COPD Flare-ups: Not Everyone Recovers

Consequences Of COPD Flare-ups: Some Improve, Others Do Not   

Background: COPD flare-ups are worsening of symptoms and are usually due to a chest infection (bronchitis or pneumonia) or inhaling something bad (like an irritant) in the air. The medical word for a COPD flare-up is an exacerbation.

Previous studies have shown that recovery for COPD flare-ups is quite variable. Some individuals are back to normal in a few weeks, while others seem to never get back to their baseline.

Study: Drs. Murray and Leidy who work at Evidera (a company that provides consulting and research services) analyzed the results of two 12-week studies evaluating a new medication (called a neutrophil elastase inhibitor) for those with COPD. All subjects completed a daily electronic dairy each evening for 2 weeks before being started on a medication or placebo and then for 12 more weeks. The 14 items in the dairy is called EXACT.

Changes in the daily EXACT score were used to measure Recovery or Worsening compared with values before starting the medication. In some subjects, there was not enough time to assess recovery or worsening because the flare-up occurred close to the end of the study. These were called “Censored” by the authors and were not analyzed.

The study was published in the February 2018 issue of the Journal of the COPD Foundation (volume 5, pages 27-37). doi:

Results: Of the 1,346 subjects, 31% had a flare-up during the 12 week period. 260 subjects recovered, while 80 experienced persistent worsening.

Recovery and persistent worsening in the those with COPD flare-ups

EXACT scores in those with a COPD flare-up at 0 days. This is noted by the two peaks. Those who recovered are noted by the solid line. Those who had persistent worsening are shown by the dashed line above the solid line.

Both groups were similar at the start of the study. The persistent worsening group had more breathlessness and chest symptoms compared with the recovery group.

Conclusions: The authors concluded that some patients have difficulty recovering from COPD flare-ups leading to worse health status and shortness of breath without any change in breathing tests (lung function).

My Comments: In my practice it is common to see individuals for are frustrated with shortness of breath and/or cough that persist after a chest infection or flare-up.

It is important to figure out why this happens. 1. In some, there may be persistent inflammation in the lungs, and then a course of prednisone should be prescribed. 2. In others, there may be weakness and deconditioning (“out of shape”) because of prolonged inactivity during the illness. For this problem, starting or re-starting an exercise program is crucial. The best approach is with a pulmonary rehabilitation program. 3. Another possible reason is psychological as anxiety or depression can make everything seem much worse. For this problem, referral to a psychologist or counselor should be considered along with possible medications for either anxiety or depression. 4. It is also important to make sure that the cause for breathing difficulty is not due to another medical problem such as a heart condition. Appropriate testing is the first step to evaluate for this possibility.

Carrier for Alpha-1 Antitrypsin Deficiency Emphysema: What Does it Mean?

Carrier for Alpha-1 Antitrypsin 

Dear Dr. Mahler:

I am 74 years old and was recently hospitalized for a flare-up of my COPD due to a chest cold. The hospital doctor referred me to the local pulmonologist, who told me that my breathing tests show “very severe” COPD. She tested me for alpha-1 antitrypsin deficiency. At my follow-up appointment, she gave me a copy of the test result and told me that I had a normal level (265 mg/dL), but that my Genotype was MF. Based on my discussion with the pulmonologist, I understand this means that I am a carrier for alpha-1 antitrypsin deficiency.  Can you help explain what all of this means? 

Otherwise, I am doing fine.  I take Advair in the round disk and Incruse powder, and do maintenance pulmonary rehab at the nearby hospital.

Many thanks.

Gloria from Northbrook, IL 

Dear Gloria:

Thanks for your question about being a carrier for alpha-1 antitrypsin deficiency, a hereditary form of emphysema. I will try to provide a simple answer to your question on a topic that can be complicated.

This structure includes possibility of a carrier of alpha-1 antitrypsin deficiency

Structure of the alpha-1 antitrypsin protein

Here is a brief review of the alpha-1 antitrypsin protein. It is made in the liver and released into the blood. One of its functions is to prevent damage to the lung. Some defects in the gene (called an allele) block the release of the protein into the blood resulting in a lower blood level called a deficiency. This makes the lungs more susceptible to injury from cigarette smoking or inhaling irritants in the air. This can cause emphysema which may develop in someone as early as in his/her 40s. The other conditions that can occur in alpha-1 antitrypsin deficiency are shown in the figure.

