Chronic obstructive pulmonary disease (COPD)

The potential capacity of your lungs is very large. When relaxed, your body needs less than a tenth of the amount of air your lungs can handle during strenuous exercise. This flexibility is the reason why lung function can gradually worsen over many years without noticeably affecting your day-to-day life. Shortness of breath caused by COPD only becomes apparent once the capacity of your lungs has already decreased a lot. The typical symptoms of COPD include the following:

• Breathing difficulties during physical activities – and while at rest in advanced COPD
• Coughing every day over a long period of time
• Sputum (coughed-up phlegm)
• Breathing sounds such as wheezing
• Symptoms that get worse when you have a cold or flu

Phases in which the disease suddenly gets much worse, known as flare-ups or exacerbations, are also typical. It is usually harder to breathe during a flare-up and you cough more, coughing up phlegm.

Several factors play a role in the development of COPD. One is a long-lasting inflammation in the bronchi of the lungs. Also, the air sacs in the lungs may become very inflated. This condition is called pulmonary emphysema.

A chronic cough ( bronchitis) may develop if the airways are frequently exposed to harmful substances such as tobacco smoke, dust or gases. This inflammation destroys the cilia (tiny hairs that line the inside of the bronchi like a carpet).

The cilia are normally able to move and are covered by a thin layer of mucus. Dust and germs from the outside air usually become trapped in this mucus layer, which prevents them from reaching the lungs. The cilia then transport the mucus out of the bronchi. This self-cleaning function is very important for healthy lungs. If the cilia are damaged, they aren’t able to move the mucus out of the lungs, and the bronchi become clogged.

In pulmonary emphysema, the walls of the air sacs are damaged. Instead of there being many small air sacs, large air sacs develop. This decreases the surface area of the lungs, and less oxygen can enter the bloodstream. People with COPD have narrow, inflamed bronchi and pulmonary emphysema at the same time, and each makes the other worse.

There is a strong link between smoking and COPD. Not all smokers develop COPD, but most people who have it do smoke or used to smoke.

Other kinds of regular lung irritation, such as long-term exposure to particular types of dust particles in the workplace, can also increase your risk of developing COPD.

It is thought that certain factors already present at birth may make some people more likely to develop COPD later on. Examples include problems with lung development in the womb and the rare “alpha-1 antitrypsin deficiency (AATD),” which affects about 1 to 2 out of 100 people who have COPD.

It is estimated that about 6% of all people over the age of 40 have COPD. It is a lot more common in men than in women.

The symptoms aren’t obvious at first, but even people with mild COPD often have a cough with sputum. Their airways are only slightly constricted in the early stages of the disease, so they hardly notice the gradual loss in lung function. Over time, though, they start having more problems breathing during physical activity. They also start coughing more, with more sputum.

Advanced COPD greatly affects your quality of life. Your airways become so narrow that you get out of breath during everyday activities like washing yourself or getting dressed, or even while resting.

At advanced stages of COPD, the lungs can no longer provide the body with enough oxygen. This leads to changes in other organs such as the heart, which now has to pump more blood through the lungs. The increased workload causes part of the muscle on the right side of the heart to grow. The medical term for this is pulmonary heart disease or “cor pulmonale.” The heart becomes weaker as a result, which can lead to things like water retention in the legs and other parts of the body.

Because of the problems caused by physical exertion, people with COPD exercise less. This means that they lose muscle mass, which makes them even less physically fit.

In people with COPD, respiratory infections that would otherwise be harmless can cause their lung function to suddenly decline and make their symptoms a lot worse. These attacks, called flare-ups or exacerbations, often need to be treated in the hospital. Flare-ups may also be caused by smoke, exhaust fumes or certain weather-related conditions such as heat, cold or high humidity. The following are typical signs of a flare-up:

• More sputum (coughed-up phlegm)
• Colored sputum, sputum with pus, or sputum that is thicker and stickier than usual
• More trouble breathing than usual
• More coughing than usual
• Increased need for medication
• Fever, decreased physical fitness, feeling more tired or other non-specific symptoms

Suddenly finding it harder to breathe usually makes people feel anxious, which can lead to even more trouble breathing. It is helpful to know how to react in these kinds of situations. An emergency plan of action can be useful here: It describes the typical symptoms and provides information on things like when it's a good idea to change your medication schedule or dose, and when to see a doctor or go to hospital.

