- Smoking Cessation
- Drug Therapy
- Oxygen Therapy
- Pulmonary Rehabilitation
- Key Points
- Resources In This Article
Treatment of Stable COPD
(See also Chronic Obstructive Pulmonary Disease.)
COPD management involves treatment of chronic stable disease and treatment of exacerbations.
Treatment of chronic stable COPD aims to prevent exacerbations and improve lung and physical function through
Surgical treatment of COPD is indicated for selected patients.
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 (percentage of predicted FEV1) in patients who quit smoking compared with those who continue.) and increases long-term survival. Simultaneous use of multiple strategies is most effective:
Quit rates > 50% at 1 yr have not been demonstrated even with the most effective interventions, such as use of bupropion combined with nicotine replacement or use of varenicline alone.
Changes in lung function (percentage of predicted FEV1) in patients who quit smoking compared with those who continue.
Recommended drug therapy is summarized in Classification and Treatment of COPD.
Inhaled bronchodilators are the mainstay of COPD management; drugs include
These two classes of drugs are equally effective. Patients with mild (group A—see Table: Classification and Treatment of COPD) disease are treated only when symptomatic. Patients with moderate to severe (group B, C, or D—see Table: Classification and Treatment of COPD) 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 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 sec 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).
Beta-agonists relax bronchial smooth muscle and increase mucociliary clearance. Albuterol aerosol, 2 puffs (90 to 100 mcg/puff) inhaled from a metered-dose inhaler 4 to 6 times/day prn, is usually the drug of choice.
Long-acting beta-agonists are preferable for patients with nocturnal symptoms or for those who find frequent dosing inconvenient. Options include salmeterol powder, 1 puff (50 mcg) inhaled bid, indacaterol 1 puff (75 mcg) inhaled once/day (150 mcg once/day in Europe), and olodaterol 2 puffs once/day at the same time each day. Also available are nebulized forms of arformoterol and formoterol. The dry-powder formulations may be more effective for patients who have trouble coordinating use of a metered-dose inhaler.
Patients should be taught the difference between short-acting and long-acting drugs, because long-acting drugs that are used as needed or more than twice/day increase the risk of cardiac arrhythmias.
Adverse effects commonly result from use of any beta-agonist and include tremor, anxiety, tachycardia, and mild, temporary hypokalemia.
Anticholinergics (antimuscarinics) relax bronchial smooth muscle through competitive inhibition of muscarinic receptors (M1, M2, and M3).
Ipratropium is a short-acting anticholinergic; dose is 2 to 4 puffs (18 mcg/puff) from a metered-dose inhaler q 4 to 6 h. Ipratropium has a slower onset of action (within 30 min; peak effect in 1 to 2 h), so a beta-agonist is often prescribed with it in a single combination inhaler or as a separate as-needed rescue drug.
Tiotropium is a long-acting quaternary anticholinergic inhaled as a powder formulation. Dose is 1 puff (18 mcg) once/day. Aclidinium bromide is available as a multidose dry-powder inhaler. Dose is 1 puff (400 mcg/puff) bid. Umeclidinium can be used as a once/day combination with vilanterol (a long-acting beta-agonist) in a dry-powder inhaler. Glycopyrrolate (an anticholinergic) can be used bid in combination with indacaterol or formoterol (long-acting beta-agonists) in a dry powder or metered dose inhaler.
Adverse effects of all anticholinergics are pupillary dilation (and risk of triggering or worsening acute angle closure glaucoma), urinary retention, and dry mouth.
Corticosteroids are often part of treatment. Inhaled corticosteroids seem to reduce airway inflammation, reverse beta-receptor down-regulation, and inhibit leukotriene and cytokine production. They do not alter the course of pulmonary function decline in patients with COPD who continue to smoke, but they do relieve symptoms and improve short-term pulmonary function in some patients, are additive to the effect of bronchodilators, and may diminish the frequency of COPD exacerbations. They are indicated for patients who have repeated exacerbations or symptoms despite optimal bronchodilator therapy. Dose depends on the drug; examples include fluticasone 500 to 1000 mcg/day and beclomethasone 400 to 2000 mcg/day.
