Stopping Smoking.
The vast majority of COPD patients are smokers. By stopping smoking patients can slow the rate of decline in lung function and thus improve the patient's prospects in terms of symptoms and survival.
The National Institute of Clinical Excellence guidance on COPD states that "All patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity."
Short-acting inhaled bronchodilators
These deliver a small dose of medicine to the lungs, causing the airway muscles to open up. Bronchodilators are also effective in preventing over-expansion of the lungs. Short-acting beta2-agonists are the most commonly used short acting bronchodilaors for COPD. Their effects last for about 4 hours. Short-acting antichloinergics are also used as bronchodilators.
Long-acting bronchodilators
Long-acting beta2-agonists are similar to the short-acting agonists described above but their effect lasts for 12 hours.
Lomg-acting anti-cholinergics need only be taken once a day.
The NICE guidance recommends that short-acting bronchodilators should be used for the initial treatment for breathlessness and exercise limitation and goes on to say that, if this isn't having an effect then the treatment should be intensified using eith er a long-acting bronchodilator or a combined therapy with a short acting beta2-agonist and a short-acting anticholinergic.
The guidance also remarks that long-acting bronchodilators appear to have additional benefits ogver combinations of short-acting drugs.
Theophylline
Theophylline causes the muscles of the airways to relax and open up. It also stregthens the diaphragm and speeds up how quickly the mucus and phlegm is cleared from the lungs. It is only used on patients who have not responded to inhalers or who can't use inhalers. This is because of side effects such as an increased heart rate and headaches. The NICE guidance says that "particular caution needs to be taken with the use of theophylline in elderly patients."
Corticosteroids
Up to 70% of patients in the UK are prescribed an inhaled steroid even though there is little evidence to suggest that steroids have any effect on the inflammatory cells that are charcteristic of COPD. The NICE guidance recommends that inhaled corticosteroids should be used for patients with very poor lung function who are "having 2 or more exacerbations which require treatment with antibiotics or oral steroids within a 12 month period. The aim of treatment is to reduce exacerbation rates and slow the decline in health status and not to improve lung function per se."
Doctors are reminded to discuss the possibility of osteoporosis and other side effects or steroids with the patient.
Steroid tablets may be prescribed for one or two weeks to deal with a bad flare up, they should not be used on a maintenance basis.
Combination therapies
For patients who don't respond to a single medication, NICE classifies the following combinations as effective:
It is recommended that combination therapies are stopped if there is no benefit within 4 weeks.
Long-term oxygen therapy(LTOT)
In extreme cases, when the oxygen in the blood is very low, the patient may need to take oxygen from and electronically operated oxygen concentrator. The NICE guidance states that to get the benefits of LTOT the patient should breath supplemental oxygen for at least 15 hours per day and that greater benefits are seen in those patients who receive oxygen for 20 hours per day. There is a high risk of fire and/or explosion for those patients who continue to smoke when receiving oxygen.
Ambulatory oxygen should be prescribed for people who are already on LTOT and who wish to continue with oxygen therapy outside the home.
Ambulatory oxygen therapy is also used in isolation as a means of improving exercise tolerance and quality of life.
Pulmonary Rehabilitation Programmes
Pulmonary rehabilitation programmes take place in groups. The aim of rehabilitation is to prevent deconditioning and to enhance the patien'ts coping skills.
Programmes feature the following:
The group sessions normally last for six weeks. The groups are normally held in hospital but there are plans to move these out into the community which will make it easier for people to attend.
Surgery
Bullectomy involves the removal of a bulla (rounded nodule) from the lung. The NICE guidance states that patients who have a single large bulla and below 50% lung functioning should be considered for a bullectomy.
Lung volume reduction surgery (LVRS) improves breathlessness by removing areas of poorly functioning lung thus decreasing lung volume and reducing the pressure on the respiratory muscles. Patients who have this operation may be at increased risk of contracting pneumonia, there is also the risk of an air leak developing when the lung is put back together.
Lung transplantation is used in the most severe cases where life expectancy is less than two years and the patient has not responded to any other kind of intervention. A lung transplant would entail the patient taking anti-rejection medication for the rest of his or her life. This medication can a have a number of side effects such as headache and high blood pressure.
