deficiency.

Signs of chronic obstructive pulmonary disease:

• Shortness of breath (initially only on exertion, later also at rest).
• Cough (gets progressively worse, especially in the morning)
• Sputum (becomes increasingly thick and difficult to cough up)
• Weight loss (possibly)

Doctors also speak of the so-called AHA symptoms (shortness of breath, cough, sputum).

In the late stages of the disease, the development of cor pulmonale is possible. In this case, the right half of the heart enlarges and becomes weaker and weaker. This weakness of the right heart leads, among other things, to oedema (water retention) in the legs and ascites in the abdomen (abdominal dropsy).

Complaints can worsen acutely at any time (exacerbation). Causes:

• viral or bacterial infections
• air pollution e.g. smog, fine dust
• damp, cold weather
• Accidents with injury to the chest
• medication

An aggravation of the symptoms is evident through

• increasing shortness of breath
• increasing cough
• increasing sputum
• change in the colour of sputum, e.g. yellow-greenish in bacterial infections
• chest tightness
• malaise, tiredness
• fever

Anyone suffering from COPD and exhibiting the above symptoms should consult their doctor as a matter of urgency!

Chronic obstructive pulmonary disease can be divided into different degrees of severity. The main criterion is the lung function (one-second capacity; the volume that can be exhaled within 1 second after maximum inhalation):

Severity	Symptoms	One-second capacity (FEV1)
0 - risk group	chronic cough and sputum	inconspicuous
1 - mild	possibly chronic symptoms: cough, sputum, shortness of breath during heavy physical exertion	inconspicuous (> 80 % of target value)
2 - moderate	possibly chronic symptoms: cough, sputum, shortness of breath	limited (50 - 80 % of target value)
3 - severe	possibly chronic symptoms: cough, sputum, shortness of breath	limited (30 - 80 % of target value)
4 - very severe	chronic undersupply of oxygen	severely restricted (< 30 % of target value)

A distinction can also be made according to the external appearance of the sufferer, and the transitions are fluid:

"pink puffer"

The so-called "pink wheezer" has emphysema as the main symptom. He is lean, with little musculature and suffers from severe shortness of breath. Irritable cough is also an occasional symptom. His most common cause of death is respiratory failure.

"Blue Bloater"

The so-called "blue bloater" has cough and sputum as his main symptoms. He is usually overweight and exhibits cyanosis (bluish discoloration of lips and nails due to oxygen deprivation). Although he suffers from hypoxia, he rarely experiences respiratory distress. His most common cause of death is right heart failure.

At the beginning, the attending physician takes an anamnesis (medical history). For this purpose, the following questions must be clarified:

• How long have you been coughing? How often?
• Do you cough up mucus more frequently (in the morning)? If so, what color is the mucus?
• Do you suffer from shortness of breath? If so, only during exertion or also at rest?
• Do you smoke? Have you ever smoked? If yes, how long and how many cigarettes/day?
• What is your profession? Are you exposed to harmful substances?
• Has your performance decreased?
• Have you lost weight?
• Do you suffer from any other diseases?
• Do you have other symptoms, such as edema (water retention) on your legs?

If COPD is present, the doctor will hear sounds when listening to the lungs (wheezing, humming). They will also look for signs of oxygen deficiency (cyanosis, blue lips or nails), or heart failure (edema, water retention in legs).

A lung function test measures the airway resistance and the capacity of the lungs to differentiate COPD from asthma, which is very important.

Blood gas levels can be used to detect oxygen deficiency. We also look for alpha-1 antitrypsin (a protein) deficiency in patients over the age of 45.

Because some lung and heart diseases can cause similar symptoms, X-rays, EKG (electrocardiogram) and further blood tests are often needed to confirm the diagnosis. Other possible investigation methods include a stress test and a questionnaire, e.g. SGRQ, which is disease specific.

