text: chronic obstructive pulmonary disease chronic obstructive pulmonary disease ( copd ) is a type of obstructive lung disease characterized by long term poor airflow . the main symptoms include shortness of breath and cough with sputum production . copd typically worsens over time . eventually walking up stairs or carrying things will be difficult . chronic bronchitis and emphysema are older terms used for different types of copd . the term " chronic bronchitis " is still used to define a productive cough that is present for at least three months each year for two years . tobacco smoking is the most common cause of copd , with a number of other factors such as air pollution and genetics playing a smaller role . in the developing world , one of the common sources of air pollution is poorly vented heating and cooking fires . long - term exposure to these irritants causes an inflammatory response in the lungs resulting in narrowing of the small airways and breakdown of lung tissue . the diagnosis is based on poor airflow as measured by lung function tests . in contrast to asthma , the airflow reduction does not improve much with the use of a bronchodilator . most cases of copd can be prevented by reducing exposure to risk factors . this includes decreasing rates of smoking and improving indoor and outdoor air quality . while treatment can slow worsening there is no cure . copd treatments include stopping smoking , vaccinations , respiratory rehabilitation , and often inhaled bronchodilators and steroids . some people may benefit from long - term oxygen therapy or lung transplantation . in those who have periods of acute worsening , increased use of medications and hospitalization may be needed . as of 2013 copd affects 329 million people or nearly 5 percent of the global population . it typically occurs in people over the age of 40 . males and females are affected equally commonly . in 2013 it resulted in 2 . 9 million deaths , up from 2 . 4 million deaths in 1990 . more than 90 % of these deaths occur in the developing world . the number of deaths is projected to increase further because of higher smoking rates and an aging population in many countries . it resulted in an estimated economic cost of $ 2 . 1 trillion in 2010 . signs and symptoms the most common symptoms of copd are sputum production , shortness of breath , and a productive cough . these symptoms are present for a prolonged period of time and typically worsen over time . it is unclear if different types of copd exist . while previously divided into emphysema and chronic bronchitis , emphysema is only a description of lung changes rather than a disease itself , and chronic bronchitis is simply a descriptor of symptoms that may or may not occur with copd . cough a chronic cough is often the first symptom to develop . when it persists for more than three months each year for at least two years , in combination with sputum production and without another explanation , there is by definition chronic bronchitis . this condition can occur before copd fully develops . the amount of sputum produced can change over hours to days . in some cases , the cough may not be present or may only occur occasionally and may not be productive . some people with copd attribute the symptoms to a " smoker 's cough " . may be swallowed or spat out , depending often on social and cultural factors . vigorous coughing may lead to rib fractures or a brief loss of consciousness . those with copd often have a history of " common colds " that last a long time . shortness of breath shortness of breath is often the symptom that most bothers people . it is commonly described as : " my breathing requires effort , " " i feel out of breath , " or " i can 't get enough air in " . different terms , however , may be used in different cultures . typically the shortness of breath is worse on exertion of a prolonged duration and worsens over time . in the advanced stages , it occurs during rest and may be always present . it is a source of both anxiety and a poor quality of life in those with copd . many people with more advanced copd breathe through pursed lips and this action can improve shortness of breath in some . other features in copd , it may take longer to breathe out than to breathe in . chest tightness may occur but is not common and may be caused by another problem . those with obstructed airflow may have wheezing or decreased sounds with air entry on examination of the chest with a stethoscope . a barrel chest is a characteristic sign of copd , but is relatively uncommon . tripod positioning may occur as the disease worsens . advanced copd leads to high pressure on the lung arteries , which strains the right ventricle of the heart . this situation is referred to as cor pulmonale , and leads to symptoms of leg swelling and bulging neck veins . copd is more common than any other lung disease as a cause of cor pulmonale . cor pulmonale has become less common since the use of supplemental oxygen . copd often occurs along with a number of other conditions , due in part to shared risk factors . these conditions include ischemic heart disease , high blood pressure , diabetes mellitus , muscle wasting , osteoporosis , lung cancer , anxiety disorder and depression . in those with severe disease , a feeling of always being tired is common . clubbing is not specific to copd and should prompt investigations for an underlying lung cancer . an acute exacerbation of copd is defined as increased shortness of breath , increased sputum production , a change in the color of the sputum from clear to green or yellow , or an increase in cough in someone with copd . this may present with signs of increased work of breathing such as fast breathing , a fast heart rate , sweating , active use of muscles in the neck , a bluish tinge to the skin , and confusion or combative behavior in very severe exacerbations . may also be heard over the lungs on examination with a stethoscope . cause the primary cause of copd is tobacco smoke , with occupational exposure and pollution from indoor fires being significant causes in some countries . typically these exposures must occur over several decades before symptoms develop . a person 's genetic makeup also affects the risk . smoking the primary risk factor for copd globally is tobacco smoking . of those who smoke about 20 % will get copd , and of those who are lifelong smokers about half will get copd . in the united states and united kingdom , of those with copd , 80 – 95 % are either current smokers or previously smoked . the likelihood of developing copd increases with the total smoke exposure . additionally , women are more susceptible to the harmful effects of smoke than men . in non - smokers , secondhand smoke is the cause of about 20 % of cases . other types of smoke , such as marijuana , cigar , and water pipe smoke , also confer a risk . women who smoke during pregnancy may increase the risk of copd in their child . air pollution poorly ventilated cooking fires , often fueled by coal or biomass fuels such as wood and animal dung , lead to indoor air pollution and are one of the most common causes of copd in developing countries . these fires are a method of cooking and heating for nearly 3 billion people with their health effects being greater among women due to more exposure . they are used as the main source of energy in 80 % of homes in india , china and sub - saharan africa . people who live in large cities have a higher rate of copd compared to people who live in rural areas . while urban air pollution is a contributing factor in exacerbations , its overall role as a cause of copd is unclear . areas with poor outdoor air quality , including that from exhaust gas , generally have higher rates of copd . the overall effect in relation to smoking , however , is believed to be small . occupational exposures intense and prolonged exposure to workplace dusts , chemicals and fumes increase the risk of copd in both smokers and nonsmokers . workplace exposures are believed to be the cause in 10 – 20 % of cases . in the united states they are believed to be related to more than 30 % of cases among those who have never smoked and probably represent a greater risk in countries without sufficient regulations . a number of industries and sources have been implicated , including high levels of dust in coal mining , gold mining , and the cotton textile industry , occupations involving cadmium and , and fumes from welding . working in agriculture is also a risk . in some professions the risks have been estimated as equivalent to that of one half to two packs of cigarettes a day . silica dust exposure can also lead to copd , with the risk unrelated to that for silicosis . the negative effects of dust exposure and cigarette smoke exposure appear to be additive or possibly more than additive . genetics genetics play a role in the development of copd . it is more common among relatives of those with copd who smoke than unrelated smokers . currently , the only clearly inherited risk factor is alpha 1 - antitrypsin deficiency ( aat ) . this risk is particularly high if someone deficient in alpha 1 - antitrypsin also smokes . it is responsible for about 1 – 5 % of cases and the condition is present in about 3 – 4 in 10 , 000 people . other genetic factors are being investigated , of which there are likely to be many . other a number of other factors are less closely linked to copd . the risk is greater in those who are poor , although it is not clear if this is due to poverty itself or other risk factors associated with poverty , such as air pollution and malnutrition . there is tentative evidence that those with asthma and airway are at increased risk of copd . birth factors such as low birth weight may also play a role as do a number of infectious diseases including hiv / aids and tuberculosis . respiratory infections such as pneumonia do not appear to increase the risk of copd , at least in adults . exacerbations an acute exacerbation ( a sudden worsening of symptoms ) is commonly triggered by infection or environmental pollutants , or sometimes by other factors such as improper use of medications . infections appear to be the cause of 50 to 75 % of cases , with bacteria in 25 % , viruses in 25 % , and both in 25 % . environmental pollutants include both poor indoor and outdoor air quality . exposure to personal smoke and secondhand smoke increases the risk . cold temperature may also play a role , with exacerbations occurring more commonly in winter . those with more severe underlying disease have more frequent exacerbations : in mild disease 1 . 8 per year , moderate 2 to 3 per year , and severe 3 . 