COPD



 		 Patient information: Overview of the management of COPD
 

 

INTRODUCTION — COPD stands for "chronic obstructive pulmonary disease." It is a condition in which the flow of air through the lungs is limited due to chronic bronchitis or emphysema. In most cases, COPD is caused by smoking. A combination of genetic and environmental factors probably explain why some smokers develop COPD and others do not. Genetic factors may also explain why some non-smokers develop COPD.

COPD is a progressive illness in which symptoms increase gradually over many years. Early symptoms may be limited to a productive cough or shortness of breath with exertion. Later in the course of the disease, intermittent episodes of more severe symptoms, including thickening of sputum, wheezing, and fever, may develop. Over time, these episodes increase in frequency and severity. Fatigue and weakness are common. Shortness of breath with minimal exertion, low oxygen levels, weight loss, and headaches from high levels of carbon dioxide in the blood are markers of severe disease. Some people get swelling in the legs or abdominal pain related to abnormalities in the heart brought about by severe lung disease.

This information sheet will discuss treatment of COPD, which is aimed at controlling symptoms and, if possible, slowing the progression of the disease. Therapy for acute episodes of worsening symptoms, which often require hospital treatment, is not included in this discussion.

DIAGNOSIS — The diagnosis of COPD is made by a physician. In general, this requires a history and physical examination, and performance of lung function tests (PFTs). These tests can measure lung function and are the most important means to diagnose COPD and to assess its severity.

SMOKING CESSATION — The first and most important part of any treatment plan for COPD is to stop smoking. This is true regardless of the duration or severity of the COPD. Studies of patients who already have COPD have shown that further progression of the disease is slowed in patients who stop smoking.

People may need to use a number of different strategies before quitting successfully. Nicotine replacement may help decrease nicotine withdrawal symptoms. Nicotine gum, lozenges, and skin patches are available over the counter. Other forms require a physician's prescription. The anti-depressant medication bupropion (Zyban) may be used to decrease the urgency to smoke. Group smoking cessation clinics or other behavioral interventions may benefit some patients. Even modest advice, such as telephone-based counseling, can help.

BRONCHODILATORS — Medications that help open the airways are a mainstay of treatment for COPD. Called "bronchodilators", most of these medicines are given in an inhaled form using a "metered dose inhaler" (MDI) or a dry powder inhaler (DPI). It is important that the patient understand how to use the inhaler properly in order to ensure that the correct dose of medication is delivered.

There are two main kinds of inhaled bronchodilators. These include albuterol (Proventil, Ventolin), formoterol (Foradil), or salmeterol (Serevent), which are "beta-agonists". Ipratropium (Atrovent), and tiotropium (Spiriva) are "anticholinergic." Both keep airways open and may decrease secretions. Because the two classes work by different mechanisms, they can be used together. A combination inhaler that contains albuterol and ipratropium (Combivent) is available. The use of the oral medication theophylline (Theodur, Slo-bid) may benefit certain patients.

STEROIDS — Steroids refer to a large class of hormone-like substances. Androgens are the steroids often used by athletes. Glucocorticoids are a different class of steroids that have anti-inflammatory properties. They are not prescribed for everyone with COPD, but they can improve symptoms in some patients. If a patient's symptoms have not improved as much as expected with bronchodilators, steroids by inhaler may be tried. Steroids given by mouth can have serious side effects, but some patients may require them to keep their lung disease under control.

COUGH MEDICINES AND CHEST THERAPY — Cough medicines to thin the sputum in a patient with COPD are not generally recommended, as they have not been shown reliably to improve the patient's symptoms. Although cough can be a bothersome symptom, cough suppressants are avoided or used with caution, as they may reduce the clearance of secretions and increase the likelihood of infection.

Certain patients with extensive secretions or an ineffective cough may benefit from chest physical therapy. This involves a physical therapist who "claps" the patient's chest and back in an attempt to loosen secretions, and then maneuvers the patient into positions that enhance drainage. It is unclear for which patients this treatment is helpful.

PREVENTION AND TREATMENT OF INFECTION — Patients with COPD are prone to acute episodes of worsening symptoms that often begin with a respiratory infection. Avoiding these infections, or treating them quickly if they occur, are important components of COPD therapy.

