treatment is available for COPDs

The goals of COPD treatment are 1) to prevent further deterioration in lung function, 2) to alleviate symptoms, 3) to improve performance of daily activities and quality of life. The treatment strategies include 1) quitting cigarette smoking, 2) taking medications to dilate airways (bronchodilators) and decrease airway inflammation, 3) vaccinating against flu influenza and pneumonia and 4) regular oxygen supplementation and 5) pulmonary rehabilitation.

Quitting cigarette smoking

The most important treatment for COPD is quitting cigarette smoking. Patients who continue to smoke have a more rapid deterioration in lung function when compared to others who quit. Aging itself can cause a very slow decline in lung function. In susceptible individuals, cigarette smoking can result in a much more dramatic loss of lung function. It is important to note that when one stops smoking the decline in lung function eventually reverts to that of a non-smoker.

Unfortunately, only about one third of the patients can abstain from smoking long term. Reasons for difficulty in quitting include nicotine addiction, stress in the workplace and at home, depression, peer pressure, and advertising from cigarette companies.

Nicotine in cigarettes is addictive, and, therefore, cessation of smoking can cause symptoms of nicotine withdrawal including anxiety, irritability, anger, depression, fatigue, difficulty concentrating or sleeping, and intense craving for cigarettes. Patients likely to develop withdrawal symptoms typically smoke more than 20 cigarettes a day, need to smoke shortly after waking up in the morning, and have difficulty refraining from smoking in non-smoking areas. However, some 25% of smokers can stop smoking without developing these symptoms. Even in those smokers who develop symptoms of withdrawal, the symptoms will decrease after several weeks of abstinence.

To help those patients with symptoms of withdrawal during the early weeks of smoking cessation, nicotine chewing gum (Nicorette Gum) and nicotine skin patches (Transderm Nicotine) are available in the United States. Both the gum and skin patches can deliver enough nicotine into the blood to reduce but not totally eliminate withdrawal symptoms. Nicotine replacement methods in conjunction with intense patient education and behavioral modification programs have improved the rates at which individuals quit smoking. Nicotine skin patches are easy to use. They generally are used for four to six weeks, sometimes with a tapering period of several additional weeks. The addiction potential of nicotine skin patches is low.

Bupropion (Zyban, Wellbutrin) is an antidepressant that has been found to decrease cravings for cigarettes. It has been shown to be of benefit to patients who want to quit smoking. Recently, varencline (Chantix), a new medication is available to aid in smoking cessation, has been approved for use in the US. Varenicline works in two ways; by cutting the pleasure of smoking and reducing the withdrawal symptoms that lead smokers to light up again and again. This medicine is taken over a 12 week course and can work in ways that bupropion does not.

In addition to nicotine withdrawal symptoms, quitting cigarette smoking also may lead to weight gain of about 8-10 pounds on average though more in some patients. Quitting smoking also can lead to depression and worsening of symptoms of chronic ulcerative colitis. Therefore quitting smoking should be undertaken with a doctor's supervision. Nevertheless, the benefits of quitting smoking (decreasing the rate of lung deterioration, decreasing risks of heart attack, lung cancer and other cancers, decreasing the chance of developing stomach ulcers, etc.) far outweigh these potential negative effects.

For more information on quitting cigarette smoking, please read the Smoking and Quitting Smoking article.

Bronchodilators

Treating airway obstruction in COPD with bronchodilators is similar but not identical to treating bronchospasm in asthma. Bronchodilators are medications that relax the muscles surrounding the small airways thereby opening the airways. Bronchodilators can be inhaled, taken orally or administered intravenously. Inhaled bronchodilators are popular because they go directly to the airways where they work. As compared with bronchodilators given orally, less medication reaches the rest of the body, and, therefore, there are fewer side effects.

Metered dose inhalers (MDIs) are used to deliver bronchodilators. An MDI is a pressurized canister containing a medication that is released when the canister is compressed. A standard amount of medication is released with each compression of the MDI. To maximize the delivery of the medications to the airways, the patient has to learn to coordinate inhalation with each compression. Incorrect use of the MDI can lead to deposition of much of the medication on the tongue and the back of the throat instead of on the airways.

To decrease the deposition of medications on the throat and increase the amount reaching the airways, spacers can be helpful. Spacers are tube-like chambers attached to the outlet of the MDI canister. Spacer devices can hold the released medications long enough for patients to inhale them slowly and deeply into the lungs. Proper use of spacer devices can greatly increase the proportion of medication reaching the airways.

Beta-agonists

Historically, one of the first medications used for asthma was adrenaline (epinephrine). Adrenaline has a rapid onset of action in opening the airways. It is still used in certain emergency situations for attacks of asthma. Unfortunately, adrenaline has many side effects including rapid heart rate, headache, nausea, vomiting, restlessness, and a sense of panic. Therefore, it is not used in the treatment of COPD.

Beta-2 agonists have the bronchodilating effects of adrenaline without many of its unwanted side effects. Beta-2 agonists can be administered by MDI inhalers or orally. They are called "agonists" because they activate the beta-2 receptor on the muscles surrounding the airways. Activation of beta-2 receptors relaxes the muscles surrounding the airways and opens the airways. Dilating airways helps to relieve the symptoms of dyspnea (shortness of breath). Beta-2 agonists have been shown to relieve dyspnea in many COPD patients, even among those without demonstrable reversibility in airway obstruction. The action of beta-2 agonists starts within minutes after inhalation and lasts for about 4 hours. Because of their quick onset of action, beta-2 agonists are especially helpful for patients who are acutely short of breath. Because of their short duration of action, these medications should be used for symptoms as they develop rather than as maintenance. Evidence suggests that when these drugs are used routinely, their effectiveness is diminished. These are referred to as rescue inhalers. Examples of beta-2 agonists include albuterol (Ventolin, Proventil), metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire), and isoetharine (Bronkosol). Levalbuterol (Xopenex) is a recently approved Beta-2 agonist.

