COPD: chronic bronchitis and emphysema

1Definition

Chronic obstructive pulmonary disease (COPD) is a common, preventable lung condition with long-lasting breathlessness, cough and sputum, caused by damage to the airways (bronchitis, bronchiolitis) and the alveoli (emphysema). The airflow limitation is persistent and usually progressive.

The diagnosis needs spirometry: a post-bronchodilator FEV1/FVC below 0.70.

• Chronic bronchitis (clinical definition): cough with sputum on most days for at least 3 months a year, for 2 years in a row, with other causes excluded.
• Emphysema (structural definition): permanent enlargement of the air spaces beyond the terminal bronchioles, with destruction of their walls.

2Classification and grading

GOLD spirometric grade (post-bronchodilator FEV1, when FEV1/FVC < 0.70)

GOLD A, B, E groups (symptoms and exacerbations)

• Group A: few symptoms (mMRC 0–1 or CAAT below 10), no exacerbation in the last year.
• Group B: more symptoms (mMRC 2 or more, or CAAT 10 or more), no exacerbation in the last year.
• Group E: exacerbations. GOLD 2026 puts a patient in group E after even one moderate or severe exacerbation in the past year. Older editions needed two moderate ones, or one needing hospital admission.

GOLD 2026 renamed the COPD Assessment Test as the Chronic Airways Assessment Test (CAAT). It still has 8 items scored 0–40.

Most patients have a mix of both. The labels "pink puffer" and "blue bloater" are stigmatising and best used only to explain the classic textbook picture.

3Causes and risk factors

• Tobacco smoking: cigarettes, bidi, hookah. Risk rises with pack-years (packs a day × years smoked).
• Household air pollution: cooking on wood, dung or crop waste in a poorly ventilated kitchen. A major cause in Indian women who have never smoked.
• Occupational dust and fumes: sweepers, farm workers, miners, textile and construction workers (the W17 sweeper, S17 labourer, S20 farmer).
• Outdoor air pollution.
• Past tuberculosis, repeated childhood chest infections, poor lung growth.
• Alpha-1 antitrypsin deficiency: a rare genetic cause of early emphysema.

Effects of smoking on pulmonary function (3 marks in S17 and W22)

• Paralyses and destroys cilia, so mucus clearance fails.
• Enlarges mucus glands and goblet cells, so sputum increases.
• Inflames the airways, narrowing them and making them more reactive.
• Releases enzymes (proteases) that destroy alveolar walls: emphysema.
• FEV1 falls faster than with normal ageing; diffusing capacity falls.
• Carbon monoxide binds haemoglobin and lowers oxygen carriage; infections become more common.

4Pathophysiology to impairments

1. Inflammation from smoke and dust narrows the small airways, enlarges mucus glands and damages cilia: cough, sputum, infections.
2. Destruction of alveolar walls (emphysema) removes the elastic recoil that holds small airways open. Airways collapse during breathing out.
3. Air gets trapped: hyperinflation. The diaphragm is pushed down and flattened, so it works at a mechanical disadvantage. Accessory muscles take over.
4. When breathing speeds up during exercise, there is less time to breathe out, so trapping worsens (dynamic hyperinflation). This is the main cause of breathlessness on exertion.
5. Mismatched ventilation and blood flow lowers oxygen; in advanced disease CO₂ rises.
6. Long-term low oxygen narrows the lung blood vessels, raising pressure: right heart failure (cor pulmonale).
7. Breathlessness leads to inactivity, which weakens the limb muscles, which makes breathlessness worse: the breathlessness spiral.

5Clinical features

• Breathlessness on exertion that slowly worsens over years; chronic cough, often worse in the morning; sputum.
• Wheeze, chest tightness, tiredness, weight loss in advanced disease.
• Signs: barrel chest (increased front-to-back diameter), use of accessory muscles, pursed-lip breathing, tripod (forward-lean) posture, reduced chest expansion, hyper-resonant percussion, quiet breath sounds with prolonged expiration and wheeze.
• Inward movement of the lower ribs on breathing in (Hoover's sign) from a flattened diaphragm.
• Cyanosis, ankle oedema and raised neck veins in cor pulmonale.

