Pulmonary specialists have a variety of options to choose from when designing treatment for individual patients. If patients smoke, getting them to quit is the most important step in controlling COPD and preventing further lung damage. Medications cannot reverse permanent damage to the lungs. But in most cases, they can help ease shortness of breath. With progression of damage, the lungs' ability to transfer oxygen into the blood decreases and oxygen therapy may be needed. Oxygen therapy helps supply the body with this needed gas and should not be viewed as a treatment of last resort.
Pulmonary rehabilitation, an often-overlooked form of therapy, may actually be the most beneficial of the various treatment options. All PR programs include an exercise program, patient education, and assessment of the person's psychosocial status. Some also include smoking cessation and attempts to identify conditions commonly associated with COPD such as heart failure, depression, and osteoporosis. Research shows that this comprehensive approach to treating COPD results in less breathlessness and a better quality of life. Also, for small group of COPD patients, one of several surgical procedures, such as lung volume reduction, may be appropriate.
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There are many medicines that can help people with COPD feel better. Some are taken on a regular schedule and some only when patients feel short of breath (rescue medications). Rescue medications may also be taken prior to physical activity or exercise in order to help decrease shortness of breath. Many patients are prescribed a combination of these two types of medications.
There is no "best" drug regimen. The regimen should be tailored to a patient's individual symptoms and needs. Close communication with healthcare providers about medications is key for good control of COPD, so patients should not be shy about asking questions about their medication—such as why it has been prescribed, when it should be taken, and how much to take—and reporting adverse side effects.
Three types of medications generally are prescribed for patients with COPD. This section has more on:
Bronchodilators help patients breathe more easily by relaxing smooth muscle around the bronchial tubes. The medicines come in pill form, or they may be administered with an inhaler. Some patients need to take more than one kind of bronchodilator. There are three types:
Beta-2 agonists: These medications may be either short- or long-acting. Long-acting bronchodilators do not work as quickly as the short-acting ones, but they last longer (up to 12 hours). Short-acting bronchodilators work within minutes to relieve episodes of breathlessness, and their effect can last up to four hours. Side effects of these drugs include anxiety, tremor, lowering of blood potassium, and heart palpitations. Common inhaled long-acting beta agonists include:
- Serevent® (salmeterol)
- Foradil® (formoterol)
- Common inhaled short-acting beta agonists include:
- Proventil®, Ventolin®, HFA (albuterol)
- Alupent® (metaproterenol)
- Maxair® (pirbuterol)
Anticholinergics: These bronchodilators relax and open airways. They are prescribed to help patients take fuller breaths and are generally administered through inhalers. The short-acting preparation, ipratropium (Atrovent®), lasts four to six hours; the long-acting, tiotropium (Spirivia®), up to 36 hours. Side effects include nervousness and a cough.
Theophylline: This third-line, long-acting drug relaxes and opens airways and is administered orally or intravenously. The dosage of this drug must be closely monitored because the therapeutic window is narrow and toxic levels easily achieved. High levels can lead to nausea, vomiting, heart rhythm problems, and seizures. This medication also interacts with a large number of other medications, including some antibiotics, antihistamine ulcer medications, and tranquilizers. Brand names include Theoair®, Theo-24®, and Uniphyl®.
Anti-inflammatory drugs, also called steroids, help reduce and prevent swelling inside the lungs' airways and decrease mucus production. They may be swallowed or administered through an inhaler. Patients generally experience fewer side effects with inhaled steroids than with steroid pills or syrups.
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These medications are quite safe and cause relatively few side effects. The most common are hoarseness, a cough, and thrush, a yeast infection of the throat or mouth that causes a white coating on the tongue. Rinsing the mouth and spitting out the water after inhaling the medication reduce the risk of thrush as does using a spacer with your inhaler. A spacer is a chamber attached to the inhaler into which you release the dosage. By breathing in and out two or three times slowly, people can typically draw more of the medication into the lungs than by using the inhaler alone.
Common inhaled steroids include:
- Vanceril®, Beclovent®, and Qvar® (beclomethasone)
- Azmacort® (triamcinolone)
- Aerobid® (flunisolide)
- Flovent® (fluticasone)
- Pulmicort® (budesonide)
This section has more on devices for delivering inhaled steroids.
Common inhaler types include:
Metered-dose inhaler. You squeeze the inhaler, and a measured dose of medicine in mist form is released.
Breath-activated metered-dose inhaler. No need to squeeze the inhaler; it is activated by breathing.
Dry-powder inhaler The medication is in powder form and is drawn into the lungs by breathing; no propellant is used.
Nebulizer. A small machine transforms liquid medication into mist, which is breathed in through a mask or mouthpiece.
Whichever type of device you use, you must use it correctly so as to avoid losing much of the drug to your mouth and stomach, and to get the most benefit from the medication. Your healthcare provider may ask you each time you visit to demonstrate your inhaler technique to make sure you're using it correctly. If you have any doubts, you should express them to your doctor.
