Chronic Obstructive Pulmonary Disease (COPD)
Treatment for COPD
There is no cure for COPD. However, both pharmacologic and lifestyle management strategies can help improve health status and physical function (GOLD 2011; Collins 2012).
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD), effective COPD management has the following goals (GOLD 2011):
- Preventing disease progression
- Relieving symptoms
- Improving exercise tolerance and health status
- Preventing and treating complications and exacerbations
- Reducing mortality
Bronchodilators are the first-line therapy for mild COPD. Bronchodilators relax airway smooth muscles, making it easier to breathe. Treatment may begin with a rescue bronchodilator used "as needed" during mild episodes of COPD. In more severe COPD, combination bronchodilator therapy (i.e., a rescue bronchodilator combined with a controller [long-acting] bronchodilator) may help relieve symptoms (ICSI 2011; GOLD 2011).
Bronchodilators include the following:
- Beta2-agonists. Short-acting beta2-adrenergic agonists (SABAs) (e.g., albuterol and levalbuterol) are rescue medications used "as-needed" to relieve acute symptoms by relaxing airway smooth muscles (Barnes 2002). The effect(s) of SABAs are immediate, but usually wear off within 4 to 6 hours. Long-acting beta2-adrenergic agonists (LABAs) (e.g., salmeterol and indacaterol) are effective for 12 or more hours (GOLD 2011). LABAs can significantly reduce exacerbations and improve respiratory health, but do not reduce hospitalization or mortality (Calverley 2007). Side effects of beta-2-agonists include increased heart rate and blood pressure, trembling, and cardiac arrhythmias (Littner 2011).
- Anticholinergics (e.g., ipratropium and tiotropium) prevent contraction of airway smooth muscle and can reduce exacerbations as well as improve symptoms and health status (Barnes 2004; Tashkin 2008; GOLD 2011). The main side effect of anticholinergics is dry mouth. A comprehensive review showed that tiotropium mist inhaler is associated with a 50% increased risk of death in people with COPD (Singh 2011). Another study showed the use of anticholinergic inhalers increased risk of acute urinary retention among COPD patients with benign prostatic hyperplasia (BPH) (i.e., benign enlargement of the prostate) (Stephenson 2011).
- Methylxanthines (e.g., theophylline) are a group of alkaloids commonly used for their effects as mild stimulants and bronchodilators (Minor 1994). They are not as well tolerated as inhaled LABAs. Side effects include headache, insomnia, nausea, heartburn, and abnormal cardiac rhythms (which have potential to be fatal in some individuals) (GOLD 2011).
Inhaled steroid medications (e.g., fluticasone and budenoside) reduce airway inflammation and frequency of exacerbation(s). They can be effective in severe COPD, especially that which co-occurs with asthma (Barnes 2010b; Roche 2011). At low doses, regular use can improve symptoms, lung function, and quality of life. Side effects include hoarse voice, cough, and oral fungal infection (Irwin 2006). Inhaled corticosteroids may also increase the risk of pneumonia and impair bone health (Barnes 2010b; Spencer 2011).
Combining inhaled corticosteroids with a LABA significantly reduces morbidity and mortality in COPD when compared to steroids alone, although much of the benefit may be due to the LABA (Barnes 2010b; Nannini 2007). Oral corticosteroids (e.g., prednisone, prednisolone), due to their adverse effects (e.g., muscle weakness and respiratory failure), are not recommended for long-term use in patients with COPD (GOLD 2011).
Surgery and Other Treatments
Oxygen therapy. Long-term oxygen therapy may be recommended for severe COPD when oxygen levels during rest fall below the normal threshold twice over a three-week period, or if there is evidence of pulmonary hypertension or failure. Stable but very severe COPD may require ventilator support to improve survival (GOLD 2011).
Surgery. Surgery is a viable treatment in a small subset of carefully selected patients with severe COPD (Van Raemdonck 2010; Gulati 2013).
- Bullectomy. In a bullectomy procedure, large air sacs (bullae) that have been damaged by emphysema are removed. Surgical removal of these bullae can help restore lung volume and allow the remaining healthy parts of the lung to function better.
- Lung volume reduction surgery (LVRS). In LVRS damaged tissue of the lung(s) is removed. LVRS can improve lung function, overall health status, and survival; however, it is indicated only for a small portion of patients with end-stage COPD who no longer respond to more conservative measures (Clarenbach 2015; Criner 2018). LVRS, while being a high-risk procedure with a high frequency of adverse effects and increased mortality risk in the short-term, is associated with a survival benefit long-term (van Agteren 2016).
