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Chronic Obstructive Pulmonary Disease (COPD) – Reading & Sharing

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States.

Conventional COPD treatments:

  • Inhaled therapy
    • Inhaled bronchodilator therapy: metered-dose inhalers and spacers, dry powder inhalers, or wet nebulizers
    • Inhaler technique should be assessed to ensure that a patient is able to use a device effectively.
    • The combination of a long-acting anticholinergic with an as-needed short-acting beta-agonist is a standard initial approach.
    • For many patients with advanced COPD, the addition of a combination inhaler containing a long-acting beta-agonist and an inhaled corticosteroid to a long-acting anticholinergic agent provides benefit in terms of symptom management and quality of life.
  • Systemic therapy
    • Theophyllines (Theo-24, Elixophyllin)
      • Has been shown to have beneficial anti-inflammatory effects and can reduce oxidative stresses that are increasingly recognized as a feature of COPD.
      • ***side effects continue to be an issue and the adverse effects often outweigh the benefits for many patients. Risks of toxicity through interactions with some antibiotics also pose potential limitations to their use and the need to monitor blood levels can be especially difficult for the many patients who are housebound as a result of their advanced disease.
    • Phosphodiesterase 4 (PDE4) inhibitors
      • Have been shown to reduce key inflammatory cells and mediators, but they do not have bronchodilator properties and their effect on patients’ perception of dyspnea is modest at best.
      • The most commonly reported adverse effects including diarrhea, nausea, headache, and weight loss. The potential for gastrointestinal toxicity suggests that the PDE4 inhibitors should be used with caution in cachectic patients.
    • Corticosteroids
      • Systemic steroids are not recommended for long-term use due to negative side effects and lack of compelling data demonstrating significant benefit.
        • Common side effects:
          • Oral corticosteroids: fluid retention, swelling in lower extremities; high blood pressure; problems with mood swings, memory, behavior, and other psychological effects, such as confusion or delirium; upset stomach; weight gain with fat deposits in your abdomen, face, and the back of the neck. (long term used may also experience elevated pressure in eyes; clouding of the lens in one or both eyes; mood face; high blood sugar, increased risk of infections especially with common bacterial viral and fungal microorganisms; thinning bones and fx; suppressed adrenal gland hormone production that may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness; thin skin, bruising, and slower wound healing.
          • Inhaled corticosteroids may also experience oral thrush and hoarseness
  • Oxygen therapy
    • In acute exacerbations of COPD
      • Common symptoms of COPD: worsening shortness of breath, increased cough (with or without increased sputum production), change in sputum colors, wheeze, chest tightness, fatigue, decreased appetite, and for some, change in mood.
    • Long-term oxygen therapy for hypoxaemic COPD
    • supplemental oxygen for the mildly hypoxaemic patient

COPD symptom burden related to dyspnea- Dyspnea and fear coexist

  • Fear, anxiety, and panic, are common in advanced COPD, when unrecognized, underestimated, and untreated, can cause overwhelming “dyspnea crises” the occurrence of which may be adding to the fear of death when dyspnea worsens.
  • Dyspnea Crises are defined in a recent American Thoracic Society consensus statement as a sustained and severe resting breathing discomfort that occurs in patients with advanced often life-limiting illness and overwhelms the patient and caregivers’ ability to achieve symptom relief.
    • Anxiolytics seem relatively unhelpful in the management of dyspnea, but may be useful for treating coexisting anxiety that can worsen dyspnea
    • a start low goes slow titration schedule for opioids, an approach supported by recent clinical trial data is suggested.

“When” to initiate advanced care planning?

  • forced expiratory volume in 1 sec less than 30%, oxygen dependence
  • one or more acute exacerbation COPD hospital admissions in the past 12 months
  • weight loss or cachexia
  • decreased functional status
  • increased dependence on others
  • age >70
  • lack of additional therapeutic options

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