Chronic obstructive pulmonary disease

What is chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.

The symptoms of COPD include cough, sputum production, and dyspnoea (difficult or laboured breathing). COPD symptoms often don't appear until significant lung damage has occurred, which usually worsens over time (WHO 2023).

It is worth noting that while COPD shares similar symptoms and can co-occur or overlap with other respiratory conditions such as Asthma and Bronchiectasis, it remains a distinct condition for diagnosis and treatment. 

What causes chronic obstructive pulmonary disease?

COPD results from a complex interaction between genes and the environment. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), there are many causes of COPD, including:

• tobacco smoke (smoking or exposure to cigarette smoke)
• genetic factors: a small number of people have a form of emphysema caused by a protein disorder called alpha-1 antitrypsin deficiency (AATD)
• lung growth and development factors (Lange et al. 2015)
• environmental factors
• other chronic conditions: such as asthma and chronic bronchitis, which are associated with an increased likelihood of developing COPD (GOLD 2020).

How common is chronic obstructive pulmonary disease?

COPD prevalence is currently monitored by the Australian Institute of Health and Welfare (AIHW) using Australian Bureau of Statistics (ABS) National Health Survey (NHS) data based on self-reported current and long-term bronchitis or emphysema. Estimates of COPD based on self-reported data are limited by potential under-reporting of the condition and changes in the way the condition is understood over time (AIHW 2023a). 

According to self-reported data in the Australian Bureau of Statistics (ABS) National Health Survey (NHS), around 638,000 (2.5%) million people in Australia were estimated to be living with COPD (including chronic bronchitis, emphysema and chronic airflow limitation (ABS 2023).

The prevalence of COPD:

• was similar for men and women overall (2.4% and 2.6% respectively), but for those aged 75 or over, COPD was more prevalent in men compared with women (8.3% and 5.4%, respectively)
• increased gradually with age until 45–54 (1.7%), after which prevalence increased more sharply (to 7.0% for those aged 75 and over)
• was 3.9% for people living in Outer regional and remote areas and 2.2% for people living in Major cities
• was 4.7% for people living in areas of most disadvantage (lowest socioeconomic areas) and 1.5% for people living in the least disadvantaged areas (highest socioeconomic areas) (Figure 1) (ABS 2023).

After adjusting for different population age structures over time, the prevalence of COPD remained stable between 2011–12 and 2022 (2.3% in 2011–12 and 2.2% in 2022) (ABS 2023).

Figure 1: Prevalence of chronic obstructive pulmonary disease, by age and sex, over time (2001 to 2022), by population group, 2022

Prevalence of COPD is also reported in The Burden of Obstructive Lung Disease (BOLD) Australia study. This used spirometry testing and self-reported symptoms of breathlessness to identify people with COPD between 2006 and 2010 (Toelle 2021). Measured data provide the most accurate estimates of COPD prevalence. However, survey-based estimates can be quickly out-dated as surveys are time consuming and expensive to conduct which prevents them being updated annually.

Linked data has also recently been used to estimate the prevalence of COPD in Australia. 

Prevalence in Aboriginal and Torres Strait Islander (First Nations) people

The AIHW uses ‘First Nations people’ to refer to Aboriginal and/or Torres Strait Islander people in this report.

Around 17,800 (10%) First Nations people aged 45 and over, were estimated to be living with COPD in 2018–19, based on the National Aboriginal and Torres Strait Islander Health survey (NATSIHS) (ABS 2019).

For more information on respiratory conditions in First Nations people, see the Aboriginal and Torres Strait Islander Health Performance Framework Measure 1.04 (AIHW 2023b).

Impact of chronic obstructive pulmonary disease

COPD can interrupt daily activities, sleep patterns and the ability to exercise. People with COPD generally rate their health worse than people without the condition. 

Measures of impact include burden of disease, health expenditure and mortality.

Burden of disease

In 2023, COPD was the fifth leading cause of burden and accounted for 3.6% of total disease burden (also known as disability-adjusted life years or DALY), 3.2% of non-fatal burden (years lived with disability or YLD) and 4.1% of fatal burden (years of life lost or YLL).

Within the respiratory conditions’ disease group, COPD accounted for:

• 50% of total burden (DALY)
• 38% of non-fatal burden (YLD)
• 71% of fatal burden (YLL) (AIHW 2023c).

