Treatment:

The appropriate medications for COPD depend on its stage of severity, which is determined by the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has proposed a strategy that is widely accepted. GOLD categorizes COPD severity as follows:

• Stage I: Smoker's cough, little or no shortness of breath, no symptoms of COPD, FEV1 greater than 80% of predicted.
• Stage II: Shortness of breath on exertion, sputum-producing cough, some symptoms of COPD, FEV1 50 - 80% of predicted.
• Stage III: Shortness of breath on mild exertion, FEV1 30 - 50% of predicted.
• Stage IV: Shortness of breath on mild exertion, right heart failure, bluish skin, nails, and lips (cyanosis), FEV1 less than 30% of predicted.

In the gold treatment strategy, medications are added, but not subtracted, as the disease gets worse. Treatment calls for:

• Patients with GOLD stages I - IV: Treatment with an inhaled anticholinergic or inhaled short-acting beta2-agonist.
• Patients with GOLD stages II - IV: Addition of an inhaled long-acting bronchodilator in place of a short-acting beta2-agonist. A combination of bronchodilators may be used. In patients who do not respond to bronchodilators, slow-release theophylline may be used.
• Patients with GOLD stages III - IV: Regular use of inhaled corticosteroids for those with repeated exacerbations. Corticosteroids for severe exacerbations.
• Patients with GOLD stage IV: Long-term oxygen therapy; surgery may be considered.

The American College of Physicians has issued revised guidelines for COPD treatment, which include:

• In patients with stable COPD, reserve treatment for those who have respiratory symptoms and FEV1 of less than 60% of predicted.
• Patients with symptoms and FEV1 of less than 60% of predicted should be treated with long-acting inhaled beta-agonists, long-acting inhaled anticholinergics, or inhaled corticosteroids. Combination inhaled therapies may be used in these patients.
• Patients with COPD and resting hypoxia should be treated with oxygen therapy.
• Patients with symptoms and FEV1 of less than 50% of predicted should consider pulmonary rehabilitation.

Treatment Approach for Stable COPD

Stopping Smoking. Stopping smoking is the first and most important step in treating COPD and slowing its progression. Quitting smoking decreases symptoms of breathlessness and cough, as well as the risk of heart disease, likely due to decreased inflammation.

Diet. Good nutrition is always important. Dietary issues become critical in late COPD, when breathing is difficult. Many patients with COPD lose muscle tone and body mass, and appear to waste away. This may be due to the extreme effort it takes to breathe, which rapidly consumes calories. Some patients find it difficult to stop the effort of breathing long enough to chew food. A nutritionist can find the right foods and design meal plans to help COPD patients be as healthy as possible. There is not strong evidence to support the use of nutritional supplements in patients with COPD. It may help to avoid cured meats, which research indicates can increase the risk of COPD.

Supplemental Oxygen. Supplemental oxygen is an important part of COPD therapy. It can:

• Improve exercise endurance
• Improve quality of life and mental outlook
• Improve sleep
• Reduce breathlessness
• Reduce pulmonary hypertension

All of these factors are affected, along with the lungs' ability to exchange carbon dioxide for oxygen. There is some evidence that supplemental oxygen may also reduce heart problems in patients with COPD. Long-term oxygen therapy given continuously through the nose has been shown to extend survival by as much as 30%.

Blending oxygen with nitrogen (Heliox) has been shown to be more effective than oxygen alone in increasing endurance time and exercise ability.

Pulmonary Rehabilitation. Pulmonary rehabilitation is a proven method of relieving shortness of breath (dyspnea), reducing hospitalizations and disability from COPD, and improving mental and physical quality of life, although there is no proof that it improves survival. The treatment is recommended for patients with stable chronic lung disease who are significantly affected by respiratory symptoms.

Many hospitals offer these programs, which are led by a team of health professionals. Pulmonary rehabilitation is tailored to individual patients, but usually includes:

• Breathing training
• Disease education
• Exercise
• Nutritional advice
• Psychological assessment

Programs generally last 6 - 12 weeks, but longer programs appear to provide more long-term benefits. In one study, an 8-week pulmonary rehabilitation program reduced the number of COPD patients admitted to the hospital by 46%. Maintenance programs may slightly improve long-term outcomes.

Exercise. Exercise is important for maintaining strength and endurance, both of which are greatly affected by COPD. Weight-bearing exercises are important for maintaining quality of life and the ability to live independently. For the greatest benefit, programs should combine low- and high-intensity exercise with strength and endurance training. The use of noninvasive ventilation (NIPPV) during exercise provides some small, very short-term benefit. Receiving supplemental oxygen during rehabilitative exercise may improve patients' endurance. There is no evidence that inspiratory muscle training is effective during pulmonary rehabilitation.

Surgery. When a patient no longer responds to medications, surgery becomes a possible option. Choices include:

• Bullectomy
• Lung transplantation
• Lung volume reduction surgery (LVRS)

General Guidelines for Treating Acute Exacerbations

The goal of COPD treatment, in addition to providing symptom relief, is to prevent exacerbations. Each exacerbation causes lung function to decline. Bringing lung function back to its pre-exacerbation state can take 6 months. When exacerbations are frequent, lung function may never return to normal, and the patient's condition spirals downward.

Studies have found that levels of inflammatory markers in the body rise dramatically during exacerbations. The more severe the exacerbation, the more these marker levels rise. This may indicate that exacerbations are associated with inflammation throughout the body, and not just in the lungs. Measurement of C-reactive protein (CRP), a marker of inflammation, is being used to confirm exacerbations, predict their severity, and help determine patient outcomes.

Exacerbations are most commonly caused by bacterial or viral infections, or by air pollution. The cause is never identified in about one-third of patients.

Treatment of exacerbations commonly includes the following measures:

Oxygen. Supplemental oxygen with controlled oxygen therapy and noninvasive positive pressure ventilation.

Bronchodilation. Inhaled anticholinergics or short-acting beta2-agonists may be used. Theophylline is not recommended, because it provides very little benefit and carries a risk of serious side effects.

Corticosteroids. Corticosteroid medications may be given either through a vein (intravenously) or by mouth (orally), for up to 2 weeks. This treatment is only possible in patients who have not received long-term oral corticosteroid therapy.

Antibiotics. These may be used if there are signs of infection, such as fever or yellow or green phlegm.