# COPD: Diagnosis, Inhalers, and Preventing Exacerbations

Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by persistent airflow limitation and chronic airway inflammation. COPD is the third leading cause of death worldwide (3.2 million deaths/year), and its prevalence continues to rise. Unlike asthma, airflow obstruction in COPD is predominantly irreversible, but proper treatment slows progression, reduces symptoms, and decreases exacerbation frequency.

Smoking — accounts for 80–90% of COPD cases. Risk is proportional to duration and intensity: 15–20% of smokers develop COPD. Passive smoking — increases risk by 20–30%. Occupational exposures — dust, chemicals, fumes (miners, construction workers, welders). Air pollution — biomass fuel (wood, coal for cooking) — leading COPD cause in developing countries. Genetics — α1-antitrypsin deficiency (1–2% of cases) — emphysema in young non-smokers.

Smoking cessation is the only intervention proven to slow lung function decline.

COPD comprises two processes: Chronic bronchitis — inflammation and hypertrophy of bronchial mucous glands, excessive mucus production, airway narrowing. Emphysema — destruction of alveolar walls, loss of elastic recoil, air trapping. Most patients have a combination. Systemic effects: muscle wasting, osteoporosis, depression, cardiovascular disease.

Spirometry is mandatory. Criterion: FEV1/FVC <0.70 AFTER bronchodilator test (post salbutamol 400 mcg inhalation). This distinguishes COPD from asthma (asthma shows reversibility). Severity by FEV1 (GOLD): GOLD 1 (mild): FEV1 ≥80%; GOLD 2 (moderate): 50–79%; GOLD 3 (severe): 30–49%; GOLD 4 (very severe): <30%.

Symptom assessment: mMRC (dyspnea) and CAT (overall impact). GOLD ABE groups (2023+): A — few symptoms, ≤1 exacerbation/year; B — more symptoms, ≤1 exacerbation/year; E — ≥2 exacerbations/year (or ≥1 hospitalization). The group determines initial therapy.

Smoking cessation (NRT, varenicline, bupropion). Vaccination: influenza (annual), pneumococcal, COVID-19, pertussis. Pulmonary rehabilitation — proven improvement in dyspnea, exercise tolerance, and quality of life.

Short-acting bronchodilator as needed: salbutamol (SABA) or ipratropium (SAMA). If symptoms persist — LABA or LAMA.

Long-acting bronchodilator: LAMA — tiotropium 18 mcg/day or umeclidinium 62.5 mcg/day. Or LABA — formoterol 12 mcg twice daily. If one isn't enough — LAMA + LABA combination.

LAMA is preferred over LABA in COPD (unlike asthma): proven exacerbation reduction.

Starting therapy: LAMA + LABA. If exacerbations continue → add ICS (fluticasone) → triple therapy LAMA + LABA + ICS. When to add ICS: blood eosinophils ≥300 cells/µL; asthma-COPD overlap; frequent exacerbations despite LAMA + LABA. When NOT to add ICS: eosinophils <100; recurrent pneumonias; fungal infections.

Triple therapy LAMA + LABA + ICS is proven to reduce mortality in COPD (IMPACT, ETHOS trials).

Roflumilast 500 mcg/day — PDE-4 inhibitor. For patients with FEV1 <50%, chronic bronchitis, and frequent exacerbations. Side effects: diarrhea, nausea, weight loss. Azithromycin 250 mg three times weekly — long-term antibiotic prophylaxis. Reduces exacerbations by 25–30%. Risks: hearing loss, resistance, QT prolongation. Theophylline — outdated bronchodilator with narrow therapeutic window. Rarely used.

An exacerbation is acute symptom worsening (dyspnea ↑, sputum ↑, purulent sputum). Mild — increase bronchodilators. Moderate — bronchodilators + systemic corticosteroids: prednisolone 40 mg/day for 5 days (not more! — REDUCE trial) + antibiotic if purulent sputum. Severe (hospitalization) — nebulized bronchodilators + systemic corticosteroids + antibiotic + oxygen (target SpO2 88–92%, not higher! — in COPD, excess oxygen suppresses respiratory drive).

Non-invasive ventilation (NIV) — for respiratory acidosis (pH <7.35). Reduces intubation need and mortality.

Long-term oxygen therapy (>15 hours/day) is indicated for: PaO2 <55 mmHg or SpO2 <88% at rest; PaO2 55–60 + cor pulmonale or polycythemia signs. Proven life extension. Portable concentrators enable mobility.

Cardiovascular disease — leading cause of death in COPD (even more than COPD itself). Lung cancer — CT screening in current/former smokers. Osteoporosis — from corticosteroids and inactivity. Depression and anxiety — in 25–40%. Muscle wasting — pulmonary rehabilitation + adequate protein.

COPD is incurable but manageable. Smoking cessation at any age slows progression. Triple inhaled therapy reduces mortality by 25–30%. Pulmonary rehabilitation is the most underrated yet most effective intervention. Lung transplantation — for select patients with end-stage COPD.

*This article is for informational purposes only and does not replace medical advice. Consult a pulmonologist before starting or changing treatment.*