These conditions do not occur in a carrier for alpha-1 antitrypsin deficiency

Conditions associated with Alpha-1 antitrypsin deficiency

The normal allele (part of a gene) for alpha-1 antitrypsin is called M. Normally, a person is MM. This means that the person inherited one M allele from each parent. The most common abnormal alleles are called S and Z.

You have one normal allele – M, and one abnormal allele F. The good news is that you do not have a deficiency of alpha-1 antitrypsin, and therefore no changes are necessary in your treatment. You may wish to share the test results with family members.

I agree with your pulmonologist that you are a carrier for alpha-1 antitrypsin deficiency. Current evidence suggests that those with the F allele have normal levels of the alpha-1 protein in the blood, but that it may not have totally normal function. As I mentioned earlier in this response, you should continue to use your inhalers and stay active with continued participation in pulmonary rehabilitation.

The Alpha-1 Foundation website [] is an excellent source of information about the disease.

Best wishes,

Donald A. Mahler, M.D.

Physical Activity in COPD is Associated with Grandparenting and Dog Walking

Greater Physical Activity in COPD Related to Grandparenting and Dog Walking 

Background: There is less physical activity in COPD than others of similar age who are healthy. There are many reasons for this including shortness of breathing with activities, muscle weakness, other medical problems, and behavioral changes. However, being physically active in COPD is critical for a good quality of life and overall health. Although participation in a pulmonary rehabilitation program is recommended for all patients with COPD, this is not always possible for a variety of reasons.

Study: Investigators in Spain wanted to find out what socio-environmental factors were related to the amount and intensity of physical activity in COPD. A total of 410 patients with COPD answered questions and wore an activity monitor for one week. Other factors considered were outdoor green (parks, forests, agricultural land, and pastures) and blue (water bodies) areas. The findings were published on-line on March 1, 2017, in the journal Thorax.

Grandparenting associated with greater physical activity in COPDResults: All participants lived in a seaside community in Catalonia that included Barcelona. 85% of the patients were men; the average age was 69 years. Average lung function was 56 percent of predicted. After adjusting for age and socio-economic status, both grandparenting (being active with grandchildren) and dog walking were significantly associated with an increase in time in moderate-to-vigorous physical activity. Being close to green and blue areas was not associated with physical activity.Woman walking a dog - greater physical activity

Conclusions: The authors concluded that grandparenting and dog walking are associated with a greater amount and intensity of physical activity.

My Comments: Grandparents typically want to “do things” with their grandchildren simply because it is fun and provides meaning in their lives. In fact, patients with COPD report that caring for their grandchildren is a motivator to participate in a pulmonary rehabilitation program (British Journal of General Practice; 2008; volume 58; pages 703-710).  Likewise, having a dog is enjoyable and requires going for walks or taking the dog to a park for exercise.

The overall message of this study is “be active.”


Maintenance Pulmonary Rehabilitation in COPD is Beneficial for Two Years

Maintenance Pulmonary Rehabilitation Increases Walking Distance

Background: Whether maintenance pulmonary rehabilitation programs help to sustain the short-term benefits is unclear.

Study: Researchers in Spain studied patients with COPD over 3 years after they completed a standard 8-week pulmonary rehabilitation program. Subjects were randomized (divided by chance) into two groups: those who received maintenance therapy and those in a control group (no maintenance).

Cycle ergometer for maintenance pulmonary rehabilitation

Cycle ergometer

What was the maintenance program?  Patients exercised at home three times a week doing: 15 minutes of chest physiotherapy; 30 minutes of lifting weights (which were bought by patients); and 30 minutes of riding a stationary cycle (provided by the hospitals). A physiotherapist called the patients every 15 days; during the alternate week, patients went to the hospital for a supervised training session.

Patients assigned to maintenance pulmonary rehabilitation did arm training with weights

Woman with COPD doing arm curls with hand weights.

What did the control group do? Patients in the control group were advised to exercise at home without any supervision. They were encouraged to walk or buy a stationary cycle for home use.

The study results were published in the March 1, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (pages 622-629).

Results: For the total of 138 patients, average age was 64 years, and the amount of air exhaled in one second (FEV1) was 34% predicted. There were 68 patients in the treatment group, and 70 in the control group. More than 50% of those who started the study failed to complete the 3 years. Main reasons for stopping were a COPD flare-up (exacerbation), other medical problems (called co-morbidities), and death.