4 per year . those with many exacerbations have a faster rate of deterioration of their lung function . pulmonary emboli ( blood clots in the lungs ) can worsen symptoms in those with pre - existing copd . pathophysiology copd is a type of obstructive lung disease in which chronic incompletely reversible poor airflow ( airflow limitation ) and inability to breathe out fully ( air trapping ) exist . the poor airflow is the result of breakdown of lung tissue ( known as emphysema ) and small airways disease ( known as obstructive bronchiolitis ) . the relative contributions of these two factors vary between people . severe destruction of small airways can lead to the formation of large air pockets — known as bullae — that replace lung tissue . this form of disease is called bullous emphysema . copd develops as a significant and chronic inflammatory response to inhaled irritants . chronic bacterial infections may also add to this inflammatory state . the inflammatory cells involved include neutrophil granulocytes and macrophages , two types of white blood cell . those who smoke additionally have lymphocyte involvement and some people with copd have eosinophil involvement similar to that in asthma . part of this cell response is brought on by inflammatory mediators such as factors . other processes involved with lung damage include oxidative stress produced by high concentrations of free radicals in tobacco smoke and released by inflammatory cells , and breakdown of the connective tissue of the lungs by proteases that are insufficiently inhibited by protease inhibitors . the destruction of the connective tissue of the lungs is what leads to emphysema , which then contributes to the poor airflow and , finally , poor absorption and release of respiratory gases . general muscle wasting that often occurs in copd may be partly due to inflammatory mediators released by the lungs into the blood . narrowing of the airways occurs due to inflammation and scarring within them . this contributes to the inability to breathe out fully . the greatest reduction in air flow occurs when breathing out , as the pressure in the chest is compressing the airways at this time . this can result in more air from the previous breath remaining within the lungs when the next breath is started , resulting in an increase in the total volume of air in the lungs at any given time , a process called hyperinflation or air trapping . hyperinflation from exercise is linked to shortness of breath in copd , as it is less comfortable to breathe in when the lungs are already partly full . hyperinflation may also worsen during an exacerbation . some also have a degree of airway to irritants similar to those found in asthma . low oxygen levels and , eventually , high carbon dioxide levels in the blood can occur from poor gas exchange due to decreased ventilation from airway obstruction , hyperinflation and a reduced desire to breathe . during exacerbations , airway inflammation is also increased , resulting in increased hyperinflation , reduced expiratory airflow and worsening of gas transfer . this can also lead to insufficient ventilation and , eventually , low blood oxygen levels . low oxygen levels , if present for a prolonged period , can result in narrowing of the arteries in the lungs , while emphysema leads to breakdown of capillaries in the lungs . both these changes result in increased blood pressure in the pulmonary arteries , which may cause cor pulmonale . diagnosis the diagnosis of copd should be considered in anyone over the age of 35 to 40 who has shortness of breath , a chronic cough , sputum production , or frequent winter colds and a history of exposure to risk factors for the disease . spirometry is then used to confirm the diagnosis . screening those without symptoms is not recommended . spirometry spirometry measures the amount of airflow obstruction present and is generally carried out after the use of a bronchodilator , a medication to open up the airways . two main components are measured to make the diagnosis : the forced expiratory volume in one second ( fev1 ) , which is the greatest volume of air that can be breathed out in the first second of a breath , and the forced vital capacity ( fvc ) , which is the greatest volume of air that can be breathed out in a single large breath . normally , 75 – 80 % of the fvc comes out in the first second and a fev1 / fvc ratio of less than 70 % in someone with symptoms of copd defines a person as having the disease . based on these measurements , spirometry would lead to over - diagnosis of copd in the elderly . the national institute for health and care excellence criteria additionally require a fev1 of less than 80 % of predicted . evidence for using spirometry among those without symptoms in an effort to diagnose the condition earlier is of uncertain effect and is therefore currently not recommended . a peak expiratory flow ( the maximum speed of expiration ) , commonly used in asthma , is not sufficient for the diagnosis of copd . severity there are a number of methods to determine how much copd is affecting a given individual . the modified british medical research council questionnaire ( ) or the copd assessment test ( cat ) are simple questionnaires that may be used to determine the severity of symptoms . scores on cat range from 0 – 40 with the higher the score , the more severe the disease . spirometry may help to determine the severity of airflow limitation . this is typically based on the fev1 expressed as a percentage of the predicted " normal " for the person 's age , gender , height and