The long-term risks of inhaled corticosteroids in elderly people are not proved but probably include osteoporosis, cataract formation, and an increased risk of nonfatal pneumonia. Long-term users therefore should undergo periodic ophthalmologic and bone densitometry screening and should possibly receive supplemental calcium, vitamin D, and a bisphosphonate as indicated.
Combinations of a long-acting beta-agonist (eg, salmeterol) and an inhaled corticosteroid (eg, fluticasone) are more effective than either drug alone in the treatment of chronic stable disease.
Oral or systemic corticosteroids should usually not be used to treat chronic stable COPD.
Theophylline plays only a small role in the treatment of chronic stable COPD now that safer, more effective drugs are available. Theophylline decreases smooth muscle spasm, enhances mucociliary clearance, improves right ventricular function, and decreases pulmonary vascular resistance and arterial pressure. Its mode of action is poorly understood but appears to differ from that of beta-2-agonists and anticholinergics. Its role in improving diaphragmatic function and dyspnea during exercise is controversial.
Theophylline can be used for patients who have not adequately responded to inhaled drugs and who have shown symptomatic benefit from a trial of the drug. Serum levels need not be monitored unless the patient does not respond to the drug, develops symptoms of toxicity, or is questionably adherent; slowly absorbed oral theophylline preparations, which require less frequent dosing, enhance adherence.
Toxicity is common and includes sleeplessness and GI upset, even at low blood levels. More serious adverse effects, such as supraventricular and ventricular arrhythmias and seizures, tend to occur at blood levels > 20 mg/L.
Hepatic metabolism of theophylline varies greatly and is influenced by genetic factors, age, cigarette smoking, hepatic dysfunction, and some drugs, such as macrolide and fluoroquinolone antibiotics and nonsedating histamine2 blockers.
Phosphodiesterase-4 inhibitors are more specific than theophylline for pulmonary phosphodiesterase and have fewer adverse effects. They have anti-inflammatory properties and are mild bronchodilators. Phosphodiesterase-4 inhibitors such as roflumilast can be used in addition to other bronchodilators for reduction of exacerbations in patients with COPD. The dose is 500 mcg po once/day.
Common adverse effects include nausea, headache, and weight loss, but these effects may subside with continued use.
Long-term oxygen therapy prolongs life in patients with COPD whose Pao2 is chronically < 55 mm Hg. Continual 24-h use is more effective than a 12-h nocturnal regimen. Oxygen therapy brings Hct toward normal levels; improves neuropsychologic factors, possibly by facilitating sleep; and ameliorates pulmonary hemodynamic abnormalities. Oxygen therapy also 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 (Hct < 30), or a coexisting heart or cerebrovascular disorder should use supplemental oxygen during long flights and should notify the airline when making their reservation. Airlines can provide supplemental oxygen, and most require a minimum notice of 24 h, a physician’s statement of necessity, and an oxygen prescription before the flight. Patients should bring their own nasal cannulas, because some airlines provide only face masks. Patients are not permitted to transport or use their own liquid oxygen, but many airlines now permit use of portable battery-operated oxygen concentrators, which also provide a suitable oxygen source on arrival.
Indications for Long-Term Oxygen Therapy in COPD
Pao2≤ 55 mm Hg or Sao2≤ 88%* in patients receiving optimal medical regimen for at least 30 days†
Pao2= 55 to 59 mm Hg or Sao2≤ 89%* for patients with cor pulmonale or erythrocytosis (Hct > 55%)
Can be considered for patients with exercise desaturation if there is symptomatic improvement; however, there is no improvement in survival or hospitalization. May also be considered for patients with nocturnal desaturation.‡
*Arterial oxygen levels are measured at rest during air breathing.
†Patients who are recovering from an acute respiratory illness and who meet the listed criteria should be given oxygen and rechecked while breathing room air after 60 to 90 days.
‡See also Long-Term Oxygen Treatment Trial Research Group: A randomized trial of long-term oxygen for COPD with moderate desaturation. New Engl J Med 375:1617–1627, 2016.
