Chronic obstructive pulmonary disease (COPD) is an umbrella term for people with chronic bronchitis, emphysema, or both. With COPD the airflow to the lungs is restricted (obstructed). COPD is usually caused by smoking. Symptoms include cough and breathlessness. The most important treatment is to stop smoking. Inhalers are commonly used to ease symptoms. Other treatments such as steroids, antibiotics, oxygen, and mucus-thinning (mucolytic) medicines are sometimes prescribed in more severe cases, or during a flare-up (exacerbation) of symptoms.

Smoking is the cause in the vast majority of cases. There is no doubt about this. The lining of the airways becomes inflamed and damaged by smoking. About 3 in 20 people who smoke one packet of cigarettes (20 cigarettes) per day, and 1 in 4 40-per-day smokers, develop COPD if they continue to smoke. For all smokers, the chances of developing COPD are between 1 in 10 and 1 in 4. Air pollution and polluted work conditions may cause some cases of COPD, or make the disease worse. The combination effect of occupational exposure to air pollutants and smoking increases the chances of developing COPD. A small number of people have a hereditary (genetic) risk of COPD due to very rare protein deficiencies that can lead to lung, liver and blood disorders. (The condition is called alpha-1-antitrypsin deficiency). Less than 1 in 100 cases of COPD are due to this. However, people who have never smoked rarely develop COPD. (Passive smoking remains, however, a potential cause.)

Cough is usually the first symptom to develop. It is productive with phlegm (sputum). It tends to come and go at first, and then gradually becomes more persistent (chronic). You may think of your cough as a 'smokers cough' in the early stages of the disease. It is when the breathlessness begins that people often become concerned. Breathlessness (shortness of breath) and wheeze may occur only when you exert yourself at first. For example, when you climb stairs. These symptoms tend to become gradually worse over the years if you continue to smoke. Difficulty with breathing may eventually become quite distressing. Sputum - the damaged airways make a lot more mucus than normal. This forms sputum. You tend to cough up a lot of sputum each day. Chest infections are more common if you have COPD. A sudden worsening of symptoms (such as when you have an infection) is called an exacerbation. Wheezing with cough and breathlessness may become worse than usual if you have a chest infection and you may cough more sputum. Sputum usually turns yellow or green during a chest infection. Chest infections can be caused by germs called bacteria or viruses. Bacteria (which can be killed using antibiotic medicines) cause about 1 in 2 or 3 exacerbations of COPD. Viruses (which cannot be killed with antibiotics) are a common cause of exacerbations too, particularly in the winter months. The common cold virus may be responsible for up to 1 in 3 exacerbations.

The most common test used in helping to diagnose the condition is called spirometry. This test estimates lung volumes by measuring how much air you can blow out into a machine. Two results are important: The amount of air you can blow out in one second (called forced expiratory volume in 1 second - FEV1) The total amount you can blow out in one breath (called forced vital capacity - FVC). Your age, height and sex affect your lung volumes. So, your results are compared to the average predicted for your age, height and sex. A value is calculated from the amount of air that you can blow out in one second divided by the total amount of air that you blow out in one breath (called FEV1/FVC ratio). A low value indicates that you have narrowed airways. The FEV1 compared with the predicted value shows how bad the COPD is.

Symptoms of COPD typically begin in people aged over 40 who have smoked for 20 years or more. A 'smoker's cough' tends to develop at first. Once symptoms start, if you continue to smoke, there is usually a gradual decline over several years. You tend to become more and more breathless. In time your mobility and general quality of life may become poor due to increasing breathing difficulties. Chest infections tend to become more frequent as time goes by. Flare-ups (exacerbations) of symptoms occur from time to time, typically during a chest infection. If the condition becomes severe then heart failure may develop. This is due to the reduced level of oxygen in the blood and changes in the lung tissue which can cause increased pressure in the blood vessels in the lungs. This increase in pressure can put a strain on the heart muscle, leading to heart failure. Heart failure can cause various symptoms including worsening breathlessness and fluid retention. Respiratory failure is the final stage of COPD. At this point the lungs are so damaged that the levels of oxygen in the blood are low. The waste product of breathing, called carbon dioxide (CO2), builds up in the blood stream. People with end-stage COPD need palliative care to make them more comfortable and ease any symptoms. Depression and/or anxiety affect at least 6 in 10 people with COPD, and can be treated if recognised.

Stop smoking is the single most important piece of advice. If you stop smoking in the early stages of COPD it will make a huge difference. Damage already done to your airways cannot be reversed. However, stopping smoking prevents the disease from worsening. It is never too late to stop smoking, at any stage of the disease. Even if you have fairly advanced COPD, you are likely to benefit and prevent further progression of the disease. Your cough may get worse for a while when you give up smoking. This often happens as the lining of the airways 'comes back to life'. Resist the temptation to start smoking again to ease the cough. An increase in cough after you stop smoking usually settles in a few weeks.

