Chronic bronchitis, emphysema and COPD ('smoker's lung')

Reviewed by Dr Patricia Macnair, GP

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What is chronic bronchitis?

Smoking is the main cause of more than 8 out of 10 cases of chronic bronchitis and quitting smoking is the most effective thing you can do to stay as healthy as possible in the long-term.

Chronic bronchitis is a chronic inflammatory condition in the lungs that causes the respiratory passages to be swollen and irritated, increases the mucus production and damages the lungs. The symptoms are coughing and breathlessness, which will get worse over the years. The definition of chronic bronchitis is chronic cough or mucus production for at least three months in two successive years when other causes have been excluded. In emphysema, there is a slightly different problem developing in the lungs as the walls between the tiny grapeshaped air sacs or alveoli are damaged and break down. They then form into much larger airspaces and there is less surface for gas exchange, so oxygen intake is less and the person feels breathless. These two conditions both come under an umbrella term 'COPD' (chronic obstructive pulmonary disease) used to describe lung damage resulting in airflow restriction. In fact, most people who have COPD have a combination of both emphysema and chronic obstructive bronchitis. COPD accounts for about 7 per cent of all days off work from sickness and the annual NHS workload for COPD exceeds that for asthma. The most important 'treatment' is to quit smoking most people who develop chronic bronchitis are smokers.

Why does a person get chronic bronchitis and COPD?

Smoking is the most important cause of chronic bronchitis. Other things that make it worse are air pollution and allergy. The seriousness of the disease depends on how much and for how long a person has been smoking. Some people may be more vulnerable than others because of their genetic make-up.

What does chronic bronchitis feel like?

You cough a lot, sometimes (especially as the disease progresses) every day. You easily get short of breath. Your sputum is thick and difficult to cough up. You become much more susceptible to chest infections.

What can I do myself?

If you smoke: QUIT! It is never too late. Your doctor or pharmacist can provide advice on smoking cessation products and techniques. Avoid environmental irritatants or pollution, such as smoke. Make sure respiratory infections are treated immediately.

Avoid passive smoking. Follow good general health advice with a balanced diet and regular exercise.

How can the doctor tell if I have COPD?

The history of symptoms is usually a good guide to the diagnosis, especially in a smoker. But some other lung and heart diseases give the same symptoms as COPD. NICE (the National Institute of Health and Clinical Excellence) recommend that to make an clear diagnosis and assess the severity of the condition.the following tests may be helpful. Chest X-ray to exclude other diagnoses (and then a CT scan if necessary to investigate abnormalities). Lung function tests known as spirometry which also look at whether the lung function improves with bronchodilator drugs. A blood test to check for infection, anaemia or other problems. Body mass index (BMI) calculation to check for overweight.

How can I make my life a bit easier?

COPD can often be improved to some extent by avoiding the factors that aggravate the symptoms and carefully following advice about the use of medical treatments. The most important thing you must do is quit smoking. If you live or work in an area with heavy air pollution, you must do everything in your power to avoid or reduce the risk. If necessary, consider getting a new job. Avoid sudden temperature changes or cold, moist weather.

Is it important to exercise by taking walks or other activities?

Yes. You should try and keep active, because this helps to keep your lungs and cardiovascular system healthy.

Medication for COPD

People with diagnosed COPD should be looked after by a multi-disciplinary team, including health professionals such as a doctor (who may be a GP or a hospital respiratory consultant) a respiratory nurse specialist, physiotherapist, and occupational therapist. These teams work in the community but if the disease progresses referral to hospital may be necessary. It's important to maintain a positive attitude to treatment of COPD. The condition is not curable but can often be improved, and there are a number of treatments your doctor may recommend. The difference between COPD and asthma is that the airway obstruction in asthma is reversible with treatment such as bronchodilator drugs, whereas in COPD it is largely irreversible. There is a small degree of reversibility in COPD, however, and it should be exploited as a proportion of patients with COPD do respond to bronchodilator agents, such as beta-agonists and anticholinergics, with significant changes in lung function. So the first aim of treatment should be to reverse some of the airway obstruction if possible. Short-acting bronchodilators are used first to open the airways and relieve symptoms as and when they occur but if a person with stable COPD remains breathless or has exacerbations, either long-acting beta-agonist inhalers or longacting anticholinergics inhalers should be used as a maintenance therapy (ie long term treatment taken regularly). Inhaled anticholinergics are very important in COPD because their unique mode of action targets the major reversible component of airflow obstruction in COPD cholinergic tone (ie constriction of the muscles in the tiny airways controlled by the nerve transmitter chemical acetylcholine). Anticholinergics drugs are not indicated in asthma, however. If the persons lung function is still poor then an inhaled corticosteroid is added in combination with the bronchodilator. There are several different combination inhalers currently in use. Oral treatments may also be used as well as inhalers in more severe COPD or during an exacerbation (a period when things get worse, for example if a chest infection occurs). These oral treatments include steroids, theophylline, and 'mucolytic' drugs which break down the thick sputum that clogs up the airways. Those patients who have become greatly limited by severe COPD should be assessed for long-term oxygen therapy (LTOT) where oxygen is supplied through a mask or nostril tubes, and can significantly improve their quality of life. NICE also recommend that a pulmonary rehabilitation programme should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation.

Managing exacerbations

COPD patients are prone to developing short-term exacerbations of their condition, during which they will feel more breathless. These exacerbations are generally the result of respiratory infections, and so will usually need treatment with antibiotics. But during an exacerbation there is a decline in the patients condition and the damage done to the lungs may, in part at least, be permanent. Frequent exacerbations contribute to a worsening of COPD, so ideally every possible step should be taken to avoid exacerbations or treat them as effectively and swiftly as possible. COPD patients should take advantage of annual vaccinations against influenza, as well as ensuring they've had a vaccination against pnemococcal infection which is recommended for anyone with COPD aged 65 or over.

Surgery
In some people with COPD, large cysts known as bullae can develop in the lung and hinder lung function. In certain circumstances these can be removed surgically and will allow better inflation of the rest of the lung tissue. But this treatment is suitable for only a minority of patients.

Summary
The main drive in COPD treatment has to be one of prevention rather than cure. COPD does occur in non-smokers but the vast majority of sufferers smoke, and their likelihood of developing the disease is related to the amount they smoke. There is an extra factor that of individual susceptibility which cannot be predicted in advance. Most people with chronic bronchitis caused by smoking do not go to their doctor until they start to become breathless, by which time much irreversible lung damage has already occurred. Those with known COPD who continue to smoke suffer a more rapid decline in their lung function than those who stop completely. The message is clear: smoking is extremely bad for your lungs and health but it's never too late to stop, however old you may be.

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