Chronic Obstructive Lung Disease

Description

Alternative Names

Treatment

Stopping Smoking and Healthy Lifestyle. Stopping smoking is the first and primary step to treating COLD and slowing its progression. In addition, all patients should maintain a healthy diet rich in fruits and vegetables. An exercise program may be useful, particularly if it is tailored to improve lung function.

Pulmonary Rehabilitation Programs. Patients with COLD need to be very active in managing their condition. Patients might check with their physicians to determine whether a pulmonary rehabilitation program would be appropriate, if one were available in their area. Such programs are conducted by a team of health professionals to improve lung function. It involves medical treatments, exercise, breathing retraining, and psychological interventions, when needed. If available and affordable, it can be extremely effective, particularly after acute exacerbations, for improving symptoms, exercise capacity, quality of life, and mood. Patients with severe COPD may benefit from programs that last at least six months.

Medications for Managing Chronic COLD. A major goal with the use of medications for COLD is to prevent acute exacerbations, which can hasten deterioration of lung function. The main treatment strategy employs a stepped approach with the use of increasingly potent medications depending on the patient's response:

• Beta 2 agonists and anticholinergics, classes of drugs known as bronchodilators, open the airways in the lungs and are the cornerstone of COLD drug therapy. In a major analysis, long-acting beta 2 agonists and anticholinergics were most effective and reduced exacerbation rates by 20% to 25%.
• Inhaled corticosteroids also reduce exacerbations by up to 25%. Studies are mixed on whether long-term use improves lung function, and these agents may also have some adverse effects with long-term use. Inhalers that combine a long-acting beta 2 agonists and a corticosteroid (Advair, Seretide, Symbicort) are even more effective than either agent alone---reducing exacerbations by 30%. Some studies suggest they may offer significant improvements in lung function and even improve survival rates, but more research is needed to confirm such findings.
• Antibiotics are sometimes used preventively, but they seem to have only a small effect in reducing illness days. Experts do not recommend them routinely.

An inhaler is a quick way of administering medicine directly into the bronchial passageways to promote clearer breathing.

Oxygen Replacement. Oxygen replacement is an important component in most COLD treatments. In fact, it is the only treatment known to improve survival in COLD patients. The patient is assessed for specific timing and needs.

Surgery. If the patient no longer responds to medications, then surgery may be an option for some patients. Choices may include bullectomy, lung reduction, or lung transplantation.

General Guidelines for Treating Acute Exacerbations

Acute exacerbations are episodes in which airways suddenly become obstructed and symptoms worsen. In general, some expert groups recommend the following treatments for patients who need to be hospitalized:

• Supplemental oxygen.
• Bronchodilators. An inhaled or nebulized beta2 agonist, with an anticholinergic agent added if the patient does not respond. Consider oral or intravenous xanthines when the condition is very severe.
• Antibiotics if there are signs of infections, particularly if the acute exacerbation is very severe. (Courses are usually 5 to 10 days.)
• Corticosteroids (short term use of oral corticosteroids in most cases; intravenous in severe cases). An important 2003 study indicated that relapse rates were significantly reduced when the patient also took oral corticosteroids in combination with antibiotics and bronchodilators for 10 days after the episode.
• Noninvasive positive-pressure ventilation in patients at risk for respiratory failure.
• Chest therapy may be helpful in some patients.

It is not always clear what triggers these episodes, so treatment can be controversial. Bacteria are obvious suspects, but because COLD patients commonly harbor bacteria, it has been difficult to determine which or even whether organisms are responsible. One 2002 study suggested that some episodes may be caused by changes in the strains of bacteria that are commonly present rather than an introduction of a new bacteria. In other cases, viruses and atypical bacteria may be responsible. In some acute exacerbations, however, no sign of infection is present. As with asthma, an inflammatory response in the airways unrelated to infection may suddenly cause changes that bring on an attack (although it is likely to be different from this response in asthma patients). In any case, even minor obstruction in the airways may be able to produce an acute exacerbation.

Treating Complications of Advanced COLD

COLD is associated with a number of complications as lung function worsens. Various treatments may be required.

Opioids. Opioids, such as morphine, are generally not used for patients with COLD because of a concern that they may reduce respiratory function. Nonetheless, some studies are reporting that low doses of oral morphine can improve severe breathlessness in patients who cannot find relief from other methods. Such agents can cause nausea, vomiting, and constipation.

Antidepressants and Antianxiety Agents. Antidepressants or antianxiety medications may be helpful.

Improving Sleep. More than half of patients with COLD often suffer from insomnia. Most of the standard sleep agents may impair lung function. Newer ones, such as zolpidem (Ambien), zaleplon (Sonata), and zopiclone (Imovane), may be less hazardous than older agents. Tricyclic antidepressants may also be helpful without significant effects on breathing. Behavioral methods are the best approach to this problem, however. [SeeWell-Connected Report #27 Insomnia.]

Treating Heart Failure. When patients are in advanced stages of COLD, they may need treatment for fluid accumulation and congestive heart failure. [See Well-Connected, Report #13, Congestive Heart Failure.]