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Treating COPD
| Author: Dr. Stan Swierzewski |
| Article Date: 6/15/2008 |
Treatment
COPD is not a reversible condition, but treatment can slow its progression (smoking cessation being the most important). Treatments available to help manage the disease include:
- medical treatment
- behavioral treatment
- surgical treatment
- other treatments
Smoking Cessation: It is critically important that COPD patients quit smoking. Once a patient has quit, the rate of decline of lung function slows considerably. Cigarette smoking is involved in many other serious health problems, including atherosclerosis, malignancies (especially lung cancer), peptic ulcer disease, ovarian failure, osteoporosis, histiocytosis-X (a disease caused by disruption of the immune system), and lesser problems, like premature wrinkling. Many hospitals offer smoking cessation classes that can help.
It is very difficult to quit smoking cigarettes because they are psychologically and physically addictive, but it can be done. Withdrawal symptoms are caused by withdrawal from nicotine and include depression, insomnia, irritability, anxiety, poor concentration, and weight gain. Some patients gain 10-20 pounds after they stop smoking. An antidepressant (buproprion, Wellbutrin®) may help reduce withdrawal symptoms and can be used alone or with nicotine replacement therapy.
There are numerous nicotine replacement systems that help smokers withdraw from nicotine, including nicotine gum, patches, inhalers, and nasal sprays. Nicotine gum was the first nicotine replacement therapy available. Each piece of gum contains 2 mg of nicotine. It is chewed slowly when symptoms of withdrawal are experienced. The major disadvantages of nicotine gum are that it takes training to use properly and the peak nicotine blood levels only approximate 40% of what one would obtain by smoking a cigarette. The gum decreases, but does not eliminate, physical withdrawal symptoms.
Medical Treatment
Bronchodilators and Anti-inflammatory Agents: Pharmacological treatment involves bronchodilators (beta2 agonists, anticholinergics, and theophylline) and anti-inflammatory drugs (corticosteroids). These are most effective when inhaled. There are several delivery methods for inhaled medications, including metered-dose inhalers, breath-actuated inhalers, dry powder inhalers, and nebulizers.
The beta2 agonists relax the smooth muscle thereby decreasing bronchoconstriction and airflow obstruction. They also improve the ability to clear mucus and the endurance of fatigued respiratory muscles. Beta2 agonists injected under the skin, such as epinephrine (Epipen), can produce serious side effects (e.g., hypertension, arrhythmia, pulmonary edema) and are only used to treat COPD patients in dire situations. Ipratropium bromide, an anticholinergic, has a greater bronchodilatory effect than beta2 agonists and has fewer side effects (tachycardia [rapid heart rate] and tremors). Ipratropium bromide is generally recommended for COPD patients who experience symptoms daily.
Theophylline is a bronchodilator and an anti-inflammatory agent. Its use is somewhat controversial because there is a narrow range of safe dosage, so it is prescribed strictly on a case-by-case basis. It may be particularly effective in relieving nocturnal symptoms and has been shown to improve diaphragmatic strength. One study showed that patients with severe COPD who discontinued theophylline had a decline in status compared to those left on the drug. However, improvement and drug levels have to be carefully monitored. Numerous drug interactions raise theophylline levels; if the blood level becomes too high, seizures and arrhythmias can occur without warning.
Corticosteroids are often used to treat inflamed airways, but their long term benefit is not clear. Steroids have not been shown to slow lung decline in COPD. They may reduce the number of exacerbations and improve symptoms in some patients, but there is no convincing evidence to support this. Approximately 10%-15% of COPD patients have a measurable response to corticosteroid therapy with an improvement in FEV1; the remainder do not.
Oral corticosteroids are used when the dose requirement is higher than can be delivered by an inhaler or when the patient cannot use an inhaler. Oral or intravenous steroids are used in acute exacerbations of COPD.
It is difficult to wean patients off steroids and many patients are left on inhaled steroids because they do well on them. Corticosteroids are now given, whenever possible, in an inhaled form rather than orally or intravenously. There are many adverse side effects associated with long term use.
