References for this review were collected by several criteria. First, therapeutic recommendations indicated by major guidelines were collected and, where appropriate, compared with earlier versions of the same guidelines. These included the GOLD guidelines (www.goldcopd.com) and the updated guidelines of the American Thoracic Society and European Respiratory Society (www.thoracic.org) on COPD; the US DHHS practice guideline on smoking cessation;16 and the pulmonary rehabiliation guideline.115
SeminarTreatment of stable chronic obstructive pulmonary disease
Introduction
Two major problems facing the clinician treating the stable COPD patient are diagnosis and attitude. First, COPD is underdiagnosed.1, 2 Even when diagnosed, the clinical importance of the disease is often underestimated.3 This underestimation might reflect, in part, an inappropriate inclination of many clinicians toward therapeutic nihilism for COPD patients. This attitude might be based on the historical approach toward such patients as stated by Williams in Middle and Old Age (Oxford Medical Publications), quoted by Fletcher and colleagues4: “Chronic bronchitis with it accompanying emphysema is a disease on which a good deal of wholly unmerited sympathy is frequently wasted. It is a disease of the gluttonous, bibulous, otiose, and obese and represents a well-deserved nemesis for these unlovely indulgences … the majority of cases are undoubtedly due to surfeit and self-indulgence.” This attitude toward COPD patients is inappropriate not only for its lack of compassion, but, at the present time, because therapeutic interventions for stable patients can result in substantial clinical benefit. This Seminar will highlight current approaches to the management of stable COPD patients. Issues relating to clinical features of COPD, its pathophysiology, and management of its severe form, including surgical treatments and ventilatory support, and future therapies are addressed elsewhere in this Series.
Several sets of guidelines by various societies provide definitions, classifications, and management strategies for COPD. The widely cited documents prepared by the American Thoracic Society,5 the European Respiratory Society,6 and the GOLD Guidelines organised by a collaboration of the National Heart, Lung and Blood Institute and WHO7 have been updated.8, 9 A stepwise approach to therapy based on the five stages of disease severity has been suggested in the recent revision of the GOLD Guidelines (Figure 1).8 This guidance provides an excellent basis for the clinician to begin therapy, although COPD patients are heterogeneous, and therapy should be individualised. Although ongoing research promises to help understand this heterogeneity and might help the clinician predict individual therapeutic responses, every COPD patient treated could be regarded as an individual clinical trial.
Section snippets
Smoking cessation
Cigarette smoking is the single most important risk factor for the development of the disease. In the USA, about 80% of patients with COPD are current or former smokers,1 and smoking accounts for about 80% of the mortality attributable to COPD.10 Smoking cessation substantially improves the rate at which lung function is lost in patients with mild COPD.11, 12, 13 Smoking cessation can also reduce symptoms of cough and sputum production,14 and can reduce airways reactivity.15 Smoking cessation,
Behavioural support
Many studies have shown that behavioural support can increase quit rates in smokers.16, 27 The more behavioural support provided, both in terms of number of sessions and duration of sessions, the greater the quit rates. The most intensive programmes generally report cessation rates of about 20% with behavioural support alone, although it is likely that those who participate in such programmes are more highly motivated than those who don't.31 Whereas intensive behavioural interventions are
Pharmacological support
Pharmacological support should be provided for all smokers for whom it is not contraindicated and who are willing to use medications.16 There are two first-line categories of pharmacological support and two second-line.
Treatment of symptomatic COPD
Most patients with COPD lose lung function slowly and gradually over a period of decades. As lung function is slowly compromised, physical limitations occur insidiously.4 Since patients with the disease typically develop dyspnoea with exertion, individuals will often compromise their level of activity and thus avoid specific complaints. As a result, patients often present with symptoms of dyspnoea only after lung function is severely compromised. The astute clinician, however, might be able to
Inhaled glucocorticoids
Inhaled glucocorticoids have been assessed in four large clinical trials87, 88, 89, 90 to look for an effect in altering the natural history of COPD. None of these showed a significant effect in reducing the rate at which lung function declines. Although a meta-analysis91 suggested that, a 5 mL per year beneficial effect in the rate of FEV1 decline was seen, this finding was not significant. Inhaled glucocorticoids, therefore, are not currently recommended for routine use in COPD patients to
Influenza
Viral infections are a major cause of COPD exacerbations and are associated with increased mortality.108 Influenza vaccination has been reported to reduce serious illness and death in COPD patients by 50%.109 Since many patients with the disease are elderly, as with other elderly patients, vaccines containing killed or live inactivated virus are recommended.8, 110 The strain of virus should be appropriate for the year, and the vaccination should be given either once in the autumn or twice in
Conclusion
COPD is a highly prevalent disorder associated with both recognised and unrecognised morbidity. Currently available treatments can be highly effective in managing patients' symptoms and in improving several key clinical outcomes. The successful implementation of these therapies, however, needs a comprehensive management plan individualised for each patient. COPD, therefore, should not engender therapeutic nihilism, but should be approached aggressively with the recognition that optimal patient
Search strategy and selection criteria
References (136)
- et al.
The effect of smoking intervention and an inhaled bronchodilator on airways reactivity in COPD: the Lung Health Study
Chest
(2003) - et al.
Up-regulation of nicotinic acetylcholine receptors following chronic exposure of rats to mainstream cigarette smoke or α4β2 receptors to nicotine
Biochem Pharmacol
(1995) - et al.
Neurobiology of the nicotine withdrawal syndrome
Pharmacol Biochem Behav
(2001) - et al.
