Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) causes severe shortness of breath, which can result from chronic bronchitis, emphysema, or both. Chronic bronchitis is defined as a constant cough and excessive mucus production that lasts for at least three months for more than two consecutive years. Emphysema is characterized by damage to the lungs, which causes them to lose their elasticity, forming pockets of dead air called bullae.

Chronic bronchitis and emphysema are generally caused by prolonged use of tobacco. Long time cigarette smoking can deplete levels of an enzyme called alpha-1 anti-trypsin. Normal levels of alpha-1 anti-trypsin help protect the lungs from damage. There is a less common form of emphysema that can occur in non-smokers. It is caused by an inherited deficiency of this enzyme (see Risk Factors).

Signs and Symptoms

• Ongoing cough, often with phlegm that may be hard to "bring up"
• Shortness of breath during exertion and, eventually, at rest
• Excessive mucus production and impaired ability to eliminate mucus
• Progressive difficulty exhaling
• Wheezing
• Recurrent respiratory infections
• Decreased exercise tolerance, including walking upstairs or carrying small packages

Causes

Smoking is the number one cause of COPD. It can also be caused by exposure to pollutants or toxic chemicals. One rare form is inherited (see Risk Factors).

Risk Factors

• Smoking, especially if you have a history of smoking one pack per day for 20 years or the equivalent (for example, 2 packs per day for 10 years)
• Inherited deficiency of an enzyme called alpha-1 anti-trypsin that normally helps protect the lungs from damage
• Passive smoking (ongoing exposure to cigarette smoke from others)
• Being over age 50
• Work exposure to toxic chemicals such as silica or cadmium
• Working around industrial smoke, excessive dust, or other air pollutants (for example, miners, furnace workers, and grain farmers)

Diagnosis

Your health care provider will listen to your chest for wheezes and decreased breath sounds (due to inflation of your lungs). Your doctor will also look for signs of increased work involved in breathing like flaring of your nostrils and contraction of the muscles between your ribs. Your respiratory rate (number of breaths per minute) may be elevated.

A chest X ray will probably be ordered which will likely reveal over-expanded (hyperinflated) areas in the lungs. A CT scan may be ordered to check the severity of your COPD. A probe placed on your finger or ear (called a pulse oximeter) may be used to check the level of oxygen in your blood. A sample of blood taken from an artery (called an arterial blood gas) may show low levels of oxygen and high levels of carbon dioxide, particularly during the late stages of disease. Lung function tests show decreased rates of airflow while you are exhaling and over-expanded lungs.

Preventive Care

• Don't smoke
• If you already smoke, quit before there has been permanent damage to your lungs
• If you have COPD, avoiding respiratory infections is very important. Your doctor will recommend that you receive an influenza vaccine each year and that you receive a pneumococcal vaccine once in your lifetime to protect you from pneumonia. Caused by this particular organism.
• Eating foods rich in antioxidants, magnesium and other minerals, and omega-3 fatty acids (including fruits, vegetables, and fish) may help prevent the development of COPD in the first place avoid worsening of your symptoms if you already have this lung condition. See Lifestyle and Nutrition and Dietary Supplements sections below.

Treatment Approach

Not smoking is the key to preventing COPD or to stop it from getting worse. Drug treatment varies depending on the severity of the disease. Your health care provider may talk with you about lifestyle changes you can make to help relieve the symptoms of COPD. These include exercising and eating a healthy diet. Support groups or therapy (see Mind/Body Medicine) can help make it easier to live with the condition.

Lifestyle

Quitting smoking is crucial. Other lifestyle measures you can take include dietary changes and exercise as described below.

Diet
Some evidence suggests that poor nutrition, particularly deficiencies in antioxidants and certain minerals including vitamins A, C, and E, potassium, magnesium, selenium, and zinc is associated with having COPD and, possibly, with worsened lung function. Such nutrients can be obtained from an adequate daily intake of fresh fruits and vegetables, nuts, and whole grains.

Exercise
Exercise helps some people with COPD. By strengthening your legs and arms and improving endurance, you may reduce breathlessness somewhat. Walking, for example, is a good exercise to build endurance. Talk to your doctor and/or respiratory therapist about how to build up slowly and safely. Attending a comprehensive pulmonary rehabilitation is the best way to learn exercise and safe breathing techniques (see below).

Breathing
There are breathing exercises (for example, a pursed lip technique, breathing from the diaphragm, or using a spirometer [breathing device] twice a day) that may help improve lung function. Talk to your doctor about working with a respiratory therapist in order to learn such exercises. It is important, when learning breathing techniques, to work with an appropriately trained professional because the techniques are not good for everyone with COPD. Attending pulmonary rehabilitation is the best way to learn exercise and breathing techniques.

Medications

• Bronchodilators (including ipratropium, albuterol, isoproterenol, metaproterenol, pirbuterol, terbutaline, levalbuterol, salmeterol, and formoterol) — increase airflow and help make it easier to breathe
• Theophylline – another type of bronchodilator
• Corticosteroids — reduce inflammation; taken by inhaler; when an attack is severe, your doctor may recommend oral or even intravenous steroids
• Antibiotics — used to treat COPD when symptoms worsen

Surgery and Other Procedures

When flare-ups are severe, requiring hospitalization, use of oxygen and nebulized lung treatments may be necessary. Occasionally, mechanical ventilation on a respirator is needed during the hospital course. At late stages of the disease, many people with COPD need continuous oxygen at home.

Lung transplant is sometimes performed for severe cases of COPD.

Nutrition and Dietary Supplements

Because supplements may have side effects or interact with medications, they should be taken only under the supervision of a knowledgeable healthcare provider. Be sure to talk to your physician about any supplements you are taking or considering taking.

