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.

Is Cold Air Dangerous For My Lungs?

How To Deal With Cold Air and Breathing

Dear Dr. Mahler:

I have had COPD for about 4 years and live in Mankato, Minnesota, where it gets very cold during the winter months. I try to go outside most days, but I am worried that the cold air will bother or hurt my lungs. It always seems harder to breathe when it is below zero. During other times of the year, I am quite active. My inhalers include Bevespi twice a day and Ventolin for rescue. What are your thoughts?

Debra from Mankato, MN

Dear Debra,

Breathing in cold and dry air can irritate the breathing tubes, particularly if you have asthma or COPD. Typical symptoms are cough, shortness of breath, and even feeling as if your lungs “hurt.”

There is no evidence that the lungs actually freeze if someone breathes in cold air. The nose and mouth are built to warm and humidify cold and dry air before this air reaches deep into the lungs.

Here are some tips for dealing with cold air and your COPD.

  1. Place a scarf over your nose and mouth or wear a cold weather face mask. A scarf helps to lock in warm air that you are exhaling. In addition, the common cold virus replicates more rapidly in your nose when bathed by cold air.
    Person wearing scarf shows how to deal with cold air and breathing

    Woman using scarf over mouth to keep in warm air that is exhaled

    An alternative approach is to purchase a cold weather mask as shown below. Wearing a face mask will keep your mouth and nose from the cold and wind. Masks are often made of water and wind resistant neoprene shells and feature breathing holes that are used to easily allow air passage to where your mouth is. Make sure to choose a face mask that’s lined with fleece that will provide comfort and warmth to your skin.

    Wearing a face mask will keep your mouth and nose from the cold and wind. Masks are often made of water and wind resistant neoprene shells and feature breathing holes that are used to easily allow air passage to where your mouth is. Make sure to choose a face mask that’s lined with fleece that will provide comfort and warmth to your skin.

    Man wearing a cold weather face mask in Toronto

  2. Pre-heat your car or truck. If possible, ask a family member to start the vehicle for a few minutes before you go out.
  3. If you use oxygen, place your oxygen tubing inside your coat to keep it warm. The cold temperature may stiffen the tubing, possibly reducing the flow of oxygen.
  4. Minimize exertion outdoors when it is cold. See if someone else can carry your oxygen system and any packages.
  5. Drink a warm glass of tea, coffee, or cocoa when you return home. This will help to “warm you up.”

Debra – I hope that these simple “tips” are helpful to you dealing with cold air. Keep active indoors during the winter months.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.

Best wishes,

Donald A. Mahler, M.D.


Valve Treatment of Emphysema Improves Breathlessness

Valve Treatment – A Minimally Invasive Approach For Emphysema

Background:  Emphysema is a type of COPD in which lung tissue is

Valve treatment can be used to reduce hyperinflation

On left: Normal size of lungs.
On right: lungs are larger due to inability to exhale completely. This is called hyperinflation.

destroyed. As a result, the person is unable to completely empty air out of the lungs.  This is called lung hyperinflation which is a major cause of shortness of breath and poor quality of life.

Surgery is one way to remove parts of the lung that are hyperinflated. However, this approach is seldom used because it is invasive and carries some risk.

A safer approach is to place valves into breathing tubes in areas of poorly functioning lungs. These one-way valves allow air to leave the lungs and prevent air entry; this reduces the amount of air trapped in the lung. The valves are placed using a tube (called a bronchoscope) that is passed into the mouth and then advanced into the breathing tubes.

Bronchoscopy used to assesss whether valve treatment is appropriate

Diagram of a scope passed into the mouth and then advanced into the lungs (called bronchoscopy)

Zephyr is a type used for valve treatment of emphysema

One type of endobronchial valve being evaluated is called Zephyr.

An endobronchial valve (called a Zephyr valve) is shown on the left. Until now, only two studies have been completed to evaluate this type of valve placed into breathing tubes. Each study was done at a single medical center. This makes it difficult to know if the results would be similar at other hospitals.

Study: A study evaluated placement of Zephyr endobronchial valves at 17 different medical centers in Europe. All patients had severe emphysema with no passage of air between parts of the lung (no collateral ventilation). The main outcome was the percentage of subjects with a 12% or higher increase in the amount of air exhaled in one second (FEV1) compared to before the procedure. The findings were published in the December 15, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (volume 196; pages 1535-1543).

Results: 65 subjects received placement of one or more valves while 32 subjects continued to receive normal care (the comparison group). At 3 months after valve placements, 55% improved their breathing tests by at least 12%, while only 7% in normal care group showed improvements. At 6 months after treatment, the valve group had an average increase in FEV1 of 21%, while there was 9% decrease in those who received normal care.

In addition, the valve treatment group had significantly better scores for shortness of breath and for quality of life and walked farther on the six minute walk test.

Lung collapse (called pneumothorax) occurred in 29% of those who received valve placement.

Conclusions: The authors concluded that valve treatment resulted in clinically meaningful benefits in lung function, shortness of breath, exercise tolerance, and quality of life. They also considered that there was “an acceptable safety profile.”

My Comments: The findings in this study provide additional support for the benefits of Zephyr valve placements to “deflate” the lungs in those with advanced emphysema. From the individual’s perspective, the most important outcomes were improved shortness of breath, ability to walk farther, and quality of life.

Identifying the “right” individual with emphysema who will benefit from valve placement is important. Before entering the study, all subjects had to qualify by having: 1. low breathing test results; 2. a CT scan of the chest which demonstrated evidence of emphysema that was at least 10% different between the “bad” part of the lung and an adjacent “good” part of the lung; and 3. no evidence of collateral ventilation using a special bronchoscopy test (see my post on December 27, 2015, for measuring collateral ventilation).

For Pain and Breathlessness: Is Any Medication Helpful?

Medications to Relieve Both Pain and Breathlessness

Dear Dr. Mahler:

Working on trying to get off pain medication-in addition to COPD I have hip and back pain issues. My doctor has been changing the drugs and manufacturers – they don’t agree with me, Considering cannibus- do you know of any specific type that might help me for both pain and breathlessness? Any suggestions will be greatly appreciated- thank you.

Gerald from Miami, OH

Dear Gerald:

Your question is quite relevant because many individuals who have COPD also suffer from pain.

The first question that I ask is do you know the cause(s) of pain in your hip and back? This is important because certain problems may be treated with surgery. For example, hip replacement is possible for severe arthritis of the hip. Also, back surgery (laminectomy) can be performed for some individuals with spinal stenosis. I encourage you to ask your health care professionals about why you are experiencing pain. It is possible that an evaluation with an orthopedic physician may be appropriate if not already done.

Can Cannabis Relieve Pain?

On July 5, 2017, I posted information about the two major components of the the marijuana plant (which is officially called Cannabis sativa)  –  cannabidiol (abbreviated CBD) and tetrahydrocannabinol (abbreivated THC). CBD is thought to have anti-inflammatory effects, while THC provides the “high” that people experience when smoking or eating marijuana.

