Treatment

A diagnosis of COPD is not the end of the world. For all stages of disease, effective therapy is available
which can control symptoms, reduce your risk of complications and exacerbations, and improve your
ability to lead an active life.

Smoking cessation

The most essential step in any treatment plan for COPD is to stop all smoking. It's the only way to keep
COPD from getting worse which can eventually reduce your ability to breathe. But quitting smoking
isn't easy. And this task may seem particularly daunting if you've tried to quit and have been
unsuccessful. Talk to your doctor about nicotine replacement products and medications that might help,
as well as how to handle relapses. It's also a good idea to avoid secondhand smoke exposure whenever
possible.

Medications

Doctors use several kinds of medications to treat the symptoms and complications of COPD. You may
take some medications on a regular basis and others as needed:

Bronchodilators. These medications which usually come in an inhaler relax the muscles around
your airways. This can help relieve coughing and shortness of breath and make breathing easier.
Depending on the severity of your disease, you may need a short-acting bronchodilator before activities,
a long-acting bronchodilator that you use every day, or both.

Short-acting bronchodilators include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol
(Xopenex), and ipratropium (Atrovent). The long-acting bronchodilators include tiotropium (Spiriva),
salmeterol (Serevent), formoterol (Foradil, Perforomist), arformoterol (Brovana), indacaterol (Arcapta)
and aclidinium (Tudorza).
Inhaled steroids. Inhaled corticosteroid medications can reduce airway inflammation and help prevent
exacerbations. Side effects may include bruising, oral infections and hoarseness. These medications are
useful for people with frequent exacerbations of COPD. Fluticasone (Flovent) and budesonide
(Pulmicort) are examples of inhaled steroids.
Combination inhalers. Some medications combine bronchodilators and inhaled steroids. Salmeterol and
fluticasone (Advair) and formoterol and budesonide (Symbicort) are examples of combination inhalers.
Oral steroids. For people who have a moderate or severe acute exacerbation, oral steroids prevent
further worsening of COPD. However, these medications can have serious side effects, such as weight
gain, diabetes, osteoporosis, cataracts and an increased risk of infection.
Phosphodiesterase-4 inhibitors. A new type of medication approved for people with severe COPD is
roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug decreases airway inflammation and
relaxes the airways. Common side effects include diarrhea and weight loss.
Theophylline. This very inexpensive medication helps improve breathing and prevents exacerbations.
Side effects may include nausea, fast heartbeat and tremor.
Antibiotics. Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate
COPD symptoms. Antibiotics help fight acute exacerbations. The antibiotic azithromycin prevents
exacerbations, but it isn't clear whether this is due to its antibiotic effect or its anti-inflammatory
properties.
Lung therapies

Doctors often use these additional therapies for people with moderate or severe COPD:

Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental oxygen. There
are several devices to deliver oxygen to your lungs, including lightweight, portable units that you can
take with you to run errands and get around town. Some people with COPD use oxygen only during
activities or while sleeping. Others use oxygen all the time. Oxygen therapy can improve quality of life
and is the only COPD therapy proven to extend life. Talk to your doctor about your needs and options.
Pulmonary rehabilitation program. These programs typically combine education, exercise training,
nutrition advice and counseling. You'll work with a variety of specialists, who can tailor your
rehabilitation program to meet your needs. Pulmonary rehabilitation may shorten hospitalizations,
increase your ability to participate in everyday activities and improve your quality of life. Talk to your
doctor about referral to a program.
Managing exacerbations

Even with ongoing treatment, you may experience times when symptoms become worse for days or
weeks. This is called an acute exacerbation, and it may lead to lung failure if you don't receive prompt
treatment. Exacerbations may be caused by a respiratory infection, air pollution, or other triggers of
inflammation. Whatever the cause, it's important to seek prompt medical help if you notice a sustained
increase in coughing, a change in your mucus or if you have a harder time breathing.

When exacerbations occur, you may need additional medications (such as antibiotics or steroids),
supplemental oxygen or treatment in the hospital. Once symptoms improve, you'll want to take
measures to prevent future exacerbations, such as taking inhaled steroids or long-acting
bronchodilators, getting your annual flu vaccine and avoiding air pollution whenever possible.

