Treatment of Stable COPD

Smoking cessation is both extremely difficult and extremely important; it slows but does not halt the rate of FEV1 decline (see figure Changes in lung function in patients who quit smoking) and increases long-term survival. Simultaneous use of multiple strategies is most effective:

• Establishment of a quit date

• Behavior modification techniques

• Group sessions

• Nicotine replacement therapy (by gum, transdermal patch, inhaler, lozenge, or nasal spray)

• Physician encouragement

Quit rates >nicotine

Changes in lung function (percentage of predicted FEV1) in patients who quit smoking compared with those who continue

During the first year, lung function improved in patients who quit smoking and declined in those who continued. Subsequently, the rate of decline in those who continued was twice that of those who quit. Function declined in those who relapsed and improved in those who quit regardless of when the change occurred. Based on data from Scanlon PD et al: Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease; the Lung Health Study. American Journal of Respiratory and Critical Care Medicine 161:381–390, 2000.

Recommended drug therapy is summarized in the table Pharmacologic Treatment of COPD.

Inhaled bronchodilators are the mainstay of COPD management; drugs include

• Beta-agonists

• Anticholinergics (antimuscarinics)

These two classes of drugs are equally effective. Patients with mild disease are treated only when symptomatic. Patients with moderate to severe COPD should be taking drugs from one or both of these classes regularly to improve pulmonary function and increase exercise capacity.

The frequency of exacerbations can be reduced with the use of anticholinergics, inhaled corticosteroids, or long-acting beta-agonists. However, there is no convincing evidence that regular bronchodilator use slows deterioration of lung function. The initial choice among short-acting beta-agonists, long-acting beta-agonists, anticholinergics, and combination beta-agonist and anticholinergic therapy is often a matter of tailoring cost and convenience to the patient’s preferences and symptoms.

For home treatment of chronic stable disease, drug administration by metered-dose inhaler or dry-powder inhaler is preferred over administration by nebulizer; home nebulizers are prone to contamination due to incomplete cleaning and drying. Therefore, nebulizers should be reserved for people who cannot coordinate activation of the metered-dose inhaler with inhalation or cannot develop enough inspiratory flow for dry powder inhalers.

For metered-dose inhalers, patients should be taught to exhale to functional residual capacity, inhale the aerosol slowly to total lung capacity, and hold the inhalation for 3 to 4 seconds before exhaling. Spacers help ensure optimal delivery of drug to the distal airways and reduce the importance of coordinating activation of the inhaler with inhalation. Some spacers alert patients if they are inhaling too rapidly. New or not recently used metered-dose inhalers require 2 to 3 priming doses (different manufacturers have slightly different recommendations for what is considered "not recently used," ranging from 3 to 14 days).

Long-term oxygen therapy prolongs life in patients with COPD whose PaO2 is chronically < 55 mm Hg. Continual 24-hour use is more effective than a 12-hour nocturnal regimen. Oxygen therapy does the following:

• Brings hematocrit toward normal levels

• Improves neuropsychologic factors, possibly by facilitating sleep

• Ameliorates pulmonary hemodynamic abnormalities

• Increases exercise tolerance in many patients

Oxygen saturation should be measured during exercise and while at rest. Similarly, a sleep study should be considered for patients with advanced COPD who do not meet the criteria for long-term oxygen therapy while they are awake (see table Indications for Long-Term Oxygen Therapy in COPD) but whose clinical assessment suggests pulmonary hypertension in the absence of daytime hypoxemia. Nocturnal oxygen may be prescribed if a sleep study shows episodic desaturation to ≤ 88%. Such treatment prevents progression of pulmonary hypertension, but its effects on survival are unknown. Patients with moderate hypoxemia above 88% or exercise desaturation may benefit symptomatically from oxygen, but there is no improvement in survival or reduction in hospitalizations (1).

