COPD (Chronic Obstructive Pulmonary Disease)

What is COPD?

Chronic obstructive pulmonary disease is a persistent, progressive narrowing of the airways combined with damage to the air sacs of the lung. It brings together two overlapping problems that used to be described separately: chronic bronchitis, in which the airway lining is inflamed and produces excess mucus, and emphysema, in which the delicate walls between air sacs are destroyed so the lung loses its elastic recoil. Unlike asthma, the airflow limitation in COPD is only partly reversible and does not return fully to normal after a bronchodilator.

COPD is one of the leading causes of death and disability in India. Tobacco smoking remains the dominant cause, but a very large share of Indian cases, particularly among women who have never smoked, is driven by lifelong exposure to biomass smoke from wood, dung or crop-residue cooking fires. Occupational dust, ambient air pollution and the airway scarring left behind by treated tuberculosis add further to the burden seen in Hyderabad clinics.

COPD cannot be reversed, but its course can be changed. Stopping the exposure that caused it, using the right inhaled therapy, completing pulmonary rehabilitation and preventing flare-ups all improve breathlessness, exercise capacity and survival. The earlier this starts, the more lung function is preserved.

Symptoms of COPD

COPD develops slowly over years, and its early symptoms are often dismissed as ageing, being unfit, or a smoker's cough. Typical features include:

• Breathlessness on exertion that gradually worsens, first on climbing stairs or walking uphill, later on dressing or bathing.
• Chronic cough, often present for months every year, sometimes worse in the morning.
• Sputum production, usually clear or white when stable, turning yellow or green during infections.
• Wheeze and chest tightness, especially during flare-ups or in cold weather.
• Frequent chest infections that take longer than expected to settle.
• Fatigue, weight loss and muscle wasting in more advanced disease.

Patients often unconsciously reduce their activity to avoid feeling breathless, so the disease can appear stable while the underlying limitation worsens. Asking specifically what a person could do a year ago that they cannot do today is often more revealing than asking whether breathlessness has increased.

Causes and risk factors

Cigarette, beedi and hookah smoking is the single largest risk factor, and risk rises with the number of years and quantity smoked. Second-hand smoke matters as well. Household air pollution from solid cooking fuels is the second major cause in India and produces a picture with more chronic bronchitis and less emphysema. Occupational exposure to mineral and organic dusts, fumes and vapours in stone cutting, construction, welding, textile and agricultural work contributes independently.

Other important factors are prior pulmonary tuberculosis, which leaves fibrotic and obstructive damage, childhood respiratory infections and poor lung growth, long-standing untreated asthma and, in a small minority, inherited alpha-1 antitrypsin deficiency, which should be suspected when emphysema appears before the age of forty-five or without a smoking history.

How COPD is diagnosed

A diagnosis of COPD requires spirometry. Symptoms and a chest X-ray alone are not sufficient, and many patients in India are treated for years for presumed COPD or asthma without ever having a breathing test.

Spirometry

After inhaling a bronchodilator, a ratio of FEV1 to FVC below 0.70 confirms persistent airflow limitation. The FEV1 as a percentage of predicted then grades severity from mild to very severe. Spirometry also distinguishes COPD from asthma, where reversibility is usually large, and from restrictive diseases such as interstitial lung disease.

Assessing the whole patient

COPD treatment

Stopping the exposure

Smoking cessation is the only intervention proven to slow the decline in lung function, and it helps at any age and any stage. Structured support, nicotine replacement and, where appropriate, prescription medication substantially raise success rates compared with willpower alone. For biomass-related disease, switching to LPG or electric cooking and improving kitchen ventilation is the equivalent step.

Inhaled bronchodilators

Long-acting bronchodilators are the foundation of drug treatment. A long-acting antimuscarinic, a long-acting beta-agonist, or a combination of the two opens the airways, reduces trapped air, and improves exercise tolerance. Dual bronchodilation is preferred for most symptomatic patients. Short-acting inhalers are used for immediate relief.

Inhaled corticosteroids and add-on therapy

An inhaled corticosteroid is added mainly for patients with frequent exacerbations, a high blood eosinophil count, or coexisting asthma, since routine use in all patients increases the risk of pneumonia. Where flare-ups continue despite triple inhaled therapy, roflumilast or long-term azithromycin may be considered in selected patients.

Pulmonary rehabilitation

A supervised programme of graded exercise, breathing technique, energy conservation, nutrition and education produces improvements in breathlessness and quality of life that no inhaler can match. Rehabilitation is recommended for anyone limited by breathlessness and is especially valuable after a hospital admission.

Oxygen, ventilation and surgery

Long-term oxygen therapy, used for at least fifteen hours a day, prolongs life in patients with persistent severe hypoxaemia. Domiciliary non-invasive ventilation helps selected patients with chronic carbon dioxide retention. Lung volume reduction, whether by endobronchial valves or surgery, benefits carefully chosen patients with severe emphysema, and transplantation is considered in advanced disease.

Vaccination and comorbidities

Influenza, pneumococcal, COVID-19 and pertussis-containing vaccines reduce infections and exacerbations. Heart disease, osteoporosis, anxiety, depression, diabetes, reflux and obstructive sleep apnea are common in COPD and each worsens outcomes if left untreated.

Exacerbations and when to seek help

An exacerbation is a sustained worsening of breathlessness, cough or sputum beyond normal day-to-day variation, usually triggered by a viral or bacterial infection or a spike in air pollution. Every exacerbation accelerates the loss of lung function and raises the risk of the next one, so prevention is a central goal of treatment.

Seek medical care urgently for breathlessness at rest, confusion or unusual drowsiness, blue lips, chest pain, high fever, ankle swelling, or oxygen saturation below the level advised by your doctor. Treatment usually involves increased bronchodilators, a short course of oral corticosteroids, antibiotics when the sputum is purulent, and controlled oxygen or non-invasive ventilation in hospital when needed.

Living well with COPD

Daily walking within tolerance, breathing techniques such as pursed-lip breathing, adequate protein intake, treating anxiety, keeping a written action plan and attending regular review all help patients stay active. Air quality precautions, including avoiding outdoor exertion on high-pollution days and keeping the kitchen well ventilated, are practical steps that matter in a large city.

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