Surgery

Surgery is an option for some people with some forms of severe emphysema who aren't helped
sufficiently by medications alone:

Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of damaged lung
tissue. This creates extra space in your chest cavity so that the remaining lung tissue and the diaphragm
work more efficiently. In some people, this surgery can improve quality of life and prolong survival.
Lung transplant. Lung transplantation may be an option for certain people who meet specific criteria.
Transplantation can improve your ability to breathe and to be active, but it's a major operation that has
significant risks, such as organ rejection and the need for lifelong immune-suppressing medications.

NON-DRUG MANAGEMENT

Smoking cessation

The most effective intervention for COPD is to help patients stop smoking. Smoking cessation halts
accelerated decline of forced expiratory volume in one second (FEV1) and returns the rate of decline to
that of a non-smoker. Lost lung function cannot be regained but salvage is possible and worthwhile at
any stage. The earlier a patient stops the better but it is never too late.

Smoking must be discussed at every available opportunity, support offered to those who express a
desire to stop and nicotine replacement therapy (NRT) or bupropion use encouraged.

Pulmonary rehabilitation

Pulmonary rehabilitation is a structured, organised, multidisciplinary team approach to COPD that is
designed to:

- Improve functional exercise capacity;

- Improve health status;

- Reduce dyspnoea;

- Reduce health service use (British Thoracic Society, 2001).

Patients attend a group session at least twice a week for a minimum of six weeks. They undertake a
supervised, individually prescribed programme of physical exercise. Carers are encouraged to attend
and sessions also contain an educational element aimed at empowering patients and improving their
self-management skills. The psychological and social needs of patients and carers can also be identified
and addressed during a programme.

NICE has recognised the benefits of rehabilitation. It recommends that all patients who are disabled to
any significant degree should be able to access pulmonary rehabilitation in a convenient location and
within a reasonable time of referral (NICE, 2004). Although there is no doubt that pulmonary
rehabilitation is highly effective (Lacasse et al, 2006), service provision remains poor. It is hoped that the
National Service Framework for COPD will improve services (DH, 2005).

Practical advice

Breathlessness can be frightening but it is not harmful. Regular exercise 3-5 times a week for 20 minutes
to the point of moderate breathlessness, such as walking, is beneficial in:

- Maintaining cardiovascular fitness;

- Preserving skeletal muscle function;

- Reducing breathlessness;

- Maintaining functional ability and independence.

All patients with COPD should be encouraged to maintain and preferably increase their level of activity.

Many patients lose weight as their disease progresses and this is associated with a poor prognosis. At
the other extreme, obesity worsens breathlessness. Healthy eating advice is therefore helpful and
patients who are over or underweight may benefit from referral to a dietitian.

PHARMACOLOGICAL MANAGEMENT

Bronchodilators

Bronchodilators are the mainstay of symptomatic management in COPD. Although improvements in
lung function may be modest, bronchodilators can reduce hyperinflation and air trapping. This improves
respiratory mechanics, and reduces breathlessness (O'Donnell, 2006).

Determining the most effective bronchodilator therapy for individual patients requires therapeutic trials
of different drugs over several weeks. The response to the trial is measured in terms of subjective
improvement in symptoms and exercise capacity rather than lung function. Response assessment should
include the following questions (Jones et al, 2001):

- Has your treatment made a difference?

- Is your breathing easier in any way?

- Can you do some things now you could not do before or the same things but faster?

- Has your sleep improved?

As anticholinergic bronchodilators work by blocking parasympathetic activity and reducing
bronchomotor tone, they have a particular role in the management of COPD.

Ipratropium bromide, the short-acting anticholinergic, has an onset of action of 30-45 minutes. This
makes it unsuitable for rapid symptom relief and it is normally used regularly, 3-4 times daily. It is
available as a pressurised metered dose inhaler (pMDI), nebuliser solution or dry powder inhaler.

The long-acting agent tiotropium has a long duration of action, making it suitable for once-daily use. It is
currently only available as a dry powder capsule for inhalation through the HandiHaler. Tiotropium is a
relatively recent introduction that has significant benefits over short-acting agents.

