Prevent Emphysema Now!
Information for Physicians on the Diagnosis and Treatment of COPD
Influenza virus vaccine should be given every Fall to anyone with airflow obstruction. This is particularly important for people over the age of 50. Pneumococcal vaccine should be given at least once in a lifetime and probably repeated every six years. Today, two new products, oseltamivir (Tamiflu™), and zanamivir (Relenza®), can modify the clinical course of both influenza A and B. Amantadine and Ranitidine are effective only in A strains of influenza.
Inhaled bronchodilators reduce symptoms and improve lung function in the majority of patients with early-stage disease. Ipratropium is the first step in therapy. Beta agonists such as albuterol are also of significant value. Ipratropium and albuterol are available in the same metered-dose inhaler (Combivent®). Salmeterol (Serevent) and formoterol (Foradil) are long-acting bronchodilators and, when used twice daily, are useful alternatives. Other novel bronchodilators are soon to be released; including tiotropium (Spivera®) a 24-hour anti-cholinergic to be released in the U.S.A. in the near future. Salmeterol (Serevent®) and formoterol (Foradil) are both compatible with the use of ipratropium. Together, both medications may improve lung function and mitigate symptoms. All patients must learn the proper technique for using metered-dose inhalers and newer inhalation devices coming to the market, for use in the delivery of anticholinergics, beta agonists, combinations, and corticosteriods.
Inhaled corticosteriods have not been shown to alter the rate of decline in FEV1 in at least five randomized, controlled, clinical trials. However, inhaled budesonide, fluticasone, and triamcinolone have all been shown to improve symptoms and to reduce the consumption of healthcare resources in patients with severe COPD. A reduction of bone density was found during the conduct of one of these trials. Thus, any symptomatic benefits should be weighted against potential systemic side effects in the long-term.
The empiric use of antibiotics is well established in the management of acute exacerbations of chronic bronchitis. Bacterial invasion is often present following a cold, when there is increased cough, increased sputum volume, and the appearance of sputum purulence (i.e., yellow or green). These common invaders, the aerobes, are H. influenzae, S. pneumonia, C. pneumoniae, and M. pneumoniae. These agents are effectively treated with macrolides, fluoroquinolones, second generation cephalosporins, trimethoprim sulfa, or doxycycline when given empirically for five to seven days. A sputum culture is not necessary.
Oral corticosteriods, (i.e., 40 mg prednisone per day, or equivalent) given for a short period of time, (i.e., approximately 7-14 days), can attenuate the degree of acute airflow obstruction during exacerbations and can often abort the progression to a severe exacerbation of COPD, thus diminishing the need for hospitalization (see Table 4).
It is now known that the inflammatory mediators involved in the pathogenesis of COPD, which lead to airway inflammation and destruction of alveolar walls, are different from those involved in asthma. A number of new pharmacologic entities are being produced to deal with early-stage disease. Longer-acting anticholinergic drugs, mucoregulators, and immunomodulators are on the horizon and are soon to be released. But, even today, great progress is being made in slowing the course of disease in patients