Here is information from the July 5 post:

“CBD oil is taken by mouth, rubbed on the skin, or may be inhaled. One of the main uses is to relieve pain and stiffness. In one study involving rats and mice, CBD significantly reduced chronic inflammation and pain. CBD is already in use for humans who have multiple sclerosis and fibromyalgia – both of which can cause chronic pain.”

Can cannabis sativa relieve pain and breathlessness?

Cannabis sativa plant

Can Cannabis Relieve Breathing Difficulty?

To my knowledge, there is no evidence that either CBD or THC makes t easier to breathe. In the book Breathe Easy (published June 2017), I provide information on medical treatments for COPD (Chapter 5) as well as other treatments to relieve shortness of breath (Chapter 9). Information about the book is available under the heading Books on my website.

Are There Medications to Help Both Pain and Breathlessness?

Opioids are narcotic medications that are used to treat both pain and breathing difficulty. I have two posts on my website about similar questions to yours. The posts were on June 29, 2016, and April 22, 2017. I suggest that you check this out by typing in “Opioids” in the Search function of the website.

I hope that this information is helpful to you.

Best wishes,

Donald A. Mahler, M.D.

Perceptions about COPD by Patients and Physicians

Perceptions about COPD: Survey Results of Patients and Physicians

Background: Little is known whether patients with COPD and physicians have similar or different views about the disease.

Study: Dr. Celli and colleagues reported on the results of two similar surveys

Dr. Celli is the first author of the study evaluating perceptions of COPD by patients and physicians

Bartolome Celli, M.D., of Brigham and Women’s Hospital

completed on-line. The aim was to compare potential differences between how COPD patients view their disease and how physicians view the disease that affects their patients. The study was published in the International Journal of COPD 2017; volume 12, pages 2189-2196.

Results:  All participants lived in Germany, Italy. or Spain. There were 334 patients with COPD, 333 General Practitioners, and 333 pulmonary specialists.

General COPD was regarded as a major health problem by both patients and physicians.

Symptoms Physicians generally paid more attention to cough, sputum (coughing up mucus), and shortness of breath of patients, while patients paid more attention to feelings of chest tightness, wheezing, and tiredness.

Honesty Almost 90% of patients declared that most of the time they were not completely frank and open with their doctors during visits. A smaller percentage of physicians had the same impression: 53% of general practitioners and 49% of pulmonary specialists thought that most of the time patients were not entirely truthful.

Conclusions: The authors concluded about perceptions that: 1. patients should be more frank and honest reporting their symptoms and feelings, and 2. physicians should be more aware of other symptoms as well as the impact of COPD on leisure and social activities.

My Comments: The lack of truthfulness by patients is quite puzzling if one assumes the goal of a visit with a physician is to deal with a medical problem and/or to optimize the person’s health. It is possible that patients may not be completely frank and open because of concerns of being judged or possibly disappointing their physician. This may be particularly relevant for someone who has COPD and continues to smoke.


Home-based Pulmonary Rehabilitation: Benefits Similar to a Standard Program

Home-based Pulmonary Rehabilitation: An Alternative Approach

Background: Unfortunately, overall participation in standard pulmonary rehabilitation programs is low. The many reasons include no interest, “I am too busy,” travel time, inconvenience, and cost, depending on the individual’s medical insurance.

Although home-based pulmonary rehabilitation offers an alternative, there is little information about its benefits. Does it work as well as a person going to the hospital or facility with an experienced nurse, respiratory therapist, and/or an exercise specialist?

Dr. Elizabeth Horton

Dr. Elizabeth Horton is Senior Lecturer in Exercise and Health at Coventry University

Study: Dr. Elizabeth Horton and colleagues from the Faculty of Health and Life Sciences, Coventry University, and the Centre for Exercise and Rehabilitation Science, University Hospitals Leicester NHS Trust, in the United Kingdom performed the study. 187 patients with COPD referred to their hospitals for pulmonary rehabilitation were assigned to either a standard program supervised by trained professionals OR to a structured unsupervised home-based pulmonary rehabilitation program. Shortness of breath with activities was selected as the main outcome to compare whether the home-based program was “as good as” the hospital-based program.

The home-based pulmonary rehabilitation program included one hospital visit with a health care professional trained in motivational interviewing, a self-management manual, instructions on exercise, and two telephone calls over the 7 weeks.

Different exercises as part of a home-based pulmonary rehabilitation program

Different types of exercises can be performed as part of a home-based pulmonary rehabilitation program

The study was published on-line on July 29, 2017, in the journal Thorax (doi: 10.1136/thoraxjnl-2016-208506).

Results: Both groups of patients had significant, but similar, gains in shortness of breath measured on the Chronic Respiratory Questionnaire Self-Report after 7 weeks. The authors did not report on changes in other outcomes such as exercise ability or albuterol rescue use.

Conclusions: The authors concluded that a structured home-based pulmonary rehabilitation program was “as good as” the standard hospital-based program for improving daily shortness of  breath.

My Comments: Not everyone with COPD is interested or able to perform physical activities for a variety of reasons. For almost all patients with COPD whom I see in my practice, I recommend participation in a standard pulmonary rehabilitation program . Major benefits include: better breathing; better quality of life; less frequent flare-ups (exacerbations); and the ability to do more physical activities.

Water exercise may be part of a home-based pulmonary rehabilitation program

Water Aerobics may be part of a home-based pulmonary rehabilitation program

If this is not possible, then I encourage the person to “do more” on their own. This may using a treadmill or exercise bike in their apartment or home, going to a community fitness center, and/or using an available swimming pool. I ask the person to write down these activities on paper or on the computer and bring this information at their next appointment.

Combination Bronchodilators – An Analysis of Benefits

Combination Bronchodilators Improve Lung Function, Quality of Life, and Shortness of Breath

Background: There are two different types of bronchodilators (inhaled medications) that relax the muscle that wraps around the breathing tubes to allow more air to go in and out of the lungs. One type is called a beta2-agonist, and the other type is called a muscarinic antagonist.

Respiratory system - shows where combination bronchodilators work to open airways

Most of the 23 branches (divisions) of breathing tubes have muscle that wraps around the outside.

Why is This Is Important for You to Know? Because these two types of bronchodilators work in different ways to open breathing tubes. In the US, there are currently 4 available combinations of these two types of bronchodilators in a single inhaler device. In alphabetical order, the brand names are: Anoro; Bevespi; Stiolto; and Utibron.

Study: Because these combination bronchodilators are relatively new, Dr. Oba and colleagues at the University of Missouri School of Medicine reviewed 23 different studies that compared combination bronchodilators with one bronchodilators (called monotherapy). The analysis was published in the journal Thorax; year 2016; volume 71; pages 15-25.

Results: A total of 27,172 patients with COPD were included in the analysis. The combination bronchodilators had significantly greater improvements in breathing tests, quality of life score, and shortness of breath with daily activities compared with just one bronchodilator. In addition, there were fewer moderate-to-severe flare-ups (called exacerbations) with combination therapies compared with long-acting beta2 bronchodilators, but not compared with long-acting muscarinic antagonists.

