Does COPD Cause Pain?

Prevalence of Pain is More Common in COPD (41%) Than Healthy Subjects (29%)

Background: Pain and shortness of breath are both unpleasant experiences which affect an individual’s quality of life. In different studies, the frequency of pain ranges from 44% to 88% in those with COPD.

Study: Dr. Annemarie Lee and colleagues at the West Park Healthcare Centre in Toronto studied 64 patients with COPD referred to a pulmonary rehabilitation program and 64 healthy subjects of the same age. All answered questionnaires about pain over a one week period, including location, its frequency, and how long it lasts, as well as questionnaires about shortness of breath, quality of life, etc..

The study is published on-line in the Journal of the COPD Foundation [2017; 4(3): In press. doi:]

Results: Age range was 48 to 91 years in the COPD group and 47 to 94 in the healthy group. Those with COPD had either severe or very severe COPD based on results of breathing tests. Pain frequency was 41% of those with COPD and 29% in healthy subjects.

anatomical locations for chest and upper back pain

Chest and upper back pain are more common in those with COPD

Pain was more common in the chest and upper back areas in those with COPD compared to healthy subjects. It was described as aching (30%), tiring (17%), and penetrating (17%). The location in the chest and upper back was associated with more air in the lungs (higher total lung capacity) as measured on breathing tests.

Those with painful experiences also had more shortness of breath with activities and higher depression scores.

Locations of the chest for pain

Rib cage

Conclusions: The authors proposed that hyperinflation of the lungs (too much air trapped in the lungs) could cause stretching of the chest wall and cause strain on ligaments between ribs as well as excessive forces on the joints.

My Comments: Unfortunately, the researchers did not evaluate the cause of pain experienced by the subjects. For example, could some of those with COPD have arthritis of the spine? 

It is important to remember that there are no pain sensors in the lung itself, but rather in the lining around the lung (called the pleura) and in areas of the muscles, joints, and ligaments in the chest wall. The treatment for too much air trapped in the lungs includes bronchodilators (inhalers that open up the breathing tubes allowing more air to exit), oxygen, and exercise training.

Arm Exercise Training Reduces Shortness of Breath in COPD

Studies Show that Arm Exercise Improves Breathlessness 

Background: Many individuals with COPD have difficulty performing arm activities due to shortness of breath and arm fatigue. As a result, upper limb exercise training is typically included in pulmonary rehabilitation programs.

Study: Dr. Zoe McKeough and colleagues from the University of Sydney in Australia reviewed all published studies on upper limb exercise training for at least four weeks. They examined: arm exercise (AE) compared with either no or sham (pretend) training; and combined arm and leg exercise compared with only arm exercise. The study was published in the November 15, 2016, issue of the Cochrane Database Systematic Reviews.

Arm crack machine used for arm exercise

Man performing arm exercise using arm crank machine

Findings: A total of twelve studies were included in the analysis. When AE training was compared with either no or sham training, there was a significant improvement in breathing difficulty (four studies of 129 subjects). When upper limb exercise combined with lower limb exercise was compared with AE alone, there was no difference in shortness of breath (2 studies of 55 subjects). There was no improvement in health-related quality of life with AE training.

When AE endurance training was compared with no or sham training OR with combined arm and leg exercise training, there was a large significant improvement in unsupported endurance arm capacity.

Conclusion: Some form of upper limb exercise training when compared with no training or a sham intervention improves breathing difficulty in those with COPD.

My Comments: Arm exercises are important for those with COPD who note breathing difficulty when performing arm activities such as lifting objects (like a grandchild), carrying a grocery package, and moving dishes from the washer and placing them in a cabinet. Also, arm exercise can substitute if someone can not perform leg exercises for whatever reason. This might include those with knee, hip, or back problems or those who use a wheelchair.

Stretch or resistance band for arm exercise

Using stretch or resistance bands at home is the easiest and least expensive way to do upper limb exercise. Ask a physical therapist to show you simple arm exercises to increase strength as well as endurance.


Marijuana Research to be Expanded for Medical Use

DEA to Allow Universities to Apply for Marijuana Research

On August 10, 2016, the New York Times ( announced that the Drug Enforcement Administration (DEA) will allow universities to apply to grow marijuana for use in federally funded research. At the present time, the University of Mississippi is the only institution authorized to grow it for use in medical studies.