All patients with COPD should have pneumococcal vaccination, which helps prevent a certain type of pneumonia. In some patients, the vaccine needs to be repeated every six years.

Patients with COPD should also receive an annual flu shot in advance of flu season. For patients who get the flu, antiviral medications may be prescribed. Antiviral medication may also be used in COPD patients who have not had a flu shot but are at risk for getting the flu.

Antibiotics have been shown to be beneficial in patients with worsening COPD symptoms in the setting of a respiratory infection. A physician may order a sputum analysis to help determine if antibiotics are indicated in a particular case.

OXYGEN — Patients with advanced COPD may have low oxygen levels in the blood. This condition, known as hypoxemia, can occur without the patient being aware of any increase in shortness of breath or other symptoms. Doctors can measure the oxygen level using a device placed on the finger or through a blood test. Patients with hypoxemia are placed on oxygen therapy, which can improve shortness of breath and may prolong life.

Some patients with COPD who travel by air may be prone to hypoxemia during travel because of the changes in air pressure inside the plane. If the physician determines a particular patient is likely to become hypoxemic during flight, in-flight oxygen will be prescribed.

Supplemental oxygen must never be used while smoking. Oxygen is explosive, and smoking while using oxygen can lead to severe facial and airway burns. Fatal fires have resulted from oxygen users attempting to smoke.

NUTRITION — More than 30 percent of patients with severe COPD are malnourished. This can make symptoms worse and increase the likelihood of infection. Some patients may be advised to increase caloric intake by using a nutritional supplement, though the long-term benefits of this therapy have not been shown.

PULMONARY REHABILITATION — Comprehensive pulmonary rehabilitation programs have been shown to improve exercise capacity, decrease hospitalizations, and enhance the quality of life in patients with COPD. A program may include education, exercise training, psychosocial support, and instruction on breathing techniques that can ease symptoms of breathlessness. Patients with severe shortness of breath or frequent hospitalizations for COPD may benefit from a rehabilitation program.

SURGERY — Surgery to correct the abnormal lung expansion (lung volume reduction surgery) has been tried with some success in patients with emphysema. This procedure involves removing the areas of lung that are most abnormal, allowing the remaining lung to expand and function more normally. Studies suggest that it may be an option for some patients who still have severe symptoms after receiving all other routine therapies including rehabilitation. Not all patients will benefit from this surgery, and some may be made worse. A special x-ray called a computed tomography (CT or CAT) scan can help determine who might be a potential candidate for this treatment.

Lung transplantation can also be considered in cases of severe COPD. If successful, the operation is likely to result in symptomatic improvement. However, lung transplantation has not been shown to prolong the life of patients with COPD, and not all patients are lung transplantation candidates.

OTHER THERAPIES — Certain patients with COPD may be given various other treatments, including: noninvasive ventilatory support (the use of a special mask and breathing machine to improve symptoms), anti-anxiety or anti-depression medications, or morphine-like medications to reduce shortness of breath.


   —Treatment of COPD and Asthma

What can you do if you have an early stage of asthmatic bronchitis, chronic bronchitis, or emphysema? 

Certainly you should change any behavior that can make it worse.  The single most important thing you can do for yourself is to stop smoking.  In fact, if you don't stop smoking, none of your other efforts will be as effective as they could be, and your COPD will get worse.

As a COPD patient—

There are many different types of treatments that can help you cope with a chronic lung disease and live your life to the fullest.  Next, we will discuss some of these treatments.  Your doctor will select the ones that will be helpful for you.

Clearing Your Lungs

Coughing has an important "cleaning action" and is something you should do every morning and evening.  You must learn to cough in such a way that you can clear your lungs of mucus with two or three coughs.  There are many ways to do this; your doctor will teach you the way that is best for your particular problem.

As an aid to this cleaning, your doctor might recommend  breathing moist or humid air, and drinking plenty of fluids every day.  This helps to thin out the mucus so that you can cough it up more easily.

Your doctor might also recommend inhaled bronchodilating drugs or anti-inflammatory drugs that open your airways and help increase the normal flow of mucus out of your lungs (See below).

