Treatment of Stable Chronic Obstructive Pulmonary Disease (COPD)

Supplementary Treatments for Chronic Obstructive Pulmonary Disease (COPD)

Pulmonary Rehabilitation

Pulmonary rehabilitation is a multidisciplinary program that is designed to maximize physical function and improve quality of life of people with chronic obstructive pulmonary disease (COPD). It is recommended for patients with COPD whose symptoms become worse upon exertion as well as for patients who experience frequence acute exacerbations of COPD symptoms. There are three major components of pulmonary rehabilitation:

  • Exercise training - Usually involves a 2-month program of supervised exercise sessions (2 or 3 sessions per week) on an outpatient basis. In between formal, supervised sessions, patients are encouraged to exercise at home.

  • Patient education - Teaching COPD patients methods of breathing control, relaxation techniques, the benefits of exercise, and the importance of smoking cessation is a major goal of the patient education aspect of pulmonary rehabilitation. Patient education may be done on an individual basis or in a group setting.

  • Nutritional advice - For reasons that are not well understood, many COPD patients are underweight initially, however, over time, they tend to become overweight due to a lack of physical activity and overeating. Nutritional advice regarding eating a well-balanced, low-fat diet to maintain appropriate body weight is also a major objective of a multidisciplinary pulmonary rehabilitation program.

Supplemental Oxygen Therapy

Patients with chronic obstructive pulmonary disease (COPD) who develop hypoxemia (low levels of oxygen in the bloodstream) will usually require supplemental oxygen therapy to increase the levels of oxygen in the bloodstream. For patients with stable COPD, supplemental oxygen therapy is done in the home setting. Studies have shown that supplemental oxygen therapy can substantially improve exercise tolerance in people with COPD and can also reduce mortality.

Patients who experience frequent acute exacerbation of COPD symptoms (e.g., cough; increased sputum production; worsening shortness of breath)that may lead to respiratory failure will usually require non-invasive ventilation. In non-invasive ventilation, the patient receives respiratory support in the hospital through a face mask or a nose mask that is connected to a portable ventilator. Non-invasive ventilation is indicated for patients with acute exacerbations of COPD who develop respiratory acidosis where the pH of the blood drops to 7.35 or lower and who have an elevated arterial carbon dioxide pressure (PaCO2) level.

The Role of Surgery in Severe Emphysema

Emphysema is a lung disease characterized by breathing difficulty that is caused by an enlargement of the air sacs (alveoli) in the lungs. Surgery is a treatment option for people with advanced emphysema whose symptoms can no longer be controlled with medical therapy. In general, there are three surgical procedures that may be considered for people with advanced emphysema:

Bullectomy

Some people with severe emphysema develop large air spaces in teh lungs called giant bullae that can not only interfere with breathing but can also cause other complications such as lung absesses or a collapsed lung. Surgical removal of these giant bullae, a procedure known as a bullectomy, can help patients breathe more easily and prevent further complications. In general, a bullectomy may be considered for patients with severe emphysema in the following situations:

  • When compression of the adjacent lung by the giant bullae is thought to contribute to the patient's breathing difficulties.
  • In patients with severe emphysema who develop hemoptysis (spitting-up blood from the lungs).
  • If the giant bullae repeatedly cause a pneumothorax (collapsed lung).
  • If the presence of the giant bullae results in the patient developing repeated lung infections.

In many cases, it is not possible to surgically remove the giant bullae and, therefore, careful patient selection is critical to ensure a successful outcome with a bullectomy.

Lung-Volume Reduction Surgery

Lung-volume reduction surgery (LVRS) is a surgical procedure during which the surgeron removes about 25% of the diseased upper lobe of the lung so that the remaining healthier areas can function better. This procedure is usually reserved for patients with severe emphysema and has been shown to improve breathing, lung capacity, and quality of life.

Lung-volume reduction surgery may be performed by one of the following two surgical techniques:

  • Midline sternotomy - open chest surgery that enables the surgeon to visualize the lungs directly and remove the diseased areas.

  • Video-assisted thoracoscopy (VATS) - this is a less-invasive type of surgery whereby the surgeon creates a series of small incisions in the lateral chest wall and then surgically removes the diseased areas of the lung using a laser under video-assisted guidance.

The effectiveness of LVRS was demonstrated by a large randomized, controlled clinical trial known as the National Emphysema Treatment Trial the results of which were published in the May 22, 2003 issue of the New England Journal of Medicine. The study found that, compared to patients who were managed by medical therapy, patients with severe emphysema who underwent LVRS had:

  • Improvement in lung function
  • Improvement in the 6-minute walk distance test
  • Improvement in exercise capacity as determined by peddling on a stationary bicyle
  • Improvement in dyspnea (shortness of breath)

In general, patients who are most ideally suited for LVRS are people with severe emphysema of the upper lobe of the lung who also have impaired exercise tolerance and the most successful outcomes have been reported for patients with these characteristics.

Lung Transplantation

Lung transplantation is usually considered as a treatment of last resort for patients with severe emphysema. The major factor limiting the widespread use of lung transplantation is the shortage of lung donors. Once a suitable donor has been found, lung transplantation may be undertaken with replacement of either a single lung or both lungs. Studies have shown that lung transplantation for severe emphysema results in improved lung function, better exercise capacity, and an overall improvement in quality of life. Survival rates for patients undergoing lung transplantation of severe emphysema have been reported to be as follows:

  • One-year = 90%
  • Between one to two years = 65% to 90%
  • Five-years = 41% to 53%

In general, patients with severe emphysema may be considered for lung transplantation if they are under age 65 and are otherwise healthy without any other serious underlying medical conditions.