Researchers at the University of Mississippi and their approved garden.

Researchers at the University of Mississippi and their approved garden.

According to John Hudak, a senior fellow at the Brookings Institution, “It will create a supply of research-grade marijuana that is diverse, but more importantly, it will be competitive and you will have growers motivated to meet the demands of researchers.”

At the same time, the DEA has turned down requests to remove marijuana from “Schedule 1” classification. According to the DEA, the drug has “no currently accepted medical use” in the United States. However, the Department of Justice has made it clear they will not prosecute as long as patients and doctors follow state law.

My Comments: In my practice I see patients who live in New Hampshire and in Vermont. Both states have legalized marijuana for medical use.  Approved use includes cancer, glaucoma, AIDS, as well as other conditions.

Although shortness of breath, or breathing difficulty, is not an approved use in either state, it is possible that anyone with COPD may qualify for another or a related reason.  For example, in Vermont medical marijuana is approved for a medical condition with one or more of the following intractable symptoms: “cachexia (weight loss) or wasting syndrome, severe pain or nausea or seizures.”

At the present, I have one patient who lives in Vermont and has severe COPD and uses oxygen 24/7. He/she is using cannabis oil for cachexia (weight loss and wasting). A drop of the oil is placed under the tongue each night for persistent breathing difficulty. He/she has reported marked improvement in his/her shortness of breath.

Approved garden for growing marijuana plants.

Approved garden for growing plants.

It is unclear how many universities will receive licenses to grow marijuana. Researchers will have to receive approval from the DEA and the Food and Drug Administration to perform medical studies. Hopefully, scientists will study the effects of oral marijuana on shortness of breath.


Primary Care Providers’ Knowledge and Beliefs about COPD

Survey of 426 Primary Care Providers about COPD

Background: Primary care physicians, nurse practitioners, and physician assistants provide the majority of care for those who have COPD. Thus, it is important to ask these primary care providers about their overall knowledge and beliefs about diagnosis and treatment of COPD.

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Dr. Barbara Yawn of the Olmstead Medical Center in Rochester, MN

Study: Barbara Yawn, MD, MSc, and colleagues at the Olmstead Medical Center in Rochester, MN, surveyed 426 primary care providers at 3 different medical meetings in 2013 and 2014. The survey asked questions about perceived barriers to diagnosis of COPD and beliefs concerning the value of available COPD medications. The findings were published in the August 2016 issue of the Journal of the COPD Foundation (volume 3; pages 628-635).

Results: Of the 426 people who answered the questions on the survey, there were 278 medical doctors (MDs) and doctors of osteopathic medicine (DOs) and 148 nurse practioners (NPs) and physician assistants (PAs). 

The two most common barriers to making a diagnosis of COPD were: ♦ patients had many chronic medical conditions, not just COPD; and ♦ patients often failed to recognize and report breathing difficulty. These barriers were similar between MDs/DOs and NPs/PAs.

Woman performing breathing test.

Woman performing breathing test (spirometry).

About one-half of the clinicians said that they had equipment (spirometry) in their office, but less than 2/3 reported using testing to diagnose COPD.

Only 10% of those answering the survey reported ordering blood tests (screening) for alpha-1 antitrypsin deficieny, a hereditary form of emphysema.

About 75% said that there were available treatments to reduce shortness of breath, and 85% answered that medications for COPD could reduce exacerbations (flare-ups) of COPD. Some of these medications are shown below.

Examples of dry-powder inhalers

Examples of dry-powder inhalers

Conclusions: Primary care providers continue to report multiple barriers to diagnose COPD including easy access to testing equipment. However, most respondents noted that effective medications were available to improve breathing difficulty and to reduce the risk of a flare-up.

My Comments: In the past, many primary care providers felt that diagnosing those with COPD was not important because: COPD was self-inflicted by smoking; and treatments for COPD were not generally effective.

This survey shows that knowledge and attitudes among primary care providers have changed. Primary care providers do not need to have testing equipment (spirometers) in their offices, but instead can refer patients for testing at the local hospital.