Variation by age and sex

In 2023:

• the rate of total burden (DALY) increased substantially between the ages of 55–59 and 75–79 (5.9 to 40.1 DALY per 1,000 population)
• males had a higher proportion of fatal burden (YLL) than females (53% and 47% respectively)
• COPD was the leading cause of total burden in women and 2^nd leading cause of total burden in men aged 70–74 and 75–79 (31.7 and 40.6 DALYs per 1,000 population and 32.1 and 39.6 DALYs per 1,000 population, respectively) (Figure 2).

Figure 2: Burden of disease due to chronic obstructive pulmonary disease, by age and sex, 2003, 2011, 2015, 2018 and 2023

Trends over time

After adjusting for different population age structures over time, the rate of COPD burden decreased by 13% (from 6.6 DALY to 5.7 DALY per 1,000 population) – or 0.7% per year on average between 2003 and 2023.

For more information, see the Australian Burden of Disease Study 2023.

Variation between population groups

In 2018, after adjusting for age differences, the rate of burden from COPD:

• was highest for people living in Remote and very remote areas and lowest for people living in Major cities (8.5 and 5.2 DALY per 1,000 population, respectively)
• was highest for people living in areas of most disadvantage (lowest socioeconomic areas) and lowest for people living in the least disadvantaged areas (highest socioeconomic areas) (7.5 and 4.3 DALY per 1,000 population, respectively) (Figure 3) (AIHW 2021).

For more information, see the Australian Burden of Disease Study 2018: Interactive data on disease burden.

Figure 3: Burden of disease due to chronic obstructive pulmonary disease by remoteness area and socioeconomic area, by sex, 2011, 2015 and 2018

Health system expenditure

Understanding the contribution of COPD to direct health care expenditure helps to explain its economic impact. In 2020–21, an estimated $831.6 million was spent on the treatment and management of COPD, representing 0.6% of total health system expenditure and 18% of expenditure for all respiratory conditions (AIHW 2023d).

Where is the money spent?

In 2020–21:

• hospital services represented 58% ($483.6 million) of COPD expenditure, similar to the proportion of total health expenditure for hospital services (63%)
• primary care accounted for 37% ($307.8 million) of COPD expenditure, around 1.3 times the primary care portion of total health expenditure (28%). The Pharmaceutical Benefits Scheme (PBS) proportion of COPD expenditure was especially large in comparison to the average, 2.6 times the proportion for total health expenditure (30% and 11%, respectively)
• referred medical services represented 4.8% ($40.1 million) of COPD expenditure, which was approximately half the referred medical services portion of total expenditure (9.8%) (Figure 4).

Figure 4: Chronic obstructive pulmonary disease expenditure attributed to each area of the health system, with comparison to all disease groups, 2020–21

In 2020–21, COPD accounted for:

• 1.5% ($247.2 million) of all PBS expenditure
• 0.6% ($315.9 million) of all public hospital admitted patient expenditure (Figure 5).

Figure 5: Proportion of expenditure attributed to chronic obstructive pulmonary disease, for each area of the health system, 2020–21

Who is the money spent on?

In 2020–21:

• the age distribution of spending on COPD reflects the prevalence distribution, with most spending on older age groups (98% on people aged 45 and over)
• 7% more COPD expenditure was attributed to males compared with females ($444.7 million and $285.7 million, respectively) with the remaining $1.2 million (0.1%) unattributed to any sex (Figure 6).

In 2018–19, it was estimated that COPD expenditure per case was:

• 21% higher for males compared with females ($1,700 and $1,400 per case, respectively)
• 67% higher than respiratory conditions as a group ($1,600 and $510 per case, respectively) (AIHW 2022).

For more information, see:

• Health system spending per case of disease and for certain risk factors
• Health system spending on disease and injury in Australia, 2020–21.

How many deaths were associated with chronic obstructive pulmonary disease?

COPD was recorded as an underlying cause of death for 7,691 deaths or 29.6 per 100,000 population in Australia in 2022. This represented 4.0% of all deaths and 51% of all respiratory deaths in 2022.

An additional 11,431 deaths had an associated cause of COPD recorded, resulting in a total of 19,122 deaths due to, or associated with, COPD. This represented 10% of all deaths and 35% of respiratory deaths.

Variation by age and sex

In 2022, COPD mortality (as the underlying cause of death) was more common amongst:

• older people (with the same proportion as for all deaths – 68% compared with 68% for total deaths for those aged 75 and over, respectively)
• males (with a higher proportion than for all deaths – 53% compared with 48% for total deaths for males, respectively).

