Chronic obstructive pulmonary disease (COPD)

Assessment and Plan: COPD (chronic obstructive pulmonary disease)

• Smoking
  • Smoking is the most common cause of COPD and therefore avoidance of smoking will prevent the disease.
  • Quitting smoking at any point will both prevent worsening of the disease and reduce exacerbations requiring hospitalization.
  • To quit smoking use a combination of several methods to assist in cessation. For instance, combine nicotine replacement with at least one additional method such as an exercise program, hypnosis, electronic cigarettes, or formal counseling such as support groups.
  • Resources to quit smoking: The recommendation to counsel patients to stop smoking, stop using tobacco products, and provide methods of cessation is reinforced by the USPSTF (10). Many resources are available to assist in smoking cessation such as the online sites:
    • 1) http://smokefree.gov/
    • 2) http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/
    • 3) Phone number for free help 1-800-QUIT-NOW.
  • Smoking among patients with cardiac rehabilitation was reduced by 36% (8), and this effect may be possible in patients undergoing Pulmonary Rehab programs.

• Medication regimen for COPD: Strict compliance to the medications prescribed by the patient’s Primary care physician or Pulmonologist is important to improve COPD symptoms, control chronic inflammation and prevent additional chronic damage to airways.

• Prevention of infections in COPD:
  • Vaccinations to prevent infection: For the immunization schedules for adults over 19 years of age posted by the CDC please visit the link below:  http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf Centers for Disease Control and Prevention   1600 Clifton Rd. Atlanta, GA 30333, USA 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348 – Contact CDC–INFO (14)
  • Nutrition to reduce risk of infection in COPD:
    • Intake a variety of 5 fruits and vegetables per day after resting.
    • Fatigue and shortness of breath may reduce ability to eat.
    • Consume small meals and supplemental shakes often to reduce susceptibility to infection, and as with many chronic diseases, obtain vitamin levels for vitamin D, vitamin B12, thiamine, and folic acid.
    • Improvement in vitamin D levels may improve both respiratory and skeletal muscle strength (4).

• Oxygen therapy according to the COPD Working Group (1):
  • COPD patients with severe hypoxemia (PaO2 ~ 50 mm Hg) and heart failure, long-term oxygen therapy (~ 15 hours/day) decreased all-cause mortality.
  • However, at 3 and 7 years there was no beneficial effect of long-term oxygen therapy on all-cause mortality in patients with COPD who had mild-to-moderate hypoxemia (PaO(2) ~ 59-65 mm Hg).
  • May result in improvement of FEV1 and PaCO2 in COPD patients with severe hypoxemia and heart failure, but not in those with mild-to-moderate hypoxemia.
  • Oxygen therapy did not improve readmissions and limited data suggests that long-term oxygen therapy increases the risk of hospitalizations.
  • Oxygen may improve health-related quality of life for COPD patients with severe hypoxemia but more evidence is needed.

• Pulmonary rehabilitation and COPD:
  • Several simple exercise tests may be useful for assessment of functional exercise capacity as described by Divo and Pinto-Plata (2):
    • Stair-climbing test
    • 6-minute walk test
    • Shuttle walk test
    • Referral for cardiopulmonary exercise testing may also be considered.
  • A 7-week hospital based pulmonary rehabilitation program performed by Egan C, et al reduced COPD patient’s total energy expenditure, reduced breathlessness, improved exercise capacity, improved quality of life, and reduced overall morbidity but results will be best maintained by patients if activity can remain consistent long term (3).

• Vitamin D and COPD:
  • COPD is associated with a higher risk of vitamin D deficiency, especially in subjects with obesity, current smokers, and with depression compared to controls (11).
  • Compared to a placebo group, patients receiving 100,000 IU of vitamin D monthly developed better inspiratory muscle strength, maximal oxygen uptake, and trend toward higher quadriceps strength and six minutes walking distance , but results were not statistically significant (4).
  • High dose vitamin D dosed monthly with 100,000 international units is controversial. The ideal dosage of vitamin D for adults has been reviewed to be 2000 international units of vitamin D3 daily which is associated with the lowest mortality (12,13). High dose vitamin D supplements is not supported by Preventive Health Advisor due to lack of research on safety, but the results of the study by Hornikx M et al does support supplementing vitamin D to COPD patients with deficient or insufficient levels. This practice should be guided by the physician by obtaining vitamin D levels to guide therapy.

• Resveratrol and COPD: Researchers believe that resveratrol may be an effective future treatment option for COPD by reducing the release of interleukins significantly (5), but more research is needed.

• Provide awareness to patients about effect of COPD medications (6):
  • Bronchodilators, including methylxanthines, sympathomimetic agents (albuterol and other beta agonists), cromolyn sodium, and corticosteroids may increase exercise capacity in patients with limited bronchospasm.
  • Methylxanthines and sympathomimetic agents (albuterol and other beta agonists) may increase heart rate during rest and exercise.
  • Sympathomimetic agents (albuterol and other beta agonists) may increase blood pressure during rest and exercise.
  • Cromolyn sodium and corticosteroids have no effect on either heart rate or blood pressure during rest and exercise.