If you have told that you have COPD and have not had breathing tests, ask your health care provider to order testing. Ask about what treatments are available to “make it easier to breathe.” BE PROACTIVE. 

Measuring Collateral Ventilation for Bronchoscopic Volume Reduction

Dear Dr. Mahler:

I read your post on December 11, 2015, about the need to measure collateral ventilation to know who might benefit from placing valves into the airways to collapse parts of emphysema lung. My pulmonary doctor has mentioned a study/program in Boston that I am considering.  I have “advanced emphysema” and am limited in doing anything more than daily activities.  I struggle with yard work, raking, and even walking our dog. I would like to know more about how is collateral ventilation measured?  Is this complicated?

Many thanks.

Albert in Saco, ME

Dear Albert:

Your question is quite important. Studies have shown that the valves are effective in collapsing lung that is not working only if there is no collateral ventilation present. Please review information about collateral ventilation on my December 11 post.

To answer your question, there are several ways to measure whether someone has collateral ventilation. If a valve is placed in a lobe in the lung with collateral ventilation, the lobe will not collapse and therefore will not help you breathe easier. In the article by Kloosters and colleagues published in the New England Journal of Medicine, the authors used a method called the Chartis System. This system was developed by Pulmonx, a company who makes the Zephyr valves used in the study.

Here is a brief summary. I will try to make this complicated process as simple as possible.

First, you are given medication to make you sleepy and temporarily forgetful

Bronchoscopy used to measure collateral ventilation

Diagram of scope passed thru mouth into the lungs (called bronchoscopy)

(called conscious sedation). Then, a bronchoscope is passed through your nose or mouth into the breathing tubes (airways). A plastic tube is then passed through the scope, and a balloon at the end of the plastic tube is inflated to block flow or air to the “target’ lobe.

The tip of the plastic tube extends beyond the balloon and can measure any air flow to determine whether collateral ventilation is present or not (see figure below).

System used to measure collateral ventilation

Scope on right with plastic tube and balloon inflated that blocks flow of air into the lobe.

You can find more information on the website:

Placement of valves into emphysema lobes has been approved in most counties in western Europe and is a common treatment for advanced emphysema in Europe. However, in the US, the Food and Drug Administration has not approved this procedure at the present time. So, you will need to go to a medical center doing a study on placement of valves for emphysema. Beth Isreal-Deaconess Medical Center in Boston is the nearest center to Saco, Maine, doing this research procedure. Certainly, your pulmonary physician can refer you for evaluation if you are interested.

Best wishes,

Donald A. Mahler, M.D.

Obesity and Shortness of Breath in COPD

Benefit of Mild to Moderate Obesity in those with COPD

Dennis Jensen, Ph.D., Assistant Professor at McGill University, presented information on the benefit of obesity on shortness of breath in those with COPD at the CHEST Annual Meeting held October 24-28, 2015, in Montreal, Quebec, Canada.

Dennis Jensen, Ph.D., Assistant Professor at McGill University in Montreal

Dennis Jensen, Ph.D., Assistant Professor at McGill University in Montreal

First, Dr. Jensen reviewed how obesity is defined. The most widely used method is called the BMI (body mass index) which is the ratio of weight squared to height using the metric system. Studies show that 54% of the general adult population in the United States and Canada are considered obese based on a BMI of 30 or higher.

In general, studies show that obese individuals who have COPD are less active, are hospitalized more, and require more home care compared to those with COPD and are normal weight.


However, there are a few paradoxes when other outcomes are considered. For example, obese individuals with COPD:

  1. have a lower all cause mortality compared with those with COPD of normal weight
  2. can exercise to a higher level (intensity) on a stationary cycle compared with non-obese COPD individuals.
  3. report lower ratings of breathlessness (dyspnea) for the same level of breathing (ventilation) while exercising on the cycle than those with COPD of normal weight


Extra weight on the chest limits the lungs from over-expanding (called hyperinflation) at rest and during exercise. Hyperinflation occurs in most individuals who have COPD and is a major cause of shortness of breath.

X-ray of the chest showing too much air in the lungs (hyperinflation) and the diaphragm muscle is pushed down.

X-ray of the chest showing too much air in the lungs (hyperinflation). This pushes the diaphragm muscle down and makes it less effective.


