REVIEW ARTICLE

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HOLISTIC MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN PRIMARY CARE

Althought the number of studies evaluating the usefulness of influenza and pneumococcal vaccines for COPD patients are still limited, vaccinations in the elderly population have been shown to reduce pneumonia and hospitalisation and deaths by 30-40%.²² Annual influenza vaccines can reduce serious illness and death in COPD patients by about 50%.²³

Long term oxygen therapy of more than 15 hours per day should also be considered if the patient is hypoxaemic (PO2 < 7.3 kPa or PO2 7.3-8 kPa with cor pulmonale or polycythaemia) as it has been shown to improve survival.²⁵ This long term oxygen therapy should be delivered by an oxygen concentrator. A careful assessment should be made by a respiratory physician as oxygen therapy is not without any hazards. Excessive oxygen therapy in COPD patients can precipitate carbon dioxide retention. The aim is to increase the baseline Po2 to at least 8 kPa or oxygen saturation of at least >90% at rest. Oxygen therapy at home should not be prescribed in patients who continue to smoke because of the risk of fire and burns to the face.

Pharmacological therapy

None of the existing medications in COPD have been shown to modify the long term rapid decline in lung function which is the hallmark of the disease. Therefore, the medication is used to control and prevent the symptoms, reduce exacerbations, improve exercise tolerance and improve the quality of life of the COPD patient.

Bronchodilators are central to symptomatic management of COPD. Short acting bronchodilator therapy (salbutamol and ipratropium) are given for quick relief of symptoms.²⁶ Regular treatment with long acting bronchodilators such as β2-agonists (e.g. salmeterol, formoterol) and anticholinergics (tiotropium) improves lung function, increase exercise capacity, reduce exacerbations and improve quality of life.^14,15 Oral methylxanthines (theophylline) are relatively weak bronchodilators and, because its potential toxicity, is less preferred since inhaled bronchodilators are available. Recent understanding of the mechanism of dyspnoea in COPD shows that the long-acting tiotropium exerts its beneficial effects by reducing dynamic hyperinflation and the resulting increased labour of breathing, improving the sensation of dyspnoea and exercise capacity.¹⁴ The choice of long-acting bronchodilators depends on the availability of the medication and the patient’s response. By combining bronchodilators with different mechanisms, this may increase the degree of bronchodilatation and improvement in symptoms.

Inhaled corticosteroid (ICS) is recommended in symptomatic patients despite receiving adequate bronchodilator therapy, those with FEV1 of less than 50% predicted and have recurrent exacerbations.¹ Although treatment with ICS does not modify the long term decline in lung function in patients with COPD, regular treatment with ICS reduce exacerbation rates and improve health status.²⁷ Combination inhalers of long-acting β2-agonist and ICS have been shown to increase lung function, reduce exacerbations, improve health related quality of life and improve symptoms compared with monotherapy treatment.¹⁵

Exacerbations are important events for the COPD patients as it is associated with further rapid decline in lung function, poorer quality of life and increased risk of mortality.^16,17 Following an exacerbation, patients may take several weeks to return to their normal baseline condition. Exacerbations are usually defined clinically by increases in dyspnoea, cough, wheeze, sputum volume or purulence. Patients usually present to their primary care providers and the majority can be treated as outpatient.

Patients should initially increase their usual short acting β2-agonists bronchodilator therapy until the exacerbation resolves, e.g. salbutamol 2-4 puffs every 3-4 hours and short-acting anticholinergic therapy (ipratropium bromide) may be added until the symptoms improves.²⁸ If the inhalers are inadequate to relieve the acute symptoms, nebulisers can be given on as needed basis for several days if a nebuliser is available. There is evidence that the use of spacer device with metered dose inhaler has a similar effect as nebulised bronchodilators for exacerbations of COPD.¹

Patients with an exacerbation and significant dyspnoea should be treated with oral prednisolone as it has been shown to improve oxygenation, reduce recurrent exacerbations and reduce length of time in hospital.²⁹ Although there is a lack of studies looking at the optimal dose and length of treatment of oral prednisolone, a dose of 30-40 mg for 7-10 days for patients not requiring hospitalisation seems adequate. Antibiotics should be given to patients with increases in sputum volume and purulence indicating an infective exacerbation of COPD. Simple first-line antibiotics should be used and the choice of antibiotics should depend on the local antibiotic policy and the pattern of local pathogens.³⁰ Patients with severe acute exacerbations of COPD require admission to hospital for more intensive treatment and monitoring due to the severe narrowing of the airways. Indications for prompt hospital assessment or admission for acute exacerbations of COPD are outlined in Table 7.

Table 7: Indications for hospital assessment or admission for acute exacerbations of COPD

Case resolution

The patient was counselled regarding smoking cessation. His spirometry confirmed moderate airflow obstruction. He was started on inhaled long-acting anticholiergic (tiotropium) once daily and inhaled short-acting β2-agonists bronchodilator (salbutamol), 2 puffs as required. He was given verbal information and a leaflet regarding COPD, his inhaler technique assessed and advised to exercise regularly. He was followed up three months later when he reported that his cough and exercise capacity had improved but still required to take his salbutamol when he walks quickly. He was started on combination inhaler (inhaled corticosteroids and long-acting β2-agonists) and was given influenza vaccination. Subsequent follow up revealed that the patient’s symptoms and exercise capacity continued to improve.

CONCLUSION

COPD is a common respiratory disease with significant morbidity and mortality. Primary care providers play a significant role in detecting early disease in the population at risk to prevent further deterioration in lung function and quality of life. The severity of COPD should be assessed and the treatment goals should be individualised to achieve normal activity as much as possible. Treatment is directed to improve symptoms, reduce exacerbations and improve quality of life. Patients with COPD should have regular follow up to ensure response to treatment and to detect complications or other comorbidities as the usual course is progressive deterioration in symptoms and lung function.

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