6Investigations

Pulmonary function tests in obstructive disease (3 marks in W20; PFT in COPD, W19)

• FEV1 reduced; FVC normal or slightly reduced.
• FEV1/FVC below 0.70 after bronchodilator.
• Little improvement after bronchodilator (asthma shows large reversibility).
• Peak expiratory flow reduced; flow–volume loop shows a "scooped" expiratory curve.
• Lung volumes: residual volume (RV), total lung capacity (TLC) and RV/TLC raised (air trapping).
• Diffusing capacity (DLCO) reduced in emphysema.

Chest X-ray in emphysema (3 marks in W18; X-ray in COPD, W24)

• Hyperinflated, very black (hyperlucent) lung fields with fewer vessel markings at the edges.
• Low, flattened diaphragms; more than 6 anterior or 10 posterior ribs visible above the diaphragm.
• Ribs more horizontal, intercostal spaces wider.
• Long, narrow ("tubular") heart shadow.
• Increased air space behind the sternum on the lateral view; bullae may be seen.

Chronic bronchitis often shows a near-normal film, or more prominent lung markings ("dirty chest") and thickened bronchial walls seen as parallel lines (tram lines). With pulmonary hypertension the pulmonary arteries at the hila look large; with cor pulmonale the heart shadow enlarges.

Other tests

7Medical management

• Stop smoking and reduce dust and smoke exposure. This is the only measure that slows the loss of lung function.
• Inhaled bronchodilators: long-acting LAMA and LABA, with reliever salbutamol. Inhaled steroids added in group E when blood eosinophils are high.
• Vaccines: influenza, pneumococcal, COVID-19 and others as advised.
• Pulmonary rehabilitation for symptomatic patients and after a hospital admission.
• Long-term oxygen therapy (ATS 2020) if resting PaO₂ is 55 mmHg or less (SpO₂ 88% or less), or 56–59 mmHg (SpO₂ 89%) with oedema, polycythaemia or right heart strain. Used for 15 hours a day or more.
• Exacerbations: nebulised bronchodilators, a short course of oral steroids, antibiotics if sputum is purulent, controlled oxygen, and non-invasive ventilation (NIV) for acidotic hypercapnic respiratory failure. Intubation and ventilation if NIV fails (S20 patient on SIMV).
• Surgery in selected patients: bullectomy, lung volume reduction, transplant.

8Complications and prevention

9PT assessment

• Subjective: breathlessness (mMRC), cough and sputum (amount, colour, morning load), wheeze, exacerbations in the last year, smoking pack-years, oxygen use, inhaler technique, sleep position, ADL that cause breathlessness, home (floor, lift, toilet), occupation and dust exposure, earning role.
• Observation: posture (forward lean), chest shape, breathing pattern and rate, accessory muscles, pursed-lip breathing, cyanosis, clubbing (suggests another cause), oedema.
• Palpation: chest expansion at three levels, trachea position.
• Auscultation: breath sounds, wheeze, crackles.
• Vital signs and SpO₂ at rest and on exertion.
• Exercise capacity: 6MWT or incremental shuttle walk test with SpO₂ and Borg breathlessness.
• Muscle strength: quadriceps, grip; respiratory muscle strength (PImax) if available.

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (W16, 5 + 5 + 5 marks; repeated in S18)

"A 50 year old male patient, chronic smoker since last 30 years, stays on 2nd floor with no lift facility, is admitted with chief complaints of dyspnea on performing activities of daily living and productive cough since past two days. His pulmonary function test shows moderate obstructive, he has mild hypoxaemia and hypercapnia. Discuss functional diagnosis, short term and long term physiotherapy management."

