Chronic Obstructive Pulmonary Disease
COPD is a chronic disease with periods of exacerbation and remission that evolves naturally to aggravation. Given that in COPD occurs irreversible airflow limitation and because the main cause of this disease is smoking, the treatment of COPD aims to establish prevention measures and curative measures for this disease.
Prevention of COPD benefit from these measures:
- Fight against smoking, avoiding both active and passive smoking and conviction of the patients who smoke to quit this habit.
- Limiting the exposure to air pollution and professional pollution by wearing masks with special filters at work.
- Early detection and treatment of bronchitis, especially asthmatic bronchitis, occurring in childhood.
- Prophylaxis of viral and bacterial infections in patients with obstructive pulmonary disease by using multivalent influenza vaccine in autumn, the use of antipneumococcal vaccines and antihaemophylus influenzae vaccines.
- The research of alpha 1 antitrypsin deficiency in family members of patients suffering from emphysema, with this origin, to detect a possible partial deficit.
Curative treatment of COPD:
The immediate objectives of the treatment of COPD require healing of acute infectious exacerbations, with return to the previous stage of COPD. Installation of a exacerbation and factors that can generate the exacerbation, should be detected: respiratory infections, heart failure, pulmonary embolism, some drugs (beta blockers, tranquilizers, hypnotics, diuretics).
COPD treatment objectives are:
- Prevent disease progression;
- Relive symptoms;
- Improve health status;
- Improve exercise tolerance;
- Prevent and treat complications;
- Prevent and treat exacerbation;
- Reduce mortality;
- Prevent or minimize side effect of the therapy.
Management of COPD should be done in accordance with the standards imposed by Global Initiative for Chronic Obstructive Lung Disease (GOLD):
- Stage I COPD (mild obstruction): reduction of risk factors by using multivalent influenza vaccine and using of short-acting bronchodilator as needed.
- Stage II COPD (moderate obstruction): reduction of risk factors by using multivalent influenza vaccine, using short-acting bronchodilator as needed, long-acting bronchodilator and cardiopulmonary rehabilitation.
- Stage III COPD (severe obstruction): reduction of risk factors by using multivalent influenza vaccine, short-acting bronchodilator as needed, long-acting bronchodilator, cardiopulmonary rehabilitation and inhaled glucocorticoids if appear repeated exacerbations.
- Stage IV COPD (very severe obstruction or moderate obstruction with evidence of chronic respiratory failure): reduction of risk factors by using multivalent influenza vaccine, short-acting bronchodilator as needed, long-acting bronchodilator, cardiopulmonary rehabilitation, inhaled glucocorticoids if appear repeated exacerbation, long-term oxygen therapy and surgical options such as lung transplantation should be considered.
Treatment of COPD is using a variety of drugs and therapeutic means, as a strategy “in steps” similar, but with some particularities, to that of the bronchial asthma. Efficiency of treatment of COPD depends on the clinical presentation and stage in which patient is diagnosed. Drugs and therapeutic resources for COPD treatment are: bronchodilators, anti-inflammatory therapy, antibiotic therapy, removal of secretions, oxygen therapy and patient rehabilitation.
Bronchodilators are widely used in the treatment of COPD, even in cases where only bring an improvement in quality of life, not in the functional parameters. Bronchodilators are used continuously, not intermittently as in bronchial asthma.
Ways to use bronchodilators are three: inhalational (preferred), oral and injectable (subcutaneous or intravenous used in severe obstructions).
Use of bronchodilators should be preceded by assessment of bronchomotricity as follows:
- Positive bronchodilator test (increase in FEV1> 15%), which is investigated only once in the time of diagnosis, indicating a benefit of the therapy.
- If thebronchodilator test is negative or at limit, but the patient stated an subjective improvement of the symptoms, such as reduction of dyspnea, bronchodilators may be prescribed.
- When bronchodilator test is negative, these substances have no purpose.
The group of bronchodilators substances is represented by: beta 2 agonists, anticholinergics and methylxanthines.
Inhaled beta 2 agonists (with spacer) qre indicated in a proper dose, according to the severity of each case, determined by spirometry. Typically, in the case of short-acting beta 2 agonists (salbutamol, terbutaline, pirbuterol), 2 sprays used 3-4 times / day are enough. For long-acting beta 2 agonists (formoterol, salmeterol) dose is 2 sprays every 12 hours. Oral formulations of long-acting beta 2 agonists, ingested before sleep, are useful in patients with nocturnal dyspnea.
Anticholinergic medications have a action which is installed slower than the action of beta 2 agonists, after about 15-30 minutes, but have a longer duration of action. These drugs reduce mucus secretion, which is why some authors consider this medications as a first-line drug in the treatment of COPD. The dose is 2 sprays, 3-4 times / day. May be associated with beta 2 agonists, because by combining the two classes of drugs will result a potentiating effect.
Methylxanthines or theophylline derivatives are considered to have a lower bronchodilator potential than beta 2 agonist and anticholinergics, doubled by a much greater risk of severe toxic reactions than the first two classes of bronchodilators. Therefore, methylxanthines are placed on stage three of treatment, after beta-2 agonists and anticholinergics, being given to patients with serious, sever and persistent symptoms, despite the maximal therapy with bronchodilator drugs from first two categories.
Long-acting theophylline will be taken at night before bedtime, by patients with nocturnal dyspnea, representing an alternative to long-acting beta 2 agonists. Oral dose of theophylline should be 400 – 800 mg / day with gradual increase up to 10 mg / kg / day.