weight . both the american and european guidelines recommended partly basing treatment recommendations on the fev1 . the gold guidelines suggest dividing people into four categories based on symptoms assessment and airflow limitation . weight loss and muscle weakness , as well as the presence of other diseases , should also be taken into account . other tests a chest x - ray and complete blood count may be useful to exclude other conditions at the time of diagnosis . characteristic signs on x - ray are lungs , a flattened diaphragm , increased airspace , and bullae while it can help exclude other lung diseases , such as pneumonia , pulmonary edema or a pneumothorax . a high - resolution computed tomography scan of the chest may show the distribution of emphysema throughout the lungs and can also be useful to exclude other lung diseases . unless surgery is planned , however , this rarely affects management . an analysis of arterial blood is used to determine the need for oxygen ; this is recommended in those with an fev1 less than 35 % predicted , those with a peripheral oxygen saturation of less than 92 % and those with symptoms of congestive heart failure . in areas of the world where alpha - 1 antitrypsin deficiency is common , people with copd ( particularly those below the age of 45 and with emphysema affecting the lower parts of the lungs ) should be considered for testing . differential diagnosis copd may need to be differentiated from other causes of shortness of breath such as congestive heart failure , pulmonary embolism , pneumonia or pneumothorax . many people with copd mistakenly think they have asthma . the distinction between asthma and copd is made on the basis of the symptoms , smoking history , and whether airflow limitation is reversible with bronchodilators at spirometry . tuberculosis may also present with a chronic cough and should be considered in locations where it is common . less common conditions that may present similarly include bronchopulmonary dysplasia and obliterative bronchiolitis . chronic bronchitis may occur with normal airflow and in this situation it is not classified as copd . prevention most cases of copd are potentially preventable through decreasing exposure to smoke and improving air quality . annual influenza vaccinations in those with copd reduce exacerbations , hospitalizations and death . vaccination may also be beneficial . smoking cessation keeping people from starting smoking is a key aspect of preventing copd . the policies of governments , public health agencies , and anti - smoking organizations can reduce smoking rates by discouraging people from starting and encouraging people to stop smoking . smoking bans in public areas and places of work are important measures to decrease exposure to secondhand smoke and while many places have instituted bans more are recommended . in those who smoke , stopping smoking is the only measure shown to slow down the worsening of copd . even at a late stage of the disease , it can reduce the rate of worsening lung function and delay the onset of disability and death . smoking cessation starts with the decision to stop smoking , leading to an attempt at quitting . often several attempts are required before long - term abstinence is achieved . attempts over 5 years lead to success in nearly 40 % of people . some smokers can achieve long - term smoking cessation through willpower alone . smoking , however , is highly addictive , and many smokers need further support . the chance of quitting is improved with social support , engagement in a smoking cessation program and the use of medications such as nicotine replacement therapy , bupropion or . occupational health a number of measures have been taken to reduce the likelihood that workers in at - risk industries — such as coal mining , construction and stonemasonry — will develop copd . examples of these measures include : the creation of public policy , education of workers and management about the risks , promoting smoking cessation , checking workers for early signs of copd , use of respirators , and dust control . effective dust control can be achieved by improving ventilation , using water sprays and by using mining techniques that minimize dust generation . if a worker develops copd , further lung damage can be reduced by avoiding ongoing dust exposure , for example by changing the work role . air pollution both indoor and outdoor air quality can be improved , which may prevent copd or slow the worsening of existing disease . this may be achieved by public policy efforts , cultural changes , and personal involvement . a number of developed countries have successfully improved outdoor air quality through regulations . this has resulted in improvements in the lung function of their populations . those with copd may experience fewer symptoms if they stay indoors on days when outdoor air quality is poor . one key effort is to reduce exposure to smoke from cooking and heating fuels through improved ventilation of homes and better stoves and chimneys . proper stoves may improve indoor air quality by 85 % . using alternative energy sources such as solar cooking and electrical heating is also effective . using fuels such as kerosene or coal might be less bad than traditional biomass such as wood or dung . management there is no known cure for copd , but the symptoms are treatable and its progression can be delayed . the major