Herbs and Breathlessness


Herbs can support lung function; to help shortness of breath, mild asthma, breathlessness, COPD and breathing problems.

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Nasal Breathe for More Oxygen and Better Health!

To get an idea of the size of the nasal cavity, run your tongue from the front of the roof of your mouth right back as far as it will go. You may be surprised to learn that the roof of the mouth is in fact the floor of the nose! The nose you see on your face comprises approx. 30% of its volume. The remaining 70% of the nasal cavity is set deep within the scull. Nature is intelligent and does not waste space; evolution has determined the importance of the nose by the amount of space it occupies within the skull.

As air enters through the nose, it is swirled through scrolled spongy bones called turbinates, which condition and guide inhaled air into a steady, regular pattern. The internal nose, with its cul-de-sacs, valves and turbinates, regulates the direction and velocity of the air to maximise exposure to a network of small arteries and veins and to the mucous blanket in order to warm, humidify and sterilise the air before it is drawn to the lungs. Dr Maurice Cottle, who founded the American Rhinologic Society in 1954, stated that the nose performs at least 30 functions, all of which are important supplements to the roles played by the lungs, heart and other organs. CO2 is needed for haemoglobin to release oxygen to your cells, which is required in the process of creating ATP for energy. So by regulating the levels of oxygen and CO2, you are able to increase your body’s ability to create and utilize energy. What’s more, its positive effects on cardiovascular health mean better stamina, greater energy, and enhanced fitness.

When we wake after a night’s sleep we usually have a good stretch (as do cats and dogs). This involves holding our breath for quite a long time. This increases carbon dioxide in the body, improving oxygen delivery to all our organs. This stimulates the heart and opens the blood vessels before we get out of bed to begin our day. This breath-hold and stretch is normal and has been part of our natural evolutionary development.

Pranayama and other controlled breathing techniques are abnormal, developed by yogis and elite sportspeople to get an oxygen advantage for competitive edge. Quiet, slow, nasal breathing is normal for ordinary people. Mouth breathing for both ordinary people, children and sportspeople is abnormal and to be discouraged. Sitting quietly for five or more minutes to slow nasal breathe using the diaphragm is to be encouraged.

To improve the quality of the air you breathe
It is imperative that nasal breathing is practised at all times during rest. To avoid over-breathing even during exercise, you must always breathe through the nose. Try it next time you go for a walk or cycle. During intensive physical exercise you may have to mouth breathe for a short time. Yogi Ramacharaka said, “One of the first lessons in the Yogi Science of Breath is to learn how to breathe through the nostrils, and to overcome the common practice of mouth-breathing. Many of the diseases to which civilized man is subject are undoubtedly caused by this common habit of mouth breathing.”

Beneficial functions of nasal breathing

  1. Breathing through the nose imposes approx. 50% more resistance to the air stream compared to mouth breathing, resulting in 10-20% more oxygen uptake.
  2. Nasal breathing filters, warms and humidifies incoming air so that it is at body temperature 37C/98.6F when it enters the lungs, bringing in nitric oxide to open airways and blood vessels.
  3. Nasal breathing removes most viruses, bacteria, and dust from the air you breathe in.
  4. Nasal breathing during physical exercise reduces the heart rate to allow muscle action to improve.
  5. When speaking, we breathe out. Then between sentences or after laughter, we breathe in. So train yourself to put your tongue against the roof your mouth to breathe in through your nose between sentences. This prevents mouth breathing. This is a lot safer and healthier when conversing with others.

