Andrew L. Ries
Chronic obstructive pulmonary disease (COPD) is a chronic, progressive, and largely irreversible disease, so the primary goals of management should be directed toward preventive health strategies to slow progression and reduce complications. Secondary goals are to improve symptoms and function and treat reversible components. Optimal management depends on the stage of disease. For patients with mild to moderate disease, early detection and diagnosis and counseling regarding appropriate preventive health strategies are important. For patients with moderate to severe disease, symptomatic treatment is also indicated.
According to the current international guidelines of the Global Initiative for Chronic Obstructive Lung Disease (GOLD), staging, and consequently treatment, should be based on a combination of both spirometric evidence of expiratory flow obstruction (i.e., GOLD grades 1 to 4 based on percent of predicted forced expiratory volume in 1 second [FEV1]) as well as assessment of symptoms with standard questionnaires. Additional therapy should be considered for more symptomatic patients within the same GOLD grade according to spirometry.
Teaching the patient and family members how to participate in the patient’s management as active partners with the physician is a key goal that affects all other goals. Patients who are adequately informed and motivated can work with the physician and maintain a level of function that the uninformed, poorly motivated, passive patient cannot.
Most patients with COPD are former or current cigarette smokers. Controlling smoking behavior is essential, regardless of the stage of disease. Smoking cessation will slow the rate of decline in FEV1 and decrease coughing and sputum production. Naturally, the more advanced the functional loss, the less the impact will be. Therefore, early detection of COPD, particularly in smokers who are at high risk, and smoking cessation should be emphasized. Physicians play an important role by setting a smoke-free example in their lives and workplace. Physician advice is important and effective in inducing smokers to quit and maintain abstinence. Several studies have demonstrated that a physician who spends a few minutes inquiring about smoking status and providing advice to quit can achieve abstinence rates of up to 10% to 20% at 1 year. The use of additional modalities such as a comprehensive smoking cessation program, nicotine replacement therapy (gum, dermal patches, nasal spray, or oral inhaler), bupropion, or clonidine (oral or patches) can lead to long-term cessation rates of as high as 50% in motivated patients.
Pulmonary infection is the most common complication in COPD. Prophylactic influenza vaccination should be administered annually, preferably in the early fall. Pneumococcal vaccination, with the expanded version (containing the capsular polysaccharide of 23 serotypes), should be administered once or twice (if <65 years of age when first vaccinated). As effective antiviral agents become available (e.g., amantadine), consider their use for the patient with COPD, particularly during epidemics of influenza A.
Another preventive approach is to assess patient exposure to occupational–environmental air pollutants and, if possible, eliminate or reduce that exposure. A final method used to prevent complications is to avoid therapies and drugs that can compromise patient function. Patients with COPD tend to become victims of polypharmacy. To avoid this problem, carefully consider the risk-to-benefit characteristics of each therapy (drug, oxygen, or mechanical device) before it is instituted. Constantly review the treatment regimen, deleting elements that have been of no benefit, particularly if they can induce long-term toxicity.
For patients with recognized COPD, pharmacotherapy is directed toward the reversible component of airway obstruction and control of secretions. Bronchodilators used to improve symptoms and increase airway caliber include sympathomimetic β-agonists, anticholinergics, and (less commonly) the methylxanthine, theophylline. The decision to treat a patient with a bronchodilator should not depend on demonstrating an acute response, as many patients who do not demonstrate an acute response during testing do respond to long-term regular therapy. Airway hyperreactivity is common in patients with COPD, and long-term therapy with bronchodilators can serve to prevent airways constriction caused by inhaled irritants. Also, these medications may have effects beyond just bronchodilation. If a long-acting bronchodilator is used for maintenance therapy, then a short-acting agent is also needed for rescue therapy.
Sympathomimetic bronchodilators are used commonly. Newer β2 agents are more selective and longer-acting and have fewer side effects than older, nonselective drugs. In addition to bronchodilation, β-agonists can also reduce airway hyperresponsiveness and enhance mucociliary clearance. The most common side effects are tachycardia and skeletal muscle tremor.
Anticholinergics have recently gained prominence in the treatment of COPD. Although their bronchodilating effects have been known for many years, the selectivity and reduced side effects of newer agents have increased their usefulness. Bronchodilation is thought to be caused by inhibition of cholinergic-mediated bronchomotor tone. The drugs are reported to be more effective in larger airways, making them particularly useful for patients with COPD. They can be used concomitantly with β2-agonists. Both short- and long-acting agents are now available.
The preferred method of administration for both β-agonists and anticholinergics is by inhalation, usually with a metered-dose inhaler (MDI). This produces more bronchodilation with fewer side effects than oral or other systemic routes. Used properly, an MDI is equally effective and less expensive than a liquid nebulizer and can be used in acute and emergency department settings. Extensions or spacers may help persons who have difficulty coordinating the MDI, particularly children and older adults. The key to MDI use is proper technique. All patients should be instructed and observed in following several key steps in using MDIs: (1) shake inhaler, remove cap, and hold upright; (2) exhale to functional residual capacity or below; (3) place inhaler 2 to 4 cm in front of open mouth; (4) activate inhaler just after the start of a slow, deep inhalation; (5) hold breath for 5 to 10 seconds; (6) exhale slowly; and (7) wait at least 1 minute before next puff.
Theophylline preparations have been used in treating patients with COPD for many years, but their use has decreased because of a narrow toxic–therapeutic margin, frequent problems with toxicity, and the advent of newer, more selective bronchodilating agents. The mechanism of bronchodilation from theophylline is still not clearly defined. Theophylline has other potentially beneficial effects, such as improved diaphragmatic function, reduced dyspnea, increased mucociliary clearance, and stimulation of respiratory drive. Because of individual variability in metabolism and the many factors that can alter metabolism (e.g., drugs such as cimetidine, erythromycin, and ciprofloxacin), blood levels must be monitored with chronic therapy. The target therapeutic level is typically 10 to 20 µg/mL. Minor side effects such as tremor, insomnia, irritability, and gastrointestinal upset can occur with levels well below 20 µg/mL. More serious side effects, including vomiting, dysrhythmias, hypotension, and seizures, generally develop at higher blood levels. Older patients are particularly susceptible to toxicity.
Corticosteroids can be beneficial for some patients with COPD. The complications of long-term use are well-known, and chronic use of systemic corticosteroids should be avoided, if possible. A meta-analysis of 16 clinical trials of oral steroid therapy for stable patients found that a 20% improvement in FEV1 occurred in approximately 10% more patients on steroids than on placebo. Many patients on corticosteroids report subjective symptom improvement, but long-term steroid use is associated with many serious side effects. A limited trial of corticosteroids is probably justified in patients who cannot be managed with standard bronchodilators alone. A single morning dose of prednisone (20–40 mg) for 5 to 7 days is a typical starting point. Treatment beyond a few weeks should be continued only with a significant improvement in pulmonary function and symptoms. For long-term therapy, the dose should be kept as low as possible to minimize side effects.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