goals of management are to reduce risk factors , manage stable copd , prevent and treat acute exacerbations , and manage associated illnesses . the only measures that have been shown to reduce mortality are smoking cessation and supplemental oxygen . stopping smoking decreases the risk of death by 18 % . other recommendations include influenza vaccination once a year , pneumococcal vaccination once every 5 years , and reduction in exposure to environmental air pollution . in those with advanced disease , palliative care may reduce symptoms , with morphine improving the feelings of shortness of breath . noninvasive ventilation may be used to support breathing . exercise pulmonary rehabilitation is a program of exercise , disease management and counseling , coordinated to benefit the individual . in those who have had a recent exacerbation , pulmonary rehabilitation appears to improve the overall quality of life and the ability to exercise , and reduce mortality . it has also been shown to improve the sense of control a person has over their disease , as well as their emotions . breathing exercises in and of themselves appear to have a limited role . lip breathing exercises may be useful . being either underweight or overweight can affect the symptoms , degree of disability and prognosis of copd . people with copd who are underweight can improve their breathing muscle strength by increasing their calorie intake . when combined with regular exercise or a pulmonary rehabilitation program , this can lead to improvements in copd symptoms . supplemental nutrition may be useful in those who are malnourished . bronchodilators inhaled bronchodilators are the primary medications used and result in a small overall benefit . there are two major types , β2 agonists and anticholinergics ; both exist in long - acting and short - acting forms . they reduce shortness of breath , wheeze and exercise limitation , resulting in an improved quality of life . it is unclear if they change the progression of the underlying disease . in those with mild disease , short - acting agents are recommended on an as needed basis . in those with more severe disease , long - acting agents are recommended . long acting agents partly work by improving hyperinflation . if long - acting bronchodilators are insufficient , then inhaled corticosteroids are typically added . with respect to long - acting agents , it is unclear if tiotropium ( a long - acting anticholinergic ) or long - acting beta agonists ( labas ) are better , and it may be worth trying each and continuing the one that worked best . both types of agent appear to reduce the risk of acute exacerbations by 15 – 25 % . while both may be used at the same time , any benefit is of questionable significance . there are several short - acting β2 agonists available including salbutamol ( ) and . they provide some relief of symptoms for four to six hours . long - acting β2 agonists such as and are often used as maintenance therapy . some feel the evidence of benefits is limited while others view the evidence of benefit as established . long - term use appears safe in copd with adverse effects include shakiness and heart palpitations . when used with inhaled steroids they increase the risk of pneumonia . while steroids and labas may work better together , it is unclear if this slight benefit outweighs the increased risks . there are two main anticholinergics used in copd , ipratropium and tiotropium . is a short - acting agent while tiotropium is long - acting . is associated with a decrease in exacerbations and improved quality of life , and tiotropium provides those benefits better than ipratropium . it does not appear to affect mortality or the overall hospitalization rate . can cause dry mouth and urinary tract symptoms . they are also associated with increased risk of heart disease and stroke . , another long acting agent which came to market in 2012 , has been used as an alternative to tiotropium . corticosteroids corticosteroids are usually used in inhaled form but may also be used as tablets to treat and prevent acute exacerbations . while inhaled corticosteroids ( ics ) have not shown benefit for people with mild copd , they decrease acute exacerbations in those with either moderate or severe disease . by themselves they have no effect on overall one - year mortality . it is unclear if they affect the progression of the disease . when used in combination with a laba they may decrease mortality compared to either ics or laba alone . inhaled steroids are associated with increased rates of pneumonia . long - term treatment with steroid tablets is associated with significant side effects . other medication long - term antibiotics , specifically those from the macrolide class such as erythromycin , reduce the frequency of exacerbations in those who have two or more a year . this practice may be cost effective in some areas of the world . concerns include that of antibiotic resistance and hearing problems with azithromycin . such as theophylline generally cause more harm than benefit and thus are usually not recommended , but may be used as a second - line agent in those not controlled by other measures . may help to reduce exacerbations in some people with chronic bronchitis . cough medicines are not recommended . oxygen supplemental oxygen is recommended in those with low oxygen levels at rest ( a partial pressure of oxygen of less than 