Chronic Obstructive Pulmonary Disease (COPD)

Definition of the Disease and its Causes:

Chronic Obstructive Pulmonary Disease (COPD) has gained prominence as one of the leading causes of death among individuals over the age of 45. According to 2020 data, COPD ranks third on the list of primary causes of death in the population, following ischemic heart disease and stroke.

COPD is a serious disease because its main symptoms, especially when associated with smoking, only appear after 20 years of smoking initiation. For a long time, it may remain asymptomatic and unnoticed, yet, without treatment, the obstruction in the respiratory pathways progresses silently, becoming irreversible and leading to early disability and decreased life expectancy. Therefore, the topic of COPD appears particularly significant today.

It is important to note that COPD is essentially a chronic disease, requiring early diagnosis in its initial stages, as the disease tends to progress.

If a doctor diagnoses “Chronic Obstructive Pulmonary Disease (COPD),” there are a series of questions that arise for the patient: What does this mean, how serious is it, what needs to change in lifestyle, and what is the expected course of the disease?

Thus, Chronic Obstructive Pulmonary Disease or COPD is a chronic inflammatory disease affecting the small airways (respiratory tract), leading to breathing disturbances due to narrowing of the air passages. Over time, emphysema develops in the lungs, where lung compliance decreases, meaning their ability to contract and expand during breathing. Consequently, the lungs always remain as if in an inhalation state, retaining too much air even during exhalation.

The main causes of COPD include:

  • Exposure to harmful environmental factors.
  • Smoking.
    As for other causes, they include:
  • Occupational hazard factors (dust containing cadmium and silicon).
  • General environmental pollution (exhaust gases from cars, SO2, NO2).
  • Recurrent respiratory infections.
  • Genetics.

Symptoms of Chronic Obstructive Pulmonary Disease:
COPD is a disease that typically manifests in the second half of life, often developing after the age of forty. The progression of the disease is gradual and long, often unnoticed by the patient.

The most common symptoms that prompt a person to visit a doctor are shortness of breath and cough – both being the most prevalent symptoms of the disease (persistent shortness of breath, frequent daily coughing accompanied by mucous secretions in the morning).

The typical COPD patient is someone aged 45-50, a smoker, complaining of recurrent shortness of breath during physical exertion.

Coughing is one of the earliest symptoms of the disease. It is often underestimated by patients. In the early stages of the disease, coughing may be intermittent, but later becomes daily.

Mucous secretion is also a relatively early symptom of the disease. In the early stages, it is produced in small amounts, mainly in the morning, and has a mucous nature. Mucous secretions rich in pus appear during periods of disease exacerbation.

Shortness of breath appears in advanced stages of the disease and is initially noticeable only during severe physical exertion. It worsens during respiratory illnesses. Later on, shortness of breath evolves: the feeling of oxygen deficiency during normal physical exertion transitions to severe respiratory failure, worsening over time. Indeed, shortness of breath becomes a common reason for visiting the doctor.

When to Suspect COPD?
Here are some algorithm questions for early COPD diagnosis:

  • Do you suffer from daily coughing several times a day? Does it bother you?
  • Do you experience mucous or mucous secretion when coughing (frequently/daily)?
  • Does shortness of breath increase rapidly/frequently compared to your peers?
  • Are you in your forties or older?
  • Do you smoke or have you smoked in the past?

If the answer is positive to more than two questions, spirometry testing with bronchodilator testing is necessary. If the forced expiratory volume in one second/forced vital capacity ratio ≤ 70, there is suspicion of COPD.

Classification and Stages of Chronic Obstructive Pulmonary Disease

Stage of Chronic Obstructive Pulmonary Disease
Classification and Frequency of Appropriate Tests
I. Mild
Characteristic: Occurrence of chronic cough and phlegm production frequently but not constantly.
Classification and Frequency of Appropriate Tests: Clinical examination, spirometry testing with bronchodilator testing – once a year. During exacerbation periods – complete blood count and chest X-ray.

II. Moderate
Characteristic: Occurrence of chronic cough and phlegm production frequently but not constantly.
Classification and Frequency of Appropriate Tests: Same size and frequency as in stage one.

III. Severe
Characteristic: Occurrence of chronic cough and phlegm production frequently but not constantly.
Classification and Frequency of Appropriate Tests: Clinical examination twice a year, spirometry testing with bronchodilator testing and cardiac mapping once a year. During exacerbation periods – complete blood count and chest X-ray.

IV. Very Severe
Characteristic: Airway obstruction ratio (forced expiratory volume in one second/forced vital capacity) ≤ 70, forced expiratory volume < 30% of predicted values, forced expiratory volume < 50% of predicted values with chronic respiratory failure or right-sided heart failure.
Classification and Frequency of Appropriate Tests: Same size and frequency as in stage three. Measurement of blood oxygen saturation (SatO2) – once or twice a year.

Complications of Chronic Obstructive Pulmonary Disease

Complications of chronic obstructive pulmonary disease include infection, respiratory failure, and chronic cor pulmonale. Additionally, patients with COPD have a higher frequency of lung cancer (bronchial carcinoma), although it is not a direct complication of the disease.