Finally, there were no differences in safety with combination bronchodilators compared with a single medication.

Conclusions: Combination therapy was most effective in improving breathing tests, ability to breathe easier with daily activities, and overall quality of life. Safety was similar between combinations and monotherapy.

Like lollipops, combnation bronchodilators are better than one

Child holding two lollipops

My Comments: These findings support the simple observation that 2 is better than 1 with most things in life, including bronchodilators. Certainly, most children would rather have two lollipops than just one. The same concept applies to combination bronchodilators for those with COPD. Make sure to ask your health care professional whether you would benefit from combination therapy.

Depression in COPD: Benefits of Treating Both Conditions

Depression in COPD: Treatments Reduce Visits to Emergency Department

Background: Depression is common in any chronic illness, including COPD. For example, in a three year study of 1,589 individuals with COPD about 1 in 4 individuals with COPD had persistent symptoms of depression over a three year period (CHEST 2016; volume 149: pages 916-926). Those with persistent or new-onset depression experienced more flare-ups (exacerbations) and a reduced walking distance.

Dr. Albrecht wrote about depression in COPD

Jennifer S. Albrecht, Ph.D., Assistant Professor at the University of Maryland School of Medicine

Study: Dr. Albrecht and colleagues from the University of Maryland School of Medicine reported on adherence to medications prescribed to treat both COPD and depression in the same individuals. Adherence refers to whether  you are taking the medications on schedule as prescribed by your health care professional.

The authors examined a random sample of those receiving Medicare who had two or more prescriptions filled for both COPD maintenance medications and anti-depressants. These individuals were followed for 12 months.

The study was published on-line in the journal Respiratory Medicine.

Results: Of the 16,075 individuals receiving Medicare, only 21% took their medications at least 80% of the time for COPD, and only 55% took their  anti-depressants at least 80% of the time. Compared to no use of medication and controlling for adherence to anti-depressants, higher levels of taking COPD medications were associated with a decreased risk of going to the Emergency Department (ED) and hospitalization. Also, higher levels of taking anti-depression medications led to fewer visits to the ED and hospitalizations compared to no use.

Depression in COPD in a woman

Woman with depression

Conclusions: Depression in COPD is common. Taking prescribed daily medications for both conditions – COPD and depression – can reduce the need for emergency visits and hospitalizations.

My Comments: There are many different reasons why someone does not take medications as prescribed even to help relieve symptoms (COPD → difficulty breathing; depression → feeling bad).

Some of the common reasons shared by patients in my practice for not taking medications are: cost (“It is very expensive”), lack of efficacy (“It doesn’t seem to work”), “I forget to take it,” and concern of side effects (“The TV add says that it may cause death”).

However, I often explain why I prescribe a particular medication, and review how to use a specific inhaler correctly. I ask the person to try the inhaler for 2-3 weeks (I usually give a sample), and that I will prescribe a different inhaler if it does not help with shortness of breath and/or reduce flare-ups (exacerbations).

Hookah Smoking Is Risk Factor for Chronic Obstructive Pulmonary Disease

Hookah Smoking 

Owner of cafe for hookah smoking

40 year old owner of cafe in United Kingdom with hookah pipe

Background: Hookah smoking involves inhaling flavored tobacco from a Turkish water pipe. It is also called “hubbly-bubbly” or “shisha” and is becoming fashionable among young people, especially in cities.

The World Health Organization has warned that a one-hour session of hookah smoking can be as harmful as smoing 100

Cigarette smoking versus hookah smoking

Smokers typically take in 12 puffs on a cigarette compared to up to 200 for hookah pipes

cigarettes. This is because a cigarette smoker typically takes between 8 to 12 puffs. In contrast, during a typical hour long hookah session, smokers may take up to 200 drags.

Hookah tobacco tastes nicer than cigarettes because of the flavor, but contains all of the same toxins known to cause lung cancer, heart disease, and COPD.

Study: In the May 23, 2017, issue of the journal Chronic Respiratory Disease, Dr. Bahtouee and colleagues from the Bushehr University of Medical Sciences in Iran reported on the frequency of COPD in hookah smokers. These researchers performed breathing tests in 245 subjects who were at least 35 years of age who were taking hookah for at least 15 years and in 245 subjects who did not smoke hookah.

Results:  Ten percent of the chronic hookah smokers had COPD. The rate was higher in those with older age, 3 or more hookahs each day, number of years of hookah smoking, daily cough of mucus and shortness of breath for two or more years.

Conclusions: Hookah smoking significantly increases the risk of COPD.

My Comments: Smoking flavored tobacco from a water pipe occurs throughout the world. A review shows that current hookah smoking among university students is 6% in the Persian Gulf region, 8% in the United Kingdom, and 10% in the United States.  States with highest prevalence were the District of Columbia (17%), Nevada (16%), and California (16%). Current hookah smoking among high school students in the US is 5.4%.

It is important to educate everyone that hookah smoking causes COPD as well as other diseases associated with cigarette smoking.

Pulmonary Embolism Can Cause A COPD Flare-up (Exacerbation)

Pulmonary Embolism Cause of 16% of Unexplained COPD Flare-ups

Background: About 70% of flare-ups of COPD (called exacerbations) are usually due to chest infections (bronchitis or pneumonia). In 30% of the time, there is no clear cause or explanation. One possibility is inhaling irritants in

Deep vein thrombosis can break off and cause pulmonary embolism

Swelling of right leg due to blood clot (called deep vein thrombosis)

the air. Another possibility is a pulmonary embolism – the medical term for a blood clot that usually starts in the legs (called deep vein thrombosis), then breaks off, and travels to the lungs. This can cause sudden shortness of breath as well as chest pain.

A blood clot in the legs can cause swelling of the leg as seen in the photo on the right. A diagram of a blood clot in a blood vessel in the leg is shown below.

Blood clot can break off and cause pulmonary embolism

Blood clot is shown above left knee.





A blood clot in the lung is typically diagnosed by a CT scan of the chest with injection of dye (contrast) into a blood vessel of the arm.

Study: Dr. Aleva and colleagues from Nijmegen, The Netherlands, performed an analysis of seven published studies examining causes of COPD flare-ups. This is called a meta-analysis. The results were published in the March 2017 issue of the journal CHEST (volume 151; pages 544-554).

Results: Of 880 patients with an unexplained flare-up of COPD, 16% were due to pulmonary embolism. In one study, those with pulmonary embolism were more likely to have chest pain when breathing in (81%) compared with those who did not have a pulmonary embolism (40%). Also, those with pulmonary embolism were less likely to have symptoms of a respiratory infection (coughing up yellow-green mucus and chest congestion).

Conclusions: Pulmonary embolism is a frequent cause of unexplained flare-ups of COPD. The authors suggest the health care providers consider this diagnosis especially when someone has chest pain and signs of heart failure and when a chest infection appears unlikely.