Bromelain
Although not studied in people with COPD specifically, bromelain (a mixture of protein-digesting enzymes found in pineapples [Ananas comosus]) can help reduce cough and diminish mucus production from a respiratory infection. In theory, therefore, it may be able to do the same if you have chronic bronchitis.

Magnesium
Magnesium deficiency may be associated with an increased risk of developing emphysema and other lung diseases. Sometimes, intravenous magnesium (that is, magnesium delivered through a vein) is part of the treatment for a COPD flare-up in the hospital. The doctor will determine if this is necessary or appropriate.

It is not known whether eating foods rich in magnesium or taking magnesium supplements will reduce your chances of developing emphysema. Such foods, however, including legumes, whole grains, and green leafy vegetables, should be a regular part of a healthy diet anyway.

Some clinicians recommend checking your magnesium level (a simple blood test) if you have COPD and taking magnesium supplements if your levels are low.

N-acetylecysteine (NAC)
A review of scientific studies found that NAC may help dissolve mucus and improve symptoms associated with chronic bronchitis and emphysema. Smokers may also benefit from NAC supplementation. Studies on large groups of people have found that NAC appears to have cancer prevention properties in people who are at risk for lung cancer (like chronic smokers who are also at risk for COPD).

Omega-3 Fatty Acids
Some experts believe that dietary and supplemental forms of omega-3 fatty acids, including alpha-linolenic acid (ALA) found in walnuts and flaxseeds, may prove helpful as part of your treatment for COPD. Scientific research is needed.

Vitamin C
According to some clinicians, taking vitamin C supplements is "safe and reasonable" if you have COPD, especially if you continue to smoke. Research to date is limited, however, and more studies are needed to know if this is truly helpful if you have COPD. In the interim, it is worthwhile to obtain adequate amounts of vitamin C by eating plenty of fresh fruit. In fact, just increasing the amount of fruit you eat by one or two servings per week may help improve lung function.

Other
Other supplements that have gained popularity for COPD, but need further study before comment can be made regarding their value include:

• Coenzyme Q10
• L-carnitine

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field of herbal medicine. Also, be sure to talk to your physician about any herbs that you are taking or considering taking.

Herbs that an herbal specialist might recommend based on clinical experience, particularly during a flare-up of your chronic bronchitis include:

• Eucalyptus (Eucalyptus globulus)– acts as an expectorant, which means that it loosens phlegm in the respiratory passages, making it easier to cough up mucus from your airways.
• Garlic (Allium sativum)– may help fight infection and has antioxidant properties (see earlier discussion under Diet in section entitled Lifestyle as well as the section on Nutrition and Dietary Supplements).
• Licorice (Glycyrrhiza glabra) — used by professional herbalists to relieve respiratory ailments such as bronchitis; considered a demulcent (soothing, coating agent); you should not use this herb if you have high blood pressure.
• Lobelia (Lobelia inflata) — also called Indian tobacco, lobelia has a long history of use by Native Americans as an herbal remedy for respiratory ailments including bronchitis. It is considered an effective expectorant, meaning that it helps clear mucus from the respiratory tract. It is important to note, however, that lobelia is a potentially toxic herb. It is considered relatively safe when used in very small doses (particularly homeopathic doses) or in combination with other herbs that affect the respiratory system. Lobelia use should only be considered with the guidance of a qualified healthcare practitioner.
• Marshmallow (Althea officinalis)— long history of use in traditional healing systems for bronchitis.
• Red Clover (Trifolium pretense)– used traditionally for spasmodic cough and bronchitis.
• Saw Palmetto (Serenoa repens/Sabal serrulata) — early in the 20th century, saw palmetto was listed in the US Pharmacopoeia as an effective remedy for bronchitis.

Acupuncture

Preliminary studies suggest that acupuncture may help relieve shortness of breath in those with COPD. More research is needed to know for certain if this is an effective use of acupuncture.

Similarly, acupressure (a technique much like acupuncture but pressure from the practitioners thumb or fingers is used instead of needles) may be a worthwhile addition to attending a pulmonary rehabilitation program where one learns breathing techniques and exercises to feel less short of breath. Again, more research in this area would be helpful.

If you are trying to quit smoking, acupuncture is an excellent treatment approach for this purpose.

Mind/Body Medicine

• The stress of having COPD is often helped by joining a support group where members share common experiences and problems.
• Yoga and tai chi are practices that use deep breathing techniques and meditation; these practices may be helpful if you have COPD. Talk to your doctor about safety for you.
• Biofeedback is another method for helping to learn a more relaxed and, therefore, more comfortable breathing pattern.
• Music therapy can help relieve anxiety associated with COPD and, possibly, shortness of breath.
• Listening to relaxation tapes on a regular basis (for example, one or two times per day) may help reduce anxiety and shortness of breath associated with COPD.

Other Considerations

If you have COPD, you are prone to respiratory infections. Your health care provider will most likely tell you to get a flu shot every year and a pneumococcal vaccine once in your lifetime.

Prognosis and Complications

COPD is considered a chronic illness. Whatever damage there is to your lungs will not improve. If you stop smoking, the damage is likely to not get worse. If you continue to smoke, however, your lungs and lung function will continue to deteriorate.

Potential complications of COPD include:

• Abnormally high pressure in the lungs called pulmonary hypertension
• Enlargement of the heart and heart failure, leading to excessive fluid and weight gain
• Abnormal rhythms of the heart
• Dependence on mechanical ventilation (a respirator) and/or oxygen therapy
• Pneumothorax (collapsing of part of the lung due to air leaking from the lung)
• Pneumonia and other infections
• Eventually, weight loss and wasting can occur

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