For patients with severe obstructive syndromes, will be used intravenous administration of methylxanthines with serum theophylline level monitoring, which must be between 5-15 micrograms / ml.
Anti-inflammatory treatment consists of corticosteroid therapy, which has a better effect in patients with reversible obstruction and eosinophilia in sputum. Corticosteroid therapy indications are represented by patients with severe COPD and COPD exacerbations.
Cortisone preparations can be administered in three ways: intravenous, oral and inhalational.
In severe exacerbations of COPD is recommended administration of hydrocortisone hemisuccinat in total dose of 500 – 1000 mg / day for 3-4 days or methylprednisolone 1.5 mg / kg intravenously every 6 hours for 3 days (with rapid decrease in dose and interruption after another 3 or 4 days).
In COPD patients with less severe exacerbations, oral prednisone is indicated in 40 mg / day (0.5 -1 mg / kg) in a single dose for 3-4 days, with progressive decrease in dose and interruption of therapy after 7 or 10 days (total duration of treatment, about 14 days).
For the long-term oral corticosteroid therapy may benefit approximately 10% -20% of patients with severe COPD (FEV1 <1 liter). Criteria for inclusion in this alternative are:
- Unsatisfactory response to conventional therapy, correctly indicated and in maximum doses;
- FEV1 increase of more than 30%, after 2-3 weeks of administration of 40 mg of prednisone.
In long-term corticosteroid therapy, the dose should be the lowest possible (<10 mg / day), to be effective and if possible to wear the alternative management model (once every two days). Major contraindications are the appereance of complications of corticosteroid therapy, which is require the quitting of this therapy.
For inhalational corticosteroid therapy, doses are 800-1600 micrograms of beclomethasone dipropionate or equivalent doses of other preparations. In general, patients who have a bronchodilator positive test, respond to corticosteroids, but also can be made the glucocorticoid reversibility test, which attempts to identify patients with good response to long-term corticosteroid therapy.
Antibiotic therapy in COPD patients:
Is use only if there is an infectious exacerbation of COPD. Antibiotic therapy is useful because it brings an immediate benefit, reducing cough and sputum and helping to lower the vital risk of severe forms of COPD.
Can be used: amoxicillin (1 g / day) or ampicillin (2-4 g / day), oxacillin (100-200 mg / day), all with a duration of 7-10 days. In high pathogenic germs infections, the indication is guided by antibiogram. In case of failure or intolerance or allergy to the antibiotics mentioned above, will be used: cephalosporins or augmentin.
Removal of secretions in COPD patients:
Removal of secretions involves several means:
- Use of mucolytics and expectorants drugs, like acetylcysteine (600 mg / day), ambroxol (90 mg / day), etc.
- Orally hydration, more than 2 liters / day, associated with aerosols with distilled water or sodium chloride 9‰.
- Physical therapy includes postural drainage, by beds provided with adjustable slope (the patient’s torso is placed 15 degrees below the feet); hand chest percussion or using special devices (vibration jackets)and breathing exercises. By teaching the patient to practice diaphragmatic breathing type, will facilitate the mobilization of diaphragmatic domes.
- Education of coughing: learning a effective coughing technique, refers both to the body positioning during coughing, and breathing control. Cough positions are: upright, with shoulders relaxed and rotate forward, head and back are slightly bent, forearms resting on thighs, bent knees and feet resting on the ground. If the patient is in bed, it will be semisitting or lying sideways, the trunk will be up and leaned in the front and knees are bent.
- Use of of drugs that stimulate ventilation by central or peripheral mechanism (doxapram, naloxone).
- Endoscopic aspiration is necessary when the secretions almost completely blocks the airway and coughing is ineffective or the patient is unconscious.
Oxygen therapy in COPD patients:
There are two methods of administration of oxygen: controlled oxygen therapy and long-term oxygen therapy. Regardless of the method, the objective is to correct hypoxemia, hypercapnia and to prevent respiratory acidosis.
- Controlled oxygen therapy, it starts concomitantly with other actions designed to combat precipitating factors of COPD. A flow of 2-4 liters / min is satisfactory, mask or nasal tube administration is intermittent (15 to 20 minutes, with intermission).
- Long-term oxygen therapy has the benefit of the reversal of pulmonary hypertension, corrects poliglobulia, sleep and behavior disorders of patients with COPD, is reducing the prone of heart failure and prolongs the survival.
Rehabilitation of COPD patients:
Rehabilitation of patients with COPD must be planned as a individualized, long-term program which involves a multidisciplinary collaboration.
Typical components of this program are:
- Kinesis therapy: simple or treadmill walking, ergonomic cycling, climbing stairs, etc.
- The various techniques of physical therapy (upper extremity exercises, controlled breathing techniques), targeting the training of respiratory muscles in patients with COPD.
- Diet high in fat and low in carbohydrate (protein content should not be changed), with positive benefits, increasing the strength of respiratory muscles, functional status and autonomy of movement. Dietary supplementation with micronutrients (phosphorus, magnesium, potassium, calcium) will strengthen the diaphragm function.
- Intermittent mechanical ventilation in stable COPD stages, with the purpose of resting inspiratory muscles. Can be use either positive pressure ventilation (given as a regimen of 3-6 hours / day during 3 consecutive days) or with negative pressure ventilation.