Chronic obstructive pulmonary disease (COPD)

Introduction:

Chronic obstructive pulmonary disease (COPD) is a chronic lung disease associated with cough, shortness of breath and sputum production. It is divided into two separate major disease states which include chronic bronchitis and emphysema. Chronic bronchitis occurs when large bronchial tubes develop chronic inflammation. In emphysema, small airway passages and air sacs become damaged. Cigarette smoking is the most common cause of COPD. Once COPD occurs from damage to airways, the disease can’t be reversed, but treatment can control symptoms and may prevent additional airway damage. Research has shown that prevention of the disease starts with avoidance of smoking or second hand smoke, irritants, like pollution, dust or chemicals. Prevention of respiratory infections may not only lead to reduced risk of the disease, but also prevent COPD exacerbations. A number of Integrative Medicine options in addition to traditional inhalers and medications are available to impact the disease course.

 

Smoking cessation:

Most common cause of COPD: 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.

How to quit smoking: Quit tobacco use as soon as possible by using 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, 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/

As well as the phone number for free help 1-800-QUIT-NOW.

Additional reasoning to quit smoking are as follows. Smoking is not only the primary cause of COPD, but According to the American College of Cardiology, American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines, European Heart Rhythm Association, and the Heart Rhythm Society, it is a risk factor for sudden cardiac death (7). Smoking among patients with cardiac rehabilitation was reduced by 36% (8), and this effect may be possible in patients undergoing Pulmonary Rehab programs. Smoking is also a major risk factor for not only lung cancer, but also for many other cancers. For instance, smoking causes approximately 40% of gastric and esophageal cancers (9).

 

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: Please review the immunization schedules by the Centers for Disease Control (CDC) to ensure adequate vaccination. If you have specific health conditions there may be specific vaccines recommended. These will need to be discussed between the patient and their physician. 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:

Maintain adequate intake of nutritious foods including a minimum of 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 and chronic obstructive pulmonary disease (COPD):

According to the COPD Working Group, a literature review of studies published from January 1, 2007 to September 8, 2010 on the effectiveness, cost-effectiveness, and safety of long-term oxygen therapy for COPD was performed. In patients with COPD who have severe hypoxemia (low levels of oxygen) in arterial blood (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 have mild-to-moderate hypoxemia (PaO(2) ~ 59-65 mm Hg). The review also suggested that long-term oxygen therapy may have a beneficial effect over time on FEV1 and PaCO2 in patients with COPD who have severe hypoxemia and heart failure. However, there is no evidence of a beneficial effect of long-term oxygen therapy on lung function or exercise factors in patients with COPD who have mild-to-moderate hypoxemia. In patients with COPD who have severe hypoxemia, long-term oxygen therapy was also found to have no effect on readmissions and there is limited data suggesting that long-term oxygen therapy increases the risk of hospitalizations. In patients with COPD who have severe hypoxemia, long-term oxygen therapy may have a beneficial effect over time on health-related quality of life but more evidence is needed. (1)

 

Pulmonary rehabilitation and COPD:

There are several performance-based measures of functional exercise capacity. During these tests, blood pressure, heart rate and oxygen levels are measured. Several types of COPD exercise testing was described by Divo and Pinto-Plata (2):

• The stair-climbing test (SCT) assesses the ability to ascend and descend a flight of stairs, as well as lower extremity strength, power, and balance. The SCT seems to be most useful for preoperative evaluations and may be used to better determine a maximal exercise capacity when Cardiopulmonary Exercise Testing is unavailable.
• In the 6-minute walk test (6MWT), the patient walks as far as you can up through a corridor in 6 minutes. The 6MWT is the simplest, can be used to evaluate response to several interventions (such as physical rehabilitation, medications, lung volume reduction interventions and transplantation) and is probably the most cost effective.
• The shuttle walk test (SWT) requires you to walk up and down a 10-meter distance at increasing speeds until you get too breathless to continue.
• Cardiopulmonary Exercise Testing (CPET) is non-invasive simultaneous measurement of the cardiovascular and respiratory system during exercise to assess a patient’s exercise capacity; however, it is more technically difficult than all the other tests.

 

Pulmonary rehab and exercise capacity:

A 7-week hospital based pulmonary rehabilitation program was performed by Egan C, et al with 47 subjects suffering from chronic obstructive pulmonary disease (COPD) in a prospective study. At the end of the study, total energy expenditure and breathlessness (Borg test) was reduced. Exercise capacity improved in the “shuttle walking test” and the 6 minute walk test. Quality of life was also significantly improved measured by a standardized scoring system. It was supported by this study that pulmonary rehabilitation reduces morbidity by improving exercise capacity, but unless the activity is sustained over the long term, benefits of the rehab program will dissipate after a year. There may be greater benefit sustained if a long term behavioral modification can be maintained.  (3)

 

Vitamin D and COPD:

Vitamin D levels and COPD: COPD was fund to be associated with a higher risk of vitamin D deficiency, especially in subjects with obesity, in current smokers, and in subjects with depression compared to controls (11).

