Stage-Managing COPD

Summarized by Robert W. Griffith, MD
October 15, 2004

Introduction

Chronic obstructive pulmonary disease (COPD) is the 4^th leading cause of death in the USA (behind heart disease, cancer, and stroke). It's typified by chronic cough, spitting or coughing up mucus (expectoration), breathlessness on exertion, and a progressive difficulty in exhaling. There are two main changes that cause it - chronic bronchitis (inflammation of the breathing tubes), and emphysema (dilatation of the tiny air sacs in the lungs). The disease develops over time, and can't be cured, only "managed"; without treatment, it will progress more rapidly.

The Global Initiative for Chronic Obstructive Lung Disease has marshaled the help of the NIH and WHO to provide up-to-date guidelines for management strategies for people with stable COPD - that is to say, those patients in whom the disease is not progressing rapidly. A review of these guidelines has been published in the journal Lancet, and we summarize the main points here.

A stepwise approach

Five stages of COPD are recognized, largely based on spirometry (lung function tests), the most important of which are the Forced Expiratory Volume in 1 second (FEV1) and the Forced Vital Capacity (FVC)¹. The suggested treatment depends on the stage of COPD:

Stage 0. The patient is at risk, and has some symptoms, but spirometry tests are normal. Treatment: Stop smoking, avoid risk factors (exposure to toxic chemicals such as silica or cadmium, second-hand smoke, dust, or other air pollutants, allergens such as fungi, molds, and house dust, poor nutrition, and periodontal disease), and have an annual 'flu shot.

Stage I: mild. The FEV1:FVC ratio is below 70%, but the FEV1 is 80% or above; there may be some symptoms. Additional Treatment: Use a short-acting bronchodilator (see below), when needed.

Stage II: moderate. The FEV1 is between 50% and 80% of its predicted value, with or without symptoms such as shortness of breath on exertion. Additional treatment: Regular use of one or more bronchodilators, and pulmonary rehabilitation exercises.

Stage III: severe. The FEV1 is between 30% and 50% of its predicted value, with increased shortness of breath, and periodic worsening. Additional treatment: inhaled glucocorticosteroids (steroids) for periodic worsening.

Stage IV: very severe. The FEV1 is below 30%, or if it's above, there are signs of respiratory failure. Additional treatment: Long-term oxygen if chronic respiratory failure is present. Surgery (either removal of lung tissue containing many dilated sacs - lung volume reduction - or a lung transplant) may be recommended.

Stopping smoking

In the USA, about 80% of patients with COPD are current or former smokers. Cigarettes are the single most important risk factor for the development of the condition. The first two links below provide help with kicking the habit.

Bronchodilators

There are three major classes of bronchodilators, which are the mainstay of COPD management, acting by increasing the diameter of the airways and thus getting more air into the lungs.

Beta-agonists: These may be short-acting or long-acting, and are given by inhalation. With a duration of action of 2 to 4 hours, short-acting inhalers are not too useful in COPD (compared with asthma, where they are very helpful). They can also be given orally, and slow-release forms are suitable for twice-a-day use. Terbutaline and albuterol (Salbuterol^®) are the most commonly prescribed short-acting beta-agonists.

Long-acting beta-agonists, which include formoterol and salmeterol, can last for 12 hours or more when inhaled. Doses greater than the recommended amount will not increase effectiveness, but will intensify side effects.

Anticholinergics: these drugs dilate the bronchi by a different mechanism from that of the beta-agonists. Short-acting ipratropium or long-acting tiotropium, both given by inhalation, are the most commonly prescribed. Tiotropium is effective when taken once-a-day.

Theophylline: This drug has only moderate bronchodilator effects, but it is also anti-inflammatory. There are dose-related side effects, and it can interact with other drugs, so dosing must be cautious. However, it can have good clinical effectiveness.

Inhaled steroids

These are not recommended for routine use in COPD to prevent lung function deterioration. However, they do improve airflow, to a certain extent, although this is less than that achieved with bronchodilators. They are also beneficial in acute worsening of symptoms, probably because of their anti-inflammatory effect. Studies are ongoing to see if they improve overall survival in COPD.

Choice of drugs

The choice of bronchodilator and the route of administration involve many considerations, depending on individual case. Sometime a combination of a beta-agonist with an anticholinergic or theophylline is appropriate. Fixed combinations of inhaled steroids and long-acting beta-agonists are used in asthma, and have been tried in more advanced COPD, although they have not yet been approved by the FDA and other drug regulatory bodies.

Many other classes of drugs have been tried in COPD. Mucolytics (to help dissolve mucus), antioxidant therapy, immunoregulating drugs, cough suppressants, and respiratory stimulants are among those that are not recommended.

Viral infections are an important cause of exacerbations of COPD, so an annual 'flu shot is necessary; in addition, pneumococcal vaccination is recommended in the elderly. Antibiotics should be prescribed for acute episodes, but should not be used routinely, as this may foster drug-resistant bacteria.

Patients with COPD lose muscle mass (and weight) due to decreased airflow. They may require androgens and nutritional supplements to help 'build them up'. Anxiety and depression are common, and, if present, necessitate appropriate therapy; this may include psychotherapy along with medication.

Conclusion

The management of COPD can be very effective in improving the quality of life and slowing progression of the disease. It must be individualized and then enthusiastically followed by patient and physician, if the best result is to be obtained.

Source

• Treatment of stable chronic obstructive pulmonary disease. SI. Rennard, Lancet, 2004, vol. 364, pp. 791--802

Footnotes
1. The FEV1 is the maximum volume of air expired in one second. It reflects the ability of the lungs to exhale used air and thereby make room for fresh air. The FVC is the maximum volume of air that can be exhaled with force and is another indicator of the lungs' size, elasticity, and how well the air passages open and close.

Related Links
Boston University's Quitnet
HHS Tobacco Cessation Guidelines
MedlinePlus: COPD
COPD International

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