COPD: Weighing Your Treatment Options

No one wants to gasp for every breath. If you have COPD (chronic obstructive pulmonary disease), you know how that feels.

This chronic, progressive lung disease reduces the amount of air that flows into and out of the lungs. Over time, COPD can lead to increased mucus production in the lungs, which makes breathing even harder.

Most treatments currently available involve inhaled forms of medications. But a new form of surgery for COPD is in clinical trials in the U.S. and Europe. In the procedure, tiny metal coils called lung volume reduction coils are placed into damaged lung tissue. The coils, developed by PneumRx, restore elasticity to the lungs, allowing them to work more efficiently. The coils can be placed into the lungs through the mouth or nose, so no incision is necessary. So far, results are promising. (There are results from a European trial in Thorax.)

COPD is an umbrella term that covers any disorder that limits lung airflow and interferes with normal breathing. The most common of these disorders are emphysema, in which the walls between the air sacs in the lungs lose their shape and elasticity; and chronic bronchitis, in which the lining of the airways is chronically irritated and inflamed.

Prevalence and Causes of COPD

According to the Centers for Disease Control and Prevention (CDC), 15 million Americans have been diagnosed with COPD. However, millions more have low lung function, so the actual number of U.S. adults with COPD is believed to be higher, possibly as high as 24 million. In 2011, COPD was the third leading cause of death among Americans.

Most cases of COPD are directly related to cigarette smoking. Other types of lung irritants, such as dust and long-term exposure to secondhand smoke, air pollution or chemical fumes can also contribute to COPD. Less commonly, it can be caused by a congenital condition called alpha-1 antitrypsin deficiency, in which the body produces a defective version of a protein that normally protects the lungs in the presence of inflammation, infection, or smoking.

Treating COPD
COPD TreatmentsTreatment of COPD is aimed at:

  • Relieving symptoms
  • Improving a person’s ability to exercise
  • Preventing progression of the disease
  • Preventing and treating sudden worsening of symptoms

There is no cure for COPD, but there are medicines and other therapies that can be used to treat it. Bronchodilators and inhaled corticosteroids are the best-known categories of COPD meds. Phosphodiesterase-4 inhibitors constitute a third important category of drugs used to treat COPD.

Chart 1: Bronchodilators – Beta-Agonists

Bronchodilators are drugs that relax the muscles around the airways, allowing more air to flow into and out of the lungs, making it easier to breathe. Several classes of drugs are used as bronchodilators. Typically, bronchodilators are administered using a device called an inhaler, which forces the drug through the mouth directly to the lungs. Less commonly, a nebulizer is used. A nebulizer is a small machine that changes liquid medicine into a fine mist that is inhaled through a mouthpiece or mask.

Category: Beta-agonists are bronchodilators that work by relaxing the muscles around the small airways (the bronchioles). Short-acting beta-agonists may be used regularly or as needed; their effects last 4-6 hours. Long-acting beta-agonists, with effects lasting 12 hours or more, are taken on a regular basis to prevent or reduce symptoms.

Drug Types:
–Short-acting beta-agonists include ProAir and Proventil (albuterol) and  Xopenex (levalbuterol)
–Long-acting beta-agonists such as Striverdi Respimat (olodaterol), Arcapta (indacaterol) and Serevent (salmeterol)
Side Effects include a fast heartbeat, heart palpitations, shakiness and cramping of the hands, legs and feet. Any of these side effects can cause anxiety, which can in turn worsen breathing difficulties. Sometimes side effects go away within minutes of using an inhaler, and sometimes they diminish over time, with continued use of the drug. Side effects may be preventable by using correct inhaler technique, rinsing your mouth after inhaling, and using your inhaler(s) only as frequently as prescribed.

Bronchodilators are drugs that relax the muscles around the airways, allowing more air to flow into and out of the lungs, making it easier to breathe. Several classes of drugs are used as bronchodilators. Typically, bronchodilators are administered using a device called an inhaler, which forces the drug through the mouth directly to the lungs. Less commonly, a nebulizer is used. A nebulizer is a small machine that changes liquid medicine into a fine mist that is inhaled through a mouthpiece or mask.
Corticocosteroids reduce inflammation in the airways and are often used in combination with bronchodilators. They are also administered using either an inhaler or a nebulizer.

Phosphodiesterase-4 inhibitors reduce inflammation. They do not have a bronchodilating effect and are generally used in combination with long-acting bronchodilators.

