COPD Treatment

I. Management of acute exacerbations

Acute exacerbations can be partially prevented. Infections are responsible for approximately half of COPD exacerbations, some of which can be prevented by vaccination against pathogens such as influenza and Streptococcus pneumoniae. Regular medication use can prevent some COPD exacerbations; LABAs, long-acting anticholinergics, inhaled corticosteroids and low-dose theophylline have all been shown to reduce the frequency of COPD exacerbations. The symptoms of acute exacerbations are treated using short-acting bronchodilators. A course of corticosteroids, usually in tablet or intravenous rather than inhaled form, can speed up recovery. Antibiotics are often used but will only help if the exacerbation is due to an infection. Antibiotics are indicated when a patient notes sputum changes, has an elevated white count, or is febrile. Severe exacerbations can require hospital care where treatments such as oxygen and mechanical ventilation may be required.

II. Management of stable COPD

Bronchodilators

Bronchodilators are medicines that relax smooth muscle around the airways, increasing the calibre of the airways and improving air flow. They can reduce the symptoms of shortness of breath, wheeze and exercise limitation, resulting in an improved quality of life for people with COPD. They do not slow down the rate of progression of the underlying disease. Bronchodilators are usually administered with an inhaler or via a nebulizer.

There are two major types of bronchodilators: beta-2-agonists and anticholinergics. Anticholinergics appear to be superior to beta-2-agonists in COPD. Anticholinergics reduce repiratory deaths while beta-2-agonists have no effect on respiratory deaths. Each type may be either long-acting (with an effect lasting 12 hours or more) or short-acting (with a rapid onset of effect that does not last as long).

  • Beta-2-agonists

Beta-2-agonists stimulate beta-2-receptors on airway smooth muscles, causing them to relax. There are several beta-2-agonists available. Salbutamol or albuterol (common brand name: Ventolin) and terbutaline are widely used short acting beta-2-agonists and provide rapid relief of COPD symptoms. Long acting beta-2-agonists (LABAs) such as salmeterol and formoterol are used as maintenance therapy and lead to improved airflow, exercise capacity, quality of life and possibly a longer life.

  • Anticholinergics

Anticholinergic drugs cause airway smooth muscles to relax by blocking stimulation from cholinergic nerves. Ipratropium is the most widely prescribed short acting anticholinergic drug. Like short-acting beta-2-agonists, short-acting anticholinergics provide rapid relief of COPD symptoms and a combination of the two is commonly used for a greater bronchodilator effect. Tiotropium is the most commonly prescribed long-acting anticholinergic drug in COPD. It is has more specificity for M3 muscarinic receptors so may have less side-effects than other anticholinergic drugs. Regular use is associated with improvements in airflow, exercise capacity, quality of life and possibly a longer life.

Corticosteroids

Corticosteroids act to reduce the inflammation in the airways, in theory reducing lung damage and airway narrowing caused by inflammation. Unlike bronchodilators, they do not act directly on the airway smooth muscle and do not provide immediate relief of symptoms. Some of the more common corticosteroids in use are prednisone, fluticasone, budesonide, mometasone, and beclomethasone. Corticosteroids are used in tablet or inhaled form to treat and prevent acute exacerbations of COPD. Inhaled corticosteroids have not been shown to be of benefit for people with mild COPD however they are beneficial for those with either moderate or severe COPD. Most people with COPD who use inhaled corticosteroids also use a long-acting bronchodilator so inhaled corticosteroids are often combined with a LABA in the same inhaler.

Other medication

Theophylline is a bronchodilator and phosphodiesterase inhibitor that in high doses can reduce symptoms for some people who have COPD. More often, side effects such as nausea and stimulation of the heart limit its use. In lower doses, it may slightly reduce the number of COPD exacerbations. The investigative phosphodiesterase-4 antagonists, roflumilast and cilomilast have completed Phase-2 clinical trials. Tumor necrosis factor antagonists such as infliximab suppress the immune system and reduce inflammation. Infliximab has been trialled in COPD but there was no evidence of benefit with the possibility of harm.

Supplemental oxygen

Oxygen can be delivered in different forms: in large containers, in smaller containers with liquid oxygen, or with the use of a oxygen concentrator (shown here) which derives oxygen from room air. The latter two options improve mobility of people requiring long-term oxygen therapy.

Supplemental oxygen can be given to people with COPD who have low oxygen levels in the body. Oxygen is provided from an oxygen cylinder or an oxygen concentrator and delivered to a person through tubing via a nasal cannula or oxygen mask. Supplemental oxygen does not greatly improve shortness of breath but can allow people with COPD and low oxygen levels to do more exercise and household activity. Long-term oxygen therapy for at least 16 hours a day can improve the quality of life and survival for people with COPD and arterial hypoxemia or with complications of hypoxemia such as pulmonary hypertension, cor pulmonale, or secondary erythrocytosis. High concentrations of supplemental oxygen can lead to the accumulation of carbon dioxide and respiratory acidosis for some people with severe COPD; lower oxygen flow rates are generally safer for these individuals.

Pulmonary rehabilitation

Pulmonary rehabilitation is a program of exercise, disease management and counselling coordinated to benefit the individual. Pulmonary rehabilitation has been shown to improve shortness of breath and exercise capacity. It has also been shown to improve the sense of control a patient has over their disease as well as their emotions.

Nutrition

Being either underweight or overweight can affect the symptoms, degree of disability and prognosis of COPD. People with COPD who are underweight can improve their breathing muscle strength by increasing their calorie intake. When combined with regular exercise or a pulmonary rehabilitation programme, this can lead to improvements in COPD symptoms.

Surgery

Surgery is sometimes helpful for COPD in selected cases. A bullectomy is the surgical removal of a bulla, a large air-filled space that can squash the surrounding, more normal lung. Lung volume reduction surgery is similar; parts of the lung that are particularly damaged by emphysema are removed allowing the remaining, relatively good lung to expand and work better. Lung transplantation is sometimes performed for severe COPD, particularly in younger individuals.