Managing Advanced COPD: What to Expect

While COPD (chronic obstructive pulmonary disease) symptoms may start out as mild to moderate - with episodes of difficulty breathing that come and go - over time, COPD tends to get worse, and many people eventually progress to the advanced stage of the disease.

Although it may not be possible to prevent COPD from reaching this stage, that doesn't mean nothing can be done to address your symptoms.

Even in its advanced form, "what we really focus on with therapy in COPD is trying to control your symptoms," says Khalilah Gates, MD , a pulmonologist and associate professor of medicine at the Feinberg School of Medicine at Northwestern University in Chicago. That means adding treatments such as supplemental oxygen as needed and possibly taking part in a pulmonary rehabilitation program.

Here's an overview of what to expect with advanced COPD, from symptoms and treatments to eventually planning for end-of-life care.

What Is Advanced COPD?

Advanced COPD, which may also be called very severe COPD, means that your breathing is severely obstructed, leading to worsening symptoms that limit your everyday activities. "Advanced COPD is not always exclusive to the lungs. We see weight loss, muscle wasting, things of that nature," Dr. Gates says.

In the past, advanced COPD was sometimes called end-stage COPD, but that term is no longer widely used. That's in part because even with similar measures of lung function, one person's COPD may look very different from someone else's, and the phrase "end stage" was often viewed as implying that death is near, which may not always be the case.

"There are some people who have severe COPD who don't feel that poorly, are pretty active, and don't have a lot of flare-ups," says Joseph Khabazza, MD , a pulmonologist at the Cleveland Clinic in Independence, Ohio. "So it doesn't always correlate with how the patient is doing, but it can."

One element of advanced COPD is poor lung function, as measured by breathing tests. But Dr. Khabazza says that this alone isn't enough to show advanced disease - a person also has to experience disruptive daily symptoms and will typically have difficulty with routine daily tasks like doing errands or laundry.

Stages of COPD

In people with COPD, lung function is measured using a type of test called spirometry, which measures how much air you blow out and how quickly. This yields a measurement known as FEV1 (forced expiratory volume in one second), which is expressed as a percentage of what a healthy person's lung volume would be.

Here are the stages (also called grades) of COPD based on lung function tests:

Stage 1 (Mild COPD) FEV1 of 80 percent or higher Stage 2 (Moderate COPD) FEV1 of 50 to 79 percent Stage 3 (Severe COPD) FEV1 of 30 to 49 percent Stage 4 (Very Severe COPD) FEV1 below 30 percent

In mild COPD (stage 1), a person may feel out of breath during activities that demand some exertion, like walking up stairs.

In moderate to severe COPD (stages 2 and 3), feeling out of breath tends to be more common with everyday activities and is often accompanied by other symptoms like increased phlegm (thick secretion from the lungs and throat).

In very severe COPD (stage 4), a person tends to feel out of breath often and may have limited mobility.

Dealing With Symptoms of Advanced COPD

By definition, someone with advanced COPD will have more symptoms than at an earlier stage of the disease, such as more difficulty breathing, more coughing, and greater fatigue. How to minimize and adapt to these symptoms is the main focus of treatment for advanced COPD.

"When we get into advanced COPD, we often see their lifestyle is impaired," due to weakness and fatigue in addition to breathing difficulties, Gates says. In response, she adds, doctors will often recommend taking new steps that build on existing treatments like inhaled medications. One option that can be particularly helpful is pulmonary rehabilitation .

Pulmonary rehab typically involves learning exercises and other techniques that can help you breathe more easily. What's more, "Within pulmonary rehab programs, we have support groups that patients have typically found very helpful," says Gates.

For people with COPD who finish pulmonary rehab, "It is crucial that they continue exercising and staying active," says Khabazza. "Someone who exercises regularly is probably going to function better than a person with moderate disease who is inactive." That's true in large part because muscles become weaker more quickly if you're physically inactive - and the steroids that many people with COPD take to help open their airways can contribute to muscle weakness.

With advanced COPD, it's more important than ever to help prevent disease exacerbations - periods of worsening symptoms - caused by an infection or exposure to smoke or another irritant. "We really focus on making sure vaccinations are up to date, because we want to minimize COPD exacerbations from a virus," Gates says.

Khabazza says that in addition to quitting smoking, people with COPD can potentially avoid exacerbations by avoiding pollution, wildfire smoke, outdoor allergens like pollen, and any chemicals or fragrances that seem to make symptoms worse. "Anything that's not clean, pure air has the potential to be a trigger, and that's going to be very individualized," he says.

Even with efforts to maintain an active lifestyle and prevent disease exacerbations, many people with advanced COPD will experience a growing symptom burden that requires additional medical treatments.

Treatments for Advanced COPD

If new treatments are needed for advanced COPD, you'll continue to take the medications you were already taking, such as long-acting and short-acting bronchodilators (drugs that help open up your airways) and steroids (drugs that reduce inflammation).

Possible additional treatments for advanced COPD include the following:

• Supplemental Oxygen You may need to start taking oxygen when you're physically active such as out doing errands. Or if you're already taking oxygen, you may need to use it more. "Some people need continuous oxygen," Khabazza says. That's a sign of very severe COPD.
• Antibiotics These drugs may be needed to treat a bacterial infection in your lungs and airways. Some antibiotics may also have helpful anti-inflammatory effects, according to Khabazza.
• Anticholinergics These drugs help relax muscles around the airways and can make it easier to cough up mucus and phlegm.
• Expectorants These drugs help thin the mucus in your airways, making it easier to cough up. You should always take them with enough water as directed.