Breathing Techniques

Learning to breathe properly is another very important lesson for people with asthmatic bronchitis, chronic bronchitis, or emphysema.  If you have COPD, you usually work very hard to breathe.  However, because you are not breathing properly, your hard work does not make you feel better and you become tired easily.

There are several things you can do to improve your breathing:

Physical Activity

Often people make the mistake of believing that if they try to avoid becoming short of breath, they will protect their lungs and heart.  Nothing could be less true.  Remaining physically active will improve your breathing ability and help you feel better and enjoy life more.

You can learn how to exercise more even if you have COPD.  As we all know, muscles will become weak if we don't use them.  This is true for the muscles of your chest, which are important in breathing, as well.  Strengthening these muscles will help stop shortness of breath.

Don't let COPD change your normal attitudes about exercise. You should walk every day, going farther each day than you did the one before.  First, walk in your house, then out of doors — walking longer distances each time. You will soon notice that you are breathing better because using the muscles in your chest helps stop shortness of breath.

Your doctor will tell you which exercises are best for you and plan an exercise program based upon your ability. Ask about local pulmonary programs.

Oxygen

Oxygen is a very helpful treatment that enables many patients with severe COPD to lead a more normal and productive life. 

If your doctor feels your body is not getting enough oxygen, he or she may prescribe it for you.  Portable cylinders will allow you to carry oxygen with you, or your doctor might tell you to use it at night during sleep when a lack of oxygen is most severe.  Liquid portable oxygen is the most practical ambulatory system. Your doctor must order the proper oxygen system which can benefit you the most. A supplier cannot change your doctor's prescription. Follow the directions you are given carefully, as you would for any medication that is prescribed.

Medications

Many different medications are used as treatment for asthmatic bronchitis, chronic bronchitis, or emphysema.  Your doctor will decide which medicine is best for you based on your medical history, breathing tests, and laboratory tests.

To help you breathe easier, your doctor may give you bronchodilator drugs.  Bronchodilators relax the muscles that surround the breathing tubes and widen them, letting air travel in and out more easily. 

Your doctor may also prescribe drugs to liquefy the mucus in your lungs, or even drugs called steroids, which reduce the swelling in your breathing tubes.  If you have an infection in your respiratory system, your medications may include antibiotics.

These medications may be available in many different forms.  In addition to pills or syrups, your doctor may prescribe a metered-dose inhaler, which has medication that you breathe in.  Liquid medications may be used with special equipment that will turn them into a mist that will provide moisture for your respiratory system. This mist-maker is called a nebulizer.  It is discussed below.

Metered-Dose Inhalers

Most of these devices, which deliver medication to your lungs as a spray, require a prescription from your doctor.  The medication in a metered-dose inhaler that can be bought without a prescription such as Primatine MistTM is adrenaline, a short-acting drug which may be dangerous for persons with heart disease. It is inadequate to treat COPD.

In order to get the maximum benefit from the medication, it is important that the inhaler be used properly.  Here are some helpful tips for using a metered-dose inhaler:

  1. Remove the cap from the mouthpiece.
  2. Shake the inhaler for a few seconds.  Breathe out.
  3. Hold the inhaler upright and place it in front of your  mouth.  Keep your mouth slightly open.  Breathe in deeply  and at the same time press the inhaler between your thumb  and forefinger.  This will force the medication from the  inhaler into your throat and lungs.
  4. Remove the inhaler and hold your breath for a few seconds; then resume normal breathing.  Wait at least  two minutes before repeating the process.  (Most inhaler  medications specify that two puffs should be taken.  Wait at least two minutes between each puff.)

Do not exceed the dose prescribed by your doctor.  If you continue to have difficulty breathing, contact your doctor immediately.

A device called a spacer or volume chamber should also be used to make it easier to take your medication.  This device catches the mist produced by a metered-dose inhaler and holds it so that you can breathe it in at a slower rate.