Those in the treatment group improved significantly more than the control group for: 1. distance walked in 6 minutes and 2. the BODE index [B = body mass index (weight and height); O = FEV1; D = breathlessness; E = 6-minute walking distance]. However, there were no differences in health-related quality of life between the two groups.

Conclusions:  The authors concluded that the 3-year maintenance pulmonary rehabilitation program provided improvements in walking distance and the BODE index compared with usual care. These improvements lasted for 2-years; after that, there no longer was a beneficial effect.

My Comments: This study is notable because it has the longest follow-up period of any published randomized trial of maintenance pulmonary rehabilitation. The findings support the benefits of continued exercise following completion of a pulmonary rehabilitation program.

One limitation of the study is that it primarily involved men so that it cannot be assumed that women would experience the same benefits.  However, women may be more compliant than men and are likely to live longer.  

I recommend participation in pulmonary rehabilitation to all of my patients with COPD and strongly encourage maintenance after completing our 12-week program.

Obesity and Worse Outcomes in COPD: More Shortness of Breath

In COPD, A Link between Obesity and Worse Outcomes (more shortness of breath, poor Quality of Life, and reduced walking distance)

Background: Although obesity is common in the United States (see post on January 1, 2017 under COPD News), the association between obesity and worse outcomes in those with COPD  is unclear.

Study: Dr. Allison Lambert, Assistant Professor of Medicine at Johns Hopkins University, and colleagues analyzed information on 3,631 participants in the COPDGene study. A body mass index of 30 or higher was used to define obesity. The findings were published in the January 2017 issue of the journal CHEST (volume 151; pages 68-77).

Obesity and worse outcomes regardless of shape

Two common types of obesity – apple and pear shapes

Findings: Overall, 35% of participants in the study were obese – which is identical to the general population in the United States.  Increasing obesity was associated with worse quality of life, reduced distance walked in six minutes, more shortness of breath, and greater odds of a severe exacerbation (sudden worsening) of COPD. 

Conclusions: The authors concluded that obesity is common among individuals with COPD and is associated with worse outcomes. These include more shortness of breath with activities, poor quality of life, shorter distance walked in six minutes, and more frequent severe exacerbations.

Obese adults walking

My Comments: If you have COPD and are obese, I strongly encourage you to lose weight. Certainly, losing weight is hard work especially with food being a focus of celebrations including birthdays, holidays, anniversaries, etc. Studies show that the most effective way to lose weight is a combination of

Seniors participating in physical activity such as walking, biking, and swimming

Seniors Exercising

eating fewer calories and an exercise program. Regular exercise can burn some calories, but its major effect with weight loss is to increase the metabolic rate (which burns more calories throughout the day). Participation in a pulmonary rehabilitation program is a great way to start an exercise routine. Talking to a nutritionist may help you select healthy and low calorie foods.

Playing a Harmonica: A Breathing Exercise for COPD

Benefits of Playing a Harmonica 

Dear Dr. Mahler:

I recently read about a pulmonary rehab program that includes playing music on a harmonica in addition to usual exercises. What are your thoughts? I haven’t tried it, but it sounds like fun.

Claudia from Jackson, MS

Dear Claudia,

I found several stories on the internet about the benefits of playing a harmonica for those with COPD.

Woman with COPD playing a harmonica

Woman with COPD playing a harmonica while breathing oxygen

There were several stories about how patients with COPD enjoyed the harmonica and found it made their breathing easier.  These anecdotes came from pulmonary rehabilitation programs at hospitals in Mountain View, CA, Austin, TX, Jacksonville, FL, and Chicago, IL. A group of patients with COPD in Colorado found their own musical group which they call the Harmonicats.

The COPD Foundation lists the following benefits of Harmonicas for Health program.

♦ Learn better control of breathing

♦ Exercise the muscles that help to breathe in and breath out

♦ Strengthen abdominal muscles for a more effective cough

♦ Relieve stress

♦ Socialize with others and have fun

One individual with COPD commented, “While I am playing the harmonica, I am enjoying it and not thinking about my breathing. I have found that playing different tunes has gradually improved my breathing capacity.

