Management of Stable COPD
Phase 2 Treating the Reversible Component of COPD and Establishing a Therapeutic Plateau

Early COPD

Premature deterioration in lung function in patients without obvious asthma should prompt the physician to further investigate the possibility of protease-inhibitor deficiency by screening for alpha-1-antitrypsin deficiency. Other factors such as occupational exposure to particulate dusts, fumes, air pollution, or wood stoves may be important.

Other coexisting illnesses that may contribute to airflow obstruction include recurrent sinus infections, allergic rhinitis, chest infections, severe esophageal reflux, and an underlying illness such as congestive heart failure, liver disease, or malignancy. The presence of these conditions might affect decisions about medication.

Carefully review and eliminate any medication taken by the patient that may be contributing to cough or bronchospasm or causing an adverse drug interaction. These might include beta-blocking drugs, ace inhibitors, diuretics, theophyllines, tranquilizers, and hypnotics. Theophylline interacts with many medications, all of which tend to increase theophylline levels. These include: cimetidine, fluconazole, and macrolide (e.g., erythromycin), and quinolone (e.g., ciprofloxacin) antibiotics. In patients of advanced age, or who have liver disease or congestive heart failure, the metabolism of theophylline is also delayed.

It is important to measure the patient's baseline pulmonary function using spirometry, both to support the diagnosis and to have a standard against which to measure the patient's response to treatment. This is especially true when the use of corticosteroids is considered, because patient education regarding the benefits and risks of this class of medications is very important.

Pulse oximetry can be used in the office when the patient is “at rest” and when “ambulating” to establish the presence of hypoxemia. This test can also disclose the problem of oxygen desaturation during simple activities of daily living, (adls), which so frequently prevents patients with COPD from engaging in simple exercise at home (See Sections F and I).

Medication Treatment Bronchodilators

After the initial spirometric testing is complete, develop an individualized medication program for the patient that includes bronchodilators to improve airflow and to reduce dyspnea. The first medication tried should be ipratropium, delivered via a metered-dose inhaler, (mdi), with or without the concomitant use of an inhaled beta-adrenergic (e.g., albuterol, bitolterol, pirbuterol, meta-proterenol, salmeterol), also delivered via an mdi. It is essential to thoroughly demonstrate the correct technique for using the mdi as outlined in Table 3 and illustrated in Figure 5. Patients with poor coordination who cannot master the press-and-breathe technique may need to use a spacer or a breath-activated device, which should allow nearly all patients to use mdis correctly. A common mistake is to prescribe these effective medications without adequate patient instruction or follow-up to monitor their use, the patient's response to treatment, and any objective improvement in airflow.

How to Use an MIDI
Check how much medicine is in the canister.

1. If the canister is new, it is full.
2. If the canister has been used repeatedly, it might be empty. The product label should show how many inhalations should be in each canister.

To check how much medicine is left in the canister, put the canister (not the mouthpiece) in a cup of water. If the canister sinks to the bottom, it is full. If the canister floats sideways on the surface, it is empty.

How to Use the Inhaler

1. Remove the cap and hold the inhaler upright.
2. Shake the inhaler.
3. Tilt your head back slightly and breathe out.
4. Position the inhaler in one of the ways illustrated in Figure 5.
5. Press down on the inhaler to release medication as you start to breathe in slowly.
6. Breathe in slowly (3 to 5 seconds).
7. Hold breath for 10 seconds to allow medicine to reach deeply into the lungs.
8. Repeat puffs as directed. Waiting 1 minute between puffs may permit the second puff to penetrate the lungs better.
9. Spacers are useful for all patients. They are particularly recommended for young children and older adults and for use with inhaled corticosteroids.

Figure 5 Proper Press and Breathe Techniques for MDI Use

A. Open mouth with inhaler 1 to 2 inches away
B. Use spacer
C. In the mouth for breath activated devices

Ipratropium bromide and albuterol sulfate are now available in a single inhaler marketed as Combivent® Inhalation Aerosol. Several studies have shown that the combination is more effective than either agent used alone. Combivent® Inhalation Aerosol is used for maintenance but can also be used to manage break-through attacks. Thus, it is one of the most versatile agents to use in COPD. The combination product may improve compliance and reduce costs.

If necessary, add either theophylline (200 to 300 mg b.i.d.) and/or slow release albuterol tablets (4 to 8 mg daily or b.i.d. if tolerated) when persistent dyspnea, lack of objective improvement, or “breakthrough” symptoms of cough, wheezing, or nocturnal exacerbations are present. Many patients cannot tolerate the tremor and gastrointestinal side effects that may accompany oral theophylline or albuterol preparations. Slow-release theophylline preparations give the best nocturnal blood levels and lessen gastrointestinal intolerance. Tremor, which may accompany the use of albuterol preparations, can be minimized by gradually increasing the dose over one or two weeks’ time.

Consider adding the new long-acting beta-adrenergic, salmeterol (delivered via an MDI), to help control breakthrough symptoms or to improve medication compliance. Its benefit in asthma is its long duration (10 to 12 hours), but its role in COPD is not yet defined. Patients using this drug need to be reminded to continue using their other inhaled bronchodilators when needed for “rescue therapy,” since salmeterol takes 75 to 90 minutes to begin acting.