More nitric oxide with every in-breath

  1. When breathing in through the nose the air releases nitric oxide, an essential gas for the maintenance of good health and blood supply to the organs. Nitric oxide was proclaimed Molecule of the Year in 1992 by the journal Science. It is an important signalling molecule in the cardiovascular system. It helps keep us free of disease, including cancer, promotes a longer life, and even helps with libido to perform better in bed (increases blood supply to the genitalia).
  2. Nasal breathing harnesses the benefits of nitric oxide, whereas mouth breathing bypasses this special gas, missing out on its health-giving effects. Nitric oxide is central to vasoregulation (the opening and closing of blood vessels), homeostasis (maintaining a stable state of physiological balance throughout the body), neurotransmission (the interactive messaging in the brain), immune defence (it is antiviral and antimicrobial), modulating blood pressure, lowering cholesterol, keeping the arteries young and flexible, and preventing the development of plaque and clots in the blood vessels, reducing the risk of heart attack and stroke.
  3. Yes, breathe in with your nose for more nitric oxide, and increase even more (five times more) by humming when breathing out. Reported by Drs Weitzberg and Lundberg in the American Journal of Respiratory and Critical Care Medicine.
  4. If you hold your out-breath until you have air hunger (i.e. not for as long as you can), it sharply increases the concentration of nitric oxide in your nasal cavity, resulting in dilation of the nasal passages. This can lead to clearing your nose and stopping the formation of nasal polyps.
  5. Try practicing 5 to 10 minutes of breath-holds out, for anything from a few seconds up to 30 or 40 seconds, then breathing normally for 30 seconds and then holding breath again, etc, this increases nitric oxide and carbon dioxide tolerance which enables you to recover from exercise more quickly because there is a quicker release of extra oxygen from the oxygen-rich spleen into the circulation and the brain.
  6. To help even more (and to improve your general health), make sure you only breathe through your nose at night. To do this, tape your mouth from corner to corner with wide surgical tape (mycropore) bought at your chemist or Superdrug store. This will ensure that you do not breathe through your mouth for 7-8 hours. Leave it on every night until you get up in the morning (the tape is easy to remove). It prevents snoring and deepens and lengthens your sleep. After a few weeks of this practice, it will become a habit and you won’t need your mouth taped.

When it comes to breathing, less is more
Try to get down to 6 breaths a minute or less. 5 seconds in, 5 seconds out. Use a timer to learn this slow breathing style. At times you may find that you are breathing so softly that you do not feel yourself breathing. True health and inner peace occur when breathing is quiet, effortless, soft, through the nose, abdominal, rhythmic and gently paused on the exhale.

Breathe using the diaphragm

Inhale through your nose and feel your abdomen gently move outward. Then slowly exhale and notice your abdomen gently moving inward. This natural abdominal or diaphragmatic breathing rhythm is more efficient as it draws more air to the larger lower lobes of the lungs for longer, deeper, slower breathing, making you feel more relaxed and calmer. This doesn’t happen with upper chest breathing which uses the smaller upper lobes causing faster shallower breathing, which in fact increases the stress hormone, cortisol.

Apart from the oxygen and nitric oxide benefits of breathing using the diaphragm, the movement of this great sheet of muscle across the centre of the abdomen has other great benefits to the abdominal organs. The diaphragm’s massaging rhythm improves lymphatic drainage, liver function, pancreas and digestive response, kidneys and spleen, and reproductive organs. Blood supply is improved, and the heart responds better with the oxygen delivery into the lungs and the carbon dioxide is released from the venous side of the heart to the lungs.

So, as well as improving air-exchange throughout the body, nasal breathing helps many health conditions, not least asthma, sleep, hay fever, colds and flu, catarrh, anxiety, and depression. Research shows breathing through the nose helps children with studying, athletes perform better, improves weight loss as a knock-on effect from improved mood and increased mental control.

How to train yourself to breathe light to breathe right

  • Sit up straight. Relax the shoulders.
  • Place one hand on your chest and one hand just above your navel.
  • Feel your abdomen gently moving outward as you inhale, and inward as you exhale.
  • As you breathe, exert gentle pressure with your hand against your abdomen and chest. This should create resistance to your breathing.
  • Breathe against your hands, concentrating on making the size of each breath less.
  • With each breath, take in less air than you would like to. Make the in-breath smaller or shorter.
  • Gently slow down and reduce your breathing movements until you feel a tolerable hunger for air.
  • Breathe out with a relaxed exhalation. Allow the natural elasticity of your lungs and diaphragm to play their role in each exhalation. Imagine a balloon slowly and gently deflating of its own accord.
  • When the in-breath becomes smaller and the out-breath is relaxed, visible breathing movements will be reduced.

Herbs to help

Herbs to help restore the respiratory system to breathe softly and slowly and to help protect it from infection:

BreathLess Tonic, LungShield COPD Tonic, Atomiser Inhaler Spray, ColdLess Antiviral Tonic, LungShield Tonic, CatarrhLess Tonic, Nasal Congestion Drops, Nasal Polyps Drops, Heart and Circulation Tonic, WorryLess Tonic, Adrenal Tonic, HayFever Tonic, MouthShield, MouthShield Toothpaste.

Adapted with thanks from Oxygen Advantage by Patrick McKeown© and other sources, by Alan Hopking


Asthma and COPD

When a person who has lung function weakness comes into contact with an allergen that irritates the airways (said to be an asthma trigger), the muscles around the walls of the airways react with an inflammatory response, tightening, causing the airways tubes to become narrower due to the lining of the airways having become inflamed and swollen. Sometimes, sticky mucus or phlegm builds up as a result of these reactions, which further narrows the airway tubes in the lungs.

