Treatment of exacerbations
Treatment of an exacerbation of COPD involves adding extra medicines temporarily to your usual treatment. This is usually steroid tablets with or without antibiotics. These medicines are usually taken until your symptoms settle down to what is normal for you. If you have frequent flare-ups then your doctor may advise on a self-management plan. This is a written plan of action agreed by you and your doctor on what to do as soon as possible after a flare-up starts to develop. For example, you may be given advice on how to increase the dose of your inhalers when needed. You may also be given some steroid tablets and/or antibiotics to have on standby so that you can start these as soon as possible when a flare-up first develops. You will also be told when you need to seek medical attention – for example if you are concerned that you are not responding to treatment.
A short course of steroid tablets called (prednisolone) is sometimes prescribed if you have a bad flare-up of wheeze and breathlessness (often during a chest infection). Steroids help by reducing the extra inflammation in the airways which is caused by infections. Steroid tablets are usually taken once per day, often for between 5 to 14 days. Depending on the strength of the tablet, you might need to take 20-60 mg as a single daily dose. If your symptoms improve quickly, your doctor may tell you to stop taking the steroids at the end of the week. If your problems are more severe, the steroid tablets may be tailed off over several days or weeks. Occasionally, some patients take steroid tablets long-term. This is not always advised as there can be serious side-effects. Some important side-effects of steroids include osteoporosis (thinning of the bones due to reduced bone density), bleeding in the stomach (gastrointestinal bleeds), a lowering of the immune system (immunosuppression) – making infections more common, weight gain (and a condition called Cushing’s syndrome), and a lowering of the body’s natural ability to make certain hormones (adrenal suppression). If you need to have steroid tablets long-term, you will usually be given some medicines to protect your bones and prevent osteoporosis.
A short course of antibiotics is commonly prescribed if you have a chest infection, or if you have a flare-up of symptoms which may be triggered by a chest infection.
Admission to hospital
If your symptoms are very severe, or if treatments for an exacerbation are not working well enough, you may need to be admitted to hospital. In hospital you can be monitored more closely. Often the same drugs are given to you but at higher doses or in a different form. Tests such as a chest X-ray or blood tests to measure how much oxygen there is in your blood (arterial blood gases) can be performed. Chest physiotherapy can be started to help you clear secretions (mucus) from your chest by coughing and suction machines. If you are very breathless it may be impossible to use your inhaler. Nebulisers are machines that turn the bronchodilator medicines into a fine mist, like an aerosol. You breathe this in with a face mask or a mouth piece. Nebulisers are no more effective than normal inhalers but they are useful in people who are very fatigued (tired) with their breathing. You may need oxygen to help you breathe. Sometimes a special machine called bi-level positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP) is used to help you breathe. This is called noninvasive ventilation (NIV). It consists of a close-fitting facemask and drives oxygen into your lungs, forcing the airways open. It can make you feel a bit claustrophobic and it is quite noisy. In very severe cases, you might need more help with breathing, in an intensive care unit (ICU). A tube can be put into your windpipe and connected to a ventilator (a machine that ‘breathes’ for you). If you have severe underlying COPD (rather than just a severe exacerbation of COPD), this is not always the best option. About 2-4 patients in 100 admitted to hospital because of their COPD will die due to that illness. Between 1in 10 and 1 in 4 people admitted to ICU with severe COPD die.
End-stage chronic obstructive pulmonary disease
Palliative care should be discussed with all people with COPD who are likely to die in the coming year. It is always difficult to be accurate about prognosis (outlook). Mostly, health professionals talk in terms of ‘days’, ‘months’ or ‘years’ when discussing prognosis for any particular disease or illness. As COPD progresses, the condition becomes more severe. You might have more frequent exacerbations and/or admissions to hospital. These factors can give a clue as to how advanced the illness is. Palliative care is usually started in COPD when you are on the maximum medication and are continuing to deteriorate (get worse). Sometimes in these situations you might choose to remain at home for any/all treatments, rather than having further hospital admissions, as things get worse. Palliative care means care or treatment to keep a person as comfortable as possible, to reduce the severity of the disease, rather than to cure it. Mostly it is about helping you with your symptoms, to make them easier to bear. Your quality of life in the end stages of COPD is very important. Palliative care is not quite the same as terminal (end of life care), when someone is dying and death is expected within a few days. Palliative care can be given in a hospice, but is just as likely to be provided by family physician, district nurse or community palliative care team. Palliative care involves not just physical treatments. Psychological and spiritual wellbeing are important too. The aim is that both you and your family feel supported and that your care is planned. The idea is that a multidisciplinary team, with different healthcare professionals can anticipate any problems before they happen, and help you with access to medication and any equipment that might be needed. But there are no any palliative care centers in Nepal.
This may help some people with severe symptoms or end-stage COPD. It does not help in all cases. Unfortunately, just because you feel breathless with COPD it does not mean that oxygen will help you. Great care has to be taken with oxygen therapy. Too much oxygen can actually be harmful if you have COPD. To be considered for oxygen you would need to have very severe COPD, and be referred to a respiratory specialist (consultant) at a hospital. Tests are done to see how bad your COPD is, and how low the oxygen levels in your blood are. This might be done with a pulse oximeter or by taking a sample of blood from an artery in your wrist (blood gases analysis). These tests are needed to decide whether oxygen will help you or not. The monitoring of oxygen levels may take place over a period of several weeks, at rest and with exercises. If found to help, oxygen needs to be taken for at least 15-20 hours a day to be of benefit. Oxygen can be given with a face mask or through little tubes (nasal cannulae or ‘nasal specs’) that sit just under your nostrils. Portable oxygen is available in cylinders, but if you need long-term oxygen therapy (LTOT), for long periods of the day, an oxygen concentrator is required. This is a big machine (about two feet square and two and a half feet tall) that plugs into a normal electrical socket. The concentrator takes oxygen from the air in your room, and concentrates it, meaning that it is separated from other gases in air, so you only have pure oxygen to breathe in. A back-up supply of oxygen cylinders is provided if you have a concentrator, in case of an electrical power cut or machine breakdown. Normally, you will only be considered for oxygen if you do not smoke. There is a serious risk of explosion or fire when using oxygen if you smoke. Oxygen might be used to treat an exacerbation of COPD in hospital but would not be prescribed short-term for an exacerbation to be used at home. Oxygen might be used in an emergency whilst awaiting transfer to a hospital (for example, by a paramedic).
Medicines such as morphine and codeine may be prescribed to try to reduce your coughing, and to help with breathlessness. Hyoscine is a medication that can be given to try to dry up secretions from your lungs. Anxiety is a common symptom when you are breathless. Morphine can help the feelings of anxiety. In some cases, other anti-anxiety drugs (such as diazepam) can be given. Depression and anxiety are common in patients with COPD, at all stages of the disease. You may already be prescribed medication for this.