CHRONIC OBSTRUCTIVE PULMONARY DISEASE OVERVIEW
COPD, or chronic obstructive pulmonary disease, is a condition in which the airways in the lungs become damaged, making it increasingly difficult for air to move in and out.
There are two major kinds of damage that can cause COPD:
●The airways in the lungs can become scarred and narrowed.
●The air sacs in the lung, where oxygen is absorbed into the blood and carbon dioxide is excreted, can become damaged.
In addition, COPD is often associated with inflammation of the airways that can lead to cough and production of phlegm (sputum).
When the damage is severe, it may become difficult to get enough oxygen into the blood and to get rid of excess carbon dioxide. These changes lead to shortness of breath and other symptoms.
Unfortunately, the symptoms of chronic obstructive pulmonary disease cannot be completely eliminated with treatment and the condition usually worsens over time. However, treatment can control symptoms and can sometimes slow the progression of the disease.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE MEDICATIONS
Bronchodilators — Medications that help open the airways, called bronchodilators, are a mainstay of treatment for chronic obstructive pulmonary disease. Bronchodilators help to keep airways open and possibly decrease secretions.
Bronchodilators are most commonly given in an inhaled form using a metered dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer. It is important to use the inhaler properly to deliver the correct dose of medication to the lungs. If you do not use the inhaler correctly, little or no medicine reaches the lungs.
There are several types of bronchodilators that can be used alone or in combination.
●Short-acting beta agonists – Short-acting beta agonists, sometimes called rescue inhalers, can quickly relieve shortness of breath and can be used when needed. Examples of short-acting beta agonists include albuterol and levalbuterol.
●Short-acting anticholinergics – Short-acting anticholinergic medication (ipratropium, Atrovent) improves lung function and symptoms. If symptoms are mild and infrequent, short-acting anticholinergic medication may be recommended only when you need it. Or, if symptoms are more severe or more frequent, it may be recommended on a regular basis, up to four times a day.
●Short-acting combination inhaler – A combination inhaler that contains albuterol and ipratropium (Combivent) is also available. Combination inhalers may be used just when needed or regularly, depending on the frequency and severity of your symptoms.
Long-acting treatments are often recommended for people who must use medication on a regular basis to control COPD symptoms.
●Long-acting beta agonists – Long-acting beta agonists may be recommended if your symptoms are not adequately controlled with other treatments. Examples of long-acting beta agonists include salmeterol, formoterol, and arformoterol, which are taken twice daily, and indacaterol, which is taken once daily.
●Long-acting anticholinergics – The long-acting anticholinergic medications improve lung function while decreasing shortness of breath and flares of COPD. Examples include tiotropium (Spiriva), umeclidinium (Incruse), glycopyrrolate (Seebri), and aclidinium (Tudorza). Some of these are taken once a day and others twice a day. This type of medication may be recommended if your symptoms are not adequately controlled with other treatments, such as the short-acting bronchodilators.
One long-acting anticholinergic, glycopyrrolate (Lonhala), comes as a solution that requires a specialized nebulizer, called a Magnair device. It is taken twice a day.
Combinations of long-acting bronchodilators are often used when symptoms are not completely controlled with one medication. The individual agents can be taken in separate inhalers, such as tiotropium and salmeterol, or in a combination inhaler.
●Long-acting bronchodilator combination inhaler – Combination inhalers that use both a long-acting beta agonist and a long-acting anticholinergic medication are also available. Umeclidinium-vilanterol (Anoro), glycopyrrolate-indacaterol (Utibron), and aclidinium-formoterol (Duaklir, available in Canada) are dry powder inhalers. Glycopyrrolate-formoterol (Bevespi) is a metered dose inhaler. Tiotropium-olodaterol (Stiolto) is a soft mist inhaler. Dosing is once or twice a day, depending on the particular preparation. This type of dual-bronchodilator therapy helps to improve lung function more than either a long-acting beta agonist or long-acting anticholinergic alone.
Glucocorticoids — Glucocorticoids (also called steroids, although they are very different from muscle building steroids) are a class of medication that has anti-inflammatory properties. Glucocorticoids can be taken with an inhaler, as a pill, or as an injection.
Glucocorticoids taken in pill form or as an injection are sometimes used for short term treatment (eg, for flares of COPD), but are not generally used long-term because of the risk of side effects.
Inhaled glucocorticoids may be recommended in combination with a long-acting bronchodilator, if your symptoms are not completely controlled with bronchodilators alone or if you have frequent flares of chronic obstructive pulmonary disease. Several such combinations are available including fluticasone-salmeterol (Advair) and budesonide-formoterol (Symbicort), which are taken twice daily, and fluticasone furoate-vilanterol (Breo), which is taken once daily.
Sometimes symptoms are not controlled with two medications, and three are needed. Usually, this means you will use two inhalers. There is also a triple inhaler that contains two bronchodilator medicines and a glucocorticoid, fluticasone furoate-umeclidinium-vilanterol (Trelegy).
PDE4 inhibitor — Roflumilast (Daliresp) is a pill that may be prescribed for people who have chronic cough and phlegm production (chronic bronchitis) and frequent exacerbations despite using inhaled bronchodilators and glucocorticoids.
Cough medicines — Cough medicines are not generally recommended for people with COPD because they have not been shown to improve COPD symptoms. Although cough can be a bothersome symptom, cough suppressants should be avoided since suppressing cough may increase the risk of developing an infection.
SUPPLEMENTAL THERAPIES FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Quitting smoking — One of the MOST important treatments for chronic obstructive pulmonary disease (COPD) is for current smokers to stop smoking. Studies of people with COPD show that the disease progresses more slowly after stopping smoking. Most people who stop smoking will cough less and produce less sputum, although this may take several months. A detailed discussion of ways to quit smoking is available separately.