Mucolytics: Mucus retention narrows the airways and increases symptoms of COPD. A lot of effort has been put into developing medications that break up and allow mucus to be cleared more effectively from the airways. Unfortunately, this has met with only very modest success. Three mucolytic medications may benefit some patients: guaifenesin, potassium iodide, and N-acetylcysteine.
Guaifenesin and potassium iodide are taken orally. N-acetylcysteine is commonly taken through a nebulizer. These are tried on a case-by-case basis to see if they improve symptoms. N-acetylcysteine can cause bronchospasm when taken through a nebulizer.
Antibiotics: Antibiotics are generally used only for acute exacerbations. Patients who experience frequent exacerbations with purulent sputum (a sign of infection) during the year may be placed on a schedule of prophylactic (preventative) treatment with antibiotics the first 10 days of each month. This is done for special cases only.
Oxygen: Oxygen is the only treatment that has been shown to improve survival. Indications for oxygen therapy include: arterial PaO2 < 55 mm Hg, or an O2 saturation of 88% with arterial PaO2 of 55-59 mm Hg, or an O2 saturation of 89% accompanied by cor pulmonale (right-sided heart failure), or polycythemia (proportion of red blood cells above 56% of blood sample).
A patient who does not qualify for oxygen as described may need oxygen while sleeping or exercising. Oxygen may be used at night only if the PaO2 at night is less than 55 mm Hg or the O2 saturation is less than 88%. If the PaO2 is less than 55 mm Hg or the O2 saturation is less than 88% during exercise, oxygen may be prescribed.
Nasal cannula is the most commonly used oxygen delivery system and is usually attached to an oxygen concentrator (not portable) or an E cylinder (portable). There are several oxygen-conserving devices used with these systems.
Behavioral Therapies
Pulmonary Rehabilitation: Patients with COPD become physically unfit. Most hospitals offer pulmonary rehabilitation programs that can improve fitness, even in severe cases. The programs usually include exercises for the lower and upper extremities, education, breathing retraining, and psychosocial support. Exercising the legs particularly can improve endurance. Upper extremity exercises may be beneficial as well. Patients use a lot of energy and tire easily because they breathe rapidly and shallowly. Learning pursed-lip breathing can help relieve these symptoms.
Nutritional Support: Nutrition is critically important for patients who lose a lot of weight. High fat, low carbohydrate diets are recommended. If a patient is significantly overweight, losing weight may be appropriate.
Surgical Treatment
Lung Volume Reduction Surgery: In lung volume reduction surgery (LVRS), the upper portions of the diseased lungs are removed. How the procedure improves symptoms and lung function for some patients is not well understood. Possibly, the chest wall and breathing muscles return to a place of mechanical advantage. Or perhaps the elastic recoil of the lungs improves as a result. There is a large multicenter study being performed to determine the benefits of surgery and how to qualify candidates for the procedure. The current selection criteria are very restrictive; only 20%-40% of patients qualify.
Lung Transplantation: Single or double lung transplantation may be an option for some severe cases. Many selection criteria have to be met and they vary from facility to facility.
Other Treatments
Immunizations: Patients with COPD should discuss influenza and pneumoccocal immunization (vaccination) with their physicians. In some cases, immunization is not recommended, but these vaccines are generally safe.
Influenza (the flu) is a respiratory illness that can be devastating to a patient with COPD. Vaccination decreases the incidence of influenza significantly but does not provide 100% protection. Influenza immunization is given every fall.
Streptococcus pneumoniae is the most common cause of bacterial pneumonia in COPD patients. Vaccination can significantly decrease the incidence of pneumonia. Pneumococcal immunization (Pneumovax™) is given every 6 years.
Nocturnal Noninvasive Ventilation: Patients with severe COPD and CO2 (carbon dioxide) retention may benefit from ventilation during the night. A mask is fitted over the nose or over the nose and mouth and attached to a ventilator. Whether this helps hasn't been proven. Its use is determined by need.