Diagram of how to use inhalerD

Mist-Generating Devices

This type of treatment, which must be prescribed by your doctor, delivers a mist of medication and moisture to your lungs.  The device that is most often used to create this mist is a "pump-driven nebulizer."  The liquid medication is placed in the nebulizer where it is changed into a mist that you inhale.  When taking this treatment, here are some points to remember:

  1. Be sure you know the amount of medication and solution to use as well as the length and timing of your treatment. Follow your doctor's or respiratory therapist's instructions  carefully about when each treatment should be scheduled  and the length of time that it should be done. 
  2. Relax and sit in a comfortable chair in an upright position.
  3. Make sure the tubing is not bent or dented, and that the  handhold is at the same level as your mouth.
  4. Put the mouthpiece in front of your teeth and keep your  mouth slightly open.
  5. Take a deep, slow breath and activate the nebulizer  control.  Let the mist fill your lungs. Hold your breath for  about two seconds before exhaling.  Remember to exhale  slowly and completely each time.

If your mouth becomes dry during your treatment, don't be afraid to stop and drink some water.  Also -- and this is very important -- if you bring up mucus during the treatment, turn your machine off and stop and cough it up.  These treatments are helpful in eliminating mucus.

If you experience any discomfort after treatment, notify your doctor.

New Developments

Progress is continually being made in the treatment of asthmatic bronchitis, chronic bronchitis, and emphysema. 

Another type of bronchodilator medication (an anticholinergic), is available in metered-dose devices. The other major type of inhaled bronchodilator is called a beta agonist. 

Beta agonist medications are also available as solutions for use with pump-driven nebulizers. Anticholinergic solutions are also useful in COPD. Both medications can be used together in the same nebulizer. Both are sold in a metered-dose inhaler (separately and mixed together for convenience).  Since these bronchodilators work on the respiratory system in different ways, they can be used together to treat COPD.

 

Chronic Obstructive Pulmonary Disease (COPD)

 

Chronic obstructive pulmonary disease (COPD) is a term referring to two lung chronic bronchitis, bronchiectasis, asthma, and emphysema, that are characterized by obstruction to airflow that interferes with normal breathing.  Both of these conditions frequently co-exist, hence physicians prefer the term COPD.

  • COPD is the fourth leading cause of death in America, claiming the lives of 120,000 Americans in 2002.
  • Beginning in 2000, women have exceeded men in the number of deaths attributable to COPD.  In 2002, over 61,000 females died compared to 59,000 males.
  • Smoking is the primary risk factor for COPD. Approximately 80 to 90 percent of COPD deaths are caused by smoking. Female smokers are nearly 13 times as likely to die from COPD as women who have never smoked.  Male smokers are nearly 12 times as likely to die from COPD as men who have never smoked.
  • Other risk factors of COPD include air pollution, second-hand smoke, history of childhood respiratory infections and heredity.  Occupational exposure to certain industrial pollutants also increases the odds for COPD.  A recent study found that the fraction of COPD attributed to work was estimated as 19.2% overall and 31.1% among never smokers.
  • In 2003, 10.7 million U.S. adults were estimated to have COPD.  However, close to 24 million U.S. adults have evidence of impaired lung function, indicating an under diagnosis of COPD.
  • In 2004, the cost to the nation for COPD was approximately $37.2 billion, including healthcare expenditures of $20.9 billion in direct health care expenditures, $7.4 billion in indirect morbidity costs and $8.9 billion in indirect mortality costs. 

     

  • Chronic bronchitis is the inflammation and eventual scarring of the lining of the bronchial tubes. When the bronchi are inflamed and/or infected, less air is able to flow to and from the lungs and a heavy mucus or phlegm is coughed up. The condition is defined by the presence of a mucus-producing cough most days of the month, three months of a year for two successive years without other underlying disease to explain the cough.
  • This inflammation eventually leads to scarring of the lining of the bronchial tubes. Once the bronchial tubes have been irritated over a long period of time, excessive mucus is produced constantly, the lining of the bronchial tubes becomes thickened, an irritating cough develops, and air flow may be hampered, the lungs become scarred. The bronchial tubes then make an ideal breeding place for bacterial infections within the airways, which eventually impedes airflow.
  • In 2003, an estimated 8.6 million Americans were diagnosed with chronic bronchitis by a health professional. Chronic bronchitis affects people of all ages, but is higher in those over 45 years old.
  • Females are more than twice as likely to be diagnosed with chronic bronchitis as males. In 2003, 2.7 million males had a diagnosis of chronic bronchitis compared to 5.8 million females.
  • Symptoms of chronic bronchitis include chronic cough, increased mucus, frequent clearing of the throat and shortness of breath.