Beta2 agonist bronchodilators work by stimulating the sympathetic beta2 receptors in the airway
smooth muscle, reducing bronchospasm. Short-acting preparations such as salbutamol and terbutaline
have a rapid onset and are useful for immediate symptom relief. In mild COPD occasional beta2 agonists
may be all that is required. Beta2 agonists work on different nervous pathways from anticholinergic
bronchodilators. Used in combination with short-acting anticholinergics they can provide better
symptom relief than either agent alone. The long-acting beta2 agonists salmeterol and formoterol are
licensed for use in COPD and are used twice daily. They have similar benefits to tiotropium in terms of
improving lung function and reducing breathlessness and exacerbations (Appleton et al, 2006).

Theophyllines are rather modest bronchodilators that are difficult to use; side-effects and drug
interactions are particularly troublesome. They are now second or third-line therapy, although they may
be helpful to some patients when additional symptom relief is sought.

Corticosteroids

NICE recommends prescribing inhaled corticosteroids for patients with FEV1 less than 50% of that
predicted and two or more exacerbations requiring antibiotics and/or oral corticosteroids in a 12-month
period. Inhaled corticosteroids should be added to a long-acting bronchodilator, either beta2 agonist or
anticholinergic (NICE, 2004). Combination inhalers of long-acting beta2 agonists and inhaled
corticosteroids are licensed for use in COPD.

Long-term oral corticosteroids are not recommended (NICE, 2004) as the side-effects outweigh the
benefits.

Mucolytics

Chronic, productive cough (a common symptom in COPD) can be exhausting and socially embarrassing.
Mucolytics loosen secretions and enable patients to clear airway mucus more easily. They have also
been found to reduce exacerbation frequency in COPD (Poole and Black, 2006) and are recommended
by NICE (2004) for patients with chronic, productive cough.

Oxygen

Destruction of alveoli and progressive airflow obstruction interfere with gas exchange and will
eventually lead to significant hypoxaemia. Clinical signs of chronic hypoxaemia include ankle oedema
and cyanosis but these may not be apparent until the patient is severely hypoxic. NICE recommends six-
monthly recording of pulse oximetry in all patients with COPD who have an FEV1 less than 50% of that
predicted to help identify those who need assessment for long-term oxygen therapy.

Some patients with normal oxygen saturation at rest desaturate on exercise and they may benefit from
ambulatory oxygen.

ACUTE EXACERBATIONS OF COPD

Acute exacerbations of COPD are important clinical events that increase disease progression. They are
defined as 'a sustained worsening of the patient's symptoms from the stable state that is beyond normal
day-to-day variation and is acute in onset' (NICE, 2004). This symptom change often calls for a treatment
change. Common symptoms include:

- Increasing breathlessness;

- Cough;

- Increased sputum production;

- Increased sputum purulence.

Patients should be encouraged by nurses to act promptly if their normal symptoms worsen. The first line
of therapy is to increase the frequency and/or dose of their short-acting bronchodilators or to add
additional short-acting agents to control breathlessness (NICE, 2004).

Antibiotics are indicated if the sputum becomes purulent. A short course of oral corticosteroids may be
needed if breathlessness interferes with daily activities and fails to respond to increased use of
bronchodilators (NICE, 2004). Patients who have frequent exacerbations of symptoms may benefit from
keeping a supply of antibiotics and/or prednisolone at home so they are able to start treatment
promptly.

Clear written information about how and when they should contact their doctor for additional help is
essential. Annual influenza vaccinations should be encouraged, and patients should also be vaccinated
against pneumococcus.

LEARNING OBJECTIVES

- Understand the importance of smoking cessation in this group of patients

- Know the full range of non-drug interventions for COPD

- Be aware of the different drugs that can be prescribed for the condition and their actions

- Know how to manage an acute exacerbation of COPD

GUIDED LEARNING

- Explain why smoking cessation is important in COPD

- Outline the range of non- pharmacological interventions

- List the various types of drugs that can be used and their different effects

- Explain how to manage an acute exacerbation of COPD

This article has been double-blind peer-reviewed.
Respiratory infection
Hyperinflation
Bronchospasm
Inflammation
Allergy

Airway Diseases COPD
Smoking
Hyperinflation
Airway collapse
Respiratory infection
Bronchospasm
Allergy
Inflammation