Figure 6: Age distribution for chronic obstructive pulmonary disease mortality, by sex, 2012 to 2022

Trends over time

After adjusting for different population age structures over time, mortality rates for COPD (as the underlying cause of death) between 2012 and 2022:

• decreased gradually until 2020 (to 19 per 100,000, likely due to COVID‑19) and then increased thereafter (up to 22 per 100,000 in 2022), similar to the trend for all-cause mortality (AIHW 2023f)
• were 1.4 to 1.7 times higher for males compared with females (Figure 7).

Figure 7: Trends over time for chronic obstructive pulmonary disease mortality, 2012 to 2022

Variation between population groups

In 2022, after adjusting for age differences, mortality rates for COPD (as the underlying cause) were:

• 1.9 times higher for people living in Remote and very remote areas compared with people living in Major cities (34.8 and 18.8 per 100,000 population, respectively)
• 2.7 times higher for people living in areas of most disadvantage compared with people living in the least disadvantaged areas (31.9 and 11.6 per 100,000 population, respectively).

The same patterns were observed for COPD deaths as an underlying cause or any cause (underlying or associated cause) of death.

Chronic obstructive pulmonary disease mortality and smoking trends

According to the 2018 Australian Burden of Disease Study, tobacco use contributed to 73% of total disability-adjusted life years (DALY) for COPD. The proportion of DALY attributed to tobacco use was higher among females compared with males (79% and 66%, respectively) (AIHW 2021).

The main risk factor for the development and progression of COPD is smoking, with smokers in the United States being 12 to 13 times more likely to die from COPD than non-smokers (U.S. Department of Health and Human Services 2014).

Improvements in COPD mortality rates tend to follow decreases in smoking rates, with a time-lag in-between due to the long latency period of COPD (smoking early in life is involved in initiating disease processes prior to the disease being diagnosed) (Laniado-Laborin 2009).

In Australia, the smoking rate of adults aged 18 and over decreased from 1980 to 2019 for both men and women, with men having consistently higher smoking rates than women (men: 41% to 14%, women: 30% to 12%) (Figure 8) (Greenhalgh et al. 2023).

For more information on the history of smoking and COPD, see Mortality from asthma and COPD in Australia (AIHW 2014). 

Figure 8: Chronic obstructive pulmonary disease death rates of people aged 45 and over, 3-year moving average, and smoking rates, 1980 to 2020

Notes

1. COPD deaths are shown as a 3-year moving average. For example, the 2020 data point represents the average of 2019, 2020 and 2021.
2. From 1979 to 1996, COPD classified according to ICD-9 codes 490, 491, 492, 496. From 1997 to 2021, COPD classified according to ICD-10 codes J40–J44.
3. Smoking refers to people those reporting that they smoke 'daily' or 'at least weekly', and smoking any combination of combustible cigarettes, cigars, pipes or waterpipes. It does not include use of electronic cigarettes/vapes or other personal vaporising devices where users inhale vapour rather than smoke. 
4. Smoking data were calculated by the Cancer Council of Victoria. Smoking rates for 1980–1992 were sourced from surveys conducted by the Anti-Cancer Council of Victoria. Smoking rates for 1995–2019 were sourced from the National Drug Strategy Household Survey.
5. Deaths registered in 2018 and earlier are based on the final version of cause of death data. Deaths registered in 2019 are based on the revised version and deaths registered in 2020 and 2021 are based on the preliminary version. Revised and preliminary versions are subject to further revision by the Australian Bureau of Statistics (ABS).

Source: AIHW analysis of the AIHW National Mortality Database, Scollo and Winstanley 2019 (Chronic Obstructive Pulmonary Disease 2023 Supplementary data table 4.1).

Treatment and management of chronic obstructive pulmonary disease

The Department of Health and Aged Care’s National Strategic Action Plan for Lung Conditions (the Action Plan) provides a detailed, person-centred roadmap for treating and managing COPD, among several other lung conditions (Department of Health and Aged Care 2019). 

This plan is complemented by The COPD-X Plan: Australian and New Zealand Guidelines for the management of COPD (the COPD-X Guidelines) which summarises the latest evidence around optimal management of people with COPD (Yang et al. 2019). 

What role do GPs play in managing chronic obstructive pulmonary disease?

General practitioners (GPs) are often the first point of contact for people who develop COPD. Until 2017, the Bettering the Evaluation and Care of Health (BEACH) survey was the most detailed source of data about general practice activity in Australia (Britt et al. 2016). In the 10-year period from 2006–07 to 2015–16, according to the BEACH survey, the estimated rate of COPD management in general practice was around 0.9 per 100 encounters (Britt et al. 2016).