My Comments: If you have a flare-up of COPD and do not have an apparent chest infection, you should be aware that a blood clot in the leg may travel to the lungs and cause shortness of breath and possible chest pain. A CT scan of the chest is typically performed to look for this problem. If found, then blood thinning medication (called anti-coagulation) is required to prevent new blood clots from forming. The body will then dissolve the blood clots in the leg and chest.

Reduction in Opioids for Pain: Could This Make My Breathing Worse?

Reduction in Opioids and Breathing is Worse

Dear Dr. Mahler:

I have COPD-my Dr. has taken me completely off the Fentanyl patch which I used for years – I have several issues that cause me a lot of pain. I have also been on Vicodin – 8 each day. They are now cutting back on it.
My problem is my breathing has worsened and I have had increased breathing exacerbations with these cut backs. Do you think there could be a connection?
Do you have any suggestions for me? Between the pain and breathing issues my quality of life is bad and I am depressed that I can’t do the things I used to. I use the Stiolto Respimat and Albulterol when I have a bad breathing situation.
Would really appreciate if you would have any suggestions for me. THANK YOU.

Sandra from Little Rock, AK

Dear Sandra:

Your experience is not unusual.

opium poppy is source of natural opiods

Opium poppy

Both fentanyl and vicodin are opioids that act on receptors in the body to relieve pain. Opioids include opiates that found in the resin of the opium poppy (incluidng morphine) as well as medications made in laboratories that are called synthetic drugs. These include fentanyl and vicodin [hydrocodone and acetaminophin (brand name is tylenol)] which you are or were taking.

Opioids are also helpful to relieve shortness of breath. Usually, they are used for those with advanced disease for palliation. It is quite possible that your worsening in breathing is related to the reduction in opioids. Remember that opioids may cause side effects including tiredness, low energy, sleepiness, and constipation.

water exercise may help shortness of breath due to reduction in opioids

Seniors doing Water Aerobics

exercise may help with shortness of breath due to reduction in opioids

Man pedaling stationary cycle being supervised by rehabilitation specialist.

Could the combination of your COPD and use of fentanyl/vicodin led to an inactive life style? If so, is it possible for you to do more activities to improve your breathing, or does your pain limit activity level? Is participation in a pulmonary rehabilitation program a possibility for you? Are water activities possible with your pain problem?

Another question that I have relates to your report of exacerbations with reduction in opioids. Are you experiencing chest congestion and coughing up yellow or green mucus with these episodes? If so, I suggest that you ask your doctor to check for bronchiectasis (see post on April 21, 2017, under COPD News) and acquired immunodeficiency (see post on November 23, 2016, under COPD News). Both of these conditions may lead to frequent flare-ups.

Finally, you may wish to ask your doctor about starting an inhaled corticosteroid medication to help reduce the risk of future flare-ups. Your current use of Stiolto Respimat as a maintenance medication is excellent as it contains two different types of long-acting bronchodilators. The 2017 GOLD recommendations suggest that an inhaled cortiosteroid be added to a medication like Stiolto if you continue to experience exacerbations.

I hope this information is helpful. Best wishes,

Donald A. Mahler, M.D.

COPD in Women: Key Findings

COPD in Women Increasing More Rapidly Worldwide

Background: COPD in women receives little attention as a health issue even though more women die of COPD each year than of breast cancer and lung cancer combined. The general perception that COPD is a disease of older men is outdated. Throughout the world, COPD is increasing more rapidly in women than in men. Since 2000, more women than men in the United States die of COPD.

Dr. Jenkins has written about COPD in women

Professor Christine Jenkins

Review: Dr. Christine Jenkins of Sydney, Australia, and co-authors described the impact of female sex on COPD in a review article in the March 2017 issue of Chest, volume 151; pages 686-696.

Key Findings about COPD in Women: 1. For the same amount of smoking or exposure to irritants in the air, women are more susceptible to developing COPD. 2. The reasons for smoking may differ between sexes. Dr. Jenkins proposed that female empowerment through tobacco smoking and weight control are likely two reasons that women smoke. 3. Women with COPD are generally younger, smoke less, and have a lower body weight for their height than men. 4. Women tend to have more shortness of breath than men for the same level of breathing tests results. 5. In a 3-year study in the US, it was found that women had more frequent flare-ups (exacerbations) of COPD than men.

Female with COPD

How Does COPD Affect Women? In many studies it was noted that women have poorer health status and quality of life compared with men. Women with COPD report higher levels of anxiety and depression than men with COPD which adds to the burden of the disease in women.

Treating Women with COPD: Smoking cessation is an important treatment for anyone with COPD. However, women may be less successful with long-term smoking cessation than men, especially with nicotine replacement therapy. Current evidence shows that inhaled bronchodilators work the same in women as in men.

COPD in Women

Summary: The authors concluded that it is important to raise awareness of COPD in women and to develop new strategies to prevent the disease.  They also emphasized the need for educational programs for women with COPD and their families to manage their disease better.

My Comments: I offer the following two general impressions based on my pulmonary practice, although I have no explanation for these observations. 1. Women with COPD seem more motivated to “get better” and use prescribed inhalers as recommended. 2. Women are more likely than men to actually participate in pulmonary rehabilitation programs.


Smoking Marijuana: Is It Safe for Someone with Mild COPD?

Smoking Marijuana and the Lungs

Dear Dr. Mahler:

I live in Massachusetts where marijuana was legalized for recreational use this past November. What are your thoughts for smoking an occasional joint to “chill?” My primary care doctor has told me that I have mild COPD. I smoked cigarettes for about 20 years, but quit two years ago. I am currently taking Tudorza Pressair twice a day, and may use ProAir a few times a month. How safe is smoking marijuana for my lungs?

Brian from Wooster, MA

Dear Brian:

Marijuana is the second most commonly smoked substance after tobacco.

Plant used for smoking marijuana

Marijuana plant

Although the harmful effects of tobacco smoke are well known, there is less information about the health effects of smoking marijuana. As most people know, marijuana can be inhaled in many ways – a joint, vaping, and water pipes – are the most common. It is impossible to predict if you will experience any lung damage from smoking an “occasional joint.” Here is some health information for you to consider.

How can smoking marijuana damage my lungs? Smoke of any kind can cause bronchitis – inflammation and swelling of the breathing tubes. Marijuana smoke contains many of the same harmful chemicals as in tobacco smoke. We do not know if light users who smoke an amount equal to 1 – 2 joints a month over a long time may worsen your mild COPD. 

Smoking marijuana may cause a lung bullae

Arrows shows a lung bulla in the right upper lobe of the lung

There is evidence that smoking marijuana can cause large air sacs, called bullea, to develop in the lung. This is more likely to happen in younger marijuana smokers (less than 45 years of age). A bulla can cause someone to be short of breathe and may rupture or “pop.” Air leaking from a ruptured bulla can lead to a collapsed lung called a pneumothorax.