These reactions cause the airways to become narrower and irritated – making it difficult to breath and leading to symptoms of asthma.

It’s not known for sure what causes asthma but it is likely to be genetic (a family history of asthma) often linked to eczema or allergies when it starts in a child, but due to other factors (such as stress, dietary deficiency, living near a busy road or other industrial pollution, smoking, drug taking) when it starts later in life.

Many aspects of modern lifestyles – such as changes in housing and diet and a more hygienic environment – may have contributed to the rise in asthma over the past few decades. Environmental pollution can make asthma symptoms worse and may play a part in causing some asthma

Research has shown that smoking during pregnancy significantly increases the risk of a child developing asthma. Similarly, children whose parents smoke are more likely to develop asthma.

Adult onset asthma may develop after a viral infection, and irritants found in the workplace may lead to a person developing asthma (known as occupational asthma).

The usual symptoms of asthma are:
shortness of breath
tightness in the chest.

Not everyone will get all of these symptoms. Some people experience them from time to time; a few people may experience these symptoms all the time.

The good news is that most people with asthma do not have to follow a special diet but it is important that they have a healthy diet of salads, green vegetables, whole grains, fruits, fish and organic meat or vegetable proteins.

In some cases, certain foods including cow’s milk, eggs, fish, shellfish, yeast products, nuts, and some food colourings and preservatives, can make symptoms worse. This is the reason for a wide diet of supportive health foods and the ABC Daily Herbal Powder.

People with asthma are also recommended to avoid Royal Jelly products as they may trigger symptoms. If you think you have a food allergy, contact your doctor or nurse for further advice.

Remember, just avoiding your triggers alone is unlikely to control your asthma. You need to take regular asthma medicines as well. Specific anti-asthmatic herbs can also be very useful.

Losing weight can help in managing asthma, and combined with a more active lifestyle, can also help to improve lung function. See WeightLess Tonic.

Base your healthy eating plan around a variety of foods, including fresh fruit and vegetables, grains and cereals. It is recommended that you eat five portions of fruit or vegetables every day and drink plenty of water.
Foods that may protect against asthma

Some foods have also been found to help protect against asthma and improve lung function.

Dutch research has shown that people who ate the most fruit and vegetables had the healthiest lung function. Vitamin C and E are also believed to help reduce the severity of the inflammatory response in the lungs of people with asthma. A diet that includes a high level of nutrients can also boost the immune system and help ward off colds and flu – both common asthma triggers.


Chronic obstructive pulmonary disease (COPD) is an umbrella term for people with chronic bronchitis, emphysema, or both. With COPD the airflow to the lungs is restricted (obstructed). COPD is usually caused by smoking. Symptoms include cough and breathlessness. The most important treatment is to stop smoking. Inhalers are commonly used to ease symptoms. Other treatments such as steroids, antibiotics, oxygen, and mucolytic (mucus-thinning) medicines are sometimes prescribed in more severe cases, or during a flare-up (exacerbation) of symptoms.

What is chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a general term which includes the conditions chronic bronchitis and emphysema. COPD is the preferred term, but you may still hear it called chronic obstructive airways disease (COAD).

Chronic means persistent.
Bronchitis is inflammation of the bronchi (the airways of the lungs).
Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs.
Pulmonary means ‘affecting the lungs’.

Chronic bronchitis or emphysema can cause obstruction (narrowing) of the airways. Chronic bronchitis and emphysema commonly occur together. The term COPD is used to describe airflow obstruction due to chronic bronchitis, emphysema, or both.

How common is chronic obstructive pulmonary disease?

COPD is common. It is estimated that about three million people in the UK have COPD. However, in many of these people, the condition has not been formally diagnosed (normally these would be mild cases). This is because in the early stages, many people put up with a cough or mild breathlessness without seeing their doctor. They may only see see their doctor when symptoms get worse. COPD mainly affects people over the age of 40 and becomes more common with increasing age. The average age when it is formally diagnosed is around 67 years. It is more common in men than women.

COPD accounts for more time off work than any other illness. A flare-up (exacerbation) of COPD is one of the most common reasons for admission to hospital (1 in 8 admissions is due to COPD).

What causes chronic obstructive pulmonary disease?

Smoking is the cause in the vast majority of cases. There is no doubt about this. The lining of the airways becomes inflamed and damaged by smoking. About 3 in 20 people who smoke one packet of cigarettes (20 cigarettes) per day, and 1 in 4 40-per-day smokers, develop COPD if they continue to smoke. For all smokers, the chances of developing COPD is between 1 in 10 and 1 in 4.

