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Chronic Obstructive Pulmonary Disease (COPD) is a widespread preventable and treatable disease marked by airflow limitation and persistent respiratory symptoms caused by airway and alveolar limitation abnormalities. COPD is a life-threatening lung disease that is usually caused by lasting exposure to harmful gases or particles. Whatever the majority of people may think, COPD is not a simple “smoker’s cough” but rather a dangerous and under-diagnosed disease.
COPD is a lung disease characterized by chronic obstruction of airflow; it interferes with normal breathing and causes coughing. The key features of the disease are airway hyperresponsiveness, inflammation, and obstruction, which, however, are often completely reversible. The most common causes of COPD are tobacco smoking, air pollution, genetic factors, occupational exposures (dust and chemical fumes and agents), asthma, airway hyperactivity, and infections (“Pocket guide to COPD diagnosis,” 2019). The disease has four stages: mild, moderate, severe, and very severe, and exacerbations may support any of them. If infected, a patient starts to cough with yellow sputum in the morning and then gradually develops shortness of breath; expiratory wheezing and audible crackles are other symptoms of the disease.
The primary guidelines for the management of COPD were developed in 2006; the GOLD report provides a comprehensive overview of guidelines from WHO, NICE in the UK, and NHLBI. The guidelines suggest that oral corticosteroid therapy has an increased rate of side effects risk, but it may be useful both for acute and stable exacerbations of COPD. Tiotropium and ipratropium – anticholinergics – can significantly reduce severe exacerbations as well as respiratory deaths; meanwhile, β2-agonists seem to increase the number of respiratory deaths. To reduce exacerbations, mucolytic agents have been proposed, especially during winter; less smoking, exercise, and timely palliative care also provide for a better quality of life.
There are several cardinal points of treatment, among them being using bronchodilators for symptom management, while a short-acting bronchodilator is for the first stage of COPD and a long-acting one for stages two and four. A long-acting theophylline preparation causes many side effects and is not well-tolerated. If there are exacerbations, they should be treated with increased frequency and dose of corticosteroids, antibiotics, and short-acting bronchodilators.
Although finding the most effective medication and dosage may be a challenging task, when treatment is correctly established, it helps to prevent and control symptoms. Pharmacological treatment of COPD reduces “the frequency and severity of exacerbations” and improves general health status and quality of life (Dixit, Bridgeman, Madduri, Kumar, & Cawley, 2016, p. 703). COPD maintenance consists of “anticholinergics, β2-adrenergic agonists, methylxanthines, corticosteroids (primarily, inhaled), and expectorants” while severe exacerbation requires anticholinergics, β2-agonists, methylxanthines, and oral corticosteroids (Edmunds & Mayhew, 2014, p. 213). Doctors recommend the following drugs: albuterol (Proventil, Ventolin), salmeterol (Serevent), theophylline (Theolair, Theo-Dur, Slo-Phyllin, Slo-Bid), and beclomethasone dipropionate (Beclovent and Vanceril) (Edmunds & Mayhew, 2014). Patients with stable COPD are to be treated according to the severity of the disease in a stepwise approach; nonpharmacologic treatment is essential as well. The goal is to improve symptoms and lung function, reduce the length of hospitalization and risk of treatment relapse and failure.
Step therapy may have to be increased if the use of a short-acting bronchodilator becomes more frequent or if the manufacturer’s recommended dosing is not enough. If a patient has tachycardia, cardiac arrhythmia, or tremor, the dose of a β2-adrenergic agonist has to be limited. As for corticosteroids, since some studies “have shown a controversial effect on growth,” it is prudent to monitor the growth of both children and adolescents (Edmunds & Mayhew, 2014, p. 214). There are several psychological variables and drugs requiring an adjustment in dosage as they affect theophylline metabolism, among them being alcohol, tobacco smoking, aging, heart or liver failure, hypoxemia, and others.
There are several rules which may help to make treatment effective; for example, patients have to be taught basics about COPD and the roles of prescribed medications. A written self-management plan may help both children and grown-ups, but if a patient has a history of severe exacerbations, a written action plan on rescue actions is not optional but mandatory. Moreover, to avoid exposure to a patient’s known allergens and irritants, appropriate environmental control measures are to be discussed and established. Patients should not use β2-adrenergic agonist bronchodilators as first-line agents and for treating sudden or worsening wheezing. Theophylline is to be taken either one hour before or two hours after a meal; the brand of the medicine should not be changed without provider consultation. While taking theophylline, caffeine-containing beverages, as well as other stimulants, are to be avoided. Corticosteroids require swishing, gargling, and spitting from the mouth after use; it is advised not to stop medication administration abruptly.
There are several important considerations related to such patient variables as geriatrics, pediatrics, and pregnancy, and lactation. As for geriatrics, “the total daily dosage of theophylline should not exceed 400 mg,” and some older adults may be unable to tolerate side effects of bronchodilators (Edmunds & Stewart, p. 214). Infants and young children require special delivery devices, so caregivers are to be taught how to use them properly, and ipratropium safety has not been yet determined for children under twelve years. If the disease is poorly controlled, it may result in higher perinatal mortality rates; however, available research does not provide for increased pregnancy and lactation risks due to the use of medications to treat COPD.
References
Edmunds, M. W., & Mayhew, M. S. (2014). Pharmacology for the Primary Care Provider (4th edition). Saint Louis: Elsevier Health Sciences.
Dixit, D., Bridgeman, M. B., Madduri, R. P., Kumar, S. T., & Cawley, M. J. (2016). Pharmacological management and prevention of exacerbations of chronic obstructive pulmonary disease in hospitalized patients. Pharmacy & Therapeutics, 41(11), 703-712.
Pocket guide to COPD diagnosis, management, and prevention. (2019). GOLD, 1-44. Web.
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