Non-pharmacological Treatments for COPD
Mulhall P, Criner G
Respirology. 2016 Apr 21. [Epub ahead of print]
Despite excellent bronchodilators for chronic obstructive pulmonary disease (COPD), and their continued development in regard to both potency and delivery, a substantial proportion of the COPD population remains impaired and continues to experience deterioration in their overall wellbeing. However, there are nonpharmacologic treatments that can provide relief for many patients.
The most important of these is smoking cessation. For continuing cigarette smokers, no pharmacologic therapy will provide more relief than quitting smoking. The use of a pharmacologic agent to assist patients in discontinuing smoking, such as one of the current nicotine replacement therapies (NRTs), should be reinforced by counseling and follow-up. The most effective NRT is likely the electronic cigarette, of which there are now several varieties. Studies have shown that the use of an NRT can double the quit rate of cigarette smoking. Besides NRTs, there are three approved medications that may further facilitate smoking cessation. These are bupropion (Zyban®), varenicline (Chantix®), and cytisine (Tabex™). Comprehensive care management programs (CCMPs) can also facilitate smoking cessation and should be more widely used. Most medical centers are able to provide access to a CCMP.
Telemedicine allows patients with COPD to connect electronically with a specialized care consultant. Telemedicine can be used to collect information from the patient and track his or her progress on a daily basis, if necessary. It has been used to alert the medical team to the early onset of acute exacerbation of COPD, thus avoiding emergency department visits and hospital admissions.[1] However, more evidence is needed as some studies state that “telemonitoring for COPD is not yet proven and further work is required.”
Pulmonary rehabilitation aims to counteract the loss of skeletal muscle that is common in COPD and to improve exercise tolerance and exertional dyspnea. Pulmonary rehabilitation consists of a variety of interventions including exercise training, nutritional supplementation, and psychosocial support, which is usually under the supervision of physiatrists in a special clinic. According to the current review, no improvements in survival or lung function have been reported thus far; however, there have been improvements in health-related quality of life, dyspnea, and exercise tolerance. There has also been a tendency for any accumulated improvements to deteriorate with time unless the above modalities are continued.
Long-term oxygen therapy is also an option for some patients with COPD. Short-term oxygen administration during exercise in patients with any degree of hypoxemia has long been known to improve dyspnea and increase exercise tolerance.[2] However, short-term oxygen administration does not appear to improve survival. For patients who are chronically hypoxemic (resting PaO2<55 mm Hg at rest), long-term oxygen therapy (18 or more hours of oxygen every day) not only improves exercise performance but improves survival substantially.[3]
In the treatment of acute exacerbations of COPD, bilevel noninvasive positive pressure ventilation (NIV) has been effective. Gas exchange and respiratory mechanics are improved, resulting in decreases in intubation rates, shortening hospitalizations, and improving mortality.[4] However, its long-term role in managing chronic hypoxemia due to COPD has not been demonstrated. A meta-analysis of several studies in which nocturnal NIV was given to subjects with hypercapnic COPD for 3 months was unable to demonstrate that lung function, gas exchange, or sleep efficiency were significantly improved.
Patients with severe emphysema typically have bullae, usually worst in the upper zones of the lung. These occupy space within the thorax but do not provide much gas exchange. In fact, they are likely to impair the function of less diseased lungs by occupying dead space within the thorax and contributing to air trapping and ventilation/perfusion mismatching. The aim of surgical lung volume reduction is to remove nonfunctional lung and thus improve lung physiology and symptoms. In the large study of its kind, the NET Trial,[5] the only patients to receive benefit were those with predominantly upper lobe disease and low prior exercise tolerance. Other subjects tended to have higher mortality. The procedure is rarely performed today, but there are attempts to achieve a similar outcome, a reduction in dead-space lung, by less invasive methods. These employ the placement of one-way valves in the lung airways that allow gas to leave bullae but not inspiratory flow. The valves, usually more than one, are placed bronchoscopically. In general, some improvement in lung function, less dyspnea, and improvements in exercise capacity have been obtained. But there has usually been an increase in adverse effects, including acute exacerbations of COPD and pneumothorax, sometimes requiring removal of the valve(s). Other experimental lung procedures with the same aim have attempted to collapse the most emphysematous lung regions by closing the airways to those regions by other means, but development of these modalities is incomplete.
Lung transplantation has been an option for patients with severe COPD since 2000, with 50% survival being in the region of 5 years and steadily improving. It should be considered only in patients with end-stage COPD, only when all other therapies have been tried and failed to provide relief, and should only be performed in those few centers where transplant surgery is routinely performed. Primary graft failure, chronic rejection, and infection are common problems. However, there can be successes where lung function and quality of life can markedly improve, and outcomes are improving with time.
Viewpoint
COPD is now the third leading cause of death in the western world and remains a condition where much advancement in therapy is needed. Smoking cessation remains a major goal, although great strides have been taken. Unfortunately, pulmonary rehabilitation has turned out to be less effective than rehabilitation for other systemic disorders. Its place in the routine management of COPD is today unclear.
To the above modalities of nonpharmacologic treatments for COPD, one can add the development in electronic communications between the patient and the pulmonary team. With modern and developing telemetry, real-time information can be exchanged between patients, the pulmonary care team, and others involved in patient care.