Air pollution and polluted work conditions may cause some cases of COPD, or make the disease worse. The combination effect of occupational exposure to air pollutants and smoking increases the chances of developing COPD.

A small number of people have a genetic (hereditary) risk of COPD due to very rare protein deficiencies that can lead to lung, liver and blood disorders. (The condition is called alpha-1-antitrypsin deficiency). Less than 1 in 100 cases of COPD are due to this.

However, people who have never smoked rarely develop COPD. (Passive smoking remains, however, a potential cause.)

What are the symptoms of chronic obstructive pulmonary disease?

Cough is usually the first symptom to develop. It is productive with sputum (phlegm). It tends to come and go at first, and then gradually becomes more persistent (chronic). You may think of your cough as a ‘smokers cough’ in the early stages of the disease. It is when the breathlessness begins that people often become concerned.
Breathlessness (shortness of breath) and wheeze may occur only when you exert yourself at first. For example, when you climb stairs. These symptoms tend to become gradually worse over the years if you continue to smoke. Difficulty with breathing may eventually become quite distressing.
Sputum – the damaged airways make a lot more mucus than normal. This forms sputum (phlegm). You tend to cough up a lot of sputum each day.
Chest infections are more common if you have COPD. A sudden worsening of symptoms (such as when you have an infection) is called an exacerbation. Wheezing with cough and breathlessness may become worse than usual if you have a chest infection and you may cough more sputum. Sputum usually turns yellow or green during a chest infection. Chest infections can be caused by bacteria or viruses. Bacteria (which can be killed using antibiotics) cause about 1 in 2 or 3 exacerbations of COPD. Viruses (not killed with antibiotics) are a common cause of exacerbations too, particularly in the winter months. The common cold virus may be responsible for up to 1 in 3 exacerbations.
Other symptoms of COPD can be more vague. Examples are weight loss, tiredness and ankle swelling.

Chest pain and coughing up blood (haemoptysis) are not common features of COPD. It is possible to have slightly blood-streaked sputum when you have a chest infection. However, chest pain, blood in the sputum or coughing up just blood, should always be reported to a doctor. This is because other conditions need to be excluded (like angina, heart attack or lung cancer).

What’s the difference between chronic obstructive pulmonary disease and asthma?

Asthma and COPD cause similar symptoms. However, they are different diseases. Briefly: In COPD there is permanent damage to the airways. The narrowed airways are fixed, and so symptoms are chronic (persistent). Treatment to open up the airways
is therefore limited.
In asthma there is inflammation in the airways which makes the muscles in the airways constrict. This causes the airways to narrow. The symptoms tend to come and go, and vary in severity from time to time. Treatment to reduce inflammation and to open up the airways usually works well.
COPD is more likely than asthma to cause a chronic (ongoing) cough with phlegm.
Night time waking with breathlessness or wheeze is common in asthma and uncommon in COPD.
COPD is rare before the age of 35 whilst asthma is common in under-35s.
There is more likely to be a history of asthma, allergies, eczema and hayfever (so-called atopy) in people with asthma.

Both asthma and COPD are common, and some people have both conditions. (See separate leaflet called ‘Asthma’ for more information.)

Do I need any tests?

COPD may be suspected by your doctor because of your symptoms. Examination of your chest can be normal in mild or early COPD. Using a stethoscope, your doctor may hear wheezes in your chest, or find signs of a chest infection. Your chest may show signs of being overinflated (hyperinflation). This is because the airways are obstructed and, as well as it being difficult for air to get into your lungs, it is also difficult for it to escape. Your history (symptoms) and physical examination will help your GP decide if COPD is likely.


The most common test used in helping to diagnose the condition is called spirometry. This test estimates lung volumes by measuring how much air you can blow out into a machine. Two results are important: the amount of air you can blow out in one second (called forced expiratory volume in 1 second – FEV1) and the total amount you can blow out in one breath (called forced vital capacity – FVC). Your age, height and sex affect your lung volumes. So, your results are compared to the average predicted for your age, height and sex.

A value is calculated from the amount of air that you can blow out in one second divided by the total amount of air that you blow out in one breath (called FEV1/FVC ratio). A low value indicates that you have narrowed airways. The FEV1 compared with the predicted value shows how bad the COPD is.

COPD is divided into mild, moderate and severe groups, depending on the level of airflow obstruction. The airflow obstruction is the FEV1, measured with spirometry.

