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Stage 4, or end-stage COPD, is the most severe form of this disease. What can patients expect in terms of symptoms and treatment?

Stage 4 of chronic obstructive pulmonary disease (COPD) is also called "very severe" or even "end-stage" COPD. This sounds ominous for a reason — patients in this stage have new difficulties to deal with:

  • Their medications are no longer as effective as before.
  • Even engaging in daily activities that aren't very strenuous can induce severe dyspnea. 
  • The risk of respiratory infections and acute execerbations rises.
  • Respiratory failure is now a serious risk. 
Despite these very real challenges, suffering from very severe COPD doesn't mean the grim reaper is right around the corner. This phase is, rather, called "end-stage" because it is the most severe stage of COPD. Though treatment becomes a challenge at this point, doctors can still help you be more comfortable. What can you expect during this stage?

What symptoms mark Stage 4 COPD?

On the whole, your symptoms won't change much — they'll simply be more severe, and flare-ups represent more of a challenge in terms of frequency and recovery. Patients suffer from extensive airflow limitations, are likely to suffer from tightness in the chest and abdominal pain, and their restricted oxygen supply also places them at risk of heart issues. 

As the body works harder to get the air it needs and eating may itself become an exhausting activity, many end-stage COPD patients find it hard to get the calories they need and suffer from involuntary weight loss. They can feel drowsy, confused, and disoriented. It is no surprise that that all this can have a huge impact on mental health, too — and many patients become depressed when they have very severe COPD.

You are more likely to require hospitalization in Stage 4 COPD, because of your increased risk of:

  • Respiratory infections
  • Breathing complications
  • Respiratory failure — which can result from a lack of oxygen coming into your lungs, carbon dioxide not being eliminated properly, or a combination of both

Finally, many people with Stage 4 COPD suffer from pulmonary hypertension. In turn, this can cause right-sided heart failure.

How is Stage 4 COPD diagnosed?

Ongoing medical checkups will feature the spirometry you'll already be familiar with at this point, as well as the "forced expiratory volume for one second" (FEV1) that typically determines the stage you're in. Stage 4 COPD is usually marked by an FEV1 of less than 30 percent, but at FEV1 of less than 50 percent combined with chronic respiratory failure can also lead to a diagnosis of Stage 4 COPD.

Chronic respiratory failure can be diagnosed with the help of an arterial blood gas test to determine your blood levels of oxgen and carbon dioxide, and a pulse oximetry test which tests your blood oxygen levels with a device attached to your finger.

Stage 4 COPD: What are your treatment and management options now?

You can expect to continue on the medications you were already using in earlier stages of COPD, such as:

  • Rescue inhalers 
  • Long-acting bronchodilators
  • Steroids
  • Antibiotics as needed

The doses will need adjusting, however, and you may need to use some of these medications more frequently. Pulmonary rehabilitation can play an important role in the management of Stage 4 COPD, and you are also likely to benefit from supplemental oxygen therapy at this point. 

Your adherence to treatment matters now more than ever. Stick to the things you learn in pulmonary rehab — follow the right diet, exercise as directed, and take your medications on time. Make a plan that determines how to manage acute flare-ups with your doctor, and stick with it when you experience one. 

Surgery may also become an option for Stage 4 COPD patients whose medications no longer offer them relief: 

  • Bullectomy. When the air sacs become enlarged, they're referred to as bullae. In some Stage 4 COPD patients, these bullae are so large that they obstruct breathing, in which case surgery can alleviate your symptoms.
  • Lung volume reduction surgery. This involves removing the upper portion of your lungs to make for easier breathing, and people who have healthy hearts and satisfactory remaining lung tissue may be candidates. Smokers and people who cannot follow their treatment plans are not candidates. 
  • Lung transplant. The ultimate step for people with extensive lung damage who are otherwise in good health, a lung transplant always carries serious risks of complications. 

Lifestyle steps to make your life with Stage 4 COPD easier

  • Participate in a pulmonary rehabilitation program. Not only will the exercises help you improve your quality of life, pulmonary rehab also offers nutritional strategies, like opting for smaller and more frequent high-protein foods to stem involuntary weight loss.
  • Stay away from known triggers as best you can. These can include extreme heat, humidity, high altitudes, and very cold weather, as well as staying indoors during high-pollution days if you live somewhere with air quality problems.
  • You can wear a mask when you go outside. 
  • Always keep your inhalers with you. 

What do end-stage COPD patients need to know about palliative care?

While end-stage COPD does not necessarily mean you're close to death, palliative care is a discipline that focuses on the needs of people for whom treatment options have been exhausted. This includes people who are expected to die soon, and for whom the best and most compassionate end-of-life care can make all the difference. Hospice care will be right for some people, as a dedicated end-of-life care team can help you:

  • Feel most comfortable, minimizing your pain and maximizing your quality of life
  • Retain control of your life and wishes during this point
  • Receive emotional support, for yourself and your family

  • Ambrosino, N., & Simonds, A. (2007). The clinical management in extremely severe COPD. Respiratory Medicine, 101(8), 1613–1624.
  • Photo courtesy of SteadyHealth

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