Treatment / management of COPD
Click here for specific treatment for Emphysema in addition to that listed below Treatment of Emphysema
The following principles of treatment apply to both COPD and Emphysema:
- Stopping smoking prevents progression of the disease.
- Bronchodilators maximise lung function, and short-acting bronchodilators are used for immediate reversal.
- Inhaled steroids and beta- agonists are used to reduce exacerbations (but inhaled steroids can increase osteoporosis and pneumonia).
- Oxygen therapy reduces the risk of pulmonary hypertension and nocturnal falls in oxygen concentration.
- Pulmonary Rehabilitation increases muscle fitness and improves (mental) outlook. It is not used just for improving lung function.
Stopping Smoking
The acceleration of COPD & Emphysema can be reduced by stopping smoking.
The most important management factor is stopping smoking. This will help slow the rate of deterioration but will not reverse existing damage to the lungs. However, it will extend life expectancy. The patient should try all strategies to stop and if they stop sufficiently early, this will prevent the continuing accelerated decline in lung function. Strategies include -:
- Support and encouragement from the GP and Chest Clinic.
- Nicotine replacement in the form of chewing gum or patches absorbed through the skin.
- Bupropion tablets (to aid the cessation of smoking).
Bronchodilator Medication
“The effectiveness of bronchodilator therapy should not be assessed by lung function alone but should include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity and rapidity of symptom relief.”
Therefore, the continuing use of bronchodilators depends on both the subjective feedback from the patient (i.e. that the symptoms have eased) and objective assessment.
Types of bronchodilators used are:
- Beta agonist inhalers such as Salbutamol (Ventolin), Terbutaline (Bricanyl), which are short- acting, Salmeterol (Serevent), Formoterol (Oxis or Foradil) which are long- acting
- Anti-cholinergic or anti-muscarinic inhalers (such as Ipratropium (Atrovent or Respontin), which are short-acting) and Tiotropium (Spiriva), which is long- acting.
However, the two drugs may be taken in combination and this has been shown to be effective in some patients. Such combinations are combivent (salbutamol and ipratropium) and Duovent (fenoterol and ipratropium).
- For mild disease, short- acting bronchodilators should be the initial treatment for the relief of breathlessness and exercise limitation.
- Patients who remain symptomatic should have their inhaled treatment intensified to include long- acting bronchodilators or combined therapy with a short- acting beta2 – agonist, and a short- acting anticholinergic. (Long-acting bronchodilators should be used in patients who do not respond to short-acting bronchodilators, because they appear to have additional benefits over combinations of short-acting drugs).
- Long-acting bronchodilators should also be used in patients who have 2 or more exacerbations a year.
Theophylline (in slow- release formulations)
Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators or in persons who are unable to use inhaled therapy. There is a need to monitor plasma levels and interactions with this drug.
Corticosteroids
Inhaled corticosteroids are mainly used for reducing the frequency of exacerbations (relapses) and to slow the decline in health status - not to improve lung function.
Inhaled corticosteroids should be used in patients:
- Who have an FEV1 of less than, or equal to, 50% of predicted,
- Who are having 2 or more exacerbations requiring treatment with antibiotics or oral corticosteroids in a 12- month period.
There is a potential risk of developing osteoporosis and increased susceptibility to pneumonia in patients treated with high dose inhaled steroids.
Maintenance use of oral corticosteroid treatment in COPD is not normally recommended.
Combination Therapy
If a patient still has symptoms on monotherapy, combination therapy may be tried, and these may include -:
- Beta2 agonist and anticholinergic (Salbutamol and Ipratropium known as Combivent).
- Beta2agonist and theophylline.
- Anticholinergic and theophylline.
- Long-acting beta2agonist and inhaled corticosteroid (Seretide).
Again, the clinical effectiveness of combined treatments is assessed by:
- Symptoms,
- Activities of daily living,
- Exercise capacity,
- Lung function.
Antibiotics
When a bacterial infection is suspected by the GP, antibiotics should be used. There are many antibiotics to choose from and newer antibiotics may be used for more severe or resistant infections.
Pulmonary Rehabilitation
Most patients are middle-aged to elderly with associated problems of increasing age. Pulmonary rehabilitation should be considered for those with moderate to severe disease.
The aim is to counteract the effects of enforced immobility or reduced mobility, which occurs as a result of breathlessness due to the disease. Exercise programmes are devised, which are tailor-made for the person. These are multidisciplinary with the aim of increasing cardio-respiratory fitness and /or mobility so that general fitness, symptoms, quality of life, social performance and independence may be improved.
Rehabilitation should address the physical, psychological, nutritional, and educational needs of the patient.
Vaccination and Antiviral therapy
Annual influenza vaccination and vaccination against Pneumococcus should be offered to all patients. Antiviral medication is recommended for, and may be used in adults who are at risk and who present with a flu-like illness. They reduce the severity of the symptoms.
Oxygen therapy
Long-term oxygen therapy (LTOT) is used in patients who have been proved to have low oxygen levels in the blood. LTOT is delivered at a specific rate (4%) to increase O2 saturation most efficiently, while not causing the patient to drift into CO2 retention. This is called "Controlled O2 Therapy".
It is generally safe at this level. However, before this treatment is implemented, the patient is assessed to ensure that -:
- They benefit sufficiently from this regime
- They do not drift into CO2 retention.
Therefore, anyone on LTOT should have been properly vetted first and so CO2 retention (excess levels of carbon dioxide in the blood tissues) is not relevant in people on controlled O2 Therapy.
LTOT is therefore beneficial to a selected patient group, normally those who no longer smoke and who have an FEV1 reading of less than 1.5 litres. It has beneficial effects on oxygen levels in the blood and on reducing the rise of the number of red blood cells, which occurs in response to low oxygen levels in the blood (known as hypoxia).
LTOT should be used for several hours a day (15 to 19). It is an indicator of severe disease. People on oxygen often have an oxygen concentrator in the home. This is a large, electronically operated machine, which is set up in the home for permanent use. It uses the oxygen present in the air, concentrating it and the person breathes it in through nasal cannulae (tubes which fit inside the nostrils) or a mask. It is fairly noisy and the tube may be very long, allowing the person to move about in the house. Cylinders of oxygen are sometimes used. They may be very large and heavy requiring special delivery and removal, set up by the bed or chair, or they may be small, for use while away from home even on aircraft.
Alpha- Antitrypsin Replacement therapy
Alpha1- Antitrypsin replacement therapy is not recommended in the management of persons with alpha-1 antitrypsin deficiency
Palliative Care
For those with end-stage disease, the full range of services available from Palliative Care Teams should be made available.
Other Factors
Patients should be managed by a multidisciplinary team and a Respiratory- Nurse Specialist should be part of that multidisciplinary team.
The patient should eat well or lose weight, if overweight. As the normal BMI (Body mass Index) is 25 to less than 20 there may be considerable variations from this norm. Advice from a dietician may be necessary. Nutritional supplements may be necessary if the person is very underweight.
Anxiety and depression, if present should be treated.
Air pollutants such as cigarette smoke should be avoided as much as possible.
Click on the link below for details of:
Amended April 2008
