**6. Preventing future exacerbations**

Pulmonary rehabilitation, smoking cessation and immunization against influenza and pneumonia have been shown to improve health quality and reduce exacerbations in COPD patients. There are also some data showing that long term oxygen therapy reduces the risk of hospitalization and shortens hospital stays in severely ill COPD patients. Long-acting inhaled bronchodilators and inhaled corticosteroids to improve symptoms and reduce the risk of exacerbations in patients with stable COPD are reviewed elsewhere with promising results.

#### **7. References**

296 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

Adding systemic (oral or intravenous) glucocorticosteroids to other therapies in the hospital management of exacerbations of COPD is recommended (Niewoehner et al. 1999). Systemic use of corticosteroids may lead to fast recovery and improvement in hypoxemia and lung functions in COPD exacerbations. The recommended dosage of prednisolon is 30-40 mg/day for 7-10 days if the patient has an initial FEV1 value below 50%. Prolonged treatment does not have a positive affect, besides it may increase the risk of side effects (e.g.

Bronchoscopic studies showed that the amount of bacteria is increased nearly in 50% of COPD patients during an exacerbation when compared to the stable state(Sethi 2004). The decision to use antibiotics and the choice of antibiotic should be guided by the patient's symptoms (e.g., presence of purulent sputum), recent antibiotic use, and local microbial resistance patterns. Prophylactic or continuous use of antibiotics does not improve outcome

Even though the most common bacteria responsible for the exacerbations are H.influenzae, S. pneumoniae and M. Catarrhalis; some enteric Gram (-) bacteria and Pseudomonas aeruginosa are also isolated in most of the patiens with hypoxemia, severe airway obstruction, malnutrition, frequent hospitalization and antibiotic use history and comorbidity(Incalzi et al. 2006). There are some studies suggesting that atypical bacteria can also be an etiologic reason for an exacerbation but antibiotherapy targeting these bacteria showed no positive affect on clinical outcomes(Diederen et al. 2007; Tasbakan et al. 2007). Viruses can also be responsible in 15-40% of all exacerbations. Most of these are present with

Antibiotherapy reduces the mortality rates and treatment failure especially in severe exacerbations of COPD(Puhan et al. 2007). Antibiotics also decrease the relapse rates of exacerbationsin outpatients(Adams et al. 2000). Therefore, antibiotherapy is strongly indicated expecially if the patient has purulant sputum and increase in dyspnea. Treatment

In order to qualify for a discharge, the patient must have stable clinical conditions and a stable or improving arterial PaO2 of greater than 60mmHg. The patient should not require short acting β-agonist more often than every 4 hours. If the patient is stable and can use a metered dose inhaler, there is no extra benefit of using nebulised forms (Jenkins et al. 1987). Patient education including topics such as medical treatment, nutrition, rehabilitation and physiotherapy programs and when to seek for professional medical help may improve the response to future exacerbations. Home support such as home mechanical ventilation, long term oxygen therapy, nebulisers or similar equipments

Pulmonary rehabilitation, smoking cessation and immunization against influenza and pneumonia have been shown to improve health quality and reduce exacerbations in COPD

muscle atrophy, hyperglycemia).

a bacterial infection.

in patients with COPD (Rabe, Hurd et al. 2007).

options according to clinical status is summarized in Table 3.

**5. Preperation for hospital discharge** 

should be arranged before discharge.

**6. Preventing future exacerbations** 


Christian Celia4, Massimo Fresta4 and Franco Alhaique1

Maria Carafa1, Carlotta Marianecci1, Paolino Donatella2, Luisa Di Marzio3,

 *"Sapienza", University of Rome, Rome* 

*3Department of Drug Science,* 

*Italy* 

*1Department of Drug Chemistry and Technologies,* 

*2Department of Experimental and Clinical Medicine,* 

*University of Chieti "G. D'Annunzio", Chieti 4Department of Pharmacobiological Sciences,* 

*Faculty of Medicine, University "Magna Graecia" Catanzaro* 

*Faculty of Pharmacy, University "Magna Graecia" Catanzaro* 

This chapter deals with recent advances in the nanovector approach to the pulmonary delivery of therapeutic substances; it also describes briefly the physiology of the lungs and

The development of an innovative nanocarrier, able to deliver the drug to the desired site of action, is highly dependent on the nature of the active substance and on its desired mode of

modulate the effect of the drug, specifically in the case of vaccines, where the delivery

Numerous approaches involving non - parenteral routes, such as intestinal, nasal, buccal, transdermal and rectal, have been examined, but most of them are inadequate for a satisfactory therapeutic response. On the other hand, the pulmonary route represents a great promise for the systemic delivery and bioavailability of peptides and proteins, since lungs are highly permeable and accessible by normal inhalation methods. Actually, the pulmonary

the main factors affecting pulmonary delivery (Figure 1).

reduce systemic exposure and improve drug targeting;

circumvent the parenteral route or reduce the number of injections;

system can modify the ratio of humoral and cellular response;

increase patent life and/or circumvent patents of competitors.

A delivery technology can thus be used to:

reduce side – effects;

 increase patient compliance; reduce the price of the therapy;

achieve sustained plasma levels of the drug;

**1. Introduction** 

action.

Tasbakan, M. S., et al. (2007). "[Role of atypical pathogens in infectious exacerbations of COPD]." Tuberk Toraks 55(4): 336-341. **16** 

Maria Carafa1, Carlotta Marianecci1, Paolino Donatella2, Luisa Di Marzio3, Christian Celia4, Massimo Fresta4 and Franco Alhaique1 *1Department of Drug Chemistry and Technologies, "Sapienza", University of Rome, Rome 2Department of Experimental and Clinical Medicine, Faculty of Medicine, University "Magna Graecia" Catanzaro 3Department of Drug Science, University of Chieti "G. D'Annunzio", Chieti 4Department of Pharmacobiological Sciences, Faculty of Pharmacy, University "Magna Graecia" Catanzaro Italy* 
