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Ta k e 5 a n d t r y A B M P F i v e - M i n u t e M u s c l e s a t w w w. a b m p . c o m / f i v e - m i n u t e - m u s c l e s . 33 It's a miraculous thing that happens every time we take a "free and easy" breath. But when lung structures undergo pathological changes, the act of breathing—which should be almost effortless—becomes labored, and a long list of complicated problems can develop. What follows is a simplified description of the progress from chronic bronchitis through end-stage emphysema. COPD typically begins with ongoing, long-term irritation to the bronchi and bronchioles. In about 90 percent of all cases, the irritation comes from tobacco or marijuana smoke. Exposure can occur as firsthand smoke (this is what the smoker inhales), secondhand smoke (this is what the smoker exhales and other people may inhale), and side-stream smoke (this is what comes off the cigarette itself ). Industrial chemicals and pollutants can also cause bronchial irritation. And a genetic anomaly called alpha-1 antitrypsin deficiency limits capacity to deal with even mild environmental pollutants, so people with this condition are at increased risk for COPD. With chronic irritation comes inflammation. Over time, the bronchial linings become permanently swollen. Mucus-producing cells replicate, increasing the amount of sticky slime in the respiratory tract. The cilia that line the bronchial tubes may also be damaged, which means contaminant-laden mucus lingers in the lungs—prolonging inflammation and promoting possible infection. These structural changes eventually become irreversible; this is chronic bronchitis. (By contrast, acute bronchitis refers to a short- term infection in the bronchi—although people with chronic bronchitis are very susceptible to bouts of acute bronchitis.) If the damage that causes chronic bronchitis doesn't stop, COPD may progress to affect the alveoli. The alveoli, readers may remember, are the tiny cup-shaped epithelial structures that make up the working tissue of the lungs. Each of our 300 million alveoli is surrounded by its own cardiovascular capillary. This is the site where oxygen from the air we inhale enters the bloodstream, and carbon dioxide exits the bloodstream to enter the alveoli, so it can be expelled when we exhale. If the alveoli are inflamed, several problems develop. First, the elastin fibers that invest the alveolar walls degenerate. This means the lungs lose their ability to recoil to their original shape during exhalation. They become like old, stretched out balloons with remnants of stale air inside—which means fresh, oxygen-rich air can't get in. The walls between the alveoli degenerate, and multiple discrete cups join together to form large hollow areas called bullae. With less surface area and fewer supplying capillaries, the capacity for oxygen-carbon dioxide exchange is impaired. Oxygen levels in the blood fall (called hypoxia), leading to a host of other complicated and serious problems. Among the complications of COPD we see are polycythemia (too many red blood cells and thickened blood), right- sided heart failure, pulmonary embolism, vulnerability to pneumonia, and ultimately respiratory and cardiovascular collapse. SYMPTOMS OF COPD It can take years for the damage of COPD to cause symptoms, and because we usually see this in people over age 65, it is easy to assume those changes are age- related. Chronic bronchitis is marked by fatigue, shortness of breath, and a cough that lingers for weeks and months after even a mild respiratory tract infection. The cough is productive, meaning the person brings up clear, sticky sputum. The fatigue seen with COPD is an important issue. A person with healthy lungs expends about 5 percent of resting A person with healthy lungs expends about 5 percent of resting energy in the effort of breathing. A person with advanced COPD puts closer to 50 percent of resting energy into this job. A big part of COPD that no one talks about is the anxiety that comes with not being able to breathe. It feels claustrophobic. A lot of people find that a face cradle is too constricting, partly because it feels closed in, and partly because it puts pressure on their oxygen tube. Watch "Respiratory Function"