COPD often goes undetected at first. Smokers in particular often think it's simply a harmless “smoker’s cough.” But symptoms like a persistent cough and frequent shortness of breath can be signs of COPD.

Initial tests can often be done by a family doctor. Any additional examinations need to be done by a lung specialist (a pulmonologist).

The doctor will first do a physical examination to check for typical COPD symptoms. They will also ask about other medical conditions and take a blood sample. It is particularly important to do a lung function test, too. This test measures how well your lungs are working – mainly how much air you can breathe in and out. Depending on the results, further tests may be done to see how advanced the COPD is or to rule out other diseases such as asthma, heart failure or lung cancer. The doctor will also ask about psychological problems such as anxiety or depression.

These tests can also be used to determine the stage of COPD and the risk of complications. This is important when it comes to planning your treatment.

The most effective way to prevent COPD is to not smoke, or to quit smoking.

Harmful substances in the environment or at the workplace can also increase your risk of developing COPD, though, so they should be avoided whenever possible. Protective measures at work can help prevent constant exposure to these substances.

Flare-ups are often triggered by respiratory infections (infections of the airways). A sore throat, sweats and fever can weaken your body even more if you already have COPD. Because of this, people with COPD should take special care to avoid infection during the cold and flu season. This includes avoiding contact with people who have colds and with large crowds. It can also be a good idea to be vaccinated against the flu, COVID-19, pneumococcal disease and RSV (the respiratory syncytial virus).

There is no cure for COPD. The goal of treatment is to relieve the symptoms and related problems, make everyday life easier and improve quality of life. The treatment also aims to slow down the progression of the disease and prevent exacerbations.

The most important thing is to stop smoking completely. This is often easier said than done. But there are many kinds of support out there, including counseling, group classes and medication. Strategies that can help you quit smoking include combining a support program and nicotine replacement therapy.

Other supportive measures include exercise and sports, breathing techniques, inhalation therapy (nebulization), and changing your diet. In Germany, public health insurers also offer disease management programs (DMPs) for people with COPD. The aim of these programs is to provide consistent treatment in close cooperation with healthcare professionals to reduce the number of severe flare-ups and slow down the progression of the disease.

If the options that don't involve medication aren't effective enough, medication is an essential part of daily COPD treatment. It is typically inhaled (breathed in), but can also be taken in the form of tablets. Depending on how far the disease has progressed, combinations of various drugs can be used – either as a long-term treatment or temporarily to relieve acute symptoms. The following medications are available:

• Drugs that open up (dilate) the airways, called bronchodilators: These drugs are typically inhaled as a powder or spray to make it easier to breathe. They include beta-2 agonists and anticholinergics.
• Steroid medications have anti-inflammatory effects and can help to prevent COPD attacks where it's hard to breathe.
• Phosphodiesterase (PDE) 4 inhibitors also reduce inflammation in the airways.
• Biologics also have anti-inflammatory effects and may be used if other medications do not help enough.
• In rare cases, antibiotics are used temporarily for prevention.

At very advanced stages of COPD, oxygen therapy is often needed as well.

If all other treatment options for severe pulmonary emphysema have been tried out, surgery is possible. Then the overly inflated (hyperinflated) parts of the lungs are reduced in size through a procedure called bullectomy or through lung volume reduction surgery. A lung transplant may even be considered in some situations.

Pulmonary rehabilitation helps people to better cope with COPD and to live as normal a life as possible. To help reach this goal, a treatment plan based on individual needs is created. The treatment plan includes a combination of physical exercise, treatments, social and emotional support, and learning about how to deal with the disease.

Pulmonary rehabilitation is an important part of the COPD disease management program (DMP). Rehabilitation can either be done on an inpatient or outpatient basis.

The impact COPD has on everyday life very much depends on the stage of the disease. For years it may only cause minor problems. But the symptoms get worse as time goes by. In advanced COPD, it’s no longer possible to live a normal life. Then extensive nursing care and support from others are usually needed.

Many find it helpful to adjust their lifestyle and daily routine according to their body's needs and responses. Some focus more on things that are especially important to them. Other people find special breathing and relaxation techniques helpful, allow themselves plenty of rest or do low-impact sports when they feel up to it.

The more the disease progresses, the greater the need for practical and emotional support from family and friends.

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.

In addition to disease management programs (DMPs), a wide range of different services for individual counseling and support are available if you have COPD. But these services are often organized differently depending on where they are, and they are not always easy to find. Our list can help you to find and make use of advice and support services in Germany.