COPD: Management of Acute Exacerbations and Chronic Stable Disease.(chronic obstructive pulmonary disease)

Publication: American Family Physician

Publication Date: 15-AUG-01

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COPYRIGHT 2001 American Academy of Family Physicians

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are treated with oxygen (in hypoxemic patients), inhaled beta2 agonists, inhaled anticholinergics, antibiotics and systemic corticosteroids. Methylxanthine therapy may be considered in patients who do not respond to other bronchodilators. Antibiotic therapy is directed at the most common pathogens, including Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Mild to moderate exacerbations of COPD are usually treated with older broad-spectrum antibiotics such as doxycycline, trimethoprim-sulfamethoxazole and amoxicillin-clavulanate potassium. Treatment with augmented penicillins, fluoroquinolones, third-generation cephalosporins or aminoglycosides may be considered in patients with more severe exacerbations. The management of chronic stable COPD always includes smoking cessation and oxygen therapy. Inhaled beta2 agonists, inhaled anticholinergics and systemic corticosteroids provide short-term benefits in patients with chronic stable disease. Inhaled corticosteroids decrease airway reactivity and reduce the use of health care services for management of respiratory symptoms. Preventing acute exacerbations helps to reduce long-term complications. Long-term oxygen therapy, regular monitoring of pulmonary function and referral for pulmonary rehabilitation are often indicated. Influenza and pneumococcal vaccines should be given. Patients who do not respond to standard therapies may benefit from surgery. (Am Fam Physician 2001;64:603-12,621-2.)

Despite public education about the dangers of smoking, chronic obstructive pulmonary disease (COPD) continues to be a major medical problem and is now the fourth leading cause of death in the United States.(1) Approximately 20 percent of adult Americans have COPD.(2) Acute bronchitis and acute exacerbations of COPD are among the most common illnesses encountered by family physicians and account for more than 14 million physician visits annually.(3,4)

To date, widespread agreement on the precise definition of COPD is lacking. The American Thoracic Society (ATS) defines COPD as a disease process involving progressive chronic airflow obstruction because of chronic bronchitis, emphysema, or both.(5) Chronic bronchitis is defined clinically as excessive cough and sputum production on most days for at least three months during at least two consecutive years.(6) Emphysema is characterized by chronic dyspnea resulting from the destruction of lung tissue and the enlargement of air spaces. Asthma, which also features airflow obstruction, airway inflammation and increased airway responsiveness to various stimuli, may be distinguished from COPD by reversibility of pulmonary function deficits.(5)

Outpatient management of patients with stable COPD should be directed at improving quality of life by preventing acute exacerbations, relieving symptoms and slowing the progressive deterioration of lung function. The clinical course of COPD is characterized by chronic disability, with intermittent acute exacerbations that occur more often during the winter months. When exacerbations occur, they typically manifest as increased sputum production, more purulent sputum and worsening of dyspnea.(7) Although infectious etiologies account for most exacerbations, exposure to allergens, pollutants or inhaled irritants may also play a role.(8) This article reviews the management of acute exacerbations and stable COPD.

Epidemiology

COPD is one of the most serious and disabling conditions in middle-aged and elderly Americans. Cigarette smoking is implicated in 90 percent of cases and, along with coronary artery disease, is a leading cause of disability.(9) Two thirds of patients with COPD have serious chronic dyspnea, and nearly 25 percent have profound total body pain.(10) COPD has a major impact on the families of affected patients. Caring for these patients at home can be difficult because of their functional limitations and anxieties about air hunger. Furthermore, patients with COPD can have frequent exacerbations that often require medical intervention. Ultimately, caregivers may have the burden of considering end-of-life decisions.

Pathophysiology

COPD is a subset of obstructive lung diseases that also includes cystic fibrosis, bronchiectasis and asthma. COPD is characterized by degeneration and destruction of the lung and supporting tissue, processes that result in emphysema, chronic bronchitis, or both. Emphysema begins with small airway disease and progresses to alveolar destruction, with a predominance of small airway narrowing and mucous gland hyperplasia.

The pathophysiology of COPD is not completely understood. Chronic inflammation of the cells lining the bronchial tree plays a prominent role. Smoking and, occasionally, other inhaled irritants, perpetuates an ongoing inflammatory response that leads to airway narrowing and hyperactivity. As a result, airways become edematous, excess mucus production occurs and cilia function poorly. With disease progression, patients have increasing difficulty clearing secretions. Consequently, they develop a chronic productive cough, wheezing and dyspnea. Bacterial colonization of the airways leads to further inflammation and the formation of diverticula in the bronchial tree....

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