I also searched for studies evaluating the use of harmonicas in patients with COPD on PubMed. There is one study published in the July-August 2012 issue of the journal Rehabilitation Nursing (volume 37; pages 207-212) that compared usual pulmonary rehabilitation (16 subjects) with the same program plus harmonica playing (9 subjects practiced 5 – 20 minutes, twice a day, for 5 days per week). The authors found no differences in functional or psychosocial outcomes between the two groups enrolled in pulmonary rehabilitation.

Claudia – despite the findings of this one study, you might consider trying a harmonica. Remember, it is one of the few musical instruments that is played breathing both in and out.  It is likely to help with better control of your breathing. Let me know how it goes if you decide to give it a try.


Donald A. Mahler, M.D.

Fraility Reduced by Pulmonary Rehabilitation in Older COPD Patients

Fraility is Common in Elderly

Background: Frailty is common as people age.  It is defined as a person having at least three of the following characteristics:

  • Low physical activityelderly-man

  • Muscle weakness

  • Slowed performance

  • Fatigue or poor endurance

  • Unintentional weight loss

In a press release, Dr. Matthew Maddocks, of King’s College London said: “Frailty affects one in ten over-65s, and one in four over-80s. We now have a good understanding of how to measure frailty through various tests.” Dr. Maddocks is the first author of the article published online in the journal Thorax. 2016 Jun 12. pii: thoraxjnl-2016-208460. doi: 10.1136/thoraxjnl-2016-208460.

Study: Researchers recruited 816 outpatients with COPD between 2011 and 2015. The mean age of participants was 70 years old.  To assess frailty, measurements in weight loss, exhaustion, low physical activity, slowness and weakness were measured before and after pulmonary rehabilitation.

The 8-week program consisted of exercise and multidisciplinary education, comprising topics such as physical activity and exercise, medication use, diet, smoking cessation, and coping strategies.

Results: More than 25% of the participants with COPD referred for rehabilitation were frail. The frail participants had double the odds of not finishing the rehabilitation program because of  worsened condition or admission to hospital.

The frail participants who completed the rehabilitation program scored consistently better in measures of breathlessness, exercise performance, physical activity and health status compared to those not classified as frail.

61% of the frail participants were no longer classified as frail at the end of the program.

Conclusions: The authors concluded that people with COPD respond favorably to pulmonary rehabilitation, and such programs could reverse their frailty.

My Comments: COPD can speed health decline and lead to frailty especially if those with COPD are inactive.  Fraility can cause a greater risk for falls, disability, hospitalization and death. This study provides additional support for participation in pulmonary rehabilitation if you have COPD. You should search online or ask your health care provider about a program in your area.

Physical Activity Reduces Risk of Death in COPD

150 Minutes or More of Physical Activity per Week Lowers Risk of Death by 47% in the Year Following Hospitalization

Study: Dr. Nguyen analyzed the risk of dying among those with COPD who were hospitalized for a worsening of breathing symptoms (called an exacerbation). The study included 2,370 individuals (55% were female; average age = 73 years) hospitalized at one of 14 hospitals in the Kaiser Permanente Southern California health system.  Patients were hospitalized between January 1, 2011, to December 31, 2011. 

Each person provided an estimate of physical activity in minutes of moderate to vigorous activity. Patients were then categorized as: Inactive – 0 minutes per week; Insufficiency Active – 1 – 149 minutes per week;  Active – 150 or more minutes per week                                                                                                                                                                            

Seniors participating in physical activity such as walking, biking, and swimming

Seniors Exercising

Results: The study was published online in the European Respiratory Journal Open Research on  March 16, 2016.

♦ 73% were inactive; 17% were insufficiently active; and 10% were active. There were a total of 464 deaths (20%) in the year following hospitalization.

♦ Those who were active had a 47% lower risk of death in the 12 months compared with inactive patients.

♦ Other lifestyle factors such as active cigarette smoking, failure to participate in pulmonary rehabilitation, and poor nutrition also predicted the risk of death.

My Comments:  It may take weeks to a few months for some to recover from a flare-up of COPD that is severe enough to require hospitalization. However, once you are feeling better, it is important to gradually increase activities to regain fitness. 

The good news of this study is that those who pursue an active life style that includes 150 minutes or more of moderate to vigorous activity have a reduced risk of dying.  This translates into 30 minutes five times a week and allows for 2 days a week for rest and recovery.