Oxygen is administered by nasal cannula at a flow rate sufficient to achieve a Pao2 > 60 mm Hg (oxygen saturation >90%), usually ≤ 3 L/min at rest. Oxygen is supplied by electrically driven oxygen concentrators, liquid oxygen systems, or cylinders of compressed gas. Stationary concentrators, which limit mobility but are the least expensive, are preferable for patients who spend most of their time at home. Such patients require small oxygen tanks for backup in case of an electrical failure and for portable use. Portable concentrators that allow mobility can be used for patients who do not require high flow rates.
A liquid system is preferable for patients who spend much time out of their home. Portable canisters of liquid oxygen are easier to carry and have more capacity than portable cylinders of compressed gas. Large compressed-air cylinders are the most expensive way of providing oxygen and should be used only if no other source is available. All patients must be taught the dangers of smoking during oxygen use.
Various oxygen-conserving devices can reduce the amount of oxygen used by the patient, either by using a reservoir system or by permitting oxygen flow only during inspiration. Systems with these devices correct hypoxemia as effectively as do continuous flow systems.
All patients with COPD should be given annual influenza vaccinations. If a patient is unable to receive a vaccination or if the prevailing influenza strain is not included in the annual vaccine formulation, prophylactic treatment with a neuraminidase inhibitor (oseltamivir or zanamivir) is sometimes used if there is close exposure to influenza-infected people. Treatment with a neuraminidase inhibitor should be started at the first sign of an influenza-like illness.
Pneumococcal polysaccharide vaccine, although of unproven efficacy in COPD, has minimal adverse effects and should also be given.
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 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.
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 mo 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 wk until the patient can exercise for 20 to 30 min nonstop with manageable dyspnea. Patients with very severe COPD can usually achieve an exercise regimen of walking for 30 min at 1 to 2 mph. Maintenance exercise should be done 3 to 4 times/wk 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 surgery consists of resecting nonfunctioning emphysematous areas. The procedure improves lung function, exercise tolerance, and quality of life in patients with severe, predominantly upper-lung emphysema who have low baseline exercise capacity after pulmonary rehabilitation. Mortality is increased in the first 90 days after lung volume reduction surgery, but survival is higher at 5 yr.
The effect on ABGs is variable and not predictable, but most patients who require oxygen therapy before surgery continue to need it. Improvement is less than that with lung transplantation. The mechanism of improvement is believed to be enhanced lung recoil and improved diaphragmatic function.
Operative mortality is about 5%. The best candidates for lung volume reduction surgery are patients with an FEV1 20 to 40% of predicted, a DLCO> 20% of predicted, significantly impaired exercise capacity, heterogeneous pulmonary disease on CT with an upper-lobe predominance, Paco2< 50 mm Hg, and absence of severe pulmonary hypertension and coronary artery disease.
Rarely, patients have extremely large bullae that compress the functional lung. These patients can be helped by surgical resection of these bullae, with resulting relief of symptoms and improved pulmonary function. Generally, resection is most beneficial for patients with bullae affecting more than one third of a hemithorax and an FEV1 about half of the predicted normal value. Improved pulmonary function is related to the amount of normal or minimally diseased lung tissue that was compressed by the resected bullae. Serial chest x-rays and CT scans are the most useful procedures for determining whether a patient’s functional status is due to compression of viable lung by bullae or to generalized emphysema. A markedly reduced DLCO (< 40% predicted) indicates widespread emphysema and suggests a poorer outcome from surgical resection.
Lung transplantation can be single or double. Perioperative complications tend to be lower with single-lung transplantation, but some evidence shows that survival time is increased with double-lung transplantation. Candidates for transplantation are patients < 65 yr with an FEV1< 25% predicted after bronchodilator therapy or with severe pulmonary hypertension. The goal of lung transplantation is to improve quality of life, because survival time is not necessarily increased. The 5-yr survival after transplantation for emphysema is 45 to 60%. Lifelong immunosuppression is required, with the attendant risk of opportunistic infections.
Relieve symptoms rapidly with primarily short-acting beta-adrenergic drugs and decrease exacerbations with inhaled corticosteroids, long-acting beta-adrenergic drugs, long-acting anticholinergic drugs, or a combination.
Encourage smoking cessation using multiple interventions (eg, behavior modification, support groups, nicotine replacement, drug therapy).
Optimize use of supportive treatments (eg, nutrition, pulmonary rehabilitation, self-directed exercise).