When the extra weight is around the chest (called central obesity- think of an apple and not a pear), not as much hyperinflation takes place with daily activities. This makes it a little easier to breathe.

My Comment

The information that Dr. Jensen presented led to an interesting discussion, particularly about what happens when someone who is overweight and has COPD loses weight. Is that good or bad for breathing? Dr. Jensen commented that there are no studies that have addressed this.

Dr. Denis O'Donnell, Professor of Medicine at Queen's University, in Kingston, Ontario, Canada

Dr. Denis O’Donnell, Professor of Medicine at Queen’s University, in Kingston, Ontario, Canada

Dr. Denis O’Donnell, another presenter at the session, commented that the benefit of obesity occurs in those with mild to moderate obesity (about 20-30 pounds of extra body weight). Extreme, or morbid, obesity causes more breathing difficulty along with other medical problems.

Brain Imaging in COPD: Similar Areas for Shortness of Breath and Fear

Affected Brain Areas Process Shortness of Breath and Fear

In the July 2015 issue of the journal CHEST, Dr. Esser and co-authors performed brain imaging using magnetic resonance imaging (MRI) in 30 patients with moderate to severe COPD and 30 healthy individuals matched for age and gender. The study was performed at the University Medical Center in Hamburg-Eppendorf, Germany.

The aim of the study was to examine changes in brain matter in those with COPD and any possible connection with the duration of COPD, fear of breathing difficulty, and physical activity.


Those with COPD had higher ratings of fear and of breathing difficulty than healthy individuals on a questionnaire. In general, the amount (volume) of gray matter in the brain was decreased in certain areas compared with the healthy controls. These brain areas are involved in the experiences of feeling short of breath and having fear.

My Comment

The brain consists of gray and white matter. Gray matter includes nerve cells (called neuronal cell bodies, dendrites, and glial cells). White matter includes mainly nerve fibers (axons). White matter connects various areas of gray matter just like a highway connects different cities.

Slice thru the brain.

Slice thru the brain.

The gray matter in the brain performs many functions including muscle control, seeing, hearing, memory, emotions, speech, decision making, and self-control.

In elderly persons, there is a correlation between the amount (volume) of gray matter in the brain and short-term memory.  The less the gray matter, the worse is short-term memory. Older smokers lose gray matter and cognitive function (ability to think) at a greater rate than those who do not smoke. In one study, chronic cigarette smokers who quit smoking lost fewer brain cells and had better brain function than those who continued to smoke. Research suggests that regular exercise may lead to increased gray matter inside part of the brain called the hippocampus.

Thus, there are many reasons not to smoke. One important reason is to preserve gray matter in our brain.

Other approaches to quit smoking are found on the website of the American Heart Association -



Cannabis Oil

Dear Dr. Mahler:

I read on-line that Cannabis oil placed on the tongue helps reduce breathing difficulty.  Is this true? I have COPD and am taking Advair Diskus twice a day and I use ProAir 2-3 times as needed on most days. Thanks.

Susan from Auburn, CA

Dear Susan:

Cannabis sativa is the name for marijuana and contains tetrahydrocannabinol (abbreviated: THC) which is responsible for the psychoactive effects.  Typically, the dried leaves and flowers of the plant are smoked or taken orally with food (baked in brownies for example).

Cannabis plant

Cannabis plant

As of July 2014, cannabis can be used for personal medical use in 23 states and the District of Columbia. California, where you live, was the first state to legalize the medical use of cannabis in 1996. Medical marijuana in the US is controlled at the state level.

Cannabis oil is made from a special strain of marijuana called “Charlotte’s web” that has low levels of THC, the ingredient that leads to the “high.” The oil has elevated levels of cannabidiol, a non-psychoactive component that has a number of therapeutic benefits including those that limit seizure activity. The oil is taken in an oral liquid form, not smoked like traditional marijuana. As of June 7, 2015, 15 states had okayed the use of cannabis oil.  California is not on that list.

My review of the medical uses of cannabis oil on the internet revealed that it has been used to treat anxiety/stress, headaches, and for pain relief. It may also stimulate appetite. I could not find any reasonable report of using cannabis oil for relieving breathing difficulty. However, if the oil does help reduce pain, it is possible that it may also make it easier to breathe.