Exacerbation - acute deterioration

If there is an acute worsening of the condition, a blood gas analysis is essential to better assess the severity.

Indications of a severe exacerbation are peak flow values < 100 l/min or a one-second capacity < 1 l.

Furthermore, we look for indications of an infection. Signs in the blood count would be, for example, increased inflammatory cells (leukocytosis) or increased CRP values (C-reactive protein, an inflammation parameter). If acute respiratory distress is present, a chest X-ray and ECG are advisable.

Goals of COPD therapy:

• Increasing exercise tolerance
• Alleviation of symptoms
• Preventing exacerbations
• Improving the quality of life
• Avoiding complications

Quitting smoking

The first priority in the treatment of COPD is smoking abstinence. This can be achieved with the help of medication and psychosocial support. Once smoking is stopped, symptoms are significantly reduced, lung function improves and mortality rates decrease. Restricting tobacco use alone is not sufficient to achieve these changes.

Vaccinations against influenza or pneumococcus are advisable, as COPD sufferers often suffer from infections, no matter how severe the disease. In addition, any exposure to (fine) dust should be avoided.

There are special training courses where you can not only learn more about the disease, but also special breathing techniques (e.g. lip-braking, breathing with pursed lips) and the correct inhalation technique can be learned.

Medication

Generally, a step-by-step therapy is recommended, which varies according to severity and symptoms.

Stage	Medication
I	fast-acting bronchodilators if required (beta-2-sympathomimetics e.g. salbutamol and/or anticholinergics e.g. ipratropium).
II	Rapid-acting bronchodilators as required (beta-2-sympathomimetics e.g. salbutamol and/or anticholinergics e.g. ipratropium AND one or more long-acting bronchodilators as continuous therapy (beta-2-sympathomimetics e.g. formoterol and/or anticholinergics e.g. tiotropium)
III	Rapid-acting bronchodilators as required (beta-2-sympathomimetics e.g. salbutamol and/or anticholinergics e.g. ipratropium AND one or more long-acting bronchodilators as continuous therapy (beta-2-sympathomimetics e.g. formoterol and/or anticholinergics e.g. tiotropium) AND inhaled cortisone (especially in exacerbations)
IV	Therapy as in stage III AND possibly oxygen therapy (long-term) or surgical intervention

Beta-2-sympathomimetics

The muscles of the airways are relaxed and bronchi dilated. This improves sputum, cough and shortness of breath. Short-acting preparations are used in acute cases, while long-acting preparations are available for long-term therapy. Their effect is slower to set in, but lasts many times longer.

Anticholinergics

They also relax the muscles of the airways and dilate the bronchial tubes. In contrast to beta-2-sympathomimetics, they have a weaker effect and it takes longer for the effect to set in.

Cortisone

Suppresses airway inflammation, thereby preventing exacerbations. Inhalers with cortisone are particularly recommended because the cortisone can then reach the lungs directly and take effect. Good results are already achieved with low doses and therefore low side effects. Tablets containing cortisone are not suitable for long-term therapy.

Theophylline

An active substance for the long-term expansion of the bronchial tubes. However, it is more of a reserve drug in case conventional therapy does not work. The reason for this is the high rate of side effects caused by a fluctuating level of the active substance. Therefore, when administering theophylline, regular monitoring of the blood level of the active substance by a doctor is necessary.

Mucolytic drugs (expectorants, mycolytics) are not necessarily recommended, but are only used in cases of excessive mucus or acute infections. Inhalations with saline solutions can also help to loosen mucus. If a bacterial infection is present, antibiotics are usually necessary.

Other therapies

Physical therapy

This supports the treatment with medication. Coughing up is supported by tapping massages and respiratory gymnastics increases performance.

Breathing exercises are used to improve breathing technique, lung ventilation (aeration) to oxygenate the body. Ideal breathing additionally helps to reduce susceptibility to infections. Respiratory therapy is used to learn special breathing techniques that give self-confidence, train abdominal muscles and increase performance. It teaches sufferers how to help themselves.