Metered-dose inhalers can be tricky to use because of the necessity of coordinating a hand movement with inhalation. Attaching a spacer, a chamber that holds the released dose of medicine so you can breathe it in slowly, can help. Common spacers include:
- E-Z Spacer®
To help you determine how long the canister will last so you can ensure that you always have an adequate supply of the medicine, date the canister of the metered-dose inhaler when you start using it. The canister is marked with the number of puffs it contains. Then be sure to count how many puffs you use each day. Divide the number of puffs in each inhaler by the number you use each day.
Most people with COPD are not helped by long-term use of these medicines. Moreover, over the long term they cause side effects including osteoporosis, hypertension, skin fragility, muscle weakness, cataracts, nervousness, depression, and irritability, along with memory and learning problems.
Rarely, people who cannot or will not effectively use an inhaler or who do not experience benefit from inhaled steroids may require steroid pills or syrups as part of their routine treatment for weeks, months, or longer. In this circumstance, the lowest possible effective dose should be used. People with COPD requiring routine steroid pills should be under the care of a specialist (a pulmonologist or allergist).
In contrast to the prohibition against their long-term use, many people with COPD periodically require a short-term (seven-to-10-day) burst of steroid pills or syrups to decrease the severity of acute attacks (called exacerbations) and prevent an emergency-room visit or hospitalization. With this regimen, the pills or syrups may be prescribed for periods ranging from a couple of days to several weeks. Many people experience some mild side effects such as increased appetite, fluid retention, moodiness, insomnia, or stomach upset. These side effects typically subside after the medicine is stopped.
Oral steroids include:
- Deltasone® (prednisone)
- Medrol® (methylprednisolone)
People with COPD are more susceptible to bacteria and viruses and so get more lung infections. Some people with COPD take antibiotics only when they get pneumonia or other infections. Others take antibiotics most of the time. Every person with COPD should get the flu vaccine annually and the pneumonia vaccine every seven to 10 years. Check with your doctor on the recommendations for these vaccines.
Some antibiotics commonly prescribed for lung infections:
- Amoxil (amoxicillin)
- Bactrim and Septra (trimethoprim/sulfamethoxazole)
- Keflex (cephalexin)
- Biaxin (clarithromycin)
- Ceftin (cefuroxime axetil)
- Cipro (ciprofloxacin)
Breathing exercises can help you feel less short of breath. They should be practiced every day, and especially when you feel short of breath or are exercising.
Pursed-lip breathing: People with COPD have air trapped in their lungs. Pursed-lip breathing helps get rid of this air.
- Breathe in slowly through your nose for two seconds.
- Purse your lips like you are going to whistle.
- Breathe out through pursed lips for four seconds or more until your lungs feel empty. Breathe out naturally; don't push the air out of your lungs.
Diaphragmatic breathing: This technique promotes diaphragm use and recruits the lower respiratory muscles.
- Breathe in slowly and deeply through your nose.
- While breathing in, push your stomach out. Place your hand on your stomach so you can feel your stomach going out.
- Breathe out slowly and deeply through your mouth. While breathing out, let your stomach relax. Feel your stomach going in with your hand.
Count 1, 2 when breathing in.
Count 1, 2, 3, 4 while slowly breathing out.
People with COPD produce extra mucus. The extra mucus can collect in your lungs, which makes breathing more difficult and puts you at increased risk of lung infections. Special ways of coughing, including deep coughing and huff coughing, can help you bring up that mucus. Be sure to use your inhaler before you try to bring up extra mucus. The medicine will open your lungs and loosen the mucus.
Deep coughing: This technique is not a hacking cough, and it's much stronger than clearing the throat. Deep coughing will not tire you out the way a long coughing spell will.
- Take a deep breath.
- Use your stomach muscles to cough hard, one to two times, not more.
- Spit out the mucus.
Huff coughing: Do a huff cough if you feel mucus moving.
- Take a really deep breath.
- Use your stomach muscles to make a series of three rapid exhalations with the airway open, making a "Ha, ha, ha" sound.
- Follow with controlled diaphragmatic breathing.
- Spit out the mucus.
Your doctor may also speak with you about other techniques and devices for bringing up mucus, including:
Small devices you breathe into, such as Acapella DM®, Acapella Choice®, and Flutter Valve®; The Vest®, an inflatable vest that shakes the chest; and postural drainage and clapping, two techniques that use gravity to promote drainage from the lungs.
Many people with COPD benefit from oxygen therapy. Oxygen therapy is necessary when there is not enough oxygen in the blood. This might be appropriate for you if you:
- Often feel short of breath
- Feel irritable or cranky
- Have headaches in the morning
- Have swollen ankles
- Have limited tolerance for exercise
Your doctor can measure blood oxygen levels with a small device that clips on the fingertip (pulse oximeter) or by drawing and analyzing blood from one of your arteries (a test known as arterial blood gases).
If blood levels are low, your doctor will prescribe compressed or liquid oxygen. Some people need it only when they sleep, some people need it when they exercise, and some people need it 24 hours a day.
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There are three systems for supplying oxygen:concentrators, compressed-gas systems, and liquid systems. Each system has advantages and disadvantages. It is important to choose the system that best fits your lifestyle. The oxygen supply company should explain and demonstrate the system you select.