11Problem list and goals

Using ABG, PFT and X-ray to set goals (7 marks in W24)

12PT management

Acute exacerbation (in hospital)

• Positions that ease breathlessness: high side-lying; sitting leaning forward with forearms on a table or knees; standing leaning forward on a wall or railing. These lift the abdominal contents and let the flattened diaphragm work better.
• Breathing control: gentle, relaxed breathing using the lower chest, shoulders relaxed; pursed-lip breathing during effort.
• Airway clearance if sputum is a problem: ACBT with huffing; positive expiratory pressure devices (PEP, flutter) if helpful; postural drainage only if it clearly helps (see the classic-vs-current box).
• Support NIV: help the patient tolerate the mask, position upright, clear secretions during breaks.
• Early mobilisation: sit out, walk with oxygen if needed, keep SpO₂ 88–92%.
• On a ventilator (S20, SIMV with right lower lobe pneumonia): regular repositioning (affected lung up for drainage), suction, manual techniques where appropriate, careful hyperinflation (risk of air trapping and pneumothorax), early sitting and limb exercises, inspiratory muscle training during weaning.
• Before discharge: refer to pulmonary rehab to start within a few weeks.

Pulmonary rehabilitation (long-term)

An individually prescribed programme of exercise training, education and behaviour change. Usually 6–12 weeks, with at least 2 supervised sessions a week plus home exercise. It improves breathlessness, exercise capacity and quality of life, and after a hospital admission it reduces readmissions (ATS 2023: strong recommendation).

• Why strengthen the leg and arm muscles (3 marks in W24): COPD weakens and wastes limb muscles (inactivity, low oxygen, inflammation, steroids, poor nutrition). Weak thighs tire early and produce lactic acid sooner, which drives breathing harder, so many patients stop exercise because of leg fatigue, not breathlessness. Strength training increases muscle strength and size, improves exercise tolerance and daily tasks (stairs, standing up, carrying), lowers breathlessness at the same workload, helps bone health and reduces falls. It also causes less breathlessness than endurance training, so very breathless patients can do it.
• Inspiratory muscle training: for weak breathing muscles, at least 30% of maximal inspiratory pressure, about 30 breaths twice a day.
• Education: disease, inhalers, airway clearance, energy conservation, action plan, smoking cessation, nutrition.
• Maintenance: keep exercising at home or in community groups after the programme ends.

Pursed-lip breathing (3 marks in S20 and W22)

Technique: breathe in through the nose, then breathe out slowly through loosely pursed lips (as if blowing on hot tea), taking about twice as long to breathe out as to breathe in. Do not force the air out.

Rationale and effects:

• Creates back-pressure in the airways, which splints the small airways open during breathing out.
• Less air trapping, so less hyperinflation.
• Slower, deeper breathing: lower breathing rate, better tidal volume and oxygen.
• Reduces breathlessness and anxiety, and helps during walking and stair climbing.

Energy conservation (7 marks in S19)

• Plan: spread heavy tasks across the week; do them at the time of day you feel best.
• Pace: slow, steady movements; rest before you get very breathless; breathe out on effort.
• Prioritise: drop or delegate tasks that are not essential.
• Position: sit to wash, dress and cook; keep often-used things between waist and shoulder height; avoid bending and reaching overhead.
• Use aids: trolley, long-handled sponge, shower stool, raised toilet seat.
• Stairs: climb slowly, one step per out-breath, rest on landings; plan trips so he climbs to the 2nd floor fewer times.

Why it matters: it lowers the oxygen cost of daily tasks, so the patient stays independent and less breathless.

By impairment

13Precautions, contraindications and stop criteria

14Education, lifestyle and home programme

• Stop all tobacco; avoid second-hand smoke, chulha smoke and dust. Use masks at work where possible.
• Learn correct inhaler and spacer technique; take medicines regularly.
• Daily walking at moderate breathlessness, plus home strengthening exercises.
• Daily airway clearance if you have sputum.
• Use energy-conservation and pacing methods for housework and stairs.
• Eat small, frequent meals; keep a healthy weight.
• Get vaccinated against influenza and pneumonia.
• Action plan: know the early signs of an exacerbation (more breathless, more or darker sputum) and when to start rescue medicines or see a doctor.