Mild (stage 1) COPD is an FEV1 at least 80% of predicted value.
Moderate (stage 2) COPD is an FEV1 between 50% and 79% of predicted value.
Severe (stage 3) COPD is an FEV1 between 30% and 49% of predicted value.
Very severe (stage 4) COPD is an FEV1 less than 30% of predicted value.

Other tests

A chest X-ray may show signs of COPD and can be used to help exclude other serious conditions (including lung cancer). Occasionally, a special CT scan of the chest – high-resolution CT (HRCT) – is needed. A blood test to make sure you are not anaemic is often helpful. (Anaemia can lead to breathlessness.) Sometimes a blood test can show changes (called polycythaemia) that suggest you have chronically low levels of oxygen (hypoxia).

A pulse oximeter is a device can be clipped on to your finger to measure your heart rate (pulse) and measure the amount of oxygen in your circulation (oxygen saturation). Lower levels than normal tend to be found in people who have COPD, especially if you have an exacerbation of your symptoms.
Related blogsSarah Jarvis’ blog posts

COPD – the forgotten epidemic – Get our LungShield-COPD
Inhalers – what are they and what do they do?
Don’t become an ex-smoker – become a non-smoker!  — Give it up by giving our SmokeLess Tonic and or our Smoking Mixture (herbal only; non-tobacco) a go – buy here

What is the progression and outlook?

Symptoms of COPD typically begin in people aged over 40 who have smoked for 20 years or more. A ‘smoker’s cough’ tends to develop at first. Once symptoms start, if you continue to smoke, there is usually a gradual decline over several years. You tend to become more and more breathless. In time your mobility and general quality of life may become poor due to increasing breathing difficulties.

Chest infections tend to become more frequent as time goes by. Flare-ups of symptoms (exacerbations) occur from time to time, typically during a chest infection.

If the condition becomes severe then heart failure may develop. This is due to the the reduced level of oxygen in the blood and changes in the lung tissue which can cause an increase in pressure in the blood vessels in the lungs. This increase in pressure can put a strain on the heart muscle leading to heart failure. Heart failure can cause various symptoms including worsening breathlessness and fluid retention.

(Note: heart failure does not mean the heart stops beating (that is called cardiac arrest). Heart failure is when the heart does not pump blood very well.

Respiratory failure is the final stage of COPD. At this point the lungs are so damaged that the levels of oxygen in the blood are low. The waste product of breathing called carbon dioxide (CO2) builds up in the blood stream. People with end-stage COPD need palliative care to make them more comfortable and ease any symptoms.

At least 25,000 people die each year in the UK from the end stages of COPD. Many of these people have several years of ill health and poor quality of life before they die.

Depression and/or anxiety affect at least 6 in 10 people with COPD, and can be treated if recognised.

How can the course of the disease be altered?

Stop smoking. This is the single most important piece of advice. If you stop smoking in the early stages of COPD it will make a huge difference. Damage already done to your airways cannot be reversed, but stopping smoking prevents the disease from worsening. It is never too late to stop smoking, at any stage of the disease. Even if you have fairly advanced COPD, you are likely to benefit and prevent further progression of the disease.

Your cough may get worse for a while when you give up smoking. This often happens as the lining of the airways ‘comes back to life’. Resist the temptation to start smoking again to ease the cough. An increase in cough after you stop smoking usually settles in a few weeks.

The NHS provides free help and advice for people having difficulty in stopping smoking. Medication (such as varenicline, brand name Champix® and bupropion, brand name Zyban®) and nicotine replacement therapy (such as patches and chewing gum) can be prescribed, and counselling offered. You could see your GP or practice nurse for further advice, or visit the NHS website: http://smokefree.nhs.uk
What are the treatments for chronic obstructive pulmonary disease?

Stopping smoking is the most important treatment. No other treatment may be needed if the disease is in the early stage and symptoms are mild.

If symptoms become troublesome, one or more of the following treatments may be advised. (Note: treatments do not cure COPD. Treatments aim to ease symptoms. Some treatments may prevent some flare-ups of symptoms.)

As a general rule, a trial of 1-3 months of a treatment will give an idea if it helps or not. A treatment may be continued after a trial if it helps, but may be stopped if it does not improve symptoms).

It can be helpful to consider treatments for three separate problems.

