Management of Stable COPD

The careful management of COPD in the outpatient setting can effectively improve symptoms, minimize deterioration in pulmonary function, and prevent hospitalization during acute exacerbations. There are four phases in the primary care physician's strategy to meet these goals:

1. Stress smoking cessation and patient education about the disease.
2. Improve pulmonary function as much as possible by treating any reversible component of the patient's lung disease and by establishing a therapeutic “plateau” to prevent accelerated deterioration in pulmonary function as the patient grows older.
3. Treat acute exacerbations of COPD in the outpatient setting.
4. Prevent non-COPD complications of therapy.

Phase 1 - Smoking Cessation and Patient Education

The primary care physician is in an ideal position to emphasize the importance of smoking cessation to all patients, but especially those with early or moderately advanced COPD. Educate your patients about the damaging effect of tobacco smoke on the progression of the disease process and on the worsening of their pulmonary function. Explain to patients that when they stop smoking they will reap many benefits, including reduced airway secretions, reduced airway inflammation, and reduced bronchospasm.

It helps to discuss the importance of behavior modification and smoking addiction. Frequently, a patient is receptive to their physician’s recommendation about a nicotine patch or referral to a smoking cessation class. It is important to schedule follow-up visits in the clinic to reinforce the patient's decision to quit smoking (See Section J).

In addition, educating the patient and his or her family about COPD, the importance of complying with medication regimens, and the value of exercise is vital to the successful management of the disease.

The most useful approach to smoking cessation is counseling that quitting is absolutely essential. Picking a quit date is key to the entire process. A variety of pharmacologic agents are available to mitigate nicotine withdrawal symptoms. These are summarized in Table 2.

When nicotine replacement is chosen, it should be started on the quit date. The advantage of the gum is that it allows the patient to titrate the rate of nicotine absorption. Four mg gum is more effective than 2 mg gum in patients who are most heavily addicted, i.e., smoking more than one pack a day, and beginning early in the morning, with the morning cigarette being the most important. When bupropion is given, it should be initiated approximately one week before the quit date. The nicotine products can be used in combination. Even if used together in full manufacturers’ doses, it is unlikely that nicotine blood levels will exceed those produced regularly by the addicted smoker. A combination of nicotine replacement and bupropion has resulted in the highest success in biologically proven cessation one year after initiation of therapy.

References

Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med 1999;159:179-187. An updated review. The fev6 is a good surrogate marker of fvc and the fev1/fev6 ratio is useful in identifying subjects with rapid rates of decline in fev.

Hilleman DE, Mohiuddin SM, Del Core MG, Sketch MH Sr. Effect of buspirone on withdrawal symptoms associated with smoking cessation. Arch Intern Med 1992;152:350-352. This non-benzodiazepine was effective in reducing the symptoms of nicotine withdrawal.

Hurt RD, Dale LC, Fredrickson PA, et al. Nicotine patch therapy for smoking cessation combined with physician advice and nurse follow-up. One-year outcome and percentage of nicotine replacement. jama 1994;271:595-600. This randomized trial showed that the nicotine patch increased smoking cessation more than physician advice and nurse follow-up.

Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997;337:1195-1202. This randomized clinical trail demonstrated the effectiveness of bupropion compared with placebo.

Jorenby DE, Keehn DS, Fiore MC. Comparative efficacy and tolerability of nicotine replacement therapies. CNS Drugs. 1995;3:227-236. A review of the effectiveness of drugs used in nicotine withdrawal.

Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340:685-691. A greater quit rate was achieved with combined therapy compared with either agent used separately.