Cannabis oil

Cannabis oil

The medical community depends on randomized studies to evaluate new treatments. To my knowledge, there are no such studies examining any effect of cannabis oil for treating breathlessness.

I hope this information is helpful for you and others.


Donald A. Mahler, M.D.


Cognitive Behavioral Therapy

Cognitive Behavioral Therapy reduces breathing difficulty

Psychological factors can contribute to breathing difficulty. Cognitive behavioral therapy (CBT) works to change unhelpful thinking and behavior by helping individuals take a more open and mindful approach toward their breathing problem. It has been effective for mood disorders, anxiety, eating disorders, substance abuse, and depression.

The diagram below shows how emotions, thoughts, and behaviors influence each other. The triangle in the middle represents cognitive behavioral therapy – all core beliefs can be summed up by self, others, and future.


Diagram shows emotions, thoughts, and behaviors influence each other.

Diagram shows emotions, thoughts, and behaviors influence each other.

In the June 2015 issue of Respiratory Physiology and Neurobiology, Livermore and colleagues from Sydney, Australia, evaluated the effects of cognitive behavioral therapy (CBT) on increased breathing difficulty in those with COPD. 18 subjects received four sessions of CBT and 13 subjects received routine care for their COPD. Before therapy started and 6 months later, all subjects breathed through a resistance system in the laboratory that made it harder to breathe. Those who were treated with CBT reported less breathing difficulty (by 17%) compared to before therapy, while there was no change in those who had routine care.

These results suggest that this “mindful” therapy may help you breathe easier. You may wish to  read and learn more about this approach and/or ask your doctor whether a therapist with experience in CBT is available where you live.


Highlights from 2015 American Thoracic Society meeting in Denver

Highlights of the American Thoracic Society conference held in Denver, CO, from May 15- 20, 2015

Here are the highlights from presentations on May 19 that considered other medical conditions that can occur in those with COPD.

1. Combined pulmonary fibrosis (lung scarring) and emphysema

Dr. Sharon Rounds

Dr. Sharon Rounds

Dr. Sharon Rounds from Brown University reviewed the combination of lung scarring in the lower parts of the lung with emphysema in the upper parts. This occurs more likely in men and causes low oxygen level. Treatment is the same as for COPD.

2. Pulmonary hypertension (high blood pressure in the blood vessels of the lungs)

Dr. Mark Dransfield from the University of Alabama described the presence of high pressure in the blood vessels of the lungs. This may be due to a low oxygen level and/or damage to the lining of the blood vessels. This problem can add to shortness of breath and is diagnosed usually by an echocardiogram (ultrasound of the chest). Oxygen is the major treatment.

Dr. Mark Dransfield

Dr. Mark Dransfield

3. Obstructive sleep apnea

As part of the highlights of the conference, Dr. Patrick Stollo from the University of Pittsburgh reported that obstructive sleep apnea may co-exist with COPD. Those who have sleep apnea typically snore at night, stop breathing for at least 10 seconds many times during sleep, and are tired during the day because of poor sleep quality. This condition is diagnosed by monitoring the oxygen level during sleep or possibly by more extensive monitoring in a sleep laboratory.

4. Lung cancer

Dr. James Jett from National Jewish Healthcare in Denver commented that even if surgery for lung cancer is not possible because of severe COPD, targeted radiation therapy may be effective with minimal damage to the lung.

5. Overlap between asthma and COPD

Dr, Claus Vogelmeier of Marburg Univeristy Hospital in Germany, discussed  individuals who have features of both asthma and COPD. Treatment should be directed for asthma.

6. Assessing dyspnea (shortness of breath)

I discussed what doctors should consider when someone with COPD finds that their breathing is getting worse. One possibility is that the person with COPD is not able to inhale the medications deep into the lungs. If so, there are options including use of nebulized medications. Other considerations for worsening breathing are weight gain, being “out of shape,” having low number of red blood cells (anemia) or a heart problem. Finally, both anxiety and depression can make breathing seem more difficult. In a study performed in Lebanon, NH, individuals who had high anxiety scores reported that their breathing felt “frightening,” or “awful.”