In contrast, Beta-2 agonists with a slower onset of action but a longer period of activity, such as salmeterol xinafoate (Serevent) and formoterol fumarate (Foradil) may be used routinely as maintenance medications. These drugs last twelve hours and should be taken twice daily and no more. Along with some of these inhalers to be mentioned, these are often referred to as maintenance inhalers.

Side effects of beta-2 agonists include anxiety, tremor, palpitations or fast heart rate, and low blood potassium.

Anti-cholinergic Agents

Acetylcholine is a chemical released by nerves that attaches to receptors on the muscles surrounding the airway causing the muscles to contract and the airways to narrow. Anti-cholinergic drugs such as ipratropium bromide (Atrovent) dilate airways by blocking the receptors for acetylcholine on the muscles of the airways and preventing them from narrowing. Ipratropium bromide (Atrovent) usually is administered via a MDI. In patients with COPD, ipratropium has been shown to alleviate dyspnea, improve exercise tolerance and improve FEV1. Ipratropium has a slower onset of action but longer duration of action than the shorter-acting beta-2 agonists. Ipratropium usually is well tolerated with minimal side effects even when used in higher doses. Tiotropium (SPIRIVA) is a long acting and more powerful version of Ipratropium and has been shown to be more effective.

In comparing ipratropium with beta-2 agonists in the treatment of patients with COPD, studies suggest that ipratropium may be more effective in dilating airways and improving symptoms with fewer side effects. Ipratropium is especially suitable for use by elderly patients who may have difficulty with fast heart rate and tremor from the beta-2 agonists. In patients who respond poorly to either beta-2 agonists or ipratropium alone, a combination of the two drugs sometimes results in a better response than to either drug alone without additional side effects.

Methylxanthines

Theophylline (Theo-Dur, Theolair, Slo-Bid, Uniphyl, Theo-24) and aminophylline are examples of methylxanthines. Methylxanthines are administered orally or intravenously. Long acting theophylline preparations can be given orally once or twice a day. Theophylline, like a beta agonist, relaxes the muscles surrounding the airways but also prevents mast cells around the airways from releasing bronchoconstricting chemicals such as histamine. Theophylline also can act as a mild diuretic and increase urination. Theophylline also may increase the force of contraction of the heart and lower pressure in the pulmonary arteries. Thus, theophylline can help patients with COPD who have heart failure and pulmonary hypertension. Patients who have difficulty using inhaled bronchodilators but no difficulty taking oral medications find theophylline particularly useful.

The disadvantage of methylxanthines is their side effects. Dosage and blood levels of theophylline or aminophylline have to be closely monitored. Excessively high levels in the blood can lead to nausea, vomiting, heart rhythm problems, and even seizures. In patients with heart failure or cirrhosis, dosages of methylxanthines are lowered to avoid high blood levels. Interactions with other medications, such as cimetidine (Tagamet), calcium channel blockers (Procardia), quinolones (Cipro), and allopurinol (Zyloprim) also can alter blood levels of methylxanthines.

Corticosteroids

When airway inflammation (which causes swelling) contributes to airflow obstruction, anti-inflammatory medications (more specifically, corticosteroids) may be beneficial. Examples of corticosteroids include Prednisone and Prednisolone. Twenty to thirty percent of patients with COPD show improvement in lung function when given corticosteroids by mouth. Unfortunately, high doses of oral corticosteroids over prolonged periods can have serious side effects, including osteoporosis, bone fractures, diabetes mellitus, high blood pressure, thinning of the skin and easy bruising, insomnia, emotional changes, and weight gain. Therefore, many doctors use oral corticosteroids as the treatment of last resort. When oral corticosteroids are used, they are prescribed at the lowest possible doses for the shortest period of time to minimize side effects. When it is necessary to use long term oral steroids, medications are often prescribed to help reduce the development of the above side effects.

Corticosteroids also can be inhaled. Inhaled corticosteroids have many fewer side effects than long term oral corticosteroids. Examples of inhaled corticosteroids include beclomethasone dipropionate (Beclovent, Beconase, Vancenase, and Vanceril), triamcinolone acetonide (Azmacort), fluticasone (Flovent), budesonide (Pulmicort), mometasone furoate (Asmanex) and flunisolide (Aerobid). Inhaled corticosteroids have been useful in treating patients with asthma, but in patients with COPD, it is not clear whether inhaled corticosteroid have the same benefit as oral corticosteroids. Nevertheless, doctors are less concerned about using inhaled corticosteroids because of their safety. The side effects of inhaled corticosteroids include hoarseness, loss of voice, and oral yeast infections. A spacing device placed between the mouth and the MDI can improve medication delivery and reduce the side effects on the mouth and throat. Rinsing out the mouth after use of a steroid inhaler also can decrease these side effects.

Advair, a powered inhaler device, contains both salmeterol (a long acting beta-agonist) and fluticasone (an inhaled steroid). This medication has shown to be effective in COPD patients with chronic bronchitis. Its major side effects include the possible development of thrush (oral candidiasis) and hoarseness.

Treatment of Alpha-1 antitrypsin deficiency

Emphysema can develop at a very young age in some patients with severe alpha-1 antitrypsin deficiency (AAT). Replacement of the missing or inactive AAT by injection can help prevent progression of the associated emphysema. This therapy is of no benefit in other types of COPD.