It is worth noting that there is currently no nationally consistent primary health care data collection to monitor provision of care by GPs. See General practice, allied health and other primary care services.

What interventions are used to treat and manage chronic obstructive pulmonary disease?

Currently, the only intervention that has been shown to slow the long-term deterioration in lung function associated with COPD is assisting smokers to quit (Mosenifar 2022). Other interventions for COPD that can help maintain quality of life and reduce symptoms include immunisations, pulmonary rehabilitation medications and, for people with very severe disease, long-term oxygen therapy (Alison et al. 2017; Puhan et al. 2016; Yang et al. 2022).

Medications are also used in COPD treatment to prevent and control symptoms, reduce the frequency and severity of exacerbations and improve exercise tolerance (George and Bender 2019).

What role do hospitals play in treating chronic obstructive pulmonary disease?

Patients may require admission to hospital for severe acute exacerbations of COPD. These so-called ‘flare ups’ are frequently due to respiratory tract infections but have also been associated with increases in exposure to air pollution and changes in ambient temperature.

The development of COPD occurs over many years and therefore affects mainly middle aged and older people while asthma affects people of all ages. The prevalence of COPD increases with age, mostly occurring in people aged 45 and over, with persons aged 85 and over having the highest prevalence in 2021–22 (4,300 hospitalisations per 1,000 population) (Figure 9).

Data from the National Hospital Morbidity Database (NHMD) show that for people aged 45 and over in 2021–22, there were 128,000 hospitalisations with a principal or additional diagnosis (any diagnosis) of COPD, representing 1.6% of all hospitalisations. 

The rest of this section discusses hospitalisations with a principal diagnosis of COPD, unless otherwise stated. However, charts and tables also include statistics for any diagnosis of COPD.

For people aged 45 and over, in 2021–22:

• there were 53,000 hospitalisations with a principal diagnosis of COPD, representing 0.7% of all hospitalisations, and 500 hospitalisations per 100,000 population
• COPD accounted for 268,000 bed days, representing 1.2% of all bed days
• 90% of COPD hospitalisations were overnight stays, with an average length of 5.5 days (Figure 10).

Variation by age and sex

In 2021–22, COPD hospitalisation rates for persons aged 45 and over:

• increased with age and were highest for people aged 85 and over (1,400 per 100,000 population)
• were similar for males compared with females (510 and 485 per 100,000 population, respectively) (Figure 10).

Figure 9: Age distribution for chronic obstructive pulmonary disease hospitalisations, by sex, 2011–12 to 2021–22

Trends over time

From 2011–12 to 2021–22, for COPD hospitalisations for persons aged 45 and over:

• the rate decreased from 720 to 500 per 100,000 population
• the proportion of overnight stays decreased slightly from 92% to 90%
• the average length of overnight stays decreased slightly from 6.5 to 5.5 days (Figure 10).

It should be noted that the rates of hospitalisations over the past few years have been affected by the COVID‑19 pandemic. For more information on this, see Chronic respiratory conditions COVID-19 impact.

Figure 10: Trends over time for chronic obstructive pulmonary disease hospitalisations, 2011–12 to 2021–22

Seasonal variation in chronic obstructive pulmonary disease hospitalisations

Admissions to hospital for COPD are typically highest in winter and early spring, consistent with trends for acute respiratory infections, such as rhinovirus (common cold), influenza, pneumonia and acute bronchitis (Figure 11).

2020 was an exception to this general trend, likely due to lockdown mandates and restrictions related to COVID‑19 pandemic. The lower hospitalisation rates persisted into 2021, but some typical seasonal variation over the course of the year was observed.

Figure 11: Hospitalisations due to acute respiratory infection and chronic obstructive pulmonary disease, by month, 2017–2021

Comorbidities of chronic obstructive pulmonary disease

People living with COPD often also live with other long-term conditions, known as ‘comorbidity’. Having a comorbid chronic condition can mean that people have complex health needs and poorer overall quality of life (AIHW 2023e).

According to the NHS, in 2022, an estimated 553,000 (87%) people who were living with COPD (including chronic bronchitis, emphysema and chronic airflow limitation), also had one or more other chronic conditions – the top 4 comorbidities were mental and behavioural conditions (49%), arthritis (45%) and asthma and back problems (both at 42%) (Figure 12) (ABS 2023).

Figure 12: Number of selected chronic conditions and types of comorbidity in people with chronic obstructive pulmonary disease, 2022