**11. Treatment**

136 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

Chest radiographs and CT-scan of chest are the mainstay of COPD imaging. Although not contributing to diagnosis of COPD, they may add valuable information regarding severity,

Radiographic features suggestive of COPD are prominent usually in advanced disease and

i. Signs of hyperinflation: Prominent hilar vascular shadows and encroachment of the heart shadow on the retrosternal space, increased radiolucency of the lung, a flat diaphragm, and a long and narrow heart shadow on a frontal radiograph, accompanied

ii. Bullae, defined as radiolucent areas larger than one centimeter in diameter and surrounded by arcuate hairline shadows. They are due to locally severe disease. iii. Rapidly tapering vascular shadows and cardiac enlargement may become evident only on comparison with previous chest radiographs. These findings are due to pulmonary

High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography and is highly specific for diagnosing emphysema and outlines bullae that are not always observed on radiographs. CT can visualise whether the emphysema is centriacinar or panacinar(Hasegawa et al.,2006;Nishino et al.,2010;Washko et al.,2008 as cited in Shapiro SD,2010). A CT scan is not indicated in the routine care of patients with COPD but is helpful when the patient is being considered for a surgical intervention such as bullectomy or lung-

The GOLD staging system is based on the FEV1/FVC ratio(see Table 2). It has been criticized for underestimating the importance of the extrapulmonary manifestations of COPD in predicting outcome(GOLD,2006;Bourdin et al,2009). The BODE index addresses this criticism. The four factors included in the BODE index are weight (BMI), airway obstruction (FEV1), dyspnea (Medical Research Council dyspnea score), and exercise capacity (sixminute walk distance)(see Table 3). This index provides better prognostic information than the FEV1 alone to assess an individual's risk of death or hospitalization due to COPD.

A component of disease assessment that is used in research studies is to evaluate the impact of airflow limitation on quality of life. The St. George's Respiratory Questionnaire (SGRQ) is a 76 item questionnaire that includes three component scores (ie, symptoms, activity, and impact on daily life) and a total score(Jones et al.,1991). It has been validated in patients with COPD, asthma, and bronchiectasis. Another questionnaire based instrument to assess quality of life is the Chronic Respiratory Disease Questionnaire

hypertension and cor pulmonale, which can be secondary to COPD.

volume reduction surgery(Fishman et al,2003 as cited in Shapiro SD,2010).

**9.5 Imaging studies** 

**9.5.1 Chest X-ray** 

**9.5.2 Computed tomography** 

include:

stage and special findings during the course of disease.

by a flat diaphragmatic contour may be seen.

**10. Stage of disease severity and progression** 

However, it is not used to guide therapy.

(CRDQ) (Guyatt et al.,1987).

Treatment of COPD encompasses health promotion, prevention, control of symptoms and exacerbations, rehabilitation and palliation. Treatment plan needs to be individualized according to the stage and characteristics of the disease, age, co-morbidities in each patient. Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends that pharmacologic and nonpharmacologic therapies should be added in a stepwise fashion to control symptoms, decrease exacerbations, and improve patient function and quality of life (GOLD,2006). Patient should be educated about the disease and should be encouraged to participate actively in therapy and understand the need of proper dosing and timing of medications as well as proper inhaler technique is essential.

ATS Statement (1995) recommended symptomatic management after the patient presented to the healthcare system with specific complaints(ATS,1995). However, new evidence suggests that the "pre-symptomatic" phase individuals progressively loose lung function in these years and also have poorer prognosis in terms of cardiac outcomes and hence earlier and more aggressive diagnosis and appropriate treatment of these previously unidentified individuals can help, not only by slowing progression but also by improving symptomatic control(GOLD,2006).

Mainstays of drug therapy of stable COPD are bronchodilators, primarily beta agonists and anticholinergics, and inhaled glucocorticoids, given alone or in combination depending upon the severity of disease and response to therapy. Attention to co-morbidities like heart disease, depression, osteoporosis and rehabilitation for acceptable quality of life is also important. Reduction of risk factors like cigarette smoking and occupational exposure should be a central feature of every comprehensive treatment plan. The only medical therapies that clearly reduce disease progression and mortality are smoking cessation and supplemental oxygen (NOTT,1980).