Corticosteroids

The use of corticosteroids in patients with COPD is controversial, but many patients benefit from short- or long-term use. The physician should clearly document in the patient record the rationale for using this therapy. Baseline measurements of spirometric data and objective assessments of the patient's response to treatment during follow-up visits should also be documented.

A trial of oral corticosteroids is indicated in patients with severe airflow limitation or in patients who continue to deteriorate despite maximal bronchodilator therapy. A typical course of steroids would be: Prednisone 40 to 60 mg daily for seven days, then gradually tapering over ten days to 10 to 20 mg daily or every other day, at which time the patient should be reassessed in the office objectively by spirometry and, if appropriate, oximetry.

Long-term corticosteroid use for patients with COPD should be maintained only in those who experience a documented improvement in their airflow obstruction after treatment. The lowest dose possible should be used and attention should be given to preventing potential side effects. The physician may want to taper the steroid to alternate-day use, adding an inhaled corticosteroid medication, to minimize systemic side effects.

Inhaled corticosteroids might also be considered for use along with inhaled bronchodilators to gain some of the therapeutic benefits of steroids while avoiding the systemic side effects associated with long-term oral steroid therapy. Four drugs are available: beclomethasone (2 to 4 puffs q.i.d.), flunisolide (2 to 4 puffs b.i.d.), fluticisone in three different strengths (2 puffs b.i.d.), and triamcinolone (2 to 4 puffs q.i.d.). Careful rinsing of the mouth after nebulization and the use of spacers will minimize oral moniliasis.

Nebulized Bronchodilators

Patients with advanced COPD or those who have difficulty using a metered-dose inhaler, either routinely or during acute exacerbations, may benefit from the use of an “updraft” or “wet” nebulizer system of inhaled ipratropium (available as a unit dose medication) or beta-adrenergic bronchodilators. The beta-adrenergic medications available for routine outpatient use include: albuterol (unit dose vial .083 mg/ml, or 0.5 ml with 2 ml normal saline), metaproterenol (unit dose vial 0.6% or 0.4%, or 0.3 ml with 2 ml normal saline), terbutaline (unit dose vial), or bitolterol (0.75 to 1 ml). Ipratropium and a beta-adrenergic agent may be used together in an updraft nebulizer.

Mucolytic Drugs

Consider adding a mucolytic agent (e.g., guaifenesin, 600 mg 1 to 4 times daily) if the patient has difficulty clearing secretions. Acetylcysteine may improve sputum clearance and loosen mucous plugs in patients with severe bronchitis, bronchiectasis, or cystic fibrosis, but because this drug may cause bronchospasm, it is usually administered in an updraft nebulizer with a bronchodilator.

Advanced COPD

Patients with advanced COPD are typically treated with both oral and inhaled bronchodilators. Careful attention to the presence of underlying sinus and bronchial infections will help prevent further deterioration in pulmonary function (See Section H.1). Oxygen therapy, regular exercise, and corticosteroid therapy also frequently play an important role in the treatment of advanced COPD. Close follow-up in the outpatient setting, with regular monitoring of the patient's pulmonary function, oxygenation, and ambulatory ability are necessary to treat this challenging group of patients effectively.

The physician should regularly review the important aspects of the treatment program with the patient, including the pathophysiology of COPD, the pursed-lip breathing technique, the correct mdi technique, the importance of smoking cessation and exercise, and the necessity of compliance with medication regimens.

Oxygen Therapy

Frontline physicians should evaluate each patient's oxygenation using oximetry, and should consider prescribing continuous oxygen therapy for those who have resting room air saturations of less than 88% or ambulatory saturations of less than 88%. Clinical consideration must be given for exceptions to these specific guidelines, of course, but ongoing, untreated hypoxemia will accelerate the development of cor pulmonale, negatively affect cognitive function, increase respiratory muscle fatigue, reduce the quality of sleep, and diminish the patient’s tolerance for mild exercise or even the simplest activities of daily living (See Sections H.5 and I). Primary care physicians may consider referring well-selected, motivated patients for transtracheal oxygen therapy which may improve comfort, reduce respiratory muscle fatigue, and improve mobility by reducing the oxygen flow rate required.

Ambulatory oxygen has become the standard of care for patients who can and will increase their exercise beyond the 50 feet of tubing that connects with a stationary source. The Nocturnal Oxygen Therapy Trial, (NOTT), showed a superiority of ambulatory oxygen with a superior survival from continuous oxygen therapy, (cot), provided from an ambulatory source, compared with nocturnal oxygen therapy, (not), provided by a stationary source. Of course, the duration of oxygen administration was greater with cot, (mean 17.7 hours, median 19.4 hours per day), compared with ambulatory oxygen, (11.8 hours per day). Thus, the improved survival could have been the result of the method or the duration of oxygen therapy. A re-analysis of the nott data strongly suggests that the ability to increase exercise along with the provision of ambulatory oxygen was the most likely reason for improved survival in the NOTT.