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Medications

Your health care provider will determine if you need medication to relieve symptoms of COPD.

Smoking cessation using nicotine replacement therapies

The supervised use of medications is an important adjunct to smoking cessation programs.

Nicotine is the ingredient in cigarettes primarily responsible for the addiction. Withdrawal from nicotine may cause you to have unpleasant side effects, such as anxiety, irritability, difficulty concentrating, anger, fatigue, drowsiness, depression, and sleep disruption. These effects usually occur during the first several weeks after you stop smoking.

Nicotine replacement therapies reduce these withdrawal symptoms. If you require your first cigarette within 30 minutes of waking up, you are most likely highly addicted and would benefit from nicotine replacement therapy.

Several nicotine replacement therapies are available.

Nicotine polacrilex is a chewing gum. Chewing pieces come in 2 strengths (ie, 2 mg, 4 mg). If you smoke 1 pack per day, you should use 4-mg pieces. If you smoke less than 1 pack per day, you should use 2-mg pieces. You should chew hourly and also chew when needed for any initial cravings within the first 2 weeks. You should gradually reduce the amount chewed over the next 3 months.

Transdermal nicotine patches are also available. Patches are well tolerated. The most common side effect is slight skin irritation where the patch is placed. Nicotine replacement therapy patches are sold under the following trade names: Nicoderm, Nicotrol, and Habitrol. Each product has a scheduled decrease in nicotine over 6-10 weeks.

The use of the antidepressant bupropion (Zyban) is effective. It is a nonnicotine aid to smoking cessation. Bupropion may also be effective for those people who have not been able to quit smoking with nicotine replacement therapies.

Inhaled steroids

Some people with COPD who respond well to oral corticosteroids can be maintained on long-term inhaled steroids.

The use of these drugs is widespread, despite little evidence of efficacy in the treatment of COPD. Inhaled corticosteroids do not slow the decline in lung function. They do, however,  decrease the frequency of exacerbations and improve disease-specific and health-related quality of life issues for some people with COPD.

Inhaled corticosteroids have fewer side effects than oral steroids, but they are less effective than oral steroids, even at high doses.

Beta2 Agonists - Bronchodilators

Inhaled beta2-agonist bronchodilators relax and open the breathing passages. They work rapidly, typically within minutes.

Beta2 agonists are primarily used to relieve symptoms of COPD. Inhaled beta2 agonists are the treatment of choice for acute exacerbations of COPD. 
 
Two long-acting beta2 agonists (ie, formoterol, salmeterol) are available. They may be useful if you frequently use short-acting beta2-bronchodilators or if you experience symptoms at night.

Maintenance treatment with aerosolized anticholinergic agents (eg, ipratropium bromide) may be more effective than beta2 agonists for people with COPD, particularly in relieving shortness of breath.

Ipratropium bromide opens the breathing passages and has minimal side effects.

It is administered by a metered-dose inhaler, at 2-4 puffs 4 times a day. Beta2 agonists can be added as needed.

Although it is slower to take effect (eg, 30-60 min) than inhaled beta2 agonists, ipratropium bromide lasts longer. Because of this, it is less suitable for use on an as-needed basis.

People undergoing exacerbations of COPD respond well to inhaled beta2-agonists and anticholinergic aerosols (eg, ipratropium bromide). Treatment usually begins with an inhaled beta2-agonist delivered via a spacer or a nebulizer, which creates a mist of the drug. Delivering the drug this way also reduces the side effects. Inhaled ipratropium bromide is also usually added.

Long-acting bronchodilators

Methylxanthines, such as theophylline, are a group of medications chemically related to caffeine. They work in COPD by opening the breathing passages. In addition, methylxanthines reduce inflammation, improve respiratory muscle function, and stimulate the brain respiratory center.

Adding theophylline to the combination of bronchodilators can be beneficial, although the response to theophylline may vary among people with COPD. Their use has decreased over the last decade because of the risks of unwanted side effects. Side effects include anxiety, tremors, insomnia, nausea, cardiac arrhythmia, and seizures.

Oral steroids

Corticosteroids are used for people who do not improve sufficiently after trying other drugs or who develop an exacerbation.

Oral steroids have been used successfully to treat acute exacerbations. They 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 2 of the following (ie, Winnipeg criteria): increased shortness of breath, increased sputum production, and increased sputum purulence.

First-line treatment choices include amoxicillin, cefaclor, or trimethoprim/sulfamethoxazole. Second-line treatment choices include azithromycin, clarithromycin, and fluoroquinolones.

Mucolytic agents

Mucolytic agents not only reduce sputum viscosity (resistance to its flow) but also improve sputum clearance.

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, you should arrange supplemental oxygen prior to the flight directly through the airline or through an airline agent (at an extra expense).
 
Supplemental oxygen may also be needed for people with COPD whose sleep is disturbed by its symptoms.

Oxygen therapy is generally safe. Toxicity from high concentrations of oxygen is well recognized, but little is known about the long-term effects of low concentrations of supplemental oxygen. Because providing oxygen reduces the death rate of people with advanced COPD, the increased survival and quality of life benefits of long-term oxygen therapy outweigh the possible risks.

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.

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: reservoir cannulas, demand pulse delivery devices, and transtracheal oxygen delivery. Transtracheal oxygen delivery is invasive and requires special training by you, your health care provider, and your caregiver.

Assisted ventilation

Progressive airflow obstruction may impair oxygenation and/or ventilation to the point where you may require assisted ventilation.
 
General guidelines that are used in determining the ideal time to begin ventilatory support are as follows:

• You have a progressive worsening of respiratory acidosis and/or an altered mental state. 
  
  
• You have significant hypoxemia despite supplemental oxygen.