Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease


shown to decrease mortality or affect the decline in lung function.45 Although side effects are rare and the treatment is usually well tolerated, recent studies have suggested an increase in risk of cardiovascular morbidity and mortality associated with the use of ipratropium bromide; therefore, caution and weighing the benefits verus the risks of therapy should be advised when treating individuals with cardiovascular risks or history of ischemic heart disease.46


In moderate COPD (FEV1 50–79%), short-acting bronchodilators can no longer control the symptoms and so a long-acting bronchodilator should


be added. Currently available drugs in the US are long-acting β-agonists (LABA), such as salmeterol, formeterol, and arformeterol, and long-acting anticholinergics, such as tiotropium. Treatment is usually associated with improvements in symptoms, lung function, quality of life and the number of exacerbations, but present data is less


encouraging when the rate of decline in FEV1 and mortality are considered.47,48


Tiotropium appears to be more effective overall than salmeterol,49


and is also superior to ipratropium in reducing the number of exacerbations; it is also favored in terms of cardiovascular safety.49,50 With advanced symptoms, a β-agonist is usually combined with an anticholinergic. Patients with moderate COPD might also benefit from early referral to pulmonary rehabilitation. A typical rehabilitation program includes focuses on disease education, respiratory care, chest physiotherapy techniques and proper use of respiratory therapy equipment. Psychosocial support and supervised physical exercise are other aspects of a comprehensive pulmonary rehabilitation program. Pulmonary rehabilitation improves symptoms, anxiety, exercise capacity, and quality of life in patients with COPD. These benefits were shown to persist after two years of follow up. Unfortunately, it is a costly therapy and is still underprescribed.51


In severe COPD (FEV1 <50%), no therapy has steered more debate in the management of COPD than inhaled corticsteroids (ICS). The first school


of thought criticizes the use of ICS in COPD as the inflammation is neutrophilic and should not respond to steroids.52


Furthermore, steroid


resistance in COPD can lead to the use of high doses of the drug, generating potentially more harm than good.53


This is especially true


given the increased incidence of pneumonia reported in several studies after the use of ICS.54


shows that ICS reduces the rate of exacerbation and improves lung function, even when reversibility is not present on spirometry.55


The


effect of ICS on lung function decline and mortality also remains controversial. What appears uniform is that ICS are beneficial in COPD only when combined with a LABA and should be considered in severe COPD, refractory to long-acting bronchodilators or when there appears to be a coexisting asthmatic component.56–59


A combination of a


long-acting anticholinergic, a LABA and inhaled corticotherapy is becoming a trend in the treatment of advanced COPD.60


Although some


data support its effectiveness, such treatment should not be done routinely as it adds significantly to the cost of healthcare, and does not alter the overall decline in lung function seen in patients with COPD.61


Theophylline preparations have been used widely in patients with COPD for decades but their use has declined owing to their narrowed therapeutic index and modest efficacy. However, new insights into the molecular action of theophylline have given this drug a new lease of life.


US RESPIRATORY DISEASE Conversely, there is large body of evidence that


Table 2: Indications of Home Oxygen in Chronic Obstructive Pulmonary Disease


Long-term Oxygen Therapy for Chronic Obstructive Pulmonary Disease a. pO2 <60mmHg or arterial


1. Pulmonary hypertension oxygen saturation <90% if:


b. pO2 <56mmHg or arterial oxygen saturation <89%


ECG = electrocardiogram


Table 3: Definition and Therapy of Chronic Obstructive Pulmonary Disease Exacerbations


COPD Exacerbations Definition


Cough increases in frequency and severity


Sputum production increases in


volume or changes character Dyspnea increases from baseline


Treatment SABA


Systemic steroids Antibiotics


Supplemental Oxygen for hypoxemia NPPV for respiratory acidosis


COPD = chronic obstructive pulmonary disease; SABA = short-acting bronchodilators; NPPV = non-invasive pressure ventilation.


Table 4: The Multidimensional body mass index/airflow obstruction/dyspnea/exercise capacity Index


BODE Index 0 FEV1% ≥65


Distance walked in six minutes (m) ≥350 MMRC dyspnea scale Body mass index


0–1 >21


1 50–64 ≤21 FEV1 = forced expiratory volume in one second; MMRC = Modified Medical Research Council.


It is now considered to have anti-inflammatory properties, and might help reverse COPD resistance to steroids.62


2 3 3 36–49 ≤35


250–349 150–249 ≤149 2


4


2. Hematocrit >55% 3. Clinical or ECG signs of cor pulmonale


Cilomilast


and roflumilast are type 4 phoshodiesterase inhibitors and have been recently evaluated in the treatment of COPD, but their effect on COPD symptoms, lung function, and exacerbations rate appear to be modest at best.63


supplemental oxygen therapy are summarized in Table 2. Other treatment options in severe COPD include lung volume reduction surgery in selected patients,65


Supplemental oxygen is the only known therapy shown to improve survival in patients with COPD.64


The indications for chronic suppressive antimicrobial


therapy, and chronic nocturnal non-invasive ventilation. Finally, assessing and treating psychiatric co-morbidities in COPD is a must that is often overlooked. Only a few patients with moderate–severe COPD have discussed end-of-life care issues with their physicians. This is a challenging task and many studies have evaluated ways to initiate discussions about prognosis, advance directives and hospice care.66


Acute Chronic Obstructive Pulmonary Disease Exacerbations


Mental status changes, acute respiratory failure, inability to take oral medication, comorbidities, and social factors dictate the need for inpatient care for acute exacerbation of COPD. Acute respiratory failure


11


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