#### **11.1 Cessation of cigarette smoking**

Smoking cessation is the single most effective therapy for the majority of COPD patients(Anthonisen et al,1994;Department of Health and Human Services(US),2008). The transition from smoking to nonsmoking status involves following five stages: precontemplation, contemplation, preparation, action, and maintenance. Smoking intervention programs include self-help, group, physician-delivered, workplace, and community programs. Setting a target date to quit may be helpful. Physicians and other

Current Overview of COPD with Special Reference to Emphysema 139

results in greater bronchodilator response and provides greater relief. The degree of bronchodilation achieved by short-acting beta agonists and anticholinergics is additive. The

This group of medications bind to the β-adrenergic receptor present on airway smooth muscle, resulting in bronchodilation and improvement in airflow. They may also help by increasing ciliary beating frequency and improving mucus transport and may improve endurance of fatigued respiratory muscles(Nava et al,1992;Santa Cruz et al,1974 as cited in

Beta agonists are available in short-acting and long-acting inhaled formulations. The shortacting-β agonists(SABA) like albuterol, its racemer levalbuterol, pirbuterol and terbutaline, have a relatively rapid onset of action after inhalation, in about 5 to 15 minutes, and the bronchodilation lasts for 2 to 4 hours. Long-acting β-agonists (LABAs) like salmeterol, formoterol, arformoterol and indacaterol have a longer onset and bronchodilation lasting for up to 12 hours or more. Salmeterol has also shown anti-inflammatory effects, to reduce

Inhaled route is preferable owing to more favorable ratio of therapeutic effect to undesirable side effects(Shim & Williams,1983 as cited in Shapiro SD,2010). A metered dose inhaler (MDI), dry powder inhaler (DPI) is the preferred mode to deliver a bronchodilator medication by inhalation as it simplifies therapy, improves compliance, and may reduce extra medication usage and patient cost. Nebulizers may be more effective in patients too weak to use an inhaler device, in those with altered mental status, or in those whose inspiratory capacity is too limited to permit effective inhalation (Tenholder et al,1992 as

Benefits of treatment include improvement in airflow obstruction and symptom relief. Although the magnitude of improvement is less and incomplete as compared to asthma patients, 25-30% patients achieve "positive bronchodilator response" as defined by the ATS. Improvement in FEV1( about 200- to 300-mL) and symptoms assessed by SGRQ have been elicited in multiple randomized placebo-controlled trials(Appleton et al,2006;Calverley et al,2003;Rodrigo et al,2008 as cited in Shapiro SD,2010). Modest benefit is noted in prevention of exacerbations with LABAs to the tune of 20-30% reduction in frequency of exacerbations(Appleton et al,2006;Sin et al,2003 as cited in Shapiro SD,2010). However, they have no effect on disease progression and alteration of lung structure(Calverley et al.,2007 as

Side-effects commonly include tremor, palpitations, anxiety, and insomnia. Ventricular arrhythmias and hypokalemia may also occur. These effects are dependent on systemic absorption and hence, spacer devices, DPIs,MDIs are preferable. R-enantiomer of albuterol, levalbuterol was promoted widely based on the possibility to have lesser side effects such as tachycardia and tremors as well as lacking the inflammatory effect of the S-enantiomer. The small difference noted in studies has raised doubts of its clinical relevance(Donahue et

A significant proportion of COPD patients have concurrent cardiac co-morbidities and although recent studies have failed to show any clinically significant adverse outcome of β2

edema, and to reduce airway epithelial cell injury in model systems.

adverse effect profile may help guide therapy.

i. Beta2(β2)-agonists:

Shapiro SD,2010).

cited in Shapiro SD,2010).

cited in Shapiro SD,2010).

al,2008 as cited in Shapiro SD,2010).

health care providers should participate in setting the target date and should follow up with respect to maintenance. Successful cessation programs should include patient education, target date to quit, follow-up support, relapse prevention, advice for healthy lifestyle changes, social support systems, pharmacological agents.

According to the US Preventive Services Task Force(USPSTF) guidelines, recommends "5- A" approach to counseling that includes i)Ask about tobacco use, ii)Advise to quit through personalized messages, iii)Assess willingness to quit, iv)Assist with quitting, v)Arrange follow-up care and support. Behavioral counseling and pharmacotherapy are most effective when used together.(USPSTF,2009)

Supervised use of pharmacologic agents is an important adjunct as withdrawal from nicotine may cause unpleasant adverse effects during the first weeks after quitting smoking. Nicotine replacement therapies are available in the form of chewing gum and transdermal patches to counter the withdrawal symptoms(U.S. Public Health Service Clinical Practice Guideline,2008). Long-term success rates have been 22-42%, compared with 2-25% with placebos. The use of an antidepressant medication, bupropion (Zyban,150 mg bid) has been shown to be effective for smoking cessation and may be used in combination with nicotine replacement therapy. Varenicline (Chantix), is a partial agonist selective for α4, β2 nicotinic acetylcholine receptors and action is thought to result from partial agonist activity at a nicotinic receptor subtype while simultaneously preventing nicotine binding. Nortriptyline and clonidine have also been proposed to help in cessation of smoking (U.S. Public Health Service Clinical Practice Guideline,2008).