     

  • Emphysema begins with the destruction of air sacs (alveoli) in the lungs where oxygen from the air is exchanged for carbon dioxide in the blood. The walls of the air sacs are thin and fragile. Damage to the air sacs is irreversible and results in permanent "holes" in the tissues of the lower lungs.  As air sacs are destroyed, the lungs are able to transfer less and less oxygen to the bloodstream, causing shortness of breath. The lungs also lose their elasticity, which is important to keep airways open.  The patient experiences great difficulty exhaling.
  • Emphysema doesn't develop suddenly.  It comes on very gradually. Years of exposure to the irritation of cigarette smoke usually precede the development of emphysema. Of the estimated 3.1 million Americans ever diagnosed with emphysema, 95 percent were 45 or older.
  • Of the emphysema sufferers, 54.8 percent are male and 45.2 percent are female. However, within in the past year, the prevalence rate for women has seen a 5 percent increase whereas men have seen a decreased of 10 percent. Therefore, the difference in prevalence rates between the sexes has become statistically insignificant.
  • Symptoms of emphysema include cough, shortness of breath and a limited exercise tolerance. Diagnosis is made by pulmonary function tests, along with the patient's history, examination and other tests.
  • Alpha1 antitrypsin deficiency-related (AAT) emphysema is caused by the inherited deficiency of a protein called alpha1-antitrypsin (AAT) or alpha1-protease inhibitor. AAT, produced by the liver, is a "lung protector." In the absence of AAT, emphysema is almost inevitable. It is responsible for 5% or less of the emphysema in the United States.
  • An estimated 100,000 Americans, primarily of northern European descent, have AAT deficiency emphysema. Another 25 million Americans carry a single deficient gene that causes Alpha-1 and may pass the gene onto their children.
  • Symptoms of AAT deficiency emphysema usually begin between 32 and 41 years of age and include shortness of breath and decreased exercise capacity.  Smoking significantly increases the severity of emphysema in AAT-deficient individuals. 
  • Blood screening is primarily used to diagnose whether a person is a carrier or AAT-deficient. If children are diagnosed as AAT-deficient through blood screening, they may undergo a liver transplant. In addition, a DNA-based cheek swab test has been recently developed for the diagnosis of AAT-deficiency.
  • A recent study suggested that there are at least 116 million carriers among all racial groups, worldwide.

COPD Treatment

  • The quality of life for a person suffering from COPD diminishes as the disease progresses. At the onset, there is minimal shortness of breath.  People with COPD may eventually require supplemental oxygen and may have to rely on mechanical respiratory assistance.
  • A recent American Lung Association survey revealed that half of all COPD patients (51%) say their condition limits their ability to work.  It also limits them in normal physical exertion (70%), household chores (56%), social activities (53%), sleeping (50%) and family activities (46%).
  • None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease.  Therefore, the goal of pharmacotherapy for COPD is to provide relief of symptoms and prevent complications and/or progression of the disease with a minimum of side effects.
  • Bronchodilator medications (prescription drugs that relax and open air passages in the lungs) are central to the symptomatic management of COPD. They can be inhaled as aerosol sprays or taken orally.
  • Additional treatment includes antibiotics, oxygen therapy, and systemic glucocorticosteroids. The efficacy of inhaled glucocorticosteroids continues to be under study, however short-term benefit has been demonstrated.  Chronic treatment with systemic steroids involves the risk of serious side effects; therefore these are used mostly for acute exacerbations.
  • Pneumonia and influenza vaccines should be given to COPD patients. Those with COPD should also live a healthy lifestyle by exercising, avoiding cigarette smoke and other air pollutants, and eating well.
  • Pulmonary rehabilitation is a preventive health-care program provided by a team of health professionals to help people cope physically, psychologically, and socially with COPD.
  • Lung transplantation is being performed in increasing numbers and may be an option for people who suffer from severe emphysema. Additionally, lung volume reduction surgery has shown promise and is being performed with increasing frequency. However, a recent study found that emphysema patients who have severe lung obstruction with either limited ability to exchange gas when breathing or damage that is evenly distributed throughout their lungs are at high risk of death from the procedure.