- Lung transplantation. Lung transplantation can improve quality of life and survival for those with very severe, end-stage COPD. However, the survival benefit is typically limited, and complications can include an increased risk of lung cancer (and other cancers, due to the subsequent need for lifelong therapy with immunosuppressive drugs) (GOLD 2011; Lane 2015; Olland 2018).
Endobronchial valve. In 2018, the FDA approved a novel device called the Zephyr Endobronchial Valve (EBV) for the treatment of COPD. The Zephyr EBV, which is placed into the airway during a minimally invasive bronchoscopic procedure, directs airflow toward healthy lung tissue and away from lung tissue damaged by emphysema. This improves overall lung efficiency. The EBV has been clinically shown to be comparable to LVRS for FEV1 and six-minute walk distance but has a 38% lower mortality risk and less overall adverse effects (PulmonX 2018).
The multi-center, randomized, controlled LIBERATE trial compared the Zephyr EBV device with standard care. One hundred twenty-eight trial participants with severe emphysema underwent an EBV-placement procedure, and 62 patients received standard care and served as controls. The main endpoint in the trial was an improvement in lung function (as measure by FEV1) of at least 15%. Forty-eight percent of subjects in the EBV group achieved this endpoint at 12 months post-intervention versus only 17% of control subjects. The Zephyr EBV also resulted in significant improvement in clinical measures of functional ability and respiratory health.
Lung collapse (pneumothorax) is one possible complication of the EBV device. It occurred in roughly 25% of subjects in the LIBERATE trial who received the device. Fortunately, the majority of cases occurred soon after the procedure and were managed successfully; the development of pneumothorax did not prevent long-term benefit from the procedure (Criner 2018).
Since COPD increases susceptibility to lower respiratory tract infections, preventive vaccines, such as pneumococcal and influenza vaccinations, are recommended in all COPD cases (ICSI 2011). Data show long-term use of antibiotics does not affect the frequency of exacerbations. Unless used to treat bacterial infections, antibiotics are not recommended for long-term COPD therapy (GOLD 2011).
Lifestyle And Dietary Management
Quitting smoking is the most important step to prevent or slow down the progress of COPD. Comprehensive smoking cessation programs include counseling, organized "quit" plans, and when necessary, nicotine replacement therapy (e.g., gum, skin patches, and other methods). The National Network of Tobacco Cessation Quit lines at 1-800-QUITNOW (1-800-784-8669) can provide smokers in every state access to information and support to quit smoking (NCI 2012). Avoiding secondhand smoke and air pollutants that contribute to COPD symptoms and exacerbations of the disease are also beneficial (GOLD 2011).
Although tobacco smoking cessation can help slow disease progression and prevent exacerbations in some cases of severe or very severe COPD, with cardiovascular and respiratory benefits becoming evident within one year of cessation, lung function will not be completely restored by stopping smoking (Godtfredsen 2011).
Exercise Programs. Air passage obstruction in COPD causes the lungs and heart to work harder to carry oxygen throughout the body. General muscle wasting also becomes a risk as COPD progresses. Exercise programs can strengthen chest muscles and facilitate breathing, reduce depression and anxiety related to COPD, and improve recovery along with health status after hospitalization (de Blasio 2012). Multidisciplinary pulmonary rehabilitation programs provide well-monitored exercise programs.
Breathing exercises. Breathing exercises induce relaxation and make breathing easier. Pursed-lip breathing stimulates relaxation, increases oxygen intake and prevents shortness of breath. It has been shown to increase exercise and walking endurance, as well as shorten recovery time(s) in patients with moderate to severe COPD (Faager 2008). Breathing exercises are an important part of a COPD rehabilitation program. Respiratory therapists work closely with physicians to personalize the best regimen for each individual.
Diet and COPD
Progressive weight loss, muscle wasting, and malnutrition are common with moderate to severe COPD (Collins 2012; de Blasio 2012). Nutritional support can contribute to weight gain and muscle mass restoration in COPD (Collins 2012). In a three-year, randomized, controlled COPD trial, higher intake of antioxidant-rich foods (i.e., fresh fruits and vegetables) resulted in significantly improved pulmonary function while an unrestricted diet resulted in lung function decline (Keranis 2010). Further, a large study showed that a healthy diet (i.e., fruits, vegetables, fish and whole-grains) was associated with lower risk of COPD (Varraso 2010).