Physical Activity includes Water Aerobics

Seniors doing Water Aerobics

Moderate to vigorous activities may include brisk walking, riding a stationary cycle, water exercises, and any other things that you like to do. Doing different activities provides variety.


For many, participation in a pulmonary rehabilitation program is the best way to achieve the target of 150 minutes of activity each week.


? Enough Progress in Pulmonary Rehabilitation

Dear Dr. Mahler:

I have stage 4 copd with a fev of 26. I have been going to pulmonary rehabilitation, and today was the 17th time. The woman that runs it said I’ve not improved enough. I’m O2 dependent need 6 liters at exercise. Day one I exercised 23 min. Day 2 32 min. Every day after is 40 min plus weights and  bands. I went from 1.0 on the si-fit to 1-3, weights 2 lbs to 3 lbs. I’m not sure how much I should be doing, I thought I was doing good from starting at no exercise at all.

Hope you can help.

Linda from Ascutney, VT

Dear Linda:

With most pulmonary rehabilitation programs, the first visit, or possibly a screening visit, is spent discussing the goals of the program for each person.  Did the “woman that runs it,” whom I assume is the pulmonary rehabilitation coordinator, ask about your individual goals?

Also, I would ask her what she expects as far as improvement for you.  Generally, changes from your baseline, or starting point, are most important to assess benefit.

Woman with COPD doing arm curls with hand weights.

Woman with COPD doing arm curls with hand weights.

Certainly, your increase in exercise time (? on the treadmill) from 23 minutes to 40 minutes is impressive. This represents a 74% percent improvement.  Also, the increase is hand weights from 2 to 3 lbs (+50%) is quite good.

An important benefit of pulmonary rehabilitation is improvement in doing daily activities. Do you find certain daily tasks have become easier? Or can you do something for a longer time period before you experience shortness of breath?

Once again, I would talk directly to the rehabilitation coordinator about your concerns. From the information that you have provided, it appears that you are making substantial progress. Keep up the hard work.

Best wishes,

Donald A. Mahler, M.D.



Can Someone with COPD Experience Second Wind?

What is Second Wind?

Dear Dr. Mahler:

I started pulmonary rehab at the local hospital about 5 weeks ago and have noticed what I call a “second wind” at times walking on the treadmill or riding the bike. My doctor has told me that my lungs are working at 53% of normal, and I take Anoro in the morning along with albuterol inhaler when I need some more relief. Can someone with COPD experience a “second wind?”

Bill from Davenport, IA

Dear Bill,

I congratulate you on participating in pulmonary rehabilitation program. There are many benefits of a supervised exercise training program, one of which is less breathlessness with daily activities.

“Second wind” is a person’s ability to breathe freely during exercise, after having been out of breath. One person described it as, “To me, it just feels like I have something left in the tank.  It’s a confidence that, between energy stores and breathing, I feel like I can do more.”

For many people, the first experience of “second wind” occurs when playing sports.  For those with COPD, “second wind” may occur during a pulmonary rehabilitation session.  Although “second wind” may be hard to explain to others, most everyone agrees that it is a pleasant feeling.

If those who  have not experienced “second wind,” consider that the start of exercise can be associated with feeling sluggish, slow to move, and it may even be hard to breathe.  These initial feelings may be unpleasant so that you may even think about stopping or “giving up.”  However, if you are able to continue, the motions of your arms, legs, and entire body may become more fluid and your energy level rises.  It is possible, even likely, that breathing becomes easier.

Woman walking on treadmill to achieve second wind

Woman exercising on treadmill

Certainly, you can experience “second wind.”  Scientists suggest that “second wind” occurs when a physical activity lasts for at least 10 minutes.  Some individuals with asthma or COPD have told me that they have experienced a “second wind” while doing any sustained activity such as house work, yard work, walking, and hiking. The key is that the activity needs to be sustained.

The 10 minute requirement is a reason why those participating in pulmonary rehabilitation have the best chance of experiencing a “second wind.”  The sessions are supervised by a trained professional who monitors your body’s responses (heart rate, breathing, and oxygen level) and also provides encouragement to do more than you did last session or last week.  The entire experience provides an environment for safely “pushing yourself” to exercise beyond the 10 minutes in order to hopefully experience a “second wind.”


Donald A. Mahler, M.D.