For anyone with asthma or COPD, smoking marijuana can cause a “breathing attack.”

What symptoms indicate that smoking marijuana is affecting my lungs? Like tobacco smoke, marijuana smoke can cause coughing, mucus, wheezing, shortness of breath, and swelling in the throat.

Does smoking marijuana increase my risk of lung cancer? The answer is unclear, but it may increase the risk of lung cancer as marijuana smoke contains over 450 unique chemicals including those that can cause cancer (called carcinogens).

Can marijuana increase my risk of a lung infection? Marijuana smokers can develop a lung infection from a mold called aspergillus. The mold, or fungus, lives on marijuana plants and is inhaled in smoke. 

Has marijuana been used to treat some medical problems? Yes, marijuana has been used to treat many conditions including nausea and chronic pain. Several states allow health care providers to prescribe marijuana for health reasons. However, the Food and Drug Administration (FDA) has not approved marijuana for any medical condition. The FDA has approved medications that contain tetrahydrocannabinol (THC), the active ingredient in marijuana, for treatment of pain and nausea.

In summary, smoke of any kind has the potential to damage your lungs, and is not recommended for anyone who has a lung condition. I hope that his information is helpful for you in making an informed decision.


Donald A. Mahler, M.D.



Breathe Easier with Two Bronchodilators: Less Shortness of Breath and Less Albuterol Use

Breathe Easier with Two Bronchodilators

Background: About 90% of patients with COPD are still short of breath with activities if using a single long-acting bronchodilator (either a beta-agonist or a muscarinic antagonist). In such situations, the 2017 GOLD statement recommends use of a combination of both classes of bronchodilators to achieve the best effects (see my post under the heading COPD News on December 3, 2016). Thus, the experts on the GOLD committee agree that you should be able to breathe easier with two bronchodilators. 

Study: Dr. Edward Kerwin and co-authors who work at GlaxoSmithKline pharmaceutical company studied a total of 494 patients with COPD who reported that they experienced at least some shortness of breath despite taking a long-acting bronchodilator tiotropium (brand name: Spiriva) in the HandiHaler device for at least three months. Patients were assigned by chance to either continue Spiriva HandiHaler OR to use a combination of

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta contains two different bronchodilaors

two bronchodilators (brand name: Anoro Ellipta). The study results were published in the International Journal of COPD, 2017, volume 12, pages 745-755.

Results: Compared with a single bronchodilator (brand name, Spiriva HandiHaler), there were significantly greater improvements in breathing tests (lung function), the need to use albuterol as a rescue inhaler, and in shortness of breathe with activities of daily living. There were no differences is side effects between treatments.

Conclusions: Two different classes of bronchodilators provide greater benefits, including being able to breathe easier, than one bronchodilator.

My Comments: The results of this study are consistent with several other trials showing quite simply that “two is better than one” in most things in life including inhaled bronchodilators.

Bevespi contains two different bronchodilators in a single device

Bevespi Aerosphere contains two different bronchodilators

At the present time there are three available “two in one” bronchodilator inhalers – brand names are Anoro, Stiolto, and Bevespi. A fourth one called Utibron should become available in the near future.

Stiolto Respimat contains two different bronchodilators

If you are taking a single inhaled bronchodilator and have shortness of breath, I suggest that you ask your health care professional whether a trial of a “combination bronchodilator” is reasonable. At least one of these options should be covered by most health insurance policies.


Chronic Heart Disease Occurs Frequently in Those with COPD

Heart Disease and COPD – Shared Risk Factors

Study: A December 1, 2016, article in the American Journal of Respiratory and Critical Care Medicine (volume 194; pages 1319-1336) reviewed information about cardiac disease in those with COPD. (DOI: 10.1164/rccm.201604-0690SO)

COPD and heart disease share risk factors that include:

  1. Older age
  2. Cigarette smoking
  3. Physical inactivity
  4. Low-grade inflammation in the body
Heart disease can occur in different parts of the heart.

Diagram of the heart

Heart disease is more common in those who have COPD (from 10 – 30%) compared with the adult population (about 1 – 2%). It contributes to the severity of COPD and is a common cause for hospitalization and death. Both heart disease and COPD can cause the same symptoms – shortness of breath and fatigue.

The three most common heart diseases in those with COPD are:

  1. ischemic disease (narrowing of the arteries in the heart)
  2. heart failure (pumping action of the heart is impaired leading to fluid build-up in the lungs)
  3. atrial fibrillation (irregular heart rhythm).

Atrial fibrillation

Atrial fibrillation is a common heart disease in COPD

The curved arrows in the right and left atrium (upper chambers) in atrial fibrillation indicate chaotic electrical activity.

This is the most common heart rhythm problem in the general population as well as in those with COPD. The atria (two top chambers of the heart) beat irregularly AND the the ventricles (lower two chambers of the heart) do not work in sequence (together) with the atria. In those with stable COPD, atrial fibrillation occurs in 5 – 15%. In those with very severe COPD, it occurs in about 20 – 30%. Atrial fibrillation can cause shortness of breath, low energy, and a feeling of skipped heart beats. There is a risk for blood clots developing in the atria. Usually, anticoagulant medications (commonly called blood thinners) are recommended to reduce the risk of clots.

What Can You Do?

Certainly, you need to reduce risk factors for both heart and lung problems if possible. That means: do not smoke; be physically active; and do whatever possible to reduce inflammation in your body. I suggest that you view the October 17, 2016, post on my website under Frequently Asked Questions (FAQs). This post describes numerous foods that are anti-inflammatory and can boost the immune system.

Finally, I encourage you to be proactive and ask your health care provider whether any shortness of breath or fatigue that you might experience could be due to a possible heart problem in addition to COPD.




Updated COPD Management Recommendations by GOLD

COPD Management Recommendations by GOLD Committee

On  World COPD Day (November 16, 2016) updated recommendations for management of those with COPD were released. The group of experts from throughout the world who made the recommendations is called the GOLD committee. GOLD stands for Global Initiative for Chronic Obstructive Lung Disease.

Bartolome Celli, M.D., of Brigham and Women's Hospital

Bartolome Celli, M.D., of Brigham and Women’s Hospital

Pulmonary physicians from the United States on the Board of Directors of GOLD include: Bartolome Celli, M.D., of Brigham and Women’s Hospital in Boston and Gerald Criner, M.D., of Louis Katz School of Medicine in Philadelphia.

Dr. Criner is on the Board of Directors which makes COPD management recommendations

Gerald Criner, M.D., Chair and Professor, Thoracic Medicine and Surgery



The COPD management recommendations can be found on the website: The major goals of treatment are to reduce symptoms (shortness of breath) and to reduce the risk of sudden worsening (called an exacerbation).

The following statements summarize the recommendations for personalized treatment of those with stable COPD.

