Have you or someone you know ever gone to the doctor for a cough that wouldn’t go away, maybe you were even a little out of breath, only to be told it’s “just a simple cough”? And then, after getting a second opinion, you find out it’s COPD—a condition you’ve never even heard of, and no one took the time to explain. You’re not alone. This happens more often than you’d think, and yet COPD is still barely talked about—not just among the public, but even in the medical world.
COPD (Chronic Obstructive Pulmonary Disease) is the second leading cause of death in India. [1] Despite this, it doesn’t receive the attention that heart disease or stroke gets. It's one of the least talked about chronic illnesses. But why? Is it social stigma? Not really. Fear? No. The root issue is simple—lack of awareness.
But to understand how we got here, let’s go back to the basics.
One reason is that COPD often doesn’t show any symptoms in its early stages. And when symptoms do show up, they usually come alongside other conditions like diabetes, osteoporosis, heart failure or even sleep apnea. As a result, the focus shifts to treating those issues, while the underlying cause—COPD—gets overlooked. On top of that, diagnosing COPD properly requires a spirometry test, which measures lung function, but unfortunately, it’s not commonly available in most primary healthcare settings.
Initially, symptoms like chronic cough with phlegm, fatigue, or shortness of breath during physical activity are easily brushed off—or misdiagnosed as seasonal asthma. This causes delays in accurate diagnosis and treatment. Often, by the time COPD is identified, the disease has already advanced and may have begun affecting other organs such as the heart, bones, or kidneys.
This is why understanding COPD and its early signs is critical.
COPD stands for Chronic Obstructive Pulmonary Disease. It primarily affects the small airways (bronchioles) and alveoli and is characterized by persistent airflow obstruction, known as air trapping. This often happens due to chronic inflammation, which narrows the airway lumen by thickening of the mucosa, triggered by harmful particles or gases.
In developed countries, smoking is the leading cause of COPD. But in India and other developing countries, it’s a different story. Non-smoking causes account for 70–80% of COPD cases, such as poor air quality, indoor smoke (from cooking or heating), occupational exposure to dust and chemicals, and toxic fumes.
You don’t have to smoke to get COPD.
Yes, we have our air quality to blame—along with our careless approach to environmental and occupational hazards. These pollutants settle in the lungs. They trigger inflammation, which thickens the mucosa of the airways and narrows their openings. During exhalation, these narrowed airways collapse, trapping air inside the lungs and damaging the alveoli. Over time, elastic lung tissue is replaced with scar tissue, turning healthy lungs into non-functional dead space.
At this point, the person starts to feel truly breathless.
Now let’s look at what makes diagnosis tricky.
Patients with COPD often present with symptoms like breathlessness, wheezing, chest tightness, chronic productive cough, and fatigue. On examination, they may appear to be in respiratory distress, with low oxygen saturation and a cachectic (wasted) appearance. These clinical signs, combined with a detailed history—such as exposure to risk factors (like smoking or indoor air pollution) and recurrent chest infections—can strongly suggest COPD.
Historically, COPD was categorized into two types: emphysema (often referred to as "pink puffers") and chronic bronchitis ("blue bloaters"). However, this classification is now considered outdated. According to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines[2], COPD is recognized as a spectrum disorder with overlapping phenotypes, and patients may present with features of both or neither.
The gold standard for diagnosis is spirometry, which shows a reduced FEV1/FVC ratio (less than 70 percent) after bronchodilator administration. This ratio compares the amount of air a person can forcibly exhale in one second (FEV1) to the total amount they can forcibly exhale in one breath (FVC). Unlike asthma, the airflow obstruction in COPD is not significantly reversible, which helps differentiate the two conditions.
Other tools in diagnosis include:
HRCT chest: to assess lung damage
Arterial blood gas (ABG): to evaluate oxygenation and CO₂ retention
Treatment, though, is where things get more complicated.
In moderate to severe cases, oxygen therapy becomes essential—but it must be carefully regulated. Oxygen saturation is typically maintained between 88–92 percent. Why? Because many COPD patients have chronic CO₂ retention (hypercapnia), which blunts their normal respiratory drive that responds to high CO₂ levels. As a result, their breathing is driven primarily by low oxygen levels (hypoxic drive). Administering high-flow oxygen can suppress this hypoxic drive, leading to worsening hypercapnia and even type 2 respiratory failure.
That’s why Venturi masks are preferred over non-rebreathing masks in these patients.
For outpatient management, inhalers are the first-line treatment. Unlike asthma, COPD patients are usually not started on steroid inhalers. Instead, treatment begins with bronchodilators:
SABA/LABA – Short-acting and long-acting beta-agonists
SAMA/LAMA – Short-acting and long-acting muscarinic antagonists
In moderate cases, a combination of LABA + LAMA is commonly prescribed. Inhaled corticosteroids (ICS) may be added in more severe stages or in patients with frequent exacerbations.
It’s important to note that there is no cure for severe COPD—damaged lung tissue cannot regenerate. That’s why early detection and avoidance of harmful exposures are critical.
One major factor is the tendency to ignore early symptoms, dismissing them as “just a cough.” And since diagnosis hinges on spirometry—which is often unavailable in primary care—many patients go undiagnosed until the disease is severe.
Even when diagnosed, treatment may be misguided. Some physicians may start steroid inhalers prematurely, which might offer short-term relief but pose long-term harm in COPD. The real backbone of treatment is long-term bronchodilator use, not steroids.
Another problem is the lack of public awareness. While most people know smoking is harmful, they often overlook the dangers of indoor smoke, dust, chemicals, and industrial vapors—all equally toxic to lung health.
At the healthcare level: Primary care providers need better training in recognizing and diagnosing COPD. Spirometry should be made more accessible. [3]
At the community level: Surveys on air quality, household exposure assessments, and awareness campaigns are essential. Industrial workers must be educated on using protective gear to avoid inhaling harmful fumes and dust.
Despite being easily preventable and treatable, COPD continues to be underdiagnosed or misdiagnosed, with many patients receiving no treatment or incorrect treatment. This has made it a significant burden on the healthcare system, quietly escalating into a major public health issue.
Let’s change that—by spreading awareness, advocating for better diagnosis, and encouraging prevention efforts. It's time we start talking about COPD before it’s too late.
Reference:
1.Global Burden of Disease Study 2019, ICMR & Public Health Foundation of India - https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30298-9/fulltext?ref=insights.onegiantleap.com
2. GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD: 2024 Report. An evidence-based strategy document for COPD diagnosis, management, and prevention. - https://goldcopd.org/2024-gold-report/
3. Burden of Chronic Obstructive Pulmonary Disease - https://web.archive.org/web/20240205114229id_/https://www.ijcdas.com/doi/pdf/10.5005/jp-journals-11007-0082
By Dr. Shubham Halingali, MBBS
MSM/DP