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Chronic obstructive pulmonary disease

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of COPD -- emphysema and/or chronic bronchitis.

Alternative Names

COPD; Alpha-1 antitrypsin deficiency; Bronchitis - chronic; Chronic bronchitis; Emphysema

Treatment

Stopping Smoking and Healthy Lifestyle. Stopping smoking is the first and primary step to treating COLD and slowing its progression. In addition, all patients should maintain a healthy diet rich in fruits and vegetables. An exercise program may be useful, particularly if it is tailored to improve lung function.

Pulmonary Rehabilitation Programs. Patients with COLD need to be very active in managing their condition. Patients might check with their physicians to determine whether a pulmonary rehabilitation program would be appropriate, if one were available in their area. Such programs are conducted by a team of health professionals to improve lung function. It involves medical treatments, exercise, breathing retraining, and psychological interventions, when needed. If available and affordable, it can be extremely effective, particularly after acute exacerbations. The benefits of pulmonary rehabilitation include improvements in symptoms, exercise capacity, quality of life, and mood. Patients with severe COPD may benefit from programs that last at least 6 months.

Medications for Managing Chronic COLD. A major goal with the use of medications for COLD is to prevent acute exacerbations, which can hasten deterioration of lung function. The main treatment strategy employs a stepped approach with the use of increasingly stronger medications depending on the patient's response:

• Beta2-agonists and anticholinergics, classes of drugs known as bronchodilators, open the airways in the lungs and are the cornerstone of COLD drug therapy. In a major analysis, long-acting beta2-agonists and anticholinergics were most effective and reduced exacerbation rates by 20% to 25%.
• Inhaled corticosteroids also reduce exacerbations by up to 25%. Studies are mixed on whether long-term use improves lung function, and these agents may also have some adverse effects with long-term use. Inhalers that combine a long-acting beta2-agonists and a corticosteroid (Advair, Seretide, Symbicort) are even more effective than either agent alone -- reducing exacerbations by 30%. Some studies suggest they may offer significant improvements in lung function and even improve survival rates, but more research is needed to confirm such findings.
• Antibiotics are sometimes used preventively, but they seem to have only a small effect in reducing illness days. Experts do not recommend them routinely.

Oxygen Replacement . Oxygen replacement is an important component in most COLD treatments. It is the only treatment known to improve survival in COLD patients. The patient is assessed for specific timing and needs.

Surgery . If the patient no longer responds to medications, then surgery may be an option for some patients. Choices may include bullectomy, lung reduction, or lung transplantation.

General Guidelines for Treating Acute Exacerbations

Doctors recommend the following treatments for patients who need to be hospitalized:

• Supplemental oxygen, either mechanical or through noninvasive positive pressure ventilation, should be given.
• Bronchodilators; an inhaled or nebulized (see Administering Inhaled Drugs, below) beta2-agonist, with an anticholinergic agent added if the patient does not respond. Theophylline is not recommended, because it provides very little benefit, and carries a risk of serious side effects.
• Antibiotics if there are signs of infections, particularly if the acute exacerbation is very severe. Courses are usually 5 to 10 days.
• Corticosteroids are usually given for up to 2 weeks (oral corticosteroids in most cases, intravenous in severe cases). An important 2003 study indicated that relapse rates were significantly reduced when the patient also took oral corticosteroids in combination with antibiotics and bronchodilators for 10 days after the episode.
• Chest therapy may be helpful in some patients.

It is not always clear what triggers acute exacerbation episodes, so treatment can be controversial. Bacteria are obvious suspects, but because COLD patients commonly harbor bacteria, it has been difficult to determine which or even whether organisms are responsible. One 2002 study suggested that some episodes may be caused by changes in the strains of bacteria that are commonly present rather than an introduction of a new bacteria. In other cases, viruses and atypical bacteria may be responsible. In some acute exacerbations, however, no sign of infection is present. As with asthma, an inflammatory response in the airways unrelated to infection may suddenly cause changes that bring on an attack (although it is likely to be different from this response in asthma patients). In any case, even minor obstruction in the airways may be able to produce an acute exacerbation.

Treating Complications of Advanced COLD

COLD is associated with a number of complications as lung function worsens. Various treatments may be required.

Opioids. Opioids, such as morphine, are generally not used for patients with COLD because of a concern that they may reduce respiratory function. Nonetheless, some studies are reporting that low doses of oral morphine can improve severe breathlessness in patients who cannot find relief from other methods. Such agents can cause nausea, vomiting, and constipation.

Antidepressants and Antianxiety Agents. Antidepressants or antianxiety medications may be helpful in reducing anxiety that complicates symptoms.

Improving Sleep. More than half of patients with COLD often suffer from insomnia. Most of the standard sleep agents may impair lung function. Newer ones, such as zolpidem (Ambien), zaleplon (Sonata), and zopiclone (Imovane), may be less hazardous than older agents. Tricyclic antidepressants may also be helpful without significant effects on breathing. Behavioral methods are the best approach to this problem, however. [ See In-Depth Report # 27: Insomnia.]

Treating Heart Failure. When patients are in advanced stages of COLD, they may need treatment for fluid accumulation and congestive heart failure. [ See In-Depth Report #13 : Congestive heart failure.]

Administering Inhaled Drugs Most COLD drugs are inhaled using metered dose inhalers, dry powder inhalers, or nebulizers. Metered-Dose Inhaler. The standard device has been the metered-dose inhaler (MDI). This device, particularly when used with a holding chamber, allows precise doses to be delivered directly to the lungs. MDI-delivered drugs must be used regularly as prescribed and the patient carefully trained in their use in order for them to be effective and safe. Some patients hold the MDI too close to their mouths, or even inside them. Others may exhale too forcefully before inhalation. The holding chamber, or spacer, allows the patient additional time to inhale the medication and so improves delivery. Spacers vary, however, in their ability to deliver medication. For example, in one study the AiroChamber-Plus was more effective than the EasiVent in delivering an inhaled steroid. It should be noted that MDIs often continue to deliver propellant after the drug has been used up. Patients should track their medicine and throw the device away when the last dose has been given. Breath-Actuated Inhalers. Breath-actuated rotary inhalers (e.g., Easi-Breathe and Autohaler) deliver the drug directly to the back of the throat as the user inhales. Their primary advantage over the MDI is their ease of use. They also do not use CFCs as propellants. In comparison studies, patients have been very successful with the breath-actuated inhalers. Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. They also do not use CFCs. Such devices include Rotahaler, Spinhaler, Turbohaler, Clickhaler, Easyhaler, Diskhaler, Discus, Twisthaler, Spiros, and others. DPIs are as effective as the older devices, and generally have a better taste and are easier to manage. They may differ, however, in their ability to deliver drugs into the airways. In one study, for example, the Turbohaler was easier to use than the Diskhaler and so achieved better delivery. The Discus is another effective DPI; it has a dose counter and protects against exhalation effects. Humidity or extreme temperatures can effect DPI performance, so these devices should not be stored in humid places (e.g., bathroom cabinets) or locations subject to high temperatures (e.g., glove compartments during summer months). Other Hand-Held Inhalers. Respimat delivers a fine-mist spray that is created by forcing the liquid medication through nozzles. It does not use any propellant. Nebulizers. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in. Nebulizers are often used in hospital settings or when the patient cannot use an inhaler.

• Review Date: 4/28/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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