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Chronic Obstructive Pulmonary Disease - Part two - Management

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VOL: 103, ISSUE: 18, PAGE NO: 28

Rachel Booker, RGN, DN (Cert), HV, is module leader, Education for Health, Warwick

The most effective intervention for COPD is to help patients stop smoking. Smoking cessation halts accelerated...

NON-DRUG MANAGEMENT

Smoking cessation

The most effective intervention for COPD is to help patients stop smoking. Smoking cessation halts accelerated decline of forced expiratory volume in one second (FEV1) and returns the rate of decline to that of a non-smoker. Lost lung function cannot be regained but salvage is possible and worthwhile at any stage. The earlier a patient stops the better but it is never too late.

Smoking must be discussed at every available opportunity, support offered to those who express a desire to stop and nicotine replacement therapy (NRT) or bupropion use encouraged.

Pulmonary rehabilitation

Pulmonary rehabilitation is a structured, organised, multidisciplinary team approach to COPD that is designed to:

- Improve functional exercise capacity;

- Improve health status;

- Reduce dyspnoea;

- Reduce health service use (British Thoracic Society, 2001).

Patients attend a group session at least twice a week for a minimum of six weeks. They undertake a supervised, individually prescribed programme of physical exercise. Carers are encouraged to attend and sessions also contain an educational element aimed at empowering patients and improving their self-management skills. The psychological and social needs of patients and carers can also be identified and addressed during a programme.

NICE has recognised the benefits of rehabilitation. It recommends that all patients who are disabled to any significant degree should be able to access pulmonary rehabilitation in a convenient location and within a reasonable time of referral (NICE, 2004). Although there is no doubt that pulmonary rehabilitation is highly effective (Lacasse et al, 2006), service provision remains poor. It is hoped that the National Service Framework for COPD will improve services (DH, 2005).

Practical advice

Breathlessness can be frightening but it is not harmful. Regular exercise 3-5 times a week for 20 minutes to the point of moderate breathlessness, such as walking, is beneficial in:

- Maintaining cardiovascular fitness;

- Preserving skeletal muscle function;

- Reducing breathlessness;

- Maintaining functional ability and independence.

All patients with COPD should be encouraged to maintain and preferably increase their level of activity.

Many patients lose weight as their disease progresses and this is associated with a poor prognosis. At the other extreme, obesity worsens breathlessness. Healthy eating advice is therefore helpful and patients who are over or underweight may benefit from referral to a dietitian.

PHARMACOLOGICAL MANAGEMENT

Bronchodilators

Bronchodilators are the mainstay of symptomatic management in COPD. Although improvements in lung function may be modest, bronchodilators can reduce hyperinflation and air trapping. This improves respiratory mechanics, and reduces breathlessness (O'Donnell, 2006).

Determining the most effective bronchodilator therapy for individual patients requires therapeutic trials of different drugs over several weeks. The response to the trial is measured in terms of subjective improvement in symptoms and exercise capacity rather than lung function. Response assessment should include the following questions (Jones et al, 2001):

- Has your treatment made a difference?

- Is your breathing easier in any way?

- Can you do some things now you could not do before or the same things but faster?

- Has your sleep improved?

As anticholinergic bronchodilators work by blocking parasympathetic activity and reducing bronchomotor tone, they have a particular role in the management of COPD.

Ipratropium bromide, the short-acting anticholinergic, has an onset of action of 30-45 minutes. This makes it unsuitable for rapid symptom relief and it is normally used regularly, 3-4 times daily. It is available as a pressurised metered dose inhaler (pMDI), nebuliser solution or dry powder inhaler.

The long-acting agent tiotropium has a long duration of action, making it suitable for once-daily use. It is currently only available as a dry powder capsule for inhalation through the HandiHaler. Tiotropium is a relatively recent introduction that has significant benefits over short-acting agents.