Coachman's seat: Rest arms on thighs or table to facilitate exhalation. Close your eyes and breathe calmly and evenly.

Lips brake: Close your lips loosely. Now exhale through the mouth as slowly as possible. The cheeks will puff out a little as you do this. This technique slows down the flow of breath and helps to keep the bronchi open.

Physical training

Exercise is an integral part of long-term COPD therapy. Regular exercise improves quality of life, increases exercise tolerance, and minimizes the frequency of exacerbations.

Long-term therapy with oxygen

In cases of severe COPD, especially right heart failure (cardiac insufficiency), oxygen therapy makes sense. Oxygen is inhaled from cylinders via a nasal probe for 16 - 18 hours per day. This prevents respiratory distress, as the oxygen saturation of the blood is stabilised.

Operation

Patients who have already developed emphysema (pulmonary hyperinflation) sometimes have the option of undergoing surgery. This involves removing tissue from the dilated bronchi that is no longer involved in gas exchange. This is called lung volume reduction surgery, which can improve lung function in some people.

Diet and weight

Unwanted weight loss may indicate a worsening of the condition. Therefore, weight should be monitored regularly. In some cases, nutritional therapy may be necessary to regain lost weight.

However, there may also be a sudden increase in weight. It is usually an indication of right heart failure. This means that the heart's capacity is no longer sufficient to maintain normal blood circulation. Blood congestion occurs, resulting in oedema (water retention), usually in the legs.

Resources

If a severe form of COPD is present, many sufferers are no longer able to cope with everyday life on their own. Small aids can then support independence. These can be shoehorn extensions or rollators (mobile walking aids).

Exacerbation

When infections or cold, damp weather affect COPD, the condition can worsen acutely. Doctors then speak of an exacerbation. Special training courses can be used to learn how to recognise and treat these at an early stage.

Exacerbations are divided into 3 degrees of severity: mild, moderate and severe.

Depending on the severity and the symptoms, care can be provided on an outpatient or inpatient basis.

Sometimes it may already be sufficient to increase the dose of medication. If symptoms such as sputum, cough and shortness of breath still increase, a doctor should be consulted. Also alarming are fever or yellow-greenish sputum, which indicate a bacterial infection. If there is indeed an infection, it is treated with antibiotics. If there is no improvement, inpatient treatment becomes necessary.

In the case of a severe exacerbation, inpatient treatment is also necessary:

• severe shortness of breath
• One-second capacity < 30
• rapid deterioration of the condition
• advanced age
• other diseases

The prognosis for COPD depends largely on whether the progression of the disease can be stopped. The first step is to stop smoking. If this is the case, all symptoms improve, lung function improves and life expectancy increases.

Medication can also improve the condition. However, damaged, non-functioning lung tissue cannot be saved. The life expectancy of sufferers is shortened by complications such as exacerbations.

Since COPD is a chronic and progressive disease, regular check-ups by a doctor are necessary. If you are mostly symptom-free, annual check-ups are sufficient. However, if your condition worsens (increase in sputum, cough or shortness of breath), the only way to detect and treat a negative development of COPD is to see your doctor soon.

Possible complications:

• frequent infections of the bronchial tubes, pneumonia
• restricted lung function, resulting in shortness of breath
• Cyanosis (blue discoloration of lips and nails due to lack of oxygen)
• Pulmonary emphysema (distension of the lungs) due to tissue destruction in the lungs
• Cor pulmonale (right heart failure), resulting in edema (water retention) in the legs
• repeated exacerbations (acute worsening)
• Heart failure and failure of the respiratory muscles - danger to life!

The most important measure to prevent COPD is to stop smoking or (not to start). Approximately 90% of all patients have smoked for a long period of time or have still not stopped.