Combined use of nicotine patch and gum in smoking cessation: a placebo-controlled clinical trial
Preventive Med
(1995) - et al.
Smoking cessation in patients with chronic obstructive pulmonary disease: a double-blind, placebo-controlled, randomised trial
Lancet
(2001) - et al.
Extended therapy with ipratropium is associated with improved lung function in COPD: a retrospective analysis of data from seven clinical trials
Chest
(1996) - et al.
Effects of formoterol (Oxis Turbuhaler) and ipratropium on exercise capacity in patients with COPD
Respir Med
(2002) - et al.
Alternative mechanisms for long-acting beta(2)-adrenergic agonists in COPD
Chest
(2001) - et al.
Efficacy of salmeterol xinafoate in the treatment of COPD
Chest
(1999) - et al.
Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
(2003)
A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol
Chest
Comparison of the efficacy, tolerability, and safety of formoterol dry powder and oral, slow-release theophylline in the treatment of COPD
Chest
Efficacy and safety of oxitropium bromide, theophylline and their combination in COPD patients: a double-blind, randomized, multicentre study (BREATH Trial)
Respir Med
The additive effect of theophylline on a high-dose combination of inhaled salbutamol and ipratropium bromide in stable COPD
Chest
Long-term effect of inhaled budesonide in mild and moderate chronic obstructive pulmonary disease: a randomised controlled trial
Lancet
Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial
Lancet
Obstructive lung disease and low lung function in adults in the United States: data from the National Health and Nutrition Examination Survey, 1988–1994
Arch Intern Med
Chronic obstructive pulmonary disease surveillance—United States, 1971- 2000
MMWR Surveill Summ
Issues concerning health-related quality of life in COPD
Chest
Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease
Am J Respir Crit Care Med
Optimal assessment and management of chronic obstructive pulmonary disease (COPD)
Eur Respir J
Global initiative for chronic obstructive lung disease. NIH: 2001; 2701: 1–100
Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper
Eur Respir J
The epidemiology of cigarette smoking and its impact on chronic obstructive pulmonary disease
Am Rev Respir Dis
Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1
JAMA
Smoking and lung function of lung health study participants after 11 years
Am J Respir Crit Care Med
Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study
Am J Respir Crit Care Med
The effect of smoking cessation and modification on lung function
Am Rev Respir Dis
US public health service clinical practice guideline: treating tobacco use and dependence
Respir Care
Cigarette smoking and disease
Behavioral and cognitive effects of smoking: relationship to nicotine addiction
Nicotine Tob Res
Abuse liability and pharmacodynamic characteristics of intravenous and inhaled nicotine
J Pharmacol Exp Ther
Relationship between mood improvement and sleep changes with acute nicotine administration in non-smoking major depressed patients
Rev Invest Clin
Influence of nicotine on simulator flight performance in non-smokers
Psychopharmacology (Berl)
Effects of cigarette smoking on performance in a simulated driving task
Neuropsychobiology
Nicotinic receptor-mediated effects on appetite and food intake
J Neurobiol
Effect of nicotine and nicotinic receptors on anxiety and depression
Neuroreport
Smoking cessation guidelines for health professionals: an update—Health Education Authority
Thorax
Have we lost our way? The need for dynamic formulations of smoking relapse proneness
Addiction
Efficacy of relapse prevention: a meta-analytic review
J Consult Clin Psychol
Physician advice to quit smoking: results from the 1990 California Tobacco Survey
J Gen Intern Med
Physician advice for smoking cessation (Cochrane Review)
Nicotine delivery kinetics and abuse liability
J Consulting Clin Psychol
Transdermal nicotine for smoking cessation: six-month results from two multicenter controlled clinical trials
JAMA
Higher dosage nicotine patches increase one-year smoking cessation rates: results from the European CEASE trial—collaborative European anti-smoking evaluation
Eur Respir J
Are higher doses of nicotine replacement more effective for smoking cessation?
Nicotine Tobacco Res
Cited by (87)
Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department
2022, Emergency Medicine Clinics of North AmericaCitation Excerpt :When compared with SABAs, ipratropium is slower in onset but lasts longer.14,15,18 The time of onset approximates 15 min, and the peak effect is 60 to 90 min with a half-life of 6 to 8 h.15,87 Use of ipratropium has been associated with reduced exacerbations, hospital admission, and length of stay in asthma, with an NNT of 1 to reduce hospitalization in acute asthma.88–93 Although GOLD guidelines recommend using a SABA first in AECOPD, the literature suggests combing albuterol with ipratropium is more effective in bronchodilation and reducing hospital admission.11,92
Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department
2016, Emergency Medicine Clinics of North AmericaRoflumilast for asthma: Weighing the evidence
2015, Pulmonary Pharmacology and TherapeuticsSelective PDE inhibitors as novel treatments for respiratory diseases
2012, Current Opinion in PharmacologyCitation Excerpt :In an attempt to find new drugs for the treatment of respiratory diseases that have a wider therapeutic window than theophylline, a considerable body of work has been undertaken to look for more selective PDE inhibitors. Theophylline has been show to inhibit the activity of a cyclic 3′, 5′ nucleotide PDE with a Ki of 100 μM [7] and this activity has been suggested to contribute to its ability to promote suppressor cell activity in lymphocytes [8] and its beneficial anti-inflammatory actions in patients with asthma [9] and COPD [10]. This research has in part, promoted an interest in the role of the various PDEs in regulating cyclic AMP levels within relevant cells involved in asthma and COPD and in the potential for modulating the function of such cells following inhibition of this enzyme with highly potent and selective inhibitors.