Whichever system you choose, the oxygen may be delivered to your body in a variety of ways. A nasal cannula may be placed under the nostrils. Oxygen can also be delivered by a face mask. A transtracheal oxygen catheter can be used when oxygen therapy is used continuously for a long time at a high flow rate. This thin tube is placed in your neck so oxygen is delivered directly into your windpipe (trachea).
Concentrators are commonly used because they are convenient for both the patient and the oxygen supply company. Concentrators plug in to an electrical outlet and extract oxygen from the room air. These systems can add to the monthly cost of electricity, are relatively noisy, and produce more heat than other types of systems. If you live in a rural area or have frequent power outages, you may need a backup system. When ambulatory, you may need an additional system to use when you go outside your home. Newer, portable, battery operated concentrators are available.
Compressed gas systems have steel or aluminum cylinder tanks of varying sizes. The smaller sizes are portable, although this system is a bit more bulky than portable liquid systems.
Liquid systems have two parts—a large stationary container and a portable unit with a small lightweight tank. You can refill your portable unit from the stationary unit. The oxygen supply company will visit periodically to refill the stationary unit.
If you need a lot of oxygen or want to be very active, your healthcare provider may consider an oxygen-saving device for you—one, for example, that delivers oxygen in a pulsed rather than continuous fashion.
You may be concerned that "wearing" oxygen will prevent you from leaving your home or otherwise change your lifestyle. The opposite is true. It will enable you to leave your home for long stretches of time. In fact, many convenient portable systems are now available, so for many patients oxygen therapy is actually liberating in that it permits them to be more active than before.
You may also worry whether oxygen therapy is safe. Oxygen therapy does not cause any harm to your lungs or your body, if used as prescribed, and you cannot develop an addiction to oxygen. The only thing you need to remember about safety is to keep your face and your oxygen away from flames.
Talk with your healthcare provider if you have specific safety concerns.
Pulmonary rehabilitation programs help people with chronic lung diseases, including COPD, better manage their condition through breathing retraining, exercise, nutritional counseling, and emotional support. The goal of pulmonary rehab is to help people lead satisfying lives by restoring them to their highest functional capacity.
There are many differences in the scheduling, length, and individual components of these programs. Because of these differences, the cost may vary. The cost also may be influenced by the geographic location, the type of center, and the type of healthcare professionals involved in the program. For example, programs with medical evaluation and individualized exercise training are more costly than programs where exercise is simply recommended and education occurs in group sessions.
Medicare and most insurance plans provide varying levels of coverage. Coverage depends on the severity of your lung disease, billing procedures, and the number of services provided. To find a program, check with your local American Lung Association or a hospital in your area.
When considering programs, keep these important questions in mind:
- Do you need a referral from a doctor?
- Is there active involvement by a team of healthcare providers?
- What services does the program offer?
- How long does the program last?
- What activities can you expect?
- Does your insurance cover the program?
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Physical conditioning activities are a key part of a pulmonary rehab program. These activities can improve the function of your heart and lungs and strengthen the muscles used for breathing.
It is common for people with respiratory disease to limit physical activities because they are fearful of becoming short of breath. When you become inactive, however, your muscle strength decreases and breathing can become even more labored. Pulmonary rehab enables you to pursue activities to the fullest extent of your abilities. It also helps you to maintain physical fitness and regain control of your breathing. Exercise training can occur one-on-one or in a group setting. It may include walking, stationary bicycling, water exercises, or simple aerobics, as well as instruction in breathing and relaxation techniques and conserving energy for daily activities.
Educational activities are an important part of a successful pulmonary rehab program for both patient and family. The educational component of a program may include written materials and group and individual classes. Videos and other visual aids may also be used. One-on-one sessions with healthcare professionals are particularly helpful for reviewing specific medications, treatments, and self-management at home.
A variety of emotions, including anxiety and depression, can interfere with daily functioning and increase shortness of breath. Studies show that depression is common because of the limitations caused by the chronic respiratory condition. Psychosocial counseling can help you and your family cope. Classes on stress management and relaxation exercises may be offered. Some rehab programs also have a support group for you and your family.
Poor nutrition is common among persons with chronic lung disease, and being underweight is an additional risk factor. Shortness of breath and fatigue can interfere with your ability to eat a balanced diet. The amount and type of food, as well as the timing of meals, can cause increased shortness of breath. A dietitian can counsel you about your diet, and group classes can instruct you in selecting and preparing foods. The dietitian may develop an individualized plan for you if problems like fatigue, shortness of breath, or poor appetite interfere with your eating a healthful diet.
The recently completed, five-year National Emphysema Therapy Trial (NETT) demonstrated that some individuals may benefit from the surgical removal of emphysematous lung. In these cases, the remaining functional lung can expand into the space left behind and improve ventilation. The study established criteria for determining who would and who would not benefit from this procedure. If you have been shown to have a lot of localized emphysema on a chest X-ray or CT scan, you should ask your doctor to help you arrange for evaluation at a medical center where this type of surgery is done, preferably by surgeons who participated in this study. The surgery is not for everyone with severe COPD and may pose an unacceptable risk for some. That is why the evaluation must be done by experts.
Last reviewed on 11/9/09
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