Treating COPD

Summarized by Robert W. Griffith, MD
December 19, 2001 (Reviewed: December 5, 2003)

Introduction

Although less people are smoking cigarettes than a few years ago, there's been little effect on the major problem presented by chronic obstructive pulmonary disease (COPD). This condition, known in some countries as chronic bronchitis and emphysema, is the 4th leading cause of death in the USA, and is seen in about 1 in 5 adults. It differs from asthma, in that the drugs normally used to improve breathing difficulties in asthma can't easily reverse the symptoms of COPD.

COPD is a chronic condition, interrupted by occasional acute attacks of severe illness, called exacerbations. These are commoner in winter. Treatment during the stable phase is largely aimed at preventing these acute exacerbations. A recent review of the management of COPD, which was published in the American Family Physician, forms the basis for this summary.

How COPD starts, and develops

Cigarette smoking is incriminated in 90% of cases. Other irritants that are inhaled (for instance, 'smog') and chance infections are sometimes responsible. Chronic inflammation of the cells lining the breathing tubes (bronchi) causes them to swell, secrete mucus, and stop expelling dust particles. There is a chronic cough with sputum, wheezing, and shortness of breath. The walls between the smallest air sacs in the lungs break down, so that larger sacs are formed -- these lead to the condition known as emphysema.

Exacerbations are usually caused by bacterial or viral infections, which can develop quite easily in the abnormal lung tissue.

The survival rate of patients with COPD is not very good -- a 60-year-old smoker with COPD is 4 times more likely to die in the next 10 years than a non-smoking asthmatic. Six out of ten such COPD patients will die before they are 70.

The best measure of the severity of reduced lung function is the amount of air that can be expelled by forcefully breathing-out during 1 second -- the forced expiratory volume per second (FEV-1). Younger COPD patients may have an inherited lack of an enzyme, alpha1-antitrypsin, which is associated with widespread emphysema in the lungs

Managing chronic stable COPD

A healthy lifestyle is vital -- no smoking, regular exercise, good nutrition. Stout patients -- called unkindly "blue bloaters" -- must lose weight, and very thin patients -- "pink puffers" -- may need nutritional supplements. Special physical therapy can help. Patients must keep up-to-date with their 'flu and pneumococcal shots

If symptoms are only mild, a drug that dilates the bronchi - a beta-2 agonist -- is probably enough medication. It's best given by what's known as a pressurized metered dose inhaler (MDI). One puff gives an exact dose of the drug for inhalation. Beta-2 agonists may be short-acting (about 6 hours, e.g. salbutamol, terbutaline) or long-acting (about 12 hours, e.g. formoterol, salmeterol).

For somewhat more severe symptoms, a different type of drug to dilate the bronchi -- an anticholinergic (e.g. ipratropium) - can be given instead of, or together with, the beta-2 agonist.

Finally, if these don't work adequately, an oral corticosteroid can be used. Continued problems mean that the patient will probably require prolonged rehabilitation involving special respiratory physical therapy.

Giving oxygen to patients who need it helps reduce mortality in patients with COPD. It can be delivered through small tubes in the nose, or via a mask with slight continuous pressure.

Managing exacerbations

Hospitalisation may be necessary, in order to make sure the best treatment is given promptly and adequately. Most cases of sudden deterioration are due to infections. They should be treated with a broad-spectrum antibiotic, like a tetracycline. In severe cases a more powerful antibiotic (e.g. cephalosporin or fluorquinalone) may be needed. Hospitalised patients should have intravenous antibiotics, the choice depending on the sensitivity test results for the bacteria responsible.

Oxygen treatment may be required to keep oxygen levels high enough. Nasal tubes, a positive pressure mask, or even an oxygen tent can be used.

Inhaled beta-2 agonists must be started at once, using a nebulizer, or by MDI if the patient can use one properly. Formoterol and salmeterol are long-acting drugs of this type; the former has the advantage of a fast onset of action. As with stable patients, inhaled ipratropium can be added to the beta-2 agonist for greater effect.

Finally, a steroid drug should be given, first by injection, and then, after a day or so, by mouth. This should improve the FEV-1 and shorten the hospital stay. Two weeks of steroid treatment is generally enough, after which the drug can be tapered off.

Sometimes, if there is a poor response to beta-2 agonists or ipratropium, the physician may recommend aminophylline or theophylline medication. However, these drugs are usually kept in reserve, as they can have unpleasant side effects.

Surgery for COPD?

This is somewhat controversial. A lung transplant can be beneficial in some cases, but it is not a procedure to be lightly undertaken. Another possibility is to cut out affected areas of the lungs (volume reduction) to stop or limit over-inflation; this procedure increases the FEV-1 and improves the amount of physical exertion that can be achieved; however, operative mortality is rather high (as high as 10%), so again it can only be recommended in carefully selected patients.

The important things for any COPD patient to remember is: stop smoking, exercise as much as possible, eat a healthy diet, and try to avoid chest infections.

Source

• COPD: Management of acute exacerbations and chronic stable disease. MH. Hunter, DA. King, Am Fam Physician, 2001, vol. 64, pp. 603--612

Related Links
Treating an Acute Attack in COPD
The Stop Smoking Center
Keep on Walking
Living with COPD

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