Treatments for stable COPD
Treatments for exacerbations of COPD
Treatments for end-stage COPD
Get our LungShield-COPD Tonic

Treatments for stable chronic obstructive pulmonary disease

The main treatments are medications given in devices called inhalers. The medicine within the inhaler is in a powdered form which you breathe in (inhale). Some people find inhalers more difficult than others to use. The medicines in standard inhalers reach the lungs better if used with a spacer device. (See separate leaflet called ‘Inhalers for Chronic Obstructive Pulmonary Disease’ for more information on the different inhaler medicines and devices.)
Short-acting bronchodilator inhalers

An inhaler with a bronchodilator medicine is often prescribed. These relax the muscles in the airways (bronchi) to open them up (dilate them) as wide as possible. The same inhalers may be used if you have asthma. People often call them relievers.

They include:

Beta-agonist inhalers. Examples are salbutamol (brand names include Airomir®, Asmasal®, Salamol®, Salbulin®, Pulvinal Salbutamol® and Ventolin®) and terbutaline (brand name Bricanyl®). These inhalers are often (but not always), blue in colour. Other inhalers containing different medicines can be blue too.
Antimuscarinic inhalers. For example, ipratropium (brand name Atrovent®). These inhalers work well for some people, but not so well in others. Typically, symptoms of wheeze and breathlessness improve within 5-15 minutes with a beta-agonist inhaler, and within 30-40 minutes with an antimuscarinic inhaler. The effect from both types typically lasts for 3-6 hours. Some people with mild or intermittent symptoms only need an inhaler as required for when breathlessness or wheeze occur. Some people need to use an inhaler regularly. The beta-agonist and antimuscarinic inhalers work in different ways. Using two, one of each type, may help some people better than one type alone.

Long-acting bronchodilator inhalers

These work in a similar way to the short-acting inhalers, but each dose lasts at least 12 hours. Long-acting bronchodilators may be an option if symptoms remain troublesome despite taking a short-acting bronchodilator.

Beta-agonist inhalers. Examples are formoterol (brand names Atimos®, Foradil®, and Oxis®) and salmeterol (brand name Serevent® – a green-coloured inhaler). You can continue your short-acting bronchodilator inhalers with these medicines.
Antimuscarinic inhalers. The only long-acting antimuscarinic inhaler is called tiotropium (brand name Spiriva®). The inhaler device is green-coloured. If you start this medication, you should stop ipratropium (Atrovent®) if you were taking this beforehand. There is no need to stop any other inhalers.

Steroid inhalers

A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups (exacerbations) of symptoms. Steroids reduce inflammation. Steroid inhalers are only used in combination with a long-acting beta-agonist inhaler. (This can be with two separate inhalers or with a single inhaler containing two medicines).The main inhaled steroid medications are:

Beclometasone. Brands include Asmabec®, Beclazone®, Becodisks®, Clenil Modulite®, Pulvinal Beclometasone® and Qvar®. These inhalers are usually brown and sometimes red in colour.
Budesonide. Brands include Easyhaler Budesonide®, Novolizer Budesonide® and Pulmicort®.
Ciclesonide. Brand name Alvesco®.
Fluticasone. Brand name Flixotide®. This is a yellow or orange coloured inhaler.
Mometasone. Brand name Asmanex Twisthaler®.

A steroid inhaler may not have much effect on your usual symptoms, but may help to prevent flare-ups. In the treatment of asthma, these medicines are often referred to as preventers. Side-effects of steroid inhalers include oral (in the mouth) thrush, sore throats and a hoarse voice. These effects can be reduced by rinsing your mouth with water after using these inhalers, and spitting out.

Combination inhalers are available, usually containing a steroid medication and either a short-acting or long-acting beta-agonist.

Combination inhalers are useful if people have severe symptoms or frequent flare-ups. Sometimes is is more convenient to use just one inhaler device. Examples of combination inhalers are:

Fostair® (formoterol and beclometasone).
Seretide® (salmeterol and fluticasone). This is a purple-coloured inhaler.
Symbicort® (formoterol and budesonide).

Because there are lots of different coloured inhalers available, it is helpful to remember their names, as well as the colour of the device. This might be important if you need to see a doctor who does not have your medical records (such as in A+E, if you are on holiday, or outside the normal opening hours of your GP surgery).
Support groups Further information from professionals

Chest, Heart & Stroke Northern Ireland
21 Dublin Road Belfast BT2 7HB Tel (helpline): 08457…

British Lung Foundation
73-75 Goswell Road London EC1V 7ER

Bronchodilator tablets

Theophylline is a bronchodilator (it ‘opens’ the airways) medicine that is sometimes used. It is used in stable COPD rather than in an acute exacerbation. Brand names of theophylline are Nuelin SA®, Slo-Phyllin® and Uniphyllin Continus®. Aminophylline is a similar drug (usually given by injection in hospital) but there are tablets (brands include Norphyllin® SR and and Phyllocontin Continus®).

