Are you getting the right treatment for your COPD?

On I-95 at mile marker 155.2 in the County of Prince William, motorists can expect potential delays due to a disabled vehicle. The south right shoulder is closed.

Chronic Obstructive Pulmonary Disease (COPD) is a common condition that causes problems with breathing and airflow to the lungs. COPD is a serious condition. It is the third leading cause of death in the United States.

Although COPD is treatable, it cannot be cured, and symptoms generally get worse over time. Symptoms of COPD include:

  • Shortness of breath
  • Cough
  • Mucus in the lungs
  • Wheezing
  • Chest tightness
  • Fatigue
  • Getting sick frequently with colds, coughs, and other chest infections

Two main lung diseases contribute to the symptoms of COPD: emphysema and chronic bronchitis. Emphysema occurs when tiny air sacs inside the lungs are destroyed. Chronic bronchitis is inflammation of the tubes which carry air to and from the tiny air sacs. Both diseases are caused by long-term exposure to tobacco or marijuana smoke; dust, fumes, or chemicals in the workplace; or particles from burning biomass (wood, dung, coal, grass).

Usually people with COPD who do not receive treatment have symptoms every day. The symptoms may be mild or more severe. Sometimes, people with COPD will have flare-ups (sometimes called “exacerbations”). During a flare-up, people with COPD cough and wheeze more than usual. They may cough up quite a bit of mucus. It can be harder to breathe, so people often feel anxious during a flare-up. When a flare-up is very severe and the person is struggling to breathe, hospitalization may be needed to get symptoms under control.

Know your COPD group

Doctors classify COPD into one of four groups, based on how severe daily symptoms are, and how many flare-ups have happened in the past year. The treatment options are different for different groups, so it is important to understand which group your COPD is in.

First, the doctor will use a short questionnaire, called the COPD Assessment Test (CAT), to determine what impact COPD symptoms are having on your daily life. A score of 10 or higher means that COPD symptoms are having a noticeable negative effect on your life.

Next, the doctor will investigate your risk of being hospitalized with a flare-up of COPD symptoms. If you have had no flare-ups in the past year, or just one flare-up that you did not need to go to the hospital for, then you are low-risk for flare-ups in the future. If you had two or more flare-ups in the past year, or one really severe one that sent you to the hospital, then you are at high risk for more flare-ups in the future.

Based on these factors, your COPD is grouped as follows:

  • Group A – mild to moderate symptoms (a score on the CAT of less than 10), and low-risk for flare-ups
  • Group B – moderate to severe symptoms (a score on the CAT of 10 or more), and low-risk for flare-ups
  • Group C – mild to moderate symptoms (a score on the CAT of less than 10), and high-risk for flare-ups
  • Group D – moderate to severe symptoms (a score on the CAT of 10 or more), and high-risk for flare-ups

COPD treatment options by group

A key treatment for anyone with COPD is to stop all smoking or smoke exposure. If your COPD was caused by exposure to chemicals, gases, or other fumes, then it is vital to stop any exposure to these damaging substances as well.

Another key intervention for COPD is pulmonary rehabilitation, which helps people set lifestyle goals for diet and exercise, and discover and avoid triggers for symptoms. It can also help people with COPD feel less anxious and depressed, and more in control of their condition.

Beyond lifestyle changes, people with COPD have a variety of medication options to help manage symptoms and reduce the number of flare-ups.

Treatment for Group A

People with group A COPD (mild to moderate symptoms, low risk of flare-ups) are usually treated with bronchodilators, which are inhaled into the lungs. These medications relax the muscles around the airways. They can make it easier to breathe and can reduce coughing.

Short-acting bronchodilators are used when you have a flare-up in symptoms, or before exercise or other activity that usually causes coughing, wheezing, or difficulty breathing. Short-acting bronchodilators generally should not be used every day, but only as a rescue medication. Some people with mild symptoms can manage their COPD with only short-acting bronchodilators.

Long-acting bronchodilators are taken every day to help keep symptoms under control over time. They are not for use during a flare-up of symptoms because they do not work fast enough to stop an acute attack of breathing problems. Many people with group A COPD are treated with a long-acting bronchodilator to control their symptoms.

Short-acting bronchodilators include:

Long-acting bronchodilators include:

Treatment for Group B

People with group B COPD (moderate to severe symptoms, low risk of flare-ups) are also treated with bronchodilators. Usually a long-acting bronchodilator is taken every day, and a short-acting bronchodilator is added in whenever symptoms flare up.

Some people with group B COPD may still have symptoms that negatively affect their daily lives, despite treatment with one long-acting bronchodilator. The next step is to use a combination of two long-acting bronchodilators every day.

Combination treatment options include:

Treatment for Group C

People with group C COPD have a high risk for flare-ups; however, daily symptoms are still only mild to moderate. Some people with group C COPD can be treated with a single long-acting bronchodilator, or a combination of two long-acting bronchodilators, and get relief from symptoms without having too many flare-ups.

If bronchodilators do not work well enough to prevent flare-ups, then doctors usually chose to add inhaled cortiocosteroids (ICS). ICS can reduce inflammation in the airways by suppressing overactive immune cells. This can help prevent flare-ups.

ICS are usually packaged together one inhaler with a bronchodilator, to make the medications simpler to take every day.

Some examples of ICS/bronchodilator combinations are:

  • Fluticasone/salmeterol (Advair)
  • Fluticasone/vilanterol (Breo)
  • Formoterol/budesonide (Symbicort)
  • Formoterol/mometasone (Dulera)

Treatment for Group D

People with group D COPD have moderate to severe daily symptoms, and a high risk for flare-ups. The first choice for this group is a combination treatment with two long-acting bronchodilators. If this is not enough to prevent flare-ups, an ICS may be added.

Some people with group D COPD do not get enough relief with two bronchodilators and ICS together. In that case, the doctor may add a new type of medication, called roflumilast (Daliresp). Roflumilast decreases airway inflammation, and also relaxes the airways. It works by a different mechanism than bronchodilators and ICS.

Another medication option for group D COPD is the antibiotic azithromycin, which can help reduce flare-ups. However, long-term use for more than one year can lead to hearing loss.

For very severe cases of COPD, surgery on the lungs might help improve symptoms. Some people might also qualify for lung transplantation.

Whatever group your COPD falls into, talk to your doctor about the many treatment options available to you. Although it can be frustrating to try different medications, sometimes it takes time to find the right combination of treatments to get symptoms and flare-ups under control.

Further reading

Centers for Disease Control and Prevention. Increase expected in medical care costs for COPD.

Mayo Clinic. COPD.

PulmCCM. New 2017 GOLD guidelines for COPD released.

U.S. National Library of Medicine. Medline Plus. COPD flare ups.


Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD, 2017.