Oxygen — People with advanced COPD can have low oxygen levels in the blood. This condition, known as hypoxemia, can occur even if the person does not feel short of breath or have other symptoms. The oxygen level can be measured with a device placed on the finger (pulse oximeter) or with a blood test (arterial blood gas). People with hypoxemia may be placed on oxygen therapy, which can improve survival and quality of life. If you need oxygen at home, you will have a small tube that goes into your nostrils (called a “cannula”) and carries oxygen from an oxygen tank or machine. Your doctor or nurse will show you how to use your devices, as well as how (and when) to clean and replace them.
Supplemental oxygen must never be used while smoking. Oxygen is explosive, and smoking while using oxygen can lead to severe burns. Fatal fires have occurred in people attempting to smoke while using oxygen.
Some people with COPD who travel by air may be prone to hypoxemia during travel because of the changes in air pressure inside the plane. If a clinician determines that you are at risk for hypoxemia during a flight, in-flight oxygen can be prescribed.
Nutrition — More than 30 percent of people with severe COPD are not able to eat enough because of their symptoms (shortness of breath, fatigue). Unintended weight loss caused by shortness of breath usually occurs in people with more advanced lung disease. Not eating enough can lead to malnutrition, which can make symptoms worse and increase the likelihood of infection.
To increase the number of calories you eat:
●Eat small, frequent meals with nutrient-dense foods (eg, eggs)
●Eat meals that require little preparation (eg, microwaveable)
●Rest before meals
●Take a daily multivitamin
●Nutritional supplements (liquids or bars) are also good sources of extra calories because they are easy to eat and require no preparation
●If you continue to lose weight, a prescription medication may be recommended to stimulate your appetite
Pulmonary rehabilitation — Pulmonary rehabilitation programs may include education, exercise training, social support, and instruction on breathing techniques that can ease symptoms of breathlessness. Pulmonary rehabilitation programs have been shown to improve a person’s ability to exercise, enhance quality of life, and decrease the frequency of exacerbations of COPD. Even people with severe shortness of breath can benefit from a rehabilitation program.
Endobronchial valves — Endobronchial valves (EBVs) are small devices that are implanted in the airways using a bronchoscope (a tube that is inserted through your mouth or nose and down your throat). The valves allow air to exit the diseased area but not re-enter. As a result, the healthier parts of the lung are able to do more of the work of breathing. EBVs may be an option for people who continue to have emphysema symptoms despite medication and pulmonary rehabilitation.
Surgery — Surgery, such as lung volume reduction surgery or lung transplantation, may be helpful in reducing symptoms in some patients with emphysema.
Lung volume reduction surgery — Lung volume reduction surgery involves removing the areas of lung that are most abnormal, which allows the remaining lung to expand and function more normally.
This procedure may be an option for people who have severe symptoms after trying all other routine therapies, including pulmonary rehabilitation. Not all patients will benefit from this surgery, and some may actually become worse. An imaging test, such as a CT scan, may be recommended to help determine if surgery is likely to be of benefit.
Lung transplantation — Lung transplantation may be considered in cases of severe chronic obstructive pulmonary disease. If successful, transplantation is likely to improve symptoms. However, lung transplantation has not yet been shown to prolong the life of people with COPD.
Other therapies — Other treatments for COPD are occasionally recommended, including: noninvasive ventilatory support (the use of a special mask and breathing machine to improve symptoms), anti-anxiety or anti-depressant medications, or morphine-like medications to reduce shortness of breath.
PREVENTION AND TREATMENT OF INFECTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASEPeople with chronic obstructive pulmonary disease are at risk for worsening symptoms as a result of respiratory infections. Avoiding these infections and treating them quickly if they occur are important parts of COPD therapy.
Vaccines — Everyone with chronic obstructive pulmonary disease should have a pneumococcal vaccination, which helps prevent a type of pneumonia.
People with COPD should also get an annual flu shot before flu season, generally in the late fall or early winter. For patients who get the flu, antiviral medications may be prescribed.
Antibiotics — Antibiotics are of some benefit in people with a bacterial respiratory infection who have worsening COPD symptoms. However, most respiratory infections are caused by viruses, which will not improve with antibiotic treatment.
Continuous use of antibiotics to prevent infection is not recommended. However, one antibiotic, azithromycin, used long-term may decrease the frequency of acute flare-ups. While it is not approved for this use, it may still be recommended by your doctor.
Although chronic obstructive pulmonary disease usually worsens over time, it is difficult to predict how quickly this will occur. A number of factors play a role in the severity of COPD symptoms, including whether you continue to smoke, are underweight, have underlying medical problems, and how your lungs function during exercise. People with COPD who have less severe symptoms, are a healthy weight, and do not smoke tend to live longer.
The BODE index is an example of an index that clinicians use to predict survival and to guide the timing of lung transplantation. It uses a combination of body mass index (BMI), severity of airflow obstruction on spirometry, degree of shortness of breath with exertion, and distance walked in six minutes.
END OF LIFE DECISIONS IN COPD
Although discussions about death and dying can be uncomfortable for patients, family members, and healthcare providers, the subject is important, especially for people with severe chronic illnesses. Not everyone with COPD will die as a result of their disease. However, discussions about what you want at the end of your life should occur well before you become seriously ill. This is particularly important for people with COPD, who are at risk for being placed on a ventilator (breathing machine) when they are very ill.
Important questions to consider include:
●Who do I want to make medical decisions for me if I cannot communicate?
●Are there specific treatments that I do or do not want at the end of my life?
Certain legal documents, called a healthcare proxy and living will, are used to communicate your preferences. The document you need depends upon where you live. In the United States, state-specific documents can be downloaded from the internet (such as www.caringinfo.org) and do not require a lawyer.