COPD Treatment: What Might Help
Successful COPD treatment (chronic obstructive pulmonary disease) requires a combination of factors: lifestyle modifications, medications, mucus clearance devices, vaccinations, oxygen therapy, and sometimes surgical procedures. The goal is not only to prolong life, but also to help maintain independence and alleviate discomfort. Here’s what to expect.
The two interventions associated with improved survival in people with COPD are smoking cessation and supplemental oxygen. Even people with advanced COPD can increase their life expectancy if they stop smoking. It is also important to avoid exposure to other airborne toxins (including secondhand cigarette smoke), to exercise as much as possible, and to follow a healthy diet.
If it is tiring to eat, it may help to consume several small meals a day rather than a few large ones. Adding a liquid protein supplement to your daily diet can improve overall nutrition and help prevent weight loss. It is also essential to drink plenty of fluids to avoid dehydration. If you have COPD, you should not push yourself when you get tired and you should avoid exerting yourself when it is too hot, too cold, or humid, or when air quality is poor.
Even routine tasks can be exhausting for an individual who has severe COPD. Activities such as bathing, grooming, and dressing often require a great deal of effort, but careful planning can help you conserve your energy and make it easier and quicker to get through these tasks. For example, instead of standing in the shower, use a bath stool or take baths. If you are most energetic in the evenings, plan ahead and lay out the next day’s clothes at night.
Although pulmonary rehabilitation programs haven’t proved to increase survival, many people with COPD find them very beneficial. Pulmonary rehabilitation is a comprehensive preventive healthcare program provided by a team of health professionals to help people cope with COPD physically, psychologically, and socially.
A typical rehabilitation program focuses on breathing exercises, exercise reconditioning, progressive relaxation training, stress and panic control techniques, and smoking cessation. It also includes educational programs on medication, diet, exercise, and caring for and operating respiratory therapy equipment.
Breath training is an important part of pulmonary rehabilitation. The objective of breath training is to improve control of breathing, decrease the amount of energy required to breathe, and improve the position and function of the respiratory muscles. A respiratory therapist can help people with COPD practice the following techniques:
• Pursed-lip breathing. First, inhale through your nose, then exhale with your lips pursed in a whistling or kissing position. Each inhalation should take about two seconds and each exhalation about four to six seconds. It is not exactly clear how pursed-lip breathing relieves symptoms; however, it appears to work by keeping the airways open.
• Diaphragmatic breathing. The diaphragm is the main muscle used for normal breathing. People with COPD, however, may also use the muscles in the rib cage, neck, and abdomen to breathe. This method is less efficient than using the diaphragm. To practice using the diaphragm, lie on your back, place your hand or a small book on your abdomen, and breathe. Your hand or the book should rise on inhalation and fall on exhalation. Practice for 20 minutes twice daily. Once you have mastered this skill while lying down, try to do it with your hand while sitting up.
• Forward-bending posture. Breathing while bending slightly forward from the waist relieves symptoms for some people with severe COPD, possibly because the diaphragm has more room to expand.
Despite their fixed lung obstruction, many people with COPD also have some reversible airway obstruction that may respond somewhat to bronchodilators, which open the airways by relaxing the bronchial muscles. Usually, these are delivered via an inhaler. A short-acting bronchodilator may be prescribed for occasional symptoms, while more frequent symptoms may call for a long-acting bronchodilator.
The two most common types of bronchodilators prescribed for COPD treatment are beta-2 agonists and anticholinergics. The former category includes the short-acting drugs albuterol (Proventil, Ventolin) and levalbuterol (Xopenex), which last for four to six hours, and the long-acting drugs salmeterol (Serevent) and formoterol (Foradil), which work for up to 12 hours. Tiotropium (Spiriva) and umeclidinium (Incruse Ellipta), taken once daily, are both long-acting anticholinergics that work for 24 hours. Another long-acting anticholinergic is aclidinium (Tudorza Pressair), which is taken twice daily.
The methylxanthine derivative theophylline (Theo-24, Elixophyllin Elixir) is another type of bronchodilator. While it is less effective than the beta-2 agonists, it does ease symptoms in some people with COPD. Theophylline is taken orally.
If bronchodilators fail to relieve airway obstruction adequately, a corticosteroid may be prescribed. Corticosteroids are anti-inflammatory drugs. In some, though not all, individuals with COPD, this type of drug can help diminish swelling in the airways. Corticosteroids can be taken via an inhaler or orally. Inhaled corticosteroids include beclomethasone (QVAR), budesonide (Pulmicort), flunisolide (Aerospan), and fluticasone (Flovent). The most frequent adverse effects of inhaled corticosteroids are irritation of the throat and yeast infection in the mouth and throat. These side effects can be reduced by rinsing your mouth, gargling gently, and following the manufacturer's instructions for cleaning the inhaler.
Oral corticosteroids include methylprednisolone (Medrol) and prednisone. Because of the difficulty in predicting who will respond to this type of therapy, it is common to institute a two- to three-week trial period of oral corticosteroids, used under careful monitoring and discontinued immediately if they show no benefit. For people who show improvement, the medications are tapered to the lowest effective dose.
