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Chronic Obstructive Pulmonary Disease (COPD) (cont.)

Other COPD Medications and Treatments

Combination Bronchodialators and Steroids

Several options are now available combining steroids and long acting bronchodialators. Several brand names are useful in the treatment of COPD (for example, fluticasone and salmeterol [Advair], budesonide and formoterol inhalation [Symbicort], formoterol and mometasone [Dulera]) with newer agents requiring only once a day dosing (Brio Ellipta).

PDE4 Inhibitors

This new class of agents inhibit the enzyme phospodiesterase type 4 involved in some of the inflammation associated with COPD. Roflumilast (Daliresp) has been shown to reduce exacerbations of COPD in select individuals, primarily those with more chronic bronchitic symptoms.

Oral Steroids

Corticosteroids are used for people who do not improve sufficiently after trying other drugs or for those who develop an exacerbation (an increase in the severity of COPD and its symptoms).

Oral steroids have been used successfully to treat acute exacerbations, and improve symptoms and lung function in this circumstance. Oral corticosteroids are generally not recommended for long-term use because of their potential side effects.

Antibiotics

In people with COPD, chronic infection of the lower airways is common. The goal of antibiotic therapy is not to eliminate organisms, but to treat acute exacerbations.

This therapy is most beneficial for people whose exacerbations are characterized by at least two of the following (ie, Winnipeg criteria):

  • increased shortness of breath,
  • increased sputum production, and
  • increased sputum purulence.

First-line treatment choices include amoxicillin, cefaclor (Raniclor), or trimethoprim/sulfamethoxazole (Bactrim DS, Septra, Septra DS, SMZ-TMP DS, Sulfatrim Pediatric). Second-line treatment choices include azithromycin (Azithromycin 3 Day Dose Pack, Azithromycin 5 Day Dose Pack, Zithromax, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax), clarithromycin (Biaxin, Biaxin XL, Biaxin XL-Pak), and fluoroquinolones.

Recent data suggest that for select COPD patients chronic use of azithromycin may reduce exacerbations, and improve quality of life. But in some patients, significant hearing loss was noted. Resistant strains of certain bacteria may occur especially non-tuberculous mycobacterium (atypical mycobacteria).

Mucolytic Agents

Mucolytic agents can reduce sputum viscosity (resistance to its flow), but may also improve sputum clearance. Some have prescribed dornase alpha (Pulmozyme) for use in COPD but it is only approved for use in cystic fibrosis. Currently, there is no proven benefit.

Oxygen Therapy

COPD is commonly associated with worsening oxygenation of the blood (hypoxemia).

Many people with COPD who are not hypoxemic at rest have worsening of their blood oxygen level during exertion. Even though studies to determine the long-term benefit of oxygen solely for exercise have not yet been conducted, home supplemental oxygen is commonly recommended for people whose blood oxygen level falls with exercise. Oxygen supplementation during exercise can prevent increases in pulmonary artery pressure, reduce shortness of breath, and improve exercise tolerance.

Oxygen therapy for people with COPD may be needed during air travel because of low airplane cabin pressure. If flying, patients should arrange supplemental oxygen prior to the flight directly through the airline or through an airline agent (at an extra expense). Airplane cabins are pressurized to the equivalent of 5000-8000 feet altitude. A special test, called a Hypoxemic Altitude Simulation Test (HAST), can help determine the need for travel when flying. Alternatively, if one lives near a mountainous area, a portable oximeter can be used to monitor for desaturations (decreased oxygen saturation) at altitude. If any desaturations occur, drive to a lower altitude. This is not quite as easy when flying in an airplane.

Sleep results in a mild decrease in oxygenation for most people. If a person's oxygen level is already borderline, sleep may result in more serious drops in oxygenation in the blood. Supplemental oxygen may be of benefit for some COPD patients during sleep. It is also not uncommon for this population to also have obstructive sleep apnea (OSA).

Oxygen therapy is generally safe. Toxicity from high concentrations of oxygen is well recognized, but little evidence suggest it could be harmful at low concentrations.. It has been demonstrated, that when people with low oxygen levels use supplemental oxygenation, they're life expectancy increases. Because of these studies, providing oxygen to COPD patients with chronically low oxygen levels will increase their life expectancy and improve quality of life. It is presumed, but unproven that using oxygen with exercise or sleep for intermittently drops in oxygen levels will also be beneficial. It definitely does help in exercise endurance in this patient group.

The major physical hazards of oxygen therapy are fires or explosions. People with COPD, their family members, and their caregivers are warned not to smoke when supplemental oxygen is in use. Overall, major accidents are rare and can be avoided by proper training.

Oxygen Delivery Systems

Long-term oxygen therapy (LTOT) is typically delivered by continuous flow nasal cannula. This method is the standard means of oxygen delivery because it is simple, reliable, and generally well tolerated. At home, a machine called an oxygen concentrator is the usual means through which oxygen is delivered. Portable tanks provide the opportunity for people with COPD to continue their oxygen therapy while away from home.

Oxygen-conserving devices enable the use of smaller, lighter, and more portable oxygen tanks. Oxygen-conserving devices function by delivering all of the supplemental oxygen during early inhalation (breathing in). In addition, they may reduce overall costs.

Three oxygen-conserving devices exist:

  1. reservoir cannulas,
  2. demand pulse delivery devices, and
  3. transtracheal oxygen delivery.

Transtracheal oxygen delivery is invasive and requires special training by the patient, a health care professional, and caregiver.

More recently, portable battery operated oxygen concentrators have been developed. These are light weight and easy to use, even strapping to a belt buckle. Unfortunately, these units are very expensive and often not covered by insurance.

Assisted Ventilation

Progressive airflow obstruction may impair oxygenation and/or ventilation to the point where the patient may require assisted ventilation.

General guidelines that are used in determining the ideal time to begin ventilatory support are as follows:

  • The patient has a progressive worsening of respiratory acidosis and/or an altered mental state.
  • The patient has significant hypoxemia despite supplemental oxygen.
Medically Reviewed by a Doctor on 6/7/2013

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