9. CHRONIC OBSTRUCTIVE AIRWAYS DISEASE (COPD)

Chronic Obstructive Airways Disease (COPD) is a long-term lung condition where airflow is limited and not fully reversible. It usually gets worse over time and is linked to harmful particles or gases (most often cigarette smoke). COPD includes two main problems:

  • Chronic bronchitis – too much mucus and airway inflammation causing cough and sputum.
  • Emphysema – damage and enlargement of air sacs (alveoli) that reduces gas exchange.

Who gets COPD & why?

The main cause is cigarette smoking (>90% of cases). Other causes include long-term exposure to air pollution, workplace dusts or fumes, biomass fuels, and a genetic condition called alpha-1 antitrypsin deficiency. COPD is more common with older age and in people with repeated lung infections.

How COPD develops (simple pathophysiology)

Irritants (like smoke) cause persistent inflammation in the airways and lungs. In chronic bronchitis this causes mucus gland enlargement, mucus buildup and airway narrowing. In emphysema the supporting lung tissue and small airways break down, causing air trapping and loss of surface area for oxygen exchange. Together these changes make it hard to breathe and lead to low oxygen or high carbon dioxide in blood.

Key symptoms

  • Long-term cough with sputum (especially in chronic bronchitis)
  • Progressive shortness of breath, worse on exertion
  • Wheezing, chest tightness
  • Frequent chest infections
  • Weight loss and fatigue in advanced disease

Diagnosis — practical approach

  1. History & exam: smoking history, chronic cough, sputum, breathlessness.
  2. Spirometry: essential test — post-bronchodilator FEV1/FVC < 0.70 confirms airflow obstruction.
  3. Assess severity: measure FEV1 % predicted and symptoms/exacerbation risk to stage patient.
  4. Other tests: chest X-ray, CT if needed, arterial blood gases for advanced disease, sputum culture during infections, and alpha-1 antitrypsin test if early emphysema or non-smoker.

Staging & treatment grouping (simple)

Treatment decisions combine lung function (FEV1), symptom burden and history of exacerbations. Patients are grouped clinically (low vs high symptoms and low vs high exacerbation risk) to guide therapy, with short-acting bronchodilators for mild intermittent symptoms and long-acting inhalers or added inhaled steroids for more severe disease.

Treatment — non-drug measures (first and most important)

  • Stop smoking: single most effective step to slow disease progression — use counseling, NRT, bupropion or varenicline as needed.
  • Vaccinations: annual influenza and pneumococcal vaccine as recommended.
  • Pulmonary rehabilitation: exercise training, breathing techniques and education to improve function.
  • Oxygen therapy: for chronic resting hypoxemia (documented PaO2 <55 mmHg or SaO2 <88% or with cor pulmonale).
  • Chest physiotherapy: to help clear thick sputum if present.
  • Avoid irritants: reduce exposure to pollution, dusts and smoke.

Drug treatment — clear, practical points

Bronchodilators are the mainstay. Choice depends on symptom frequency and severity.

Short-acting bronchodilators

  • SABA (inhaled): salbutamol/albuterol — quick relief for breathlessness.
  • SAMA (inhaled): ipratropium — useful for symptom relief or in combination with SABA.

Long-acting bronchodilators

  • LABA: salmeterol, formoterol — give regular bronchodilation, improve symptoms and reduce exacerbations.
  • LAMA: tiotropium, aclidinium — long-lasting anticholinergics, very helpful in COPD; once-daily tiotropium is widely used.
  • Combination LABA+LAMA: often more effective when single agents are insufficient.

Inhaled corticosteroids (ICS)

Added for patients with frequent exacerbations or severe airflow limitation (usually combined with LABA). ICS reduce exacerbation risk but carry some pneumonia risk — use based on exacerbation history and eosinophil counts when possible.

Other drugs

  • Theophylline: limited role due to side effects and drug interactions; monitor blood levels if used.
  • Phosphodiesterase-4 inhibitor (roflumilast): for severe chronic bronchitis with frequent exacerbations (500 mcg daily) — watch for weight loss and mood changes.
  • Antibiotics: used for bacterial exacerbations; macrolides may be considered in frequent exacerbators under specialist care.

Managing exacerbations (practical)

  • Short-acting bronchodilators (nebulized or inhaler + spacer)
  • Oral corticosteroids for a short course to speed recovery
  • Antibiotics if increased sputum purulence or signs of infection
  • Controlled oxygen with monitoring to avoid CO2 retention
  • Hospitalize if severe breathlessness, hypoxia, confusion, or hemodynamic instability

Monitoring & counselling (what to tell the patient)

  • Quit smoking — most important step to slow disease.
  • Use inhalers correctly — demonstrate technique and use a spacer for MDIs.
  • Recognize exacerbation signs (worse breathlessness, increased sputum, fever) and seek early care.
  • Attend pulmonary rehab and vaccination appointments.
  • Track symptoms and exercise tolerance; report weight loss, swelling, or worsening breathlessness.

Detailed Notes:

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