The Treatment of COPD (Chronic Obstructive Pulmonary Disease)

Learn about the latest on the treatment of COPD, whose objective is to improve the quality of life and reduce hospitalization.

Written and verified by la médico Sandra Golfetto Miskiewicz.

Last update: 16 December, 2022

Much progress has been made in the study of chronic obstructive pulmonary disease (COPD). Today, the treatment of COPD has expanded from medical treatment that includes various types of bronchodilators and surgical procedures to breathing exercises and the use of acupuncture. But beyond that, a change in lifestyle is one of the main factors that improve the quality of life of a person with COPD.

Why do COPD patients require treatment?

The goal of the treatment of COPD is to reduce the severity and frequency of crises that can compromise the patient’s life. These exacerbations are expressed as severe shortness of breath, a feeling of tightness in the chest, weakness, and dizziness.

In addition, treatment seeks to improve the quality of life and survival of the patient, with short-term benefits (control of the disease, control of crises) and long-term (control of risk, decrease the progress of the disease).

Changes in lifestyle

Quit smoking

One of the most challenging but key lifestyle changes to mitigate the progression of COPD is to quit smoking.

There are 2 methods to facilitate this process:

• Behavior changes: In smoking, there is a physical and a psychological dependence. To help the COPD patient in this transition, the possible consequences of cigarette or tobacco use should be made clear from the beginning.

We can also help patients by avoiding exposure to cigarette smoke in the environment that surrounds them, including family members and acquaintances, as well as recognizing their achievements along the way. Persistence on the part of the patient and those around them brings great benefits to both.

• Pharmacological treatment: The use of varenicline, continuous-release bupropion, nortriptyline, nicotine chewing gums, nicotine nasal inhalers, or the well-known nicotine patches are effective as aids in smoking cessation as long as there are no medical contraindications.

Many patients benefit from the combination of both methods, using medical/chemical adjuncts while receiving psychological help.

Proper eating habits and supplements

Studies have shown that between 25% and 40% of COPD patients are underweight, and 35% have low muscle mass, which markedly influences inadequate muscle function and decreases the ability to exercise.

In the case of COPD patients, several factors have been raised as the cause of this loss of muscle mass:

• Energy expenditure at rest due to the use of more nutrients to maintain adequate oxygen saturation (amount of oxygen) in the blood and, therefore, in the muscles.
• A decrease in the amount of oxygen that reaches the muscles that limits their development.
• Inflammation.

COPD patients are advised to do the following

• Ideally, eat 5-6 meals a day instead of the usual 3.
• Eat smaller portions.
• Consume foods rich in antioxidant vitamins (A, C, and E) in order to improve chronic inflammation of tissues, and selenium, especially if they’re smokers.
• Use vegetable fats (preferably rich in omega 9 and 3) and oily fish (salmon, trout, bonito, cod, anchovies, etc).
• Avoid vegetables that produce intestinal gas.
• Fluids and sodium should be restricted if the patient has cor pulmonale (heart failure secondary to pulmonary disease).

When there’s difficulty meeting the nutritional requirements of the person, oral supplements can be used. It’s important to consider that these should be used in conjunction with food and not as a replacement for it.

Advice and guidance from nutritionists should be sought to maintain an adequate diet adapted to each individual, with the aim of avoiding malnutrition and thus reducing the risk of exacerbations.

Pulmonary rehabilitation

Pulmonary rehabilitation programs include pulmonary resistance and strength training as well as education, nutritional planning, and psychological support.

These programs, carried out 2-3 times a week, are designed to improve cardiovascular activity, increase levels of physical activity, and improve tolerance of symptoms associated with COPD, also reducing readmissions to hospitals.

Vaccines

Vaccines for COPD patients should be administered according to the Centers for Disease Control and Prevention (CDC) schedules :

• Anti-influenza: Must be administered annually. It’s been shown to reduce COPD exacerbations.
• Anti-pneumococcus: There are 2 types of pneumococcal vaccines, and there are separate indications for each.
• 23-valent pneumococcal polysaccharide (PPSV-23 or Pneumovax): For all people with COPD or current smokers.
• 13-valent conjugated pneumococcus (PCV-13 or Prevnar): In patients older than or equal to 65 years, younger susceptible patients, or those patients who require frequent use of systemic steroids.

The pharmacological treatment of COPD

People with COPD require long-acting medications (long-acting bronchodilators) continuously regardless of whether they have symptoms or not. This is known as the base treatment. Treatment with long-acting bronchodilators improves lung function, exercise capacity, and the patient’s quality of life.

However, to control exacerbation symptoms, short-acting medications (short-acting bronchodilators) are required to complement the basic treatment and act quickly to relieve symptoms and improve exercise tolerance.

COPD patients are also more susceptible to lung infections and therefore, may require antibiotics at any given time as medically prescribed.

Through the 2021 Spanish Guide to Chronic Obstructive Pulmonary Disease (GesEPOC), experts have sought to individualize COPD treatment by classifying patients as low and high risk.

This division is achieved by evaluating 3 parameters:

1. The degree of obstruction, measured by FEV1 (%) (volume of air expired in the first second) post-bronchodilator (measured by spirometry ).
2. Level of dyspnea, measured according to the modified scale of the Medical Research Council (mMRC).
3. The history of exacerbations during the previous year.

High-risk patients are subclassified into three phenotypes: Non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator.

