What is the treatment for pulmonary issues?

Pulmonary Disease Management: A Comprehensive Approach

The optimal management of pulmonary diseases, particularly COPD, requires a staged approach with bronchodilators as the cornerstone of therapy, with treatment intensity increasing based on disease severity, symptom burden, and exacerbation risk. 1

Smoking Cessation

• Smoking cessation is the single most important intervention for all COPD patients and should be strongly encouraged at every clinical encounter 1, 2
• Nicotine replacement therapy (gum or transdermal patches) and behavioral interventions can increase success rates with up to 30% sustained cessation rates 2, 1
• Many smokers require repeated attempts to achieve success, with heavy smokers and those with multiple previous attempts being less likely to succeed 2

Pharmacological Management

Bronchodilator Therapy

• For mild disease with intermittent symptoms: short-acting bronchodilators (β2-agonist or anticholinergic) as needed 2, 1
• For moderate disease: regular therapy with long-acting bronchodilator monotherapy, with long-acting muscarinic antagonists (LAMAs) preferred for exacerbation prevention 2, 1
• For severe disease: combination of long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) is recommended 1
• Long-acting inhaled therapies reduce exacerbations by 13% to 25% compared to placebo 2
• Combination therapy with regular β2-agonist and anticholinergic provides better bronchodilation than either agent alone 3

Inhaled Corticosteroids (ICS)

• ICS may be added to bronchodilator therapy for patients with persistent exacerbations or those with asthma-COPD overlap 1
• ICS combined with LABA may reduce mortality compared to placebo (RR 0.82) and ICS alone (RR 0.79) 2
• A trial of oral corticosteroids (30mg prednisolone daily for two weeks) is indicated in assessing moderate to severe disease 2

Delivery Devices

• Inhaler technique must be demonstrated to patients and regularly checked, as 76% of COPD patients make important errors with metered-dose inhalers 1
• For patients unable to use handheld inhalers effectively, nebulized therapy may be appropriate 4
• During acute exacerbations, spacers and dry-powder devices can achieve good response, though some breathless patients may find nebulizers easier to use 2

Management of Exacerbations

• Antibiotics should be used when sputum becomes purulent (7-14 day course) 2, 1
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2
• Inexpensive antibiotics like amoxicillin, tetracycline derivatives, and amoxicillin/clavulanic acid are sufficient in most cases 2
• Systemic corticosteroids (prednisolone 30mg daily for 5-7 days) improve recovery time 2, 1

Oxygen Therapy

• Supplemental oxygen reduces mortality rates among symptomatic patients with resting hypoxia (RR 0.61) 2
• Oxygen concentrators are the preferred mode for home use in patients requiring long-term oxygen therapy 1
• In end-stage COPD, short bursts of oxygen may help intractable dyspnea 1

Pulmonary Rehabilitation

• Rehabilitation programs increase exercise tolerance, improve quality of life, and reduce breathlessness 2, 1
• Programs should include physiotherapy, muscle training, nutritional support, and education 1
• Pulmonary rehabilitation should be considered in moderate to severe disease 2

Preventive Measures

• Annual influenza vaccination is recommended for all COPD patients 2, 1
• Pneumococcal vaccination may be considered, with revaccination every 5-10 years 1

Common Pitfalls and Caveats

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1
• There is no evidence supporting the use of prophylactic antibiotics given continuously or intermittently 2, 1
• Non-invasive ventilatory support should be considered for patients with severe nocturnal hypoxemia or respiratory muscle weakness 1
• Bronchodilator reversibility testing may not predict symptomatic benefit from bronchodilator therapy 2
• For COPD exacerbations, the combination of increased breathlessness, increased sputum volume, and development of purulent sputum should trigger antibiotic therapy 2