  1. Long-acting bronchodilators (last 12 – 24 hours) are preferred over short-acting drugs (last 4 – 6 hours) for those with occasional shortness of breath.
  2. Either one or two long-acting bronchodilators may be used as initial treatment.  Increase to two bronchodilators is recommended if improvement is not achieved with one drug. The three approved dual bronchodilators available for prescription in the US are shown below.
    Anoro Ellipta enables patients to breathe easier with two bronchodilators

    Anoro Ellipta dry powder inhaler

    Stiolto Respimat delivers a fine mist.

    Stiolto Respimat delivers a fine mist.


    Bevespi contains two different bronchodilators in a single device

    Bevespi is a pressurized metered-dose inhaler

  3. For those who have a history of sudden worsening of COPD (exacerbation), use of an inhaled corticosteroid may be considered in addition to a long-acting beta-agonist bronchodilator (Advair, Symbicort, and Breo).
  4. For severe hereditary alpha-1 antitrypsin deficiency, replacement therapy (also called augmentation therapy) should be considered.
  5. Medicines to suppress coughing (called antitussives) are not recommended.
  6. If breathing difficulty is severe and disabling, low dose narcotics (opioids like morphine) may be considered.

These COPD management recommendations are based on the results of published clinical trials.   

November is National COPD Awareness Month: Wear Orange

World COPD Awareness Day is November 16 

An estimated 24 million Americans suffer from COPD, while almost one-half have not yet been diagnosed. It is likely that these individuals who don’t know that they have COPD blame their shortness of breath on “getting older” or being “out of shape.”

With early diagnosis and treatment, people with COPD can improve their quality of life and begin to breathe a little easier.

Woman promoting COPD awareness

Woman with COPD using portable oxygen system

As part of National COPD Awareness Month, many organizations and individuals are trying to raise COPD awareness by hosting events, leading discussions, and conducting other outreach activities to help people take the first step toward improving the lives of those with COPD.

The US COPD Coalition urges the nation to “GO ORANGE” for COPD in November. The color ORANGE calls attention to and provides visual solidarity among efforts across the nation. ORANGE is also the color that the U.S. Environmental Protection Agency’s Air Quality Index uses to represent days with unhealthy air quality for sensitive groups, including people with lung disease.

Breathe New Hampshire
is sponsoring a COPD Wellness Workshop from 10 am – 12 noon on November 19 @ 145 Hollis St., Unit C, Manchester, NH  03101
603-669-2411 or 800-835-8647  email

I and other panelists will be presenting information about COPD and will answer questions. I hope to see you there.

Key facts about COPD:

  1. It is the 3rd leading cause of death in the US.
  2. 5.2% of adult men and 6.7% of adult women have COPD.
  3. Alpha-1 antitrypsin deficiency is a genetic risk factor for emphysema/COPD. If you have not been tested, ask your health care provider to order the blood test.

Additional information is available on the COPD Foundation website:

Emotional Intelligence is Associated with Wellbeing and Self-Management

Emotional Intelligence Is Important in COPD

Background: Emotional intelligence is the ability to understand and manage personal thoughts and feelings. It can influence your communication with others. It is a trainable skill that has been used in corporate business to improve well-being and performance.

first author of study evaluating emotional intelligence.

Dr., Roberto Benzo of the Mayo Clinic.

Study: Dr. Roberto Benzo from the Mayo Clinic studied 310 patients with COPD who were 69 years of age on average. The key breathing test (FEV1) was 42% of the predicted value on average. All subjects answered numerous questionnaires. The study findings were published in the Annals of the American Thoracic Society in January 2016 (volume 13, pages 10-16).

Findings: Emotional intelligence was significantly and independently associated with self-management abilities, quality of life (shortness of breath, fatigue, emotions and mastery) after adjusting for age and breathing test results.

Conclusions: Dr. Benzo and his team concluded that emotional intelligence is important for those with COPD. The authors commented that attention to it may address the current gap that exists in the treatment of emotional parts of COPD which is related to decreased quality of life and increased health care use.

Store employee tying shoe of elderly shopper.

Store employee tying shoe of elderly shopper

My Comments: I congratulate Dr. Benzo and his colleagues on addressing a novel feature of COPD that has not received much attention in daily care and management efforts.

Emotional intelligence affects:

  • Performance at school or work. Emotional intelligence can help you navigate the social complexities of the workplace, lead and motivate others, and excel in your career. In fact, when it comes to gauging job candidates, many companies now view emotional intelligence as being as important as technical ability and use testing before hiring.
  • Physical health. If you’re unable to manage your emotions, you probably are not managing your stress either. This can lead to serious health problems. Uncontrolled stress can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. The first step to improving emotional intelligence is to learn how to relieve stress.
  • Mental health. Uncontrolled emotions and stress can also impact your mental health, making you vulnerable to anxiety and depression. If you are unable to understand, be comfortable with, and manage your emotions, you’ll be at risk of being unable to form strong relationships which can leave you feeling lonely and isolated.
  • Relationships. By understanding your emotions and how to control them, you’re better able to express how you feel and understand how others are feeling. This allows you to communicate more effectively and forge stronger relationships, both at work and in your personal life.

Prednisone for A Worsening (Exacerbation) of COPD

The Good and Bad of Prednisone

Dear Dr. Mahler:

My problem is that I seem to need prednisone for a long time after every cold or chest infection. I am 76 years old, have had COPD for about 3 years, and take Spiriva HandiHaler and the higher dose of Symbicort inhaler along with ProAir when needed.  Since January when I caught a chest cold, I have been on different doses most of the time. My doctor has tapered me off prednisone, but within about 3-4 days, my breathing turns bad again. Do you have any suggestions? I am concerned because I am hungry all of the time and have gained about 10 pounds since January.

Thanks for any help.

Ida from Piscataway, NJ

Dear Ida:

The body responds to any infection by calling in (recruiting) inflammation cells to fight the

A microscopic view of a blood smear shows an eosinophil (an inflammatory cell) n the center surrounded by smaller red blood cells.

A microscopic view of a blood smear shows an eosinophil (an inflammatory cell) in the center surrounded by many smaller red blood cells.

virus or bacteria. However, in a chest infection, the inflammation (appears as redness and swelling) causes the walls of the breathing tubes to thicken.  This causes narrowing of the breathing tubes (as shown on the right of the figure) making it harder to breathe.

Photo on right shows chronic bronchitis due to inflammation and there is yellow mucus inside the airway

Photo on right shows redness and swelling (inflammation) of the wall of the breathing tube. Prednisone is used to reduce inflammation for a worsening (exacerbation) of COPD.

Prednisone is frequently used to treat a chest infection that causes you to be more short of breath. It is an anti-inflammatory medication that is used to treat a lot of inflammatory conditions including a worsening of asthma and COPD. Prednisone is effective in reducing the number of eosinophils. Based on results of different studies, it is usually given at a high dose (like 40 mg) for a total of 5 days.

For unclear reasons, in some individuals the inflammation persists for weeks to months, and 5 days of treatment is not enough.  In such cases, your breathing gets worse within a few days of stopping the medication. If this is happening, you will likely need a longer course of prednisone that is tapered slowly. Because long term use may cause side  effects, you need to work closely with your health care provider to figure out the dose of prednisone and how long you will require it.