15Prognosis and discharge criteria

Prognosis is worse with lower FEV1, frequent exacerbations, low BMI, low exercise capacity and continued smoking. Stopping smoking slows decline; pulmonary rehab improves symptoms and function; long-term oxygen improves survival when resting oxygen is severely low.

Discharge from hospital: stable on home medicines and oxygen if prescribed; independent with breathing control, airway clearance and inhalers; can walk and manage stairs with pacing; referred to pulmonary rehab.

16Exam corner

Past questions (MUHS, 2016–2026)

• W16 Q3(a) and S18 Q3(b), 5 + 5 + 5 marksThe worked example in section 10 (S18: age 45, same story).
• S17 Q3(a), 5 + 5 + 5 marks50-year-old labourer with COPD, acute exacerbation; smoker; only earning member; moderate obstruction with good reversibility. ICF, and physiotherapy in acute and chronic stages.
• W17 Q3(b), 5 + 3 + 7 marks50-year-old sweeper with COPD for 10 years; breathless at rest, thick sputum; on nasal-prong oxygen. Impairments, activity and participation; short- and long-term management.
• S20 Q3(b), 5 + 3 + 7 marks60-year-old farmer with a COPD exacerbation and respiratory failure, in ICU on SIMV; right lower lobe pneumonia. Impairments, activity and participation; short- and long-term management.
• 7-mark questionsEnergy conservation techniques for COPD patients and their importance (S19). Relevance of ABG, PFT and X-ray in decision-making for goal setting in COPD (W24).
• 3-mark questionsEffects of smoking on pulmonary function (S17, W22). Radiological findings of emphysema (W18). Pursed-lip breathing effects (S20) and rationale in COPD (W22). PFT in obstructive lung disease (W20). PFT findings in COPD (W19). Rationale of pursed-lip breathing in COPD (W21). X-ray findings in COPD (W24). Importance of peripheral muscle strengthening in COPD (W24). Hypoxic drive in COPD (W25).

Technique cards for this topic: dyspnoea and energy conservation, oxygen therapy, ABG, breathing exercises, respiratory muscle training, exercise testing, pulmonary rehabilitation, X-ray and PFT.

Keywords to underline

FEV1/FVC < 0.70 GOLD grade hyperinflation dynamic hyperinflation breathlessness spiral SpO₂ 88–92% pursed-lip breathing ACBT pulmonary rehabilitation energy conservation pacing action plan

Answer skeleton: COPD long answer

1. Restate: age, job, smoking, home, PFT grade, blood gases, acute or stable.
2. [ICF, 5] ICF diagram from the case; one-line diagnosis; reasoning (hyperinflation, sputum, deconditioning).
3. [Short-term, 3–5] Acute care: positioning, breathing control, airway clearance, controlled oxygen, NIV support, early mobilisation.
4. [Long-term, 5–7] Pulmonary rehab with doses (endurance, strength, IMT), education, energy conservation, stairs, smoking cessation, action plan, outcome measures.

Draw these

• The breathlessness spiral (section 4)
• Spirometry curves (section 6)
• Forward-lean positions as stick figures (sitting and standing)

Viva questions

1. Why is the oxygen target 88–92% in some COPD patients?
2. How does pursed-lip breathing help?
3. What is dynamic hyperinflation?
4. Why does leaning forward relieve breathlessness?
5. What are the components of pulmonary rehabilitation?
6. What are the X-ray features of emphysema?

Linked practical spots

• Chest X-ray of hyperinflation: flat diaphragms, horizontal ribs, narrow heart.
• PFT report with FEV1/FVC 0.55 and FEV1 60% predicted: moderate obstruction (GOLD 2).
• ABG with pH 7.32, PaCO₂ 58 mmHg, raised bicarbonate: acute-on-chronic respiratory acidosis.