Beta2 agonist bronchodilators work by stimulating the sympathetic beta2 receptors in the airway smooth muscle, reducing bronchospasm. Short-acting preparations such as salbutamol and terbutaline have a rapid onset and are useful for immediate symptom relief. In mild COPD occasional beta2 agonists may be all that is required. Beta2 agonists work on different nervous pathways from anticholinergic bronchodilators. Used in combination with short-acting anticholinergics they can provide better symptom relief than either agent alone. The long-acting beta2 agonists salmeterol and formoterol are licensed for use in COPD and are used twice daily. They have similar benefits to tiotropium in terms of improving lung function and reducing breathlessness and exacerbations (Appleton et al, 2006).

Theophyllines are rather modest bronchodilators that are difficult to use; side-effects and drug interactions are particularly troublesome. They are now second or third-line therapy, although they may be helpful to some patients when additional symptom relief is sought.

Corticosteroids

NICE recommends prescribing inhaled corticosteroids for patients with FEV1 less than 50% of that predicted and two or more exacerbations requiring antibiotics and/or oral corticosteroids in a 12-month period. Inhaled corticosteroids should be added to a long-acting bronchodilator, either beta2 agonist or anticholinergic (NICE, 2004). Combination inhalers of long-acting beta2 agonists and inhaled corticosteroids are licensed for use in COPD.

Long-term oral corticosteroids are not recommended (NICE, 2004) as the side-effects outweigh the benefits.

Mucolytics

Chronic, productive cough (a common symptom in COPD) can be exhausting and socially embarrassing. Mucolytics loosen secretions and enable patients to clear airway mucus more easily. They have also been found to reduce exacerbation frequency in COPD (Poole and Black, 2006) and are recommended by NICE (2004) for patients with chronic, productive cough.

Oxygen

Destruction of alveoli and progressive airflow obstruction interfere with gas exchange and will eventually lead to significant hypoxaemia. Clinical signs of chronic hypoxaemia include ankle oedema and cyanosis but these may not be apparent until the patient is severely hypoxic. NICE recommends six-monthly recording of pulse oximetry in all patients with COPD who have an FEV1 less than 50% of that predicted to help identify those who need assessment for long-term oxygen therapy.

Some patients with normal oxygen saturation at rest desaturate on exercise and they may benefit from ambulatory oxygen.

ACUTE EXACERBATIONS OF COPD

Acute exacerbations of COPD are important clinical events that increase disease progression. They are defined as 'a sustained worsening of the patient's symptoms from the stable state that is beyond normal day-to-day variation and is acute in onset' (NICE, 2004). This symptom change often calls for a treatment change. Common symptoms include:

- Increasing breathlessness;

- Cough;

- Increased sputum production;

- Increased sputum purulence.

Patients should be encouraged by nurses to act promptly if their normal symptoms worsen. The first line of therapy is to increase the frequency and/or dose of their short-acting bronchodilators or to add additional short-acting agents to control breathlessness (NICE, 2004).

Antibiotics are indicated if the sputum becomes purulent. A short course of oral corticosteroids may be needed if breathlessness interferes with daily activities and fails to respond to increased use of bronchodilators (NICE, 2004). Patients who have frequent exacerbations of symptoms may benefit from keeping a supply of antibiotics and/or prednisolone at home so they are able to start treatment promptly.

Clear written information about how and when they should contact their doctor for additional help is essential. Annual influenza vaccinations should be encouraged, and patients should also be vaccinated against pneumococcus.

LEARNING OBJECTIVES

- Understand the importance of smoking cessation in this group of patients

- Know the full range of non-drug interventions for COPD

- Be aware of the different drugs that can be prescribed for the condition and their actions

- Know how to manage an acute exacerbation of COPD

GUIDED LEARNING

- Explain why smoking cessation is important in COPD

- Outline the range of non- pharmacological interventions

- List the various types of drugs that can be used and their different effects

- Explain how to manage an acute exacerbation of COPD

This article has been double-blind peer-reviewed.

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