The goal should be to get you off prednisone. If this is not possible, then the goal should be the lowest dose of prednisone to allow you to breathe comfortably and function.

There are many possible side effects of prednisone.  If used short term ( a few days to a few weeks), prednisone may cause difficulty sleeping, extra energy, change in mood, a “hyper” feeling, and an increase in blood glucose (sugar).  If used long term (more than a few weeks), other problems may occur such as an increase in the risk of an infection, a feeling of fatigue, high blood pressure, weight gain, swelling of the legs, and thinning of the bones (osteoporosis). Certainly, you should discuss the benefits and possible side effects of prednisone with your health care provider.


Donald A. Mahler, M.D.


Music Therapy Improves Breathlessness and Fatigue in COPD

Weekly Music Therapy Helps Those with COPD

Reason for the Study: Many of those with COPD are socially isolated. As a result, they are less physically active, are “out of shape,” and may have symptoms of depression.  The researchers proposed that music therapy would improve breathing difficulty, psychologically well-being, and quality of life.

Study: Researchers from Mt. Sinai Hospital in New York City studied a total of 68 patients with moderate to severe COPD. Age of the subjects ranged from 48 to 88 years. The study lasted 6 weeks. It was published in the December 2015 issue of the journal Respiratory Medicine, volume 109, pages 1532-1539.

  1. Study Group: Weekly therapy sessions included live music, visualizations, playing a wind instrument (like the horn, trumpet, or flute), and singing using breath control techniques led by certified music therapists. Subjects were encouraged to choose their own music and to be active in therapeutic activities.
  2. Control Group: Standard care (continuing current treatments)
Singing Group

Singing Group

Results:  Those in the Study Group reported improvements in depression symptoms and “mastery” of their COPD along with reduced levels of shortness of breath and fatigue compared with the control group.

Dr. Jonathan Raskin, Medical Director, Pulmonary Rehabilitation, Department of Medicine, Mount Sinai Beth Israel

Dr. Jonathan Raskin, Medical Director, Pulmonary Rehabilitation, Department of Medicine, Mount Sinai Beth Israel

Comments: Coauthor Dr. Jonathan Raskin added that, “Music therapy has emerged as an essential component to an integrated approach in the management of chronic respiratory disease.” Dr. Raskin suggested that such therapy combined with participation in a pulmonary rehabilitation program may provide additive benefits in the management of COPD.

Listening to music can release endorphins into the body. This may contribute to the “good feelings” that individuals report while listening to or singing songs, and playing an instrument.

I encourage you to watch the YouTube video below of the late Fred Knittle, then 83 years young singing the song “Fix You” as part of the Young@Heart chorus. He originally rehearsed this version of “Fix You” with his best friend, but his friend passed away before the performance. Fred decided to perform alone, aided by oxygen. You won’t forget this video.


Can Cold Weather Affect COPD?

Dr. Mahler:

How severely does cold weather affect COPD? My father has COPD and is on oxygen. He lives in Northern NH. Since winter has arrived, his COPD has become significantly worse.

Lori from Worcester, MA

Dear Lori:

Exposure to cold air can cause narrowing of the breathing tubes (bronchoconstriction). This typically occurs when going from indoors to very cold air outdoors, or when exercising outdoors in the cold. I live in New Hampshire and so far the winter has not been particularly cold.

View of Presidential range in Northern New Hamphsire from Bretton Woods resort

View of Presidential range in Northern New Hamphsire from Bretton Woods resort

I suggest that your father consider other possibilities for worsening of his COPD. Do you mean that he is more short of breath? It is common for many people to be less active during the winter particularly in northern climates. How often does he get out to shop, go to appointments, visit with others, etc? Does he drive?

Less physical activity and less social interactions may contribute to depression. Could this be a factor?

It is most important that your father see his health care provider, or possibly a pulmonary physician, to help figure out his problem. He should not assume that his COPD has progressed as there are other possible explanations.

For example, does he have a history of heart disease? Breathing tests should be ordered to find out if there has been any change in his lung function. His oxygen saturation should be checked at rest with with walking to determine if his oxygen flow rate is appropriate. Some blood tests may be necessary to check for anemia, liver or kidney problems, etc.

Please share my response with your father.

Best wishes,

Donald A. Mahler, M.D.


Alpha-1 News

Food and Drug Administration holds meeting on Alpha-1 Antitrypsin Deficiency

On September 29, 2015, Alphas and Alpha-1 caregivers packed a public meeting held by the US Food and Drug Administration to discuss Patient-Focused Drug Development for Alpha-1 Antitrypsin Deficiency. About 250 people filled the room, while about 600 attended online.

Alpha-1 Foundation Board member Liz Johnson explained the impact of Alpha-1 on daily life based on results of a survey of just under 1,700 response: 1. Nearly 100% of those with Alpha-1 affecting their lungs reported shortness of breath.  2. 37% of these individuals reported that shortness of breath had a significant or extremely significant effect on their daily lives,  including dressing, washing, bending down, or tying shoes. 3. 72% of the total noted breathlessness with exercise. 4. Among those affected with liver involvement, 74% reported abdominal pain as a symptom, and 73% had abdominal swelling.

Fred Walsh, AlphaNet coordinator

Fred Walsh, AlphaNet coordinator

AlphaNet coordinator Fred Walsh commented that: “Pulmonary rehab is essential and should be widely available and inexpensive. A rescue inhaler can help everybody. I can’t believe there is no generic version of albuterol.”

Most speakers said that they were satisfied with augmentation therapy, but nearly all expressed the need for new therapies, especially for Alpha-1 liver disease.

Pujita Vaidya, MPH, gave an overview of the Patient-Focused Drug Development Initiative and said that the FDA will summarize patient testimony with a summary of “What We Learned,” from the Alpha-1 hearing.

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 -



Acupuncture for Relief of Breathlessness

Can Acupuncture Help my Breathing?

Dear Dr. Mahler:

I want to know your thoughts on using acupuncture to help my breathing.   I was told 6 years ago that I had COPD, and my breathing continues to slowly get worse. I was taking Spiriva and Advair for years, and use ProAir several times a day. My doctor recently had me stop both Spiriva and Advair, and tried me on Anoro.  It may have helped a little, but I really can’t do the things that I want because I get winded easily. On some days, I am short of breath just getting out of bed or getting dressed. I did pulmonary rehabilitation in the past, but can’t exercise because of back pain due to spinal stenosis. I tried acupuncture a few years ago for my back pain, and it helped a lot. Do you think that it can help my breathing problem?

Betty from Red Bank, NJ

Dear Betty:

According to traditional Chinese medicine, qi is the life force that flows through pathways in our body. If there is an  imbalance between complementary forces – yin (means shady side) and yang (means sunny side) – qi is disrupted and illness develops. Acupuncture involves the placement of thin needles into the skin to correct imbalances in qi.  There are at least 350 different acupuncture points in the body where energy flow can be accessed. Generally, at each treatment, 5 – 20 needles are inserted at various acupuncture sites and left in place for 10 – 20 min. Usually, there are 6 – 12 treatments over a few months.