Take care not to be exposed to harmful environmental conditions such as dusty, cold or heavily polluted air (smoky rooms!) for longer than absolutely necessary. This applies to both work and leisure.

Vaccinations against influenza and pneumococcus are recommended.

If you already suffer from chronic obstructive pulmonary disease, you can do the following to avoid an exacerbation (acute worsening):

• If you are still smoking, give it up. Your condition will improve and the risk of an exacerbation will decrease significantly.
• Attend patient education classes, which can help minimize hospitalizations. You will get the opportunity to learn the proper management of your condition. You will also be taught the correct dosage of medication in the event of an exacerbation.
• Get regular and adequate exercise.
• Get vaccinated against influenza and pneumococcus.
• Take advantage of breathing exercises. This improves your breathing technique, lung ventilation and thus oxygen supply to the body. It also reduces the risk of acute respiratory infections. Exercises are e.g. coachman's seat, lip brake.
• Undergo tapping massages. They support the expectoration of mucus.
• Avoid heavily smoky rooms, as well as places with heavy air pollution (dust, smoke).
• Pay special attention to your diet and weight. Every unnecessary kilo of weight puts a strain on your body, just as being underweight worsens your prognosis.
• Drink regularly and plenty (water!) and inhale with saline solutions. This makes it easier to cough up mucus.
• If you are exposed to high levels of pollutants in the workplace, you should contact your company doctor and seek treatment immediately.
• Support your immune system. To do this, eat a healthy diet (plenty of fresh vegetables and fruit, sufficient fluids) and avoid stress and similar damaging factors.

COPD and sport

With the help of physiotherapy and respiratory training, you can fight your shortness of breath and increase endurance as well as performance.

Apart from the physical benefits, exercise reduces anxiety and depression.

Another positive side effect is improvements in blood lipid levels, high blood pressure or other risk factors for cardiovascular diseases.

Training programs are an integral part of the therapy. Correct inhalation techniques and first aid measures for acute respiratory distress are taught there.

Many sufferers limit their physical performance to a minimum out of fear. However, the reduction in physical performance leads to a decrease in quality of life, isolation and depression. A vicious circle begins. To prevent this from happening to you, you should exercise regularly and sufficiently in your everyday life.

Patients with mild symptoms in particular should maintain or increase their performance so that they do not get out of breath so quickly during exertion.

Good planning of sporting activities is necessary, as physical performance is limited by COPD. In general, any type of sport can be practiced, but it should be clarified in advance with the doctor which types of sport are most appropriate or suitable.

It is particularly important not to increase the duration and intensity of the training too quickly. Otherwise there is a risk of overstraining and losing the fun of exercise.

Increase the intensity of the exercises slowly but steadily:

Start with a few minutes of exercise, several times a day. Even if you have slight complaints or little motivation. Before and after the training (possibly also during) you should measure the peak flow (respiratory flow strength).

Exercise is always more fun when done in company. Many places have their own lung sports groups that train together in a targeted manner.

Training should always begin with a short warm-up phase (stretching, slow walking). This stimulates the metabolism and the overloaded respiratory muscles relax noticeably.

Use the "lip brake" during training to prevent respiratory distress or to keep it within a tolerable range. Breathe out as slowly as possible with loosely closed lips. Your cheeks will puff out slightly. This breathing technique slows down breathing and keeps bronchial tubes open.

After you have finished exercising, stretching exercises help to prevent cramping.

Particularly suitable sports:

• Exercise bike
• Cycling
• light jogging, Nordic walking
• "therapeutic" stair climbing
• Inspiratory muscle training (special training for the respiratory muscles)
• special strength training with a gymnastic band for the respiratory muscles

Some studies give reason to believe that strength training has a particularly positive effect on COPD. However, further testing of this assumption is still pending.

People with COPD benefit from exercise, and their quality of life improves because breathing becomes easier and there are fewer episodes of breathlessness.

To be sure how much exercise is healthy for you, you should consult a doctor beforehand.