Once the doctor classifies the patient, the prescribed therapy can be as follows:

Low-risk patients: Inhaled treatment

Monotherapy with any of the following drugs:

• Long-acting bronchodilators (LDLD):
  • Beta-2 adrenergic agents (LABA): Salmeterol, formoterol, indacaterol, olodaterol, and vilanterol.
  • Anticholinergics (LAMA): Tiotropium, aclidinium, glycopyrronium, and umeclidinium.
• In case of few or intermittent symptoms, use short-acting bronchodilators (BDCD) as needed:
  • Anticholinergics (SAMA): Ipratropium bromide.
  • Short-acting beta-2 agonists (SABA): Salbutamol or terbutaline.

Double bronchodilator therapy

First, adequate compliance with monotherapy and application technique must be confirmed. If the patient remains symptomatic or with limitations regarding exercise that don’t improve with monotherapy, double bronchodilatory therapy is used. This is intended to reduce the requirements for rescue medication and improve symptoms and the quality of life of the patient. It consists of:

• Association of LABA and LAMA
• Association of two BDLD

High-risk patients: Inhaled treatment

Non-exacerbator phenotype

Patients who presented maximum exacerbation during the previous year without requiring hospital care.

• Double bronchodilation: Existing BDLD combinations (LABA / LAMA).

Eosinophilic exacerbator phenotype

Patients with COPD who presented two or more outpatient exacerbations in the previous year separated by 4 weeks after the exacerbation had resolved or 6 weeks from the onset of symptoms, or who required hospital care.

In addition, a blood sample is taken to determine the concentration of eosinophils in the blood (> 300 eosinophils / mm ³ in stable phase).

• First option: The use of inhaled corticosteroid (IC) associated with a LABA.
• Second option: Triple therapy with CI + LABA + LAMA.

Non-eosinophilic exacerbator phenotype

Patients with exacerbator phenotype characteristics but with <300 eosinophils / mm ³ in peripheral blood.

• LABA + LAMA Association.
• If eosinophils> 100 cells / mm ³, associate IC.

Similarly, if the symptoms persist despite adequate treatment, the doctor can determine in the physical examination if there are other associated comorbidities that may be aggravating the clinical picture and that require complementary laboratory or radiological tests for adequate treatment.

Oxygen therapy

Indicated only in patients with advanced lung disease with low oxygen saturation at rest (SatO2 <89% or PaO2 <55 mm Hg).

Infections and COPD treatment

Due to the inflammatory and immune changes that occur in the epithelium of the bronchi of COPD patients, they’re more susceptible to both viral and bacterial respiratory infections and, at the same time, they’re more prone to frequent exacerbations.

Post-evaluation, the physician may prescribe antibiotic therapy if they believe that there’s the possibility of an associated bacterial infection. Antibiotics should be taken according to the prescribed dose and time even when there’s improvement in symptoms.

Antibiotics are not useful in the treatment of viral infections, so it’s important to avoid self-medication, as it increases the risk of bacterial resistance and can limit the amount of antibiotics available to treat infections when they’re really required.

COVID-19 and COPD

An important section to deal with is the association of COVID-19 in COPD patients. There aren’t enough studies that show an increased risk of contracting COVID-19 in patients with COPD.

But it has been reported that if infected with COVID-19, they have a higher risk of complications and mortality, due to greater difficulty in accessing treatment, personal management, medical care, and a decrease in the lung reserve.

With the recent COVID-19 pandemic, the management and early diagnosis of COPD have been difficult, due to the decrease in face-to-face consultations, the performance of spirometries, and the lower possibility of complying with rehabilitation programs.

However, it’ s essential to maintain routine evaluations as much as possible, which can be carried out remotely with the use of online consultations.

Patients with symptoms of respiratory distress, fever, or other symptoms suggestive of COVID-19 should be evaluated for possible infection.

How to prevent COVID-19 infection in COPD patients?

For COPD patients, as well as for their caregivers and relatives, it’s vitally important to maintain general measures of social distancing, frequent and adequate washing of hands, and the use of a mask–preferably N95.

An exception can be made in those patients with severe respiratory distress in which the use of surgical masks is prescribed so as not to limit ventilation.

Similarly, patients should receive their annual flu vaccination.

The use of inhaled and systemic corticosteroids in patients with COPD and risk of COVID-19 has been a controversial topic, however, the Global Initiative for the Diagnosis, Management, and Prevention Of Chronic Obstructive Lung Disease (GOLD) explains that there isn’t enough evidence to indicate a suspension of their use and therefore, experts recommend continuing with the medication prescribed by the treating physician.

The surgical treatment of COPD

Surgery in patients with COPD is an alternative in cases where the symptoms are severe and frequent.

There are 3 types of surgeries available:

• Bullectomy: Consists of the resection or destruction of the larger bullae (air sacs resulting from the destruction of hundreds of alveoli) in the lung that prevents the adequate exchange of gases in the lung.
• Lung volume reduction surgery: This procedure involves removing approximately 30% of the lung tissue in patients with emphysema predominantly in the upper lobes. The goal is to ventilate the remaining healthy lung tissue and allow the diaphragm to mobilize more efficiently.
• Lung transplant: Like the aforementioned surgeries, lung transplantation is a treatment for severe COPD. It improves respiratory capacity and quality of life. However, the risks of surgery and the possibilities of organ rejection should be taken into account despite the immunosuppressive treatment that’s taken daily.

Similarly, not every patient with COPD is a candidate for the aforementioned surgeries. This will depend on the general conditions of the patient, the cessation of smoking, and the evaluation of the doctor.

It’s always important to remember that it’s the doctor who must indicate the appropriate treatment for each patient and their comorbidities, as any medication can present adverse effects and interaction with other drugs, which is why it’s vitally important not to self-medicate.

With each medical visit, the doctor evaluates the possible changes and adapts treatments according to the level of risk, phenotype. and other controllable comorbidities.