The body breaks down (metabolises) theophylline in the liver. This metabolism varies from person to person. The blood levels of the drug, therefore, can vary enormously. This is particularly the case in smokers, people with liver damage or impairment, and in heart failure. In some conditions, the breakdown is reduced, and blood levels increase. In other conditions, the breakdown is increased and so blood levels of theophylline fall. This is very important as the toxic (dangerous) dose for theophylline is only just above the dose that is needed for the medicine to work well.

Blood tests are done to measure the amount of theophylline in the blood, to check it is neither too high nor too low. Theophylline interacts with lots of other medicines too, so sometimes it cannot be prescribed, due to other medicines that you take. Theophylline commonly causes side-effects which include palpitations (fast heartbeat), nausea (feeling sick), headache and occasionally abnormal irregular heartbeat (arrhythmia) or even convulsions (fits).
Mucolytic medicines

A mucolytic medicine such as carbocisteine (Mucodyne®), erdosteine (Erdotin®) and mecysteine (Visclair®) makes the sputum less thick and sticky, and easier to cough up. This may also have a knock-on effect of making it harder for bacteria (germs) to infect the mucus and cause chest infections. The number of flare-ups of symptoms (exacerbations) tends to be less in people who take a mucolytic. It needs to be taken regularly (usually two or three times per day) and is most likely to help if you have moderate or severe COPD and have frequent or bad flare-ups (exacerbations).
Treatment of exacerbations

Treatment of an exacerbation of COPD involves adding extra medicines temporarily to your usual treatment. This is usually steroid tablets with or without antibiotics. These medicines are usually taken until your symptoms settle down to what is normal for you.

If you have frequent flare-ups then your doctor may advise on a self-management plan. This is a written plan of action agreed by you and your doctor on what to do as soon as possible after a flare-up starts to develop. For example, you may be given advice on how to increase the dose of your inhalers when needed. You may also be given some steroid tablets and/or antibiotics to have on standby so that you can start these as soon as possible when a flare-up first develops. You will also be told when you need to seek medical attention – for example if you are concerned that you are not responding to treatment.
Steroid tablets

A short course of steroid tablets called (prednisolone) is sometimes prescribed if you have a bad flare-up of wheeze and breathlessness (often during a chest infection). Steroids help by reducing the extra inflammation in the airways which is caused by infections.

Steroid tablets are usually taken once per day, often for between 5 to 14 days. Depending on the strength of the tablet, you might need to take 6 or even 8 as a single daily dose. If your symptoms improve quickly, your doctor may tell you to stop taking the steroids at the end of the week. If your problems are more severe, the steroid tablets may be tailed off over several days or weeks. Occasionally, some patients take steroid tablets long-term. This is not always advised as there can be serious side-effects.

Some important side-effects of steroids include osteoporosis (thinning of the bones due to reduced bone density), bleeding in the stomach (gastrointestinal bleeds), a lowering of the immune system (immunosuppression) – making infections more common, weight gain (and a condition called Cushing’s syndrome), and a lowering of the body’s natural ability to make certain hormones (adrenal suppression). If you need to have steroid tablets long-term, you will usually be given some medicines to protect your bones and prevent osteoporosis. (See separate leaflet called ‘Osteoporosis’ for more information.)

A short course of antibiotics is commonly prescribed if you have a chest infection, or if you have a flare-up of symptoms which may be triggered by a chest infection.
Admission to hospital

If your symptoms are very severe, or if treatments for an exacerbation are not working well enough, you may need to be admitted to hospital. In hospital you can be monitored more closely. Often the same drugs are given to you but at higher doses or in a different form. Tests such as a chest X-ray or blood tests to measure how much oxygen there is in your blood (arterial blood gases) can be performed. Chest physiotherapy can be started to help you clear secretions (mucus) from your chest by coughing and suction machines.

If you are very breathless it may be impossible to use your inhaler. Nebulisers are machines that turn the bronchodilator medicines into a fine mist, like an aerosol. You breathe this in with a face mask or a mouth piece. Nebulisers are no more effective than normal inhalers but they are useful in people who are very fatigued (tired) with their breathing.

You may need oxygen to help you breathe. Sometimes a special machine called bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) is used to help you breathe. This is called noninvasive ventilation (NIV). It consists of a close-fitting facemask and drives oxygen into your lungs, forcing the airways open. It can make you feel a bit claustrophobic and it is quite noisy. In very severe cases, you might need more help with breathing, in an intensive care unit (ICU). A tube can be put into your windpipe and connected to a ventilator (a machine that ‘breathes’ for you). If you have severe underlying COPD (rather than just a severe exacerbation of COPD), this is not always the best option.