If symptoms become troublesome, one or more of the following treatments may be advised

• Short-acting bronchodilator inhalers. An inhaler with a bronchodilator medicine is often prescribed. These relax the muscles in the airways (bronchi) to open them up (dilate them) as wide as possible. The same inhalers may be used if you have asthma. People often call them relievers.
• Long-acting bronchodilator inhalers. These work in a similar way to the short-acting inhalers, but each dose lasts at least 12 hours. Long-acting bronchodilators may be an option if symptoms remain troublesome despite taking a short-acting bronchodilator.
• Steroid inhalers. A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups (exacerbations) of symptoms. Steroids reduce inflammation. Steroid inhalers are only used in combination with a long-acting beta-agonist inhaler. (This can be with two separate inhalers or with a single inhaler containing two medicines.) A steroid inhaler may not have much effect on your usual symptoms, but may help to prevent flare-ups. In the treatment of asthma, these medicines are often referred to as preventers. Side-effects of steroid inhalers include oral (in the mouth) thrush, sore throats and a hoarse voice. These effects can be reduced by rinsing your mouth with water after using these inhalers, and spitting out. Combination inhalers are useful if people have severe symptoms or frequent flare-ups. Sometimes is is more convenient to use just one inhaler device.

As COPD progresses, the condition becomes more severe. You might have more frequent exacerbations and/or admissions to hospital. These factors can give a clue as to how advanced the illness is. Palliative care is usually started in COPD when you are on the maximum medication and your condition is continuing to get worse (deteriorate). Sometimes in these situations you might choose to remain at home for any/all treatments, rather than having further hospital admissions, as things get worse. Your quality of life in the end stages of COPD is very important.  Palliative care can be given in a hospice, but is just as likely to be provided by your GP, district nurse or community palliative care team. The idea is that a multidisciplinary team, with different healthcare professionals, can anticipate any problems before they happen. The team can help you with access to medication and any equipment that might be needed.

Oxygen supplementation help some people with severe symptoms or end-stage COPD. It does not help in all cases. Unfortunately, just because you feel breathless with COPD it does not mean that oxygen will help you. Great care has to be taken with oxygen therapy.

To be considered for oxygen you would need to have very severe COPD, and be referred to a consultant (respiratory specialist) at a hospital. Your GP cannot just prescribe oxygen to you in this situation. Tests are done to see how bad your COPD is, and how low the oxygen levels in your blood are. This might be done with a pulse oximeter (mentioned earlier) or by taking a sample of blood from an artery in your wrist (blood gases). These tests are needed to decide whether oxygen will help you or not. The monitoring of oxygen levels may take place over a period of several weeks, at rest and with exercises. If found to help, oxygen needs to be taken for at least 15-20 hours a day to be of benefit.

Two immunisations are advised. A yearly 'flu jab' each autumn protects against possible influenza and any chest infection that may develop due to this. Immunisation against pneumococcus (a germ that can cause serious chest infections). This is a one-off injection and not yearly like the 'flu jab'.

Studies have shown that people with COPD who exercise regularly tend to improve their breathing, ease symptoms, and have a better quality of life. Any regular exercise or physical activity is good. However, ideally the activity that you do should make you at least a little out of breath, and be for at least 20-30 minutes, at least four to five times a week. If you are able, a daily brisk walk is a good start if you are not used to exercise. But, if possible, try to increase the level of activity over time. You may be referred for pulmonary rehabilitation or be under the care of a community respiratory team. You will be given exercises and advice to try to help you stay as fit as possible. This is important because, effectively, you may become disabled due to your breathlessness.

Obesity can make breathlessness worse. If you are overweight or obese it is harder to exercise, and exercise makes you more breathless. It becomes a bit of a vicious cycle. If you are obese the chest wall is made heavy by fat. This means that you have to work much harder to breathe in and take a good breath, to inflate the lungs and expand the chest. A dietician may be able to give you advice on healthy eating and weight loss.

If you have COPD and plan to fly then you should discuss this with the airline. Some airlines may request a fitness to fly assessment. Although your GP might be able to give some advice, they are not well placed to make the final decision. Your consultant (respiratory specialist) may be able to help or alternatively you may need to see a specialist in aviation medicine. When travelling by air you should keep your medicines, especially your inhalers, in your hand luggage. If you are on LTOT, you will need to inform the airline. It is possible to use your own oxygen in-flight but individual circumstances may differ. Some people with COPD are more likely to need in-flight oxygen. Some people are more at risk of a punctured lung (pneumothorax) at altitude, despite the fact that the aircraft cabin is pressurised.

More information can be found in the files below by the ATS.