Some patients need supplemental oxygen during air travel because flight cabin pressure in commercial airliners is below sea level air pressure (often equivalent to 1830 to 2400 m [6000 to 8000 ft]). Eucapnic COPD patients who have a PaO2 > 68 mm Hg at sea level generally have an in-flight PaO2 > 50 mm Hg and do not require supplemental oxygen. All patients with COPD with a PaO2 ≤ 68 mm Hg at sea level, hypercapnia, significant anemia (hematocrit < 30), or a coexisting heart or cerebrovascular disorder should use supplemental oxygen during long flights and should notify the airline when making their reservation. Now that approved portable oxygen concentrators are ubiquitous, very few airlines still provide oxygen. Patients are advised to rent or purchase a portable oxygen concentrator for use during air travel, including enough spare batteries to account for the flight time and possible delays.

All patients with COPD should be given annual influenza vaccinations

Pneumococcal polysaccharide vaccine and pneumococcal conjugate vaccine should be administered because they are effective in reducing community-acquired pneumonia and invasive pneumococcal infections in older adults.

COPD patients are at risk of weight loss and nutritional deficiencies because of a higher energy cost of daily activities; reduced caloric intake relative to need because of dyspnea; and the catabolic effect of inflammatory cytokines such as tumor necrosis factor (TNF)-alpha. Generalized muscle strength and efficiency of oxygen use are impaired. Patients with poorer nutritional status have a worse prognosis, so it is prudent to recommend a balanced diet with adequate caloric intake in conjunction with exercise to prevent or reverse undernutrition and muscle atrophy. Split-meal feeding can be helpful.

Excessive weight gain should be avoided, and obese patients should strive to gradually reduce body fat.

Studies of nutritional supplementation alone have not shown improvement in pulmonary function or exercise capacity. Trials of appetite stimulants, anabolic steroids, growth hormone supplementation, and TNF antagonists in reversing undernutrition and improving functional status and prognosis in COPD have been disappointing.

Pulmonary rehabilitation programs serve as adjuncts to drug treatment to improve physical function; many hospitals and health care organizations offer formal multidisciplinary rehabilitation programs. Pulmonary rehabilitation includes exercise, education, and behavioral interventions. Treatment should be individualized; patients and family members are taught about COPD and medical treatments, and patients are encouraged to take as much responsibility for personal care as possible.

The benefits of rehabilitation are greater independence and improved quality of life and exercise capacity. Pulmonary rehabilitation typically does not improve pulmonary function. A carefully integrated rehabilitation program helps patients with severe COPD accommodate to physiologic limitations while providing realistic expectations for improvement. Patients with severe disease require a minimum of 3 months of rehabilitation to benefit and should continue with maintenance programs.

An exercise program can be helpful in the home, in the hospital, or in institutional settings. Graded exercise can ameliorate skeletal muscle deconditioning resulting from inactivity or prolonged hospitalization for respiratory failure. Specific training of respiratory muscles is less helpful than general aerobic conditioning.

A typical training program begins with slow walking on a treadmill or unloaded cycling on an ergometer for a few minutes. Duration and exercise load are progressively increased over 4 to 6 weeks until the patient can exercise for 20 to 30 minutes nonstop with manageable dyspnea. Patients with very severe COPD can usually achieve an exercise regimen of walking for 30 minutes at 1 to 2 mph (1.6 to 3.2 km per hour). Maintenance exercise should be done 3 to 4 times/week to maintain fitness levels. Oxygen saturation is monitored, and supplemental oxygen is provided as needed.

Upper extremity resistance training helps the patient in doing daily tasks (eg, bathing, dressing, house cleaning). The usual benefits of exercise are modest increases in lower extremity strength, endurance, and maximum oxygen consumption.

Patients should be taught ways to conserve energy during activities of daily living and to pace their activities. Difficulties in sexual function should be discussed and advice should be given on using energy-conserving techniques for sexual gratification.

Surgical options for treatment of severe COPD include

• Lung volume reduction

• Lung transplantation