50 – 55 mmhg or oxygen saturations of less than 88 % ) . in this group of people it decreases the risk of heart failure and death if used 15 hours per day and may improve people 's ability to exercise . in those with normal or mildly low oxygen levels , oxygen supplementation may improve shortness of breath . there is a risk of fires and little benefit when those on oxygen continue to smoke . in this situation some recommend against its use . during acute exacerbations , many require oxygen therapy ; the use of high concentrations of oxygen without taking into account a person 's oxygen saturations may lead to increased levels of carbon dioxide and worsened outcomes . in those at high risk of high carbon dioxide levels , oxygen saturations of 88 – 92 % are recommended , while for those without this risk recommended levels are 94 – 98 % . surgery for those with very severe disease , surgery is sometimes helpful and may include lung transplantation or lung volume reduction surgery . lung volume reduction surgery involves removing the parts of the lung most damaged by emphysema allowing the remaining , relatively good lung to expand and work better . lung transplantation is sometimes performed for very severe copd , particularly in younger individuals . exacerbations acute exacerbations are typically treated by increasing the usage of short - acting bronchodilators . this commonly includes a combination of a short - acting inhaled beta agonist and anticholinergic . these medications can be given either via a metered - dose inhaler with a spacer or via a with both appearing to be equally effective . may be easier for those who are more unwell . oral corticosteroids improve the chance of recovery and decrease the overall duration of symptoms . they work equally well as intravenous steroids but appear to have fewer side effects . five days of steroids work as well as ten or fourteen . in those with a severe exacerbation , antibiotics improve outcomes . a number of different antibiotics may be used including amoxicillin , doxycycline and azithromycin ; it is unclear if one is better than the others . the fda recommends against the use of fluoroquinolones when other options are available due to higher risks of serious side effects . there is no clear evidence for those with less severe cases . for those with type 2 respiratory failure ( acutely raised co2 levels ) non - invasive positive pressure ventilation decreases the probability of death or the need of intensive care admission . additionally , theophylline may have a role in those who do not respond to other measures . fewer than 20 % of exacerbations require hospital admission . in those without acidosis from respiratory failure , home care ( " hospital at home " ) may be able to help avoid some admissions . prognosis copd usually gets gradually worse over time and can ultimately result in death . it is estimated that 3 % of all disability is related to copd . the proportion of disability from copd globally has decreased from 1990 to 2010 due to improved indoor air quality primarily in asia . the overall number of years lived with disability from copd , however , has increased . the rate at which copd worsens varies with the presence of factors that predict a poor outcome , including severe airflow obstruction , little ability to exercise , shortness of breath , significantly underweight or overweight , congestive heart failure , continued smoking , and frequent exacerbations . long - term outcomes in copd can be estimated using the index which gives a score of zero to ten depending on fev1 , body - mass index , the distance walked in six minutes , and the modified mrc dyspnea scale . significant weight loss is a bad sign . results of spirometry are also a good predictor of the future progress of the disease but not as good as the index . epidemiology globally , as of 2010 , copd affected approximately 329 million people ( 4 . 8 % of the population ) . the disease affects men and women almost equally , as there has been increased tobacco use among women in the developed world . the increase in the developing world between 1970 and the 2000s is believed to be related to increasing rates of smoking in this region , an increasing population and an aging population due to fewer deaths from other causes such as infectious diseases . some developed countries have seen increased rates , some have remained stable and some have seen a decrease in copd prevalence . the global numbers are expected to continue increasing as risk factors remain common and the population continues to get older . between 1990 and 2010 the number of deaths from copd decreased slightly from 3 . 1 million to 2 . 9 million and became the fourth leading cause of death . in 2012 it became the third leading cause as the number of deaths rose again to 3 . 1 million . in some countries , mortality has decreased in men but increased in women . this is most likely due to rates of smoking in women and men becoming more similar . copd is more common in older people ; it affects 34 – 200 out of 1000 people older than 65 years , depending on the population under review . in england , an estimated 0 . 84 million people ( of 50 million ) have a diagnosis of copd ; this translates into approximately one person in 59 receiving a diagnosis of copd at some point in their lives . in the most socioeconomically deprived parts of the country , one in 32 people were diagnosed with copd , compared with one in 98 in the most affluent areas . in the united states approximately 6 . 