About 2-4 patients in 100 admitted to hospital because of their COPD will die due to that illness. Between 1in 10 and 1 in 4 people admitted to ICU with severe COPD die.
End-stage chronic obstructive pulmonary disease
Palliative care

Palliative care should be discussed with all people with COPD who are likely to die in the coming year. It is always difficult to be accurate about prognosis (outlook). Mostly, health professionals talk in terms of ‘days’, ‘months’ or ‘years’ when discussing prognosis for any particular disease or illness.

As COPD progresses, the condition becomes more severe. You might have more frequent exacerbations and/or admissions to hospital. These factors can give a clue as to how advanced the illness is. Palliative care is usually started in COPD when you are on the maximum medication and are continuing to deteriorate (get worse). Sometimes in these situations you might choose to remain at home for any/all treatments, rather than having further hospital admissions, as things get worse.

Palliative care means care or treatment to keep a person as comfortable as possible, to reduce the severity of the disease, rather than to cure it. Mostly it is about helping you with your symptoms, to make them easier to bear. Your quality of life in the end stages of COPD is very important. Palliative care is not quite the same as terminal (end of life care), when someone is dying and death is expected within a few days. Palliative care can be given in a hospice, but is just as likely to be provided by your GP, district nurse or community palliative care team. Palliative care involves not just physical treatments. Psychological and spiritual wellbeing are important too. The aim is that both you and your family feel supported and that your care is planned. The idea is that a multidisciplinary team, with different healthcare professionals can anticipate any problems before they happen, and help you with access to medication and any equipment that might be needed.

Home oxygen

This may help some people with severe symptoms or end-stage COPD. It does not help in all cases. Unfortunately, just because you feel breathless with COPD it does not mean that oxygen will help you. Great care has to be taken with oxygen therapy. Too much oxygen can actually be harmful if you have COPD.

To be considered for oxygen you would need to have very severe COPD, and be referred to a respiratory specialist (consultant) at a hospital. Your GP cannot just prescribe oxygen to you in this situation. Tests are done to see how bad your COPD is, and how low the oxygen levels in your blood are. This might be done with a pulse oximeter (mentioned earlier) or by taking a sample of blood from an artery in your wrist (blood gases). These tests are needed to decide whether oxygen will help you or not. The monitoring of oxygen levels may take place over a period of several weeks, at rest and with exercises.

If found to help, oxygen needs to be taken for at least 15-20 hours a day to be of benefit. Oxygen can be given with a face mask or through little tubes (nasal cannulae or ‘nasal specs’) that sit just under your nostrils. Portable oxygen is available in cylinders, but if you need long-term oxygen therapy (LTOT), for long periods of the day, an oxygen concentrator is required. This is a big machine (about two feet square and two and a half feet tall) that plugs into a normal electrical socket. The concentrator takes oxygen from the air in your room, and concentrates it, meaning that it is separated from other gases in air, so you only have pure oxygen to breathe in. A back-up supply of oxygen cylinders is provided if you have a concentrator, in case of an electrical power cut or machine breakdown.

Normally, you will only be considered for oxygen if you do not smoke. There is a serious risk of explosion or fire when using oxygen if you smoke.

Oxygen might be used to treat an exacerbation of COPD in hospital but would not be prescribed short-term for an exacerbation to be used at home. Oxygen might be used in an emergency whilst awaiting transfer to a hospital (for example, by a paramedic).

In summary

COPD is usually caused by smoking.
COPD should be considered as a possible diagnosis in anyone aged over 35 years old who smokes, or has ever smoked and has persistent problems such as cough with lots of phlegm, breathlessness or wheeze, and recurrent chest infections.
Symptoms usually become worse if you continue to smoke.
Symptoms are unlikely to get much worse if you stop smoking.
Treatment with inhalers often eases symptoms, but no treatment can reverse the damage to the airways.
A flare-up of symptoms, often during a chest infection, may be helped by increasing the dose of usual treatments. This may be combined with a short course of steroid tablets and/or antibiotics.

Order BreathLess Tonic or LungShield (COPD)

Further help & information

British Lung Foundation
References | Provide feedback
Original Author: Dr Tim Kenny Current Version: Dr Tim Kenny
Last Checked: 05/01/2011 Document ID: 4219 Version: 41 © EMIS

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

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