When used for long periods of time, corticosteroids can cause osteoporosis (bone loss), high blood pressure, weight gain, diabetes, cataracts, and thinning of the skin. These side effects are less common with inhaled corticosteroids than oral ones because little of the medication is absorbed into the bloodstream.
Combination medications containing both a corticosteroid and a long-acting beta-2 agonist (LABA) are another possible treatment for COPD. Two such drugs are Advair (which contains the corticosteroid fluticasone and the LABA salmeterol) and Symbicort (which contains the corticosteroid budesonide and the LABA formoterol).
Both Advair and Symbicort are recommended only for people with severe COPD who have frequent flare-ups. In 2013 the FDA approved Breo Ellipta, which contains the corticosteroid fluticasone and the LABA vilanterol, as a once-daily maintenance drug for COPD.
Other combination medications approved for COPD include Anoro Ellipta, which includes the anticholinergic umeclidinium and the LABA vilanterol; Stiolto Respimat, which includes the anticholinergic tiotropium and the LABA olodaterol; and Combivent Respimat, which contains the short-acting beta-2 agonist albuterol and the anticholinergic ipratropium.
Daliresp (roflumilast), an oral medication taken once daily, was OK’d by the FDA in 2011 to reduce the risk of COPD flare-ups in people with severe chronic bronchitis with a history of exacerbations. It is intended to treat the symptoms of cough and excess mucus linked to bronchitis. It is not intended for treatment of emphysema. Daliresp belongs to a class of drugs known as phosphodiesterase (PDE)-4 inhibitors. PDE-4 is an inflammation-causing enzyme that is thought to be overproduced in individuals with chronic bronchitis. Daliresp should be considered when first-line therapies are not tolerated or are not providing adequate benefit. Expectorants (such as guaifenesin, found in Mucinex, Robitussin, and other medications) may help loosen mucus secretions in the airways in some people, but the objective evidence of their benefit is weak.
Although many COPD exacerbations are caused by viruses, antibiotics (such as azithromycin, tetracycline, ampicillin, erythromycin, and combinations of trimethoprim and sulfamethoxazole) are commonly prescribed when increased production of yellow or green phlegm signals a respiratory infection, which can aggravate COPD. Moderate worsening of symptoms can be treated at home, but severe episodes require hospitalization.
Mucus clearance devices
People with COPD who have chronic, moderate to severe mucus accumulation may benefit from a mucus clearance device (an acapella valve or flutter valve)—a small, handheld object shaped like a pipe. Blowing into it creates vibrations in the chest that loosen mucus and help medication penetrate the lungs more easily. Some studies suggest that using a mucus clearance device before an inhaled bronchodilator can improve both lung function and exercise capacity while reducing shortness of breath.
People with COPD should have annual flu shots as well as a pneumonia vaccination. These steps help minimize the risk of infections that can lead to episodes of temporary but severely worsened symptoms.
Some people with COPD also benefit from home oxygen therapy, which typically enhances sleep and mood, increases mental alertness and stamina, and allows people to carry out their daily activities more efficiently. By reducing the blood pressure in the lungs and the workload of the right side of the heart, oxygen therapy may prevent the development of cor pulmonale, a heart disease caused by high blood pressure in the lungs. Some people fear that using supplemental oxygen will worsen their COPD or make them dependent on oxygen. This, however, is not a cause for concern.
To determine whether you need oxygen therapy, your doctor will measure oxygen levels (along with other variables such as carbon dioxide levels) in your blood. Having too little oxygen in the blood can cause symptoms such as fatigue, irritability, an inability to concentrate, breathlessness, heart problems, and fluid retention.
If your doctor recommends oxygen therapy, you will receive a prescription detailing the flow rate (how many liters of oxygen you breathe in per minute). Different flow rates may be prescribed for different activities, such as sleeping versus exercising.
For some people, using too much oxygen can slow breathing, allowing carbon dioxide to build up in the blood, so it’s important to carefully follow the flow rates determined by your doctor.
People with COPD who need and use continuous oxygen therapy 24 hours a day tend to have a longer life span than those who use it only while awake (15 hours per day). By the same token, individuals who use oxygen therapy 15 hours per day do better than those who use it only while they are sleeping.
Lung volume reduction
Some individuals with emphysema may benefit from lung volume reduction surgery, an operation to remove diseased lung tissue. The procedure is believed to create more space in the chest cavity for the working lung tissue to expand. This appears to prolong life for people whose emphysema predominantly affects the upper lobes and reduces exercise capacity.
Several experimental procedures are being studied as possible alternatives to lung volume reduction surgery or lung transplantation. These treatments include minimally invasive surgical procedures as well as a nonsurgical option known as endoscopic lung volume reduction. Researchers are also studying new drug treatments for COPD.
(Originally published Jul. 11, 2016; updated Feb. 24, 2017)