3 % of the adult population , totaling approximately 15 million people , have been diagnosed with copd . 25 million people may have copd if currently undiagnosed cases are included . in 2011 , there were approximately 730 , 000 hospitalizations in the united states for copd . in the united state , copd , is estimated to be the third leading cause of death in 2011 . history the word " emphysema " is derived from the greek meaning " inflate " composed of ἐν en , meaning " in " , and , meaning " breath , blast " . the term chronic bronchitis came into use in 1808 while the term copd is believed to have first been used in 1965 . previously it has been known by a number of different names , including chronic obstructive bronchopulmonary disease , chronic obstructive respiratory disease , chronic airflow obstruction , chronic airflow limitation , chronic obstructive lung disease , nonspecific chronic pulmonary disease , and diffuse obstructive pulmonary syndrome . the terms chronic bronchitis and emphysema were formally defined in 1959 at the guest symposium and in 1962 at the american thoracic society committee meeting on diagnostic standards . early descriptions of probable emphysema include : in 1679 by t. bonet of a condition of " voluminous lungs " and in 1769 by giovanni morgagni of lungs which were " turgid particularly from air " . in 1721 the first drawings of emphysema were made by . these were followed with pictures by matthew baillie in 1789 and descriptions of the destructive nature of the condition . in 1814 charles badham used " catarrh " to describe the cough and excess mucus in chronic bronchitis . rené laennec , the physician who invented the stethoscope , used the term " emphysema " in his book a treatise on the diseases of the chest and of mediate ( 1837 ) to describe lungs that did not collapse when he opened the chest during an autopsy . he noted that they did not collapse as usual because they were full of air and the airways were filled with mucus . in 1842 , john hutchinson invented the , which allowed the measurement of vital capacity of the lungs . however , his could only measure volume , not airflow . and pinelli in 1947 described the principles of measuring airflow . in 1953 , dr. george l. , an american , first described a new disease he named " smoker 's respiratory syndrome " in the 1953 journal of the american medical association . this was the first association between tobacco smoking and chronic respiratory disease . early treatments included garlic , cinnamon and ipecac , among others . modern treatments were developed during the second half of the 20th century . evidence supporting the use of steroids in copd were published in the late 1950s . bronchodilators came into use in the 1960s following a promising trial of . further bronchodilators , such as salbutamol , were developed in the 1970s , and the use of labas began in the mid - 1990s . society and culture copd has been referred to as " smoker 's lung " . people with emphysema have been known as " pink " or " type a " due to their frequent pink complexion , fast respiratory rate and pursed lips , and people with chronic bronchitis have been referred to as " blue " or " type b " due to the often bluish color of the skin and lips from low oxygen levels and their ankle swelling . this terminology is no longer accepted as useful as most people with copd have a combination of both emphysema and chronic bronchitis . many health systems have difficulty ensuring appropriate identification , diagnosis and care of people with copd ; britain 's department of health has identified this as a major issue for the national health service and has introduced a specific strategy to tackle these problems . economics globally , as of 2010 , copd is estimated to result in economic costs of $ 2 . 1 trillion , half of which occurring in the developing world . of this total an estimated $ 1 . 9 trillion are direct costs such as medical care , while $ 0 . 2 trillion are indirect costs such as missed work . this is expected to more than double by the year 2030 . in europe , copd represents 3 % of healthcare spending . in the united states , costs of the disease are estimated at $ 50 billion , most of which is due to exacerbation . copd was among the most expensive conditions seen in u.s. hospitals in 2011 , with a total cost of about $ 5 . 7 billion . research , an immune - suppressing antibody , has been tested in copd but there was no evidence of benefit with the possibility of harm . shows promise in decreasing the rate of exacerbations but does not appear to change quality of life . a number of new , long - acting agents are under development . treatment with stem cells is under study . while there is tentative data that it is safe and with promising animal data there is little human data as of 2014 . some of the human data that is available has found poor results . other animals chronic obstructive pulmonary disease may occur in a number of other animals and may be caused by exposure to tobacco smoke . most cases of the disease , however , are relatively mild . in horses it is known as recurrent airway obstruction , can be quite severe , and most often is linked to an allergic reaction to a fungus contained in contaminated hay or straw . copd is also commonly found in old dogs .