Chronic Obstructive Pulmonary Disease (COPD)

How can the course of the disease be altered?

Stop smoking. This is the single most important piece of advice. If you stop smoking in the early stages of COPD it will make a huge difference. Damage already done to your airways cannot be reversed, but stopping smoking prevents the disease from worsening. It is never too late to stop smoking, at any stage of the disease. Even if you have fairly advanced COPD, you are likely to benefit and prevent further progression of the disease. Your cough may get worse for a while when you give up smoking. This often happens as the lining of the airways ‘comes back to life’. Resist the temptation to start smoking again to ease the cough. An increase in cough after you stop smoking usually settles in a few weeks. Medication (such as varenicline, and bupropion) and nicotine replacement therapy (such as patches and chewing gum) can be prescribed, and counseling offered.

What are the treatments for chronic obstructive pulmonary disease?

Stopping smoking is the most important treatment. No other treatment may be needed if the disease is in the early stage and symptoms are mild. 

If symptoms become troublesome, one or more of the following treatments may be advised. (Note: treatments do not cure COPD. Treatments aim to ease symptoms. Some treatments may prevent some flare-ups of symptoms.)

As a general rule, a trial of 1-3 months of a treatment will give an idea if it helps or not. A treatment may be continued after a trial if it helps, but may be stopped if it does not improve symptoms). 
It can be helpful to consider treatments for three separate problems.

  • Treatments for stable COPD
  • Treatments for exacerbations of COPD
  • Treatments for end-stage COPD

Treatments for stable chronic obstructive pulmonary disease

The main treatments are medications given in devices called Rotahalers/inhalers. The medicine within the inhaler is in a powdered form, which you breathe in (inhale). Some people find inhalers more difficult than others to use. The medicines in standard inhalers reach the lungs better if used with a spacer device.

Short-acting bronchodilator inhalers

An inhaler with a bronchodilator medicine is often prescribed. These relax the muscles in the airways (bronchi) to open them up (dilate them) as wide as possible. The same inhalers may be used if you have asthma. People often call them relievers. They include:

  • Beta-agonist inhalers. Examples are salbutamol and terbutaline. These inhalers are often (but not always), blue in colour. Other inhalers containing different medicines can be blue too.
  • Antimuscarinic inhalers. For example, ipratropium. These inhalers work well for some people, but not so well in others. Typically, symptoms of wheeze and breathlessness improve within 5-15 minutes with a beta-agonist inhaler, and within 30-40 minutes with an antimuscarinic inhaler. The effect from both types typically lasts for 3-6 hours. Some people with mild or intermittent symptoms only need an inhaler as required for when breathlessness or wheeze occur. Some people need to use an inhaler regularly. The beta-agonist and antimuscarinic inhalers work in different ways. Using two, one of each type, may help some people better than one type alone.

Long-acting bronchodilator inhalers

These work in a similar way to the short-acting inhalers, but each dose lasts at least 12 hours. Long-acting bronchodilators may be an option if symptoms remain troublesome despite taking a short-acting bronchodilator.

  • Beta-agonist inhalers. Examples are formoterol and salmeterol (a green-coloured inhaler). You can continue your short-acting bronchodilator inhalers with these medicines.
  • Antimuscarinic inhalers. The only long-acting antimuscarinic inhaler is called tiotropium. If you start this medication, you should stop ipratropium if you were taking this beforehand. There is no need to stop any other inhalers.

Steroid inhalers

A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups (exacerbations) of symptoms. Steroids reduce inflammation. Steroid inhalers are only used in combination with a long-acting beta-agonist inhaler. (This can be with two separate inhalers or with a single inhaler containing two medicines). The main inhaled steroid medications are:

  • Beclometasone: These inhalers are usually brown and sometimes red in colour.
  • Budesonide
  • Ciclesonide
  • Fluticasone
  • Mometasone

A steroid inhaler may not have much effect on your usual symptoms, but may help to prevent flare-ups. In the treatment of asthma, these medicines are often referred to as preventers. Side-effects of steroid inhalers include oral (in the mouth) thrush, sore throats and a hoarse voice. These effects can be reduced by rinsing your mouth with water after using these inhalers, and spitting out.

Combination inhalers are available, usually containing a steroid medication and either a short-acting or long-acting beta-agonist.

Combination inhalers are useful if people have severe symptoms or frequent flare-ups. Sometimes is is more convenient to use just one inhaler device. Examples of combination inhalers are:

  • salmeterol and fluticasone.
  • formoterol and budesonide.

Because there are lots of different coloured inhalers available, it is helpful to remember their names, as well as the colour of the device. This might be important if you need to see a doctor who does not have your medical records

Bronchodilator tablets

Theophylline is a bronchodilator (it ‘opens’ the airways) that is sometimes used. It is used in stable COPD rather than in an acute exacerbation. Aminophylline is a similar drug (usually given by injection in hospital) but there are tablets.
The body breaks down (metabolises) theophylline in the liver. This metabolism varies from person to person. The blood levels of the drug, therefore, can vary enormously. This is particularly the case in smokers, people with liver damage or impairment, and in heart failure. In some conditions, the breakdown is reduced, and blood levels increase. In other conditions, the breakdown is increased and so blood levels of theophylline fall. This is very important as the toxic (dangerous) dose for theophylline is only just above the dose that is needed for the medicine to work well. Blood tests are done to measure the amount of theophylline in the blood, to check it is neither too high nor too low. Theophylline interacts with lots of other medicines too, so sometimes it cannot be prescribed, due to other medicines that you take. Theophylline commonly causes side-effects which include palpitations (fast heartbeat), nausea (feeling sick), headache and occasionally abnormal irregular heartbeat (arrhythmia) or even convulsions (fits).

Mucolytic medicines

A mucolytic medicine such as carbocisteine (Mucodyne) makes the sputum less thick and sticky, and easier to cough up. This may also have a knock-on effect of making it harder for bacteria (germs) to infect the mucus and cause chest infections. The number of flare-ups of symptoms (exacerbations) tends to be less in people who take a mucolytic. It needs to be taken regularly (usually two or three times per day) and is most likely to help if you have moderate or severe COPD and have frequent or bad flare-ups (exacerbations).

 

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