Surgery for COPD

In general, surgery for COPD is a last resort when other treatments fail to adequately control symptoms. The following surgical procedures may be an option for some people:

• Bullectomy This procedure removes large air spaces in the lungs (bullae) that can form when the walls of air sacs (alveoli) are destroyed as a result of COPD, potentially making breathing more difficult.
• Endobronchial Valve Implant In this procedure, a valve is placed that allows air to exit - but not enter - a damaged area of the lung.
• Lung Volume Reduction Removing damaged lung tissue may help you breathe more easily.
• Lung Transplant This major surgery replaces a damaged lung with a healthy donor lung. There's a strict eligibility criteria. If you're around age 70 or younger, "it's worth starting to have conversations with your provider about the possibility of being considered for a lung transplant," suggests Gates.

Palliative Care and Hospice Care for Advanced COPD

Many people have misconceptions about what palliative care and hospice care mean in the context of COPD, according to Gates.

"I think a lot of people, when they hear ‘palliative,' they think, You're sending me there so I can pass away. And that's not our intention at all," she says. "Our intention is to look at your symptoms and allow our palliative doctors to help manage them."

Palliative care specialists focus on helping you manage symptoms in ways other than treating the underlying disease. For example, Khabazza says, you may be prescribed medications that help with symptoms like coughing or feeling short of breath. "With palliative care, people still want aggressive care. They still go to the hospital when they're sick; they still see their doctors," he says. "But it helps with symptomatic treatment."

A research review published in the journal Respiratory Medicine found that in the context of chronic respiratory diseases like COPD, palliative care led to improvement in breathing control and use of advance care planning. No difference was seen in other areas such as overall symptom burden, quality of life, or psychological well-being.

A separate study, published in the journal BMC Palliative Care , found that compared with standard hospital care, people with advanced COPD who received specialized palliative care were more likely to both report pain and get pain relief. They were also more likely to receive relief for breathing difficulties, anxiety, and delirium (confused thinking).

Hospice care, on the other hand, is end-of-life care focused on staying out of the hospital, rather than intervening with aggressive treatments. "Hospice is really a patient-driven, patient preference option," says Gates. It typically involves home care focused on comfort and symptom management.

"Some people can be at home in hospice for a long period of time, and it adds a lot to the end of their life," says Khabazza, adding that this period can be several months or even longer.

Advance Care Planning for COPD

When it comes to making medical decisions - even if you're receiving palliative care or hospice care - if at all possible, "the patient should be the decision-maker," Khabazza emphasizes. But sometimes that's not possible.

"Sometimes patients end up getting sick and on a ventilator, and then they can't make decisions," says Khabazza. "So it's important to have plans in place so that if a patient does end up incapacitated, there is a decision-maker who they've had discussions with about their wishes."

Talk to your healthcare team and your loved ones about your wishes regarding end-of-life care. You may decide to complete a healthcare proxy. This simple document lets you designate someone else to make care decisions in the event that you cannot make them for yourself.

Ultimately, Khabazza says, hospice care and end-of-life planning are about peace of mind. "It's saying, ‘I just want to stay out of the hospital, to be at home with my family on my terms,'" he says.

The Takeaway

You may need new treatments as your COPD becomes more severe, including starting or increasing your use of supplemental oxygen and participating in pulmonary rehab. If you have advanced disease that has led to frequent hospitalizations, you may consider hospice care as an alternative to lifesaving care.

Editorial Sources and Fact-Checking

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Sources

1. What Is COPD? National Heart, Lung, and Blood Institute . October 25, 2023.
2. Lung Function in COPD. Kaiser Permanente . August 6, 2023.
3. Chronic Obstructive Pulmonary Disease (COPD). Cleveland Clinic . May 17, 2022.
4. Understanding Your COPD Medications. American Lung Association . May 14, 2024.
5. COPD Treatment. National Heart, Lung, and Blood Institute . October 25, 2023.
6. Santos MF et al. Palliative Care Interventions in Chronic Respiratory Diseases: A Systematic Review. Respiratory Medicine . November 2023.
7. Henoch I et al. Benefits, for Patients With Late Stage Chronic Obstructive Pulmonary Disease, of Being Cared for in Specialized Palliative Care Compared to Hospital. A Nationwide Register Study. BMC Palliative Care . August 24, 2021.

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David Mannino, MD

Medical Reviewer

David Mannino, MD, is the chief medical officer at the COPD Foundation . He has a long history of research and engagement in respiratory health.

After completing medical training as a pulmonary care specialist, Dr. Mannino joined the Centers for Disease Control and Prevention (CDC) Air Pollution and Respiratory Health Branch. While at CDC, he helped to develop the National Asthma Program and led efforts on the Surveillance Reports that described the U.S. burden of asthma (1998) and COPD (2002).

After his retirement from CDC in 2004, Mannino joined the faculty at the University of Kentucky, where he was involved both clinically in the College of Medicine and as a teacher, researcher, and administrator in the College of Public Health. He served as professor and chair in the department of preventive medicine and environmental health from 2012 to 2017, with a joint appointment in the department of epidemiology.

In 2004, Mannino helped to launch the COPD Foundation, where he served as a board member from 2004 through 2015, chairman of the Medical and Scientific Advisory Committee from 2010 through 2015, and chief scientific officer from 2015 to 2017.

Mannino has over 350 publications and serves as an associate editor or editorial board member for the following journals: American Journal of Respiratory and Critical Care Medicine , Chest , Thorax , European Respiratory Journal , and the Journal of the COPD Foundation . He was also a coauthor of the Surgeon General's Report on Tobacco in 2008 and 2014.

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Quinn Phillips

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A freelance health writer and editor based in Wisconsin, Quinn Phillips has a degree in government from Harvard University. He writes on a variety of topics, but is especially interested in the intersection of health and public policy. Phillips has written for various publications and websites, such as Diabetes Self-Management , Practical Diabetology , and Gluten-Free Living , among others.

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