  • Respiratory Failure: A condition of the external respiratory system, where either the supply of oxygen concentration and carbon dioxide in arterial blood at a normal level is not guaranteed, or it is achieved through increased external respiratory effort. This primarily manifests as shortness of breath.
  • Chronic Cor Pulmonale: Enlargement and dilation in the right-sided heart chambers, which occurs due to increased blood pressure in the pulmonary circulation, arising as a result of lung diseases. Patients primarily complain of shortness of breath as well.
Bronchial carcinoma

Diagnosis of chronic obstructive pulmonary disease (COPD)

Diagnosis of chronic obstructive pulmonary disease (COPD) relies on clinical data including complaints, medical history, and physical examination. Specific symptoms indicative of chronic bronchitis during physical examination include “glass hour” nails and/or “drumstick” fingers, rapid breathing and shortness of breath, changes in chest shape (barrel chest characteristic of lung hyperinflation), decreased chest movement during breathing, decreased intercostal spaces with the progression of respiratory failure, altered percussion note on tapping, diminished breath sounds or adventitious dry crackles, worsened with forced inspiration (meaning rapid breathing after deep inspiration). Heartbeats may be difficult to hear. In late stages, scattered cyanosis, increased severity of breathlessness, and peripheral edema may occur. For ease of understanding, the disease is categorized into two types: emphysematous and inflammatory, although mixed cases are more common in practical medicine.

The key stage in diagnosing COPD

The key stage in diagnosing COPD is pulmonary function testing. It is essential for establishing diagnosis, determining disease severity, formulating an individualized treatment plan, assessing treatment effectiveness, estimating disease progression, and evaluating work capacity. The FEV1/FVC ratio is most commonly used in clinical practice for diagnostic purposes. A reduction in FEV1/FVC ratio to less than 70% is an early sign of airflow limitation even if FEV1 >80% of predicted values. Lack of significant improvement in peak expiratory flow with bronchodilators also indicates COPD. When complaint is first diagnosed and changes in respiratory function occur, forced breathing is repeated throughout the year. COPD is considered chronic if recorded three times or more per year (regardless of treatment) and COPD is diagnosed.

Monitoring FEV1 values is an important method for confirming diagnosis. The FEV1 index is measured with a spirometer repeatedly over several years. The normal annual decline in FEV1 for adults ranges from 30 ml per year. While the distinctive decrease for COPD patients is 50 ml per year or more.
Bronchodilator testing – is the initial examination where the highest value of FEV1 is assessed, COPD stage and severity are determined, asthma is excluded (in case of a positive result), treatment strategy and volume are determined, treatment effectiveness is evaluated and disease progression is predicted. It is very important to differentiate between COPD and asthma, as they have similar clinical presentations – chronic obstructive syndrome. The main distinguishing feature in diagnosis is the reversibility of airway obstruction, which is characteristic of asthma. It has been determined that the increase in FEV1 after bronchodilator intake in persons diagnosed with COPD is less than 12% of baseline value (or ≤200 ml), while it usually exceeds 15% in patients with asthma.

Chest X-ray has helpful value, as changes appear only in late stages of the disease.
Electrocardiography (ECG) may reveal characteristic changes for pulmonary heart.
Echocardiography (EchoCG) is necessary for detecting signs of pulmonary hypertension and changes in right heart chambers.
Complete blood count analysis – can assess hemoglobin and hematocrit levels (which may rise due to increased red blood cell count).
Measurement of blood oxygen level (SpO2) – oxygen saturation, a non-gaseous examination performed to determine the degree of respiratory failure, usually present in severe COPD patients. Blood oxygen saturation below 88%, measured at rest, indicates inadequate oxygenation and the need for oxygen therapy.

The treatment of COPD contributes to:

  1. Reducing clinical symptoms.
  2. Increasing physical activity tolerance.
  3. Preventing disease progression.
  4. Preventing and treating complications and exacerbations.
  5. Improving quality of life.
  6. Reducing mortality rates.

The main treatment approaches include:

  1. Reducing the impact of risk factors.
  2. Educational programs.
  3. Pharmacotherapy.

Reducing the impact of risk factors
Quitting smoking is considered essential. This is the most effective way to reduce the risk of developing COPD.
Workplace hazardous factors should be monitored and their impact reduced by using adequate ventilation and air filters.

Educational programs
Educational programs for COPD include:

  1. Basic knowledge about the disease and general treatment approach with encouragement for patients to quit smoking.
  2. Teaching proper use of personal respiratory devices, inhalers, and nebulizers.
  3. Self-control practice using peak flow meters to study emergency measures for self-help.

Patient education plays an important role in patient treatment and affects future outcomes (evidence level: A).
Peak flow measurement test (peak flow meter) allows the patient to monitor peak expiratory flow volume daily, a parameter closely correlated with FEV1 value.

For COPD patients at every stage, physical training programs are recommended to increase physical exercise tolerance.


COPD treatment depends on disease stage, symptom severity, degree of airflow obstruction, presence of respiratory or pulmonary heart failure, and comorbidities. Medications used to combat COPD are divided into drugs for relieving exacerbations and others for preventing exacerbations.
To control occasional bronchospasm exacerbations, short-acting beta-agonist inhalation is recommended, such as salbutamol and fenoterol.
Medications for preventing exacerbations include:

  • Formoterol
  • Tiotropium bromide
  • Combination medications such as Budesonide and Formoterol.

If inhalation is not possible or ineffective, the use of theophylline may be necessary.
In the event of a bacterial exacerbation of COPD, antibiotics are required. Such as: amoxicillin at a dose of 0.5-1 gram three times a day, azithromycin at a dose of 500 mg for three days, clarithromycin SR at a dose of 1000 mg once daily, or 500 mg twice daily, amoxicillin + clavulanic acid at a dose of 625 mg twice daily, cefuroxime 750 mg twice daily.

Corticosteroids help alleviate COPD symptoms, which are also given by inhalation (such as beclomethasone dipropionate and fluticasone propionate). If COPD is stable, systemic corticosteroids are not necessary.
Traditional and mucus-relieving cough suppressants have a weak positive effect in patients with COPD.
For patients with severe deterioration in partial oxygen pressure (PaO2) less than 55 mmHg at rest, oxygen therapy is recommended.

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