COPD

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable chronic lung disease characterized by persistent airflow limitation due to airway and alveolar abnormalities. It encompasses emphysema (destruction of alveolar walls) and chronic bronchitis (chronic airway inflammation and mucus hypersecretion). Diagnosis requires post-bronchodilator spirometry demonstrating FEV1/FVC ratio below 0.70. GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2024 guidelines classify COPD severity by spirometry grade (GOLD 1–4) and exacerbation/symptom risk (GOLD groups A–E). COPD affects approximately 16 million diagnosed Americans and an estimated equal number who are undiagnosed. It is the fourth leading cause of death in the U.S., and exacerbations are a major driver of hospitalizations and mortality.

• Chronic cough, often productive of mucus (sputum)
• Shortness of breath — initially with exertion, progressing to rest
• Wheezing or chest tightness
• Reduced exercise tolerance and activity limitation
• Frequent respiratory infections (colds, bronchitis) that linger
• Acute exacerbations: sudden worsening of breathlessness, increased sputum production, sputum color change (yellow/green)
• Weight loss and fatigue in advanced disease
• Cyanosis (bluish lips or fingertips) in severe hypoxemia

Spirometry is the diagnostic gold standard for COPD and is required to confirm diagnosis — clinical symptoms alone are insufficient. The USPSTF recommends against screening spirometry in asymptomatic adults but recommends spirometry for adults with respiratory symptoms or risk factors. GOLD 2024 recommends case-finding spirometry in any patient who smokes, has exposure history, or presents with dyspnea, chronic cough, or sputum production. The new GLI-2023 race-neutral reference equations should be used to interpret results, replacing prior race-adjusted calculations. Alpha-1 antitrypsin (AAT) deficiency testing should be performed at least once in all COPD patients — especially those with early onset, predominant emphysema at lower lobes, or family history.

GOLD 2024 recommends long-acting bronchodilators (LAMA — tiotropium, umeclidinium; LABA — salmeterol, formoterol) as the foundation of stable COPD management for all symptomatic patients. Dual bronchodilation (LAMA + LABA) is superior to monotherapy for most patients with moderate-to-severe disease. Triple therapy (LAMA + LABA + inhaled corticosteroid [ICS]) is indicated for patients with frequent exacerbations and blood eosinophil count ≥100 cells/μL. Dupilumab (Dupixent) was FDA-approved in 2024 as the first biologic for eosinophilic COPD (blood eosinophils ≥300 cells/μL), demonstrating reduced exacerbation rates. Phosphodiesterase-4 inhibitors (roflumilast) reduce exacerbations in chronic bronchitis phenotype. Pulmonary rehabilitation significantly improves functional status and quality of life and is underutilized, particularly among Black patients. Supplemental oxygen for patients with resting SpO₂ ≤88% improves survival. Smoking cessation is the single most effective intervention to slow COPD progression — NRT, varenicline (Chantix), and bupropion are all effective. Vaccination (influenza annually, pneumococcal [PCV15 or PCV20], COVID-19, RSV [RSVpreF for adults ≥60]) reduces exacerbation risk significantly.