Multiple needles placed into skin of individual.

Multiple needles placed into skin of individual.

Acupuncture is most commonly used for pain relief, and is generally safe when done by an appropriately trained practitioner using clean technique and single-use needles.

Effects of Acupuncture in COPD

Different studies have examined the effects of acupuncture for those who have COPD. In November 2014, Coyle and colleagues from Australia reviewed the results of 16 studies which compared acupuncture with no treatment in patients with COPD (medical journal: Alternative Therapies in Health and Medicine)( Overall, patients had less breathlessness and had better quality of life after acupuncture compared with placebo (sham or pretend treatment). In a few studies, investigators measured levels of endorphins (naturally occurring narcotic substances made in our bodies), and found that they increased after acupuncture, while there was no change in these levels after placebo. It is possible that the release of endorphins (just like taking morphine) with acupuncture may have contributed to a feeling that breathing was easier and quality of life was improved.

Should You Try Acupuncture?

I suggest that you share this information  with your doctor and ask about any possible risks. Also, you will need to find out if there is a licensed acupuncturist in your area. If there is, you may wish to call her/his office and ask specifically about that person’s experience in treating those with COPD. Acupressure points for relieving breathing problems are shown below (sites A – E).

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problems.

Acupressure points for relieving breathing problemPlease let me know if you try acupuncture and whether it is helpful for you.

Please let me know if you try acupuncture and if it helps you.  Best wishes,

Donald A. Mahler, M.D.

Difficulty Having Sex

Question about Difficulty Having Sex

Dear Dr. Mahler:

I am having difficulty having sex with my wife. I am 57 years old, and have been married for 25 years. My doctor says that I have moderate COPD with a touch of emphysema. My COPD medications are Spiriva in the morning, and ProAir as rescue inhaler which I use 1 -2 times a day. Both help me breathe easier. I work four 12-hour days as a foreman at a gun factory, and am tired a lot of the time.

It is hard to write about this, but our sex life isn’t what it used to be. I want to have sex on the weekends, but my breathing gets difficult when I get excited and my junk isn’t always ready. My doctor seems very young, and I am not comfortable talking to her about this problem. The commercials on television are interesting, but I have not tried any ED medications. Do you have any suggestions?

Bill from Warren, CT

Dear Bill,

Your question – about difficulty having sex by someone who has COPD – is generally not discussed during medical training, and there is little written in the respiratory journals about your problem.

Erectile dysfunction (ED) is defined as the inability to get or keep an erection firm enough to have sexual intercourse. Although occasional ED is not uncommon, the frequency of this problem increases with age. The Massachusetts Male Aging Study (Journal of Urology, year 1994, volume 151, pages 54-61) showed that at age 40 about 40% of men have this problem, while the rate increases to 70% in men in their 70s. In the National Health and Social Life Survey (Journal of the American Medical Association, year 1999, volume 281, pages 537-544)  there was a decrease in sexual desire with increasing age. Also, sexual problems were more likely in men who had poor physical and emotional health.

For someone who has COPD, sexual problems may be due to ED, breathing difficulty (shortness of breath) with sexual activity, or both. ED is more frequent and more severe in those with COPD than men of similar age but without COPD. Other medical conditions (called comorbidities) such as heart disease, high blood pressure, diabetes, depression, alcohol use, and physical inactivity may also contribute to ED. Certain medications used to treat high blood pressure and to treat depression as well as previous surgery for cancers of the prostate, bladder, and colon (that alter nerve pathways and blood flow) may also affect erectile function. These are important considerations that you should discuss with your doctor.

It is important to remember that ED can be treated depending on the underlying cause. Treatments range from counseling and lifestyle changes to drugs and surgery. If you suffer from ED, it is important to talk to your doctor so that he/she can help identify the cause of your ED and figure out the most appropriate therapy.

If COPD is contributing to your sexual problem, here are some strategies that can make your breathing easier for when you are having sex.

  1. Be as fit and as active as possible to improve your stamina. A pulmonary rehabilitation program may be quite helpful in getting you started on exercise.
  2. Plan to have sex when you and your partner feel the most energetic. This could be in the morning, in the middle of the day, or at night. Whatever works best for you and your partner.
  3. Use a fan to provide a flow of air on the face to relieve any shortness of breath.
  4. Take albuterol inhaler about 15 minutes before sex just like you would before exercise.
  5. Consider using oxygen during sexual activity. It has been suggested that if you use oxygen when walking, then you will probably need to use oxygen during sex.
  6. Try different positions to find out what works best for you and your partner. Try to avoid positions that put pressure on your chest which will make breathing more difficult.
  7. Take a break during sex if your breathing becomes too difficult. Remember, your breathing increases during sex just like with physical activities.
  8. Enjoyable sex is not only about giving and having organisms, but about intimacy.

Dr. Robert Sandhaus from National Jewish Health Center in Denver has said, “Sometimes that means coming to organism and sometimes not.”

Finally, it is important to share your feelings and thoughts with your wife and with your doctor. If you are uncomfortable talking to your primary care doctor for whatever reason, ask for a referral to a specialist who has more knowledge and experience with sexual problems in those with COPD. The

Viagra pills

Viagra pills

availability of ED medications starting in 1998 has made talking about sexual problems much easier.

Please let me know how things go for you.

Donald A. Mahler, M.D.

My Breathing is Worse… What Should I Do?

Breathing is Worse Requires Medical Assessment

Dear Dr. Mahler:

I am 72 years old and take Advair twice a day for my COPD. About 5 weeks ago my arm swelled up, and my primary care doctor thought it was due to an insect bite. She prescribed an antibiotic. When it did not get better, I saw my oncologist who diagnosed that the swelling was due to a blockage in my armpit because my previous breast cancer had spread to the lymph glands. I just completed 4 weeks of radiation treatments.

I am writing to you because my breathing has been worse for the past month or so. I went to the Emergency Room two weeks ago to be checked out. A CT scan was normal except for emphysema. There was no blood clot to my lungs. What should I do? I am using albuterol 2 -3 times per day, but it really doesn’t help much. I do take Ativan every couple of days because I have been feeling anxious.

Linda from Montpelier, VT

Dear Linda:

Sorry to hear about the cancer recurrence.

Regarding your shortness of breath, it is important to have breathing tests done and your oxygen saturation checked to see if these results show any changes. Without this information, it is impossible to know if your breathing is worse because of your COPD or another reason, such as anemia, anxiety, being out of shape (reduced physical activity while you were receiving your radiation treatments, and possible heart disease. All of these conditions are common causes for chronic breathing difficulty.

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

Oximeter which measures the percentage of oxygen being carried by hemoglobin in the blood

Spirometry performed to assess why Breathing is Worse

Woman performing breathing test.







Donald A. Mahler, M.D.