A placebo controlled intervention study evaluated the effect of supplementation with high doses of vitamin D in a 3 month rehabilitation program in 50 patients with chronic obstructive pulmonary disease (COPD). Results indicate that compared to the placebo group, patients receiving a monthly dose of 100,000 IU of vitamin D had a larger improvement on inspiratory muscle strength (-11±12 cmH2O vs 0±14 cmH2O; p = 0.004) and maximal oxygen uptake (110±211 ml/min vs -20±187 ml/min; p = 0.029). There was a similar trend towards higher quadriceps strength and six minutes walking distance, but there was no statistical difference between groups. This analysis suggested that in patients with COPD, high dose supplementation with vitamin D may be beneficial when combined with a rehabilitation program. (4)

Please see Preventive Health Advisor section on vitamin D. 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:

An ingredient found in red wine, resveratrol, may slow down the inflammatory process related to chronic obstructive pulmonary disease (COPD). In this study, researchers tested the effects of resveratrol on lung fluid samples taken from 15 cigarette smoking control subjects and 15 people with COPD. First, macrophages (cells involved in the inflammatory process) were artificially spurred into action by an interleukin ([IL]-1β) (a chemical released by the lung, which stimulates the growth and activity of cells that contribute to lung damage) or cigarette smoke to stimulate the release of interleukin IL-8 and granulocyte macrophage-colony stimulating factor (GM-CSF) before resveratrol was added by researchers. Resveratrol was added at a concentration of 100 micromoles per liter. The effect of resveratrol was examined on both basal and stimulated cytokine release. The introduction of resveratrol reduced basal release of interleukin in stimulated samples for both smokers and people with COPD by 94% and 88% respectively, and inhibited GM-CSF release by 79% and 76% respectively. It also nearly eliminated interleukin production all together in the non-stimulated samples, in essence reducing the number of cells that contribute to lung damage. Researchers believe that resveratrol may be an effective treatment option for COPD. (5)

 

Effect of COPD medications at rest and during exercise (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.

 

 

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.

 

 

References:

 

1.COPD Working Group. Long-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2012;12(7):1-64. Epub 2012 Mar 1. http://www.ncbi.nlm.nih.gov/pubmed/23074435

 

2.Divo M, Pinto-Plata V. Role of exercise in testing and in therapy of COPD. Med Clin North Am. 2012 Jul;96(4):753-66. http://www.ncbi.nlm.nih.gov/pubmed/22793943

 

3.Egan C, Deering BM, Blake C, Fullen BM, McCormack NM, Spruit MA, Costello RW. Short term and long term effects of pulmonary rehabilitation on physical activity in COPD. Respir Med. 2012 Dec;106(12):1671-9. http://www.ncbi.nlm.nih.gov/pubmed/23063203

 

4.Hornikx M, Van Remoortel H, Lehouck A, Mathieu C, Maes K, Gayan-Ramirez G, Decramer M, Troosters T, Janssens W. Vitamin D supplementation during rehabilitation in COPD: a secondary analysis of a randomized trial. Respir Res. 2012 Sep 25;13:84. http://www.ncbi.nlm.nih.gov/pubmed/23006613

 

5.Culpitt SV, Rogers DF, Fenwick PS, Shah P, De Matos C, Russell RE, Barnes PJ, Donnelly LE. Inhibition by red wine extract, resveratrol, of cytokine release by alveolar macrophages in COPD. Thorax 2003. 58:942–946. http://www.ncbi.nlm.nih.gov/pubmed/14586044

 

6.Gauer RL, O’Connor FG. Department of Family Medicine Uniformed Services University of the Health Sciences. How To Write And Exercise Prescription. http://www.move.va.gov/download/Resources/CHPPM_How_To_Write_And_Exercise_Prescription.pdf

7.Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology/American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association and the Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death–executive summary: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Eur Heart J. 2006 Sep;27(17):2099-140. http://www.ncbi.nlm.nih.gov/pubmed/16923744

 

8.Rod S. Taylor, Allan Brown, Shah Ebrahim, Judith Jolliffe, Hussein Noorani, Karen Rees, Becky Skidmore, James A. Stone, David R. Thompson, Neil Oldridge. Exercise-Based Rehabilitation for Patients with Coronary Heart Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials. Am J Med. 2004;116:682– 692. http://exerciseprescription.wiki.umt.edu/file/view/Taylor+et+al,+2004.pdf

 

9.Gammon MD, Schoenberg JB, Ahsan H, et al. Tobacco, alcohol, and socioeconomic status and adenocarcinomas of the esophagus and gastric cardia. J Natl Cancer Inst. 1997;45:273–6. http://www.ncbi.nlm.nih.gov/pubmed/9293918

 

10.U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and Tobacco-Related Diseases: Recommendation Statement. November 2003. http://www.uspreventiveservicestaskforce.org/3rduspstf/tobacccoun/tobcounrs.htm

 

11.Persson LJ, Aanerud M, Hiemstra PS, Hardie JA, Bakke PS, Eagan TM. Chronic obstructive pulmonary disease is associated with low levels of vitamin D. PLoS One. 2012;7(6):e38934. Epub 2012 Jun 21. http://www.ncbi.nlm.nih.gov/pubmed/22737223

 

12.Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr. 1999 May; 69:842–856. http://ajcn.nutrition.org/content/69/5/842.long

 

13.Michaëlsson K, Baron JA, Snellman G, et al. Plasma vitamin D and mortality in older men: a community-based prospective cohort study. Am J Clin Nutr. 2010 Oct;92(4):841-8. http://ajcn.nutrition.org/content/92/4/841.long

 

14.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