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A Review of the GOLD Guidelines for the Diagnosis and Treatment of Patients With COPD: Non-pharmacologic Therapy for COPD

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Non-pharmacologic Therapy for COPD

Although pharmacologic treatment is essential for effective management of the symptoms of COPD, there a number of non-pharmacologic interventions that are crucial for ensuring successful outcomes. Non-pharmacologic therapy, such as pulmonary rehabilitation or oxygen therapy, reduces the burden of COPD symptoms, improves QoL, and increases physical and emotional involvement in everyday activities. Pulmonary rehabilitation, which includes exercise training, nutrition counselling and patient education, has proven most beneficial for patients with stage II to stage IV COPD, as it addresses disease-specific aspects not sufficiently covered by medical therapy, including depression, muscle wasting and social isolation.[1]

Education is important in order for patients to understand their disease and to improve compliance with various aspects of treatment.[81] Fundamental information on COPD, medical therapy, specific aspects of medical treatment, dyspnoea, exacerbations, end-of-life issues and most importantly, smoking cessation, are all topics that should be addressed in COPD educational programmes.[1] COPD education has been shown to increase adherence to treatment regimens.[82] Adherence strategies should be developed not only for pharmacologic agents, but also for non-pharmacologic interventions, such as smoking cessation, exercise programmes, and proper use of nebulisers and spacers for inhalers.[1]

Reducing Risk Factors

Avoidance of risk factors is recommended for patients with all stages of COPD.[1] Smoking cessation is the most effective and cost-efficient means of reducing COPD risk and also prevents or delays the development of airflow limitation.[1] Gradual declines in FEV1 are a normal part of ageing. However, decline is accelerated in patients with COPD who smoke. In a landmark prospective, epidemiologic study of the early stages of development of COPD, Fletcher and Peto[83] found that smoking cessation can slow the progression of COPD. Although lost lung function cannot be recovered after patients stop smoking, the rate of decline in FEV1 can be slowed to levels normally seen in age-matched non-smokers. Successful smoking cessation is difficult to achieve; however, and strategies require a comprehensive approach that includes both pharmacologic and non-pharmacologic interventions. Healthcare providers play a crucial role in smoking cessation efforts undertaken by their patients. They are responsible for delivering smoking cessation messages and interventions. Consistent and persistent patient education and counselling are important.[1] Smokers achieve and maintain significantly higher quit rates when guided and counselled by a physician or health professional compared with quit rates in smokers who implement self-initiated cessation strategies.[84] To support patient counselling, there are a number of pharmacologic options that have been approved for smoking cessation and should be considered for use by patients to assist in their quitting efforts. These include nicotine replacement products, bupropion and varenicline.[1] Reducing and eliminating occupational exposures to airborne pollutants should also be a main priority in risk-factor avoidance.[1]

Pulmonary Rehabilitation

Pulmonary rehabilitation, an important component of any COPD management strategy, is effective for reducing patient symptoms, improving QoL, and increasing a patient's physical and emotional participation in activities of daily living.[1] The main goal of pulmonary rehabilitation is to restore a patient to the fullest medical, emotional, social and vocational status possible.[85] Pulmonary rehabilitation has been shown to increase maximum workload, maximum oxygen uptake and endurance time at constant load.[6] To be successful, pulmonary rehabilitation should focus on exercise training, nutritional counselling, and patient education.[1,6] Exercise training should include aerobic and resistance exercises to improve aerobic capacity and muscle strength.[1,86,87] Although improvements may be seen after 1month, longer periods of exercise training may be required to reach peak efficacy.[88] However, an exercise training programme that results in sustained effects has yet to be developed.[1] Successful pulmonary rehabilitation reconditions patients, improves ventilatory efficiency[89] and decreases hyperinflation.[90] Casaburi et al.[91] have shown that the addition of a bronchodilator (tiotropium) to a pulmonary rehabilitation programme can provide additional improvement in exercise tolerance, dyspnoea and QoL scores, and appears to help maintain the benefits of the programme. Nutrition counselling should also be offered because nutritional status plays a key role in symptoms, disability and prognosis of COPD.[92,93] Overweight and underweight patients experience COPD complications more frequently than patients within the normal weight range for their height.[1,6] Again, patient education is an important component that needs to be integrated into pulmonary rehabilitation programmes.[1] In addition to the benefits for patients, pulmonary rehabilitation appears to decrease healthcare utilisations and expenditures resulting from the treatment of COPD.[94] A maintenance care programme comprised of weekly telephone calls that provided encouragement and reinforcement of the initial rehabilitation programme, resulted in a reduction in the decline in QoL measures and walking limitations that inevitably occur after the end of a rehabilitation programme.[95] Healthcare utilisation was also reduced in patients under the maintenance programme.[95]

Oxygen Therapy

Currently, oxygen therapy is typically integrated into treatment regimens of patients with stage IV COPD and may be delivered as long-term continuous therapy, during exercise, or on an as-needed basis to relieve episodes of acute dyspnoea.[1] Oxygen therapy improves pulmonary hypertension, increases exercise capacity and lung function, improves the mental and emotional states of patients, and increases the chances for survival in patients with chronic respiratory failure.[6,96,97] The use of oxygen in patients with COPD should be based on assessment of the patient needs to determine appropriate sources (e.g. gas or liquid), methods of delivery (e.g. cylinder of oxygen concentrator), duration of use and rates of administration.[1,6]

Non-invasive ventilatory support is primarily used during severe exacerbations leading to acute respiratory failure. Non-invasive positive pressure ventilation (NIPPV), although not considered standard care for patients with chronic respiratory failure, may be helpful for some patients with severe chronic hypercapnic respiratory failure.[98,99] NIPPV administered by a face mask, has been demonstrated to avert the need for intubation for 56–77% of patients with acute exacerbations of COPD.[100,101] In addition, NIPPV has been demonstrated to reduce the length of intensive care unit stays and the mortality rate during hospitalisation.[101,102]

Surgical Options

Surgical procedures, such as bullectomy (i.e. removal of the bullae to promote re-expansion of compressed lung regions), may be performed in selected patients with advanced COPD to improve dyspnoea and lung function.[103] Lung volume reduction surgery (LVRS), wherein parts of the lung are resected to reduce hyperinflation, may help improve respiratory muscle function, lung elasticity and expiratory flow rates, as well as QoL.[1,104] The procedure is expensive and is recommended only for carefully selected patients.[1] Results of the National Emphysema Treatment Trial showed that survival increased in patients with upper-lobe – predominant emphysema and low exercise capacity after LVRS compared with optimal medical management consisting of pulmonary rehabilitation and pharmacologic therapy.[105] Lung transplantation in selected patients with very advanced COPD can improve functional capacity and QoL for patients, although the survival benefit is questionable.[106,107] The commonest setting for lung transplantation in the USA is single-lung transplantation for advanced COPD and emphysema. Postoperative complications are common and include acute rejection, opportunistic infection and bronchiolitis obliterans – all of which may aggravate underlying COPD and result in acute respiratory failure.[1,106] In all surgical procedures, the potential risk of postoperative pulmonary and cardiac complications needs to be considered. Factors such as continued smoking, poor health, age, obesity and the level of COPD severity must also be assessed, as they are associated with an increased risk of postoperative complications.[1]

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