Beta-agonists are bronchodilators that work by relaxing the muscles around the small airways (the bronchioles). Short-acting beta-agonists may be used regularly or as needed; their effects last 4-6 hours. Long-acting beta-agonists, with effects lasting 12 hours or more, are taken on a regular basis to prevent or reduce symptoms.

Potential side effects of beta-agonists include a fast heartbeat, heart palpitations, shakiness and cramping of the hands, legs and feet. Any of these side effects can cause anxiety, which can in turn worsen breathing difficulties. Sometimes side effects go away within minutes of using an inhaler, and sometimes they diminish over time, with continued use of the drug. Side effects may be preventable by using correct inhaler technique, rinsing your mouth after inhaling, and using your inhaler(s) only as frequently as prescribed.

Chart 2: Bronchodilators – Anticholinergic Drugs


Category: Anticholinergic drugs are another type of bronchodilator that work by preventing the large airways (the bronchi) from tightening. 

Drug Types:
–Short-acting anticholinergics (sometimes called antimuscarinic agents) such as Atrovent  (ipratropium)
–Long-acting anticholinergics including Tudorza (aclidinium) and Spiriva (tiotropium)

Side Effects: include dry mouth which, in addition to being annoying, can lead to tooth decay, gum disease, sores in the mouth, fungal infections in the mouth, cracked lips and poor nutrition due to difficulty chewing and swallowing.  Dry mouth can be treated by using prescription or over-the-counter mouth moisturizers; taking frequent, small sips of water; chewing sugar-free gum or sucking sugar-free candies; and avoiding any products that contribute to dry mouth such as alcohol, tobacco and over-the-counter antihistamines and decongestants.

There have been some reports of more serious side effects associated with anticholinergics, such as prostate problems and an increase in cardiovascular events. Some research findings link anticholinergics to an increased risk of death, while other research actually contradicts these original findings.

Anticholinergic drugs are another type of bronchodilator that work by preventing the large airways (the bronchi) from tightening. The main side effect of anticholinergic drugs is dry mouth which, in addition to being annoying, can lead to tooth decay, gum disease, sores in the mouth, fungal infections in the mouth, cracked lips and poor nutrition due to difficulty chewing and swallowing.

Chart 3: Bronchodilators – Methylxanthines


Category: Methylxanthines are another type of bronchodilator that relax the muscles surrounding the airways and may also decrease swelling in the lungs. However, theophylline, the most commonly used methylxanthine, is less effective than other long-acting bronchodilators and has more side effects, so it is not recommended if other alternatives are available.

Drug Types: Methylxanthines such as Theolair and Uniphyl (theophylline)

Side Effects include the development of atrial and ventricular arrhythmias (heart rhythm irregularities, which can be fatal) and grand mal convulsions (which can occur in people with no history of epilepsy). Other side effects include headaches, insomnia, nausea, and heartburn. Methylxanthines have significant interactions with a number of commonly used drugs, complicating their use.

Methylxanthines are another type of bronchodilator that relax the muscles surrounding the airways and may also decrease swelling in the lungs. However, theophylline, the most commonly used methylxanthine, is less effective than other long-acting bronchodilators and has more side effects, so it is not recommended if other alternatives are available.

Side effects associated with methylxanthines include the development of atrial and ventricular arrhythmias (heart rhythm irregularities, which can be fatal) and grand mal convulsions (which 
can occur in people with no history of epilepsy). Other side effects include headaches, insomnia, nausea, and heartburn. Methylxanthines have significant interactions with a number of commonly used drugs, complicating their use.

Chart 4: Corticocosteroids

Category: Corticocosteroids reduce inflammation in the airways and are often used in combination with bronchodilators. They are also administered using either an inhaler or a nebulizer. Inhaled corticosteroids decrease swelling in the airways. Regular treatment with them improves symptoms, lung function and quality of life, and reduces the frequency of COPD exacerbations.

Drug Types: Inhaled corticosteroid such as Pulmicort (budesonide)

Side Effects: Inhaled corticosteroid use is associated with oral candidiasis (a yeast infection of the mouth or throat, often called thrush), a hoarse voice, skin bruising, and an increased risk of pneumonia. Some of these side effects can be minimized and even prevented by rinsing your mouth after using your inhaler. The National Institutes for Health provide these instructions regarding inhaler use, for example: “When you are finished, place the cover back on the inhaler and twist shut. Rinse your mouth with water and spit out the water. Do not swallow the water. This helps prevent hoarseness, throat irritation, and infections in the mouth.”

Inhaled corticosteroids decrease swelling in the airways. Regular treatment with them improves symptoms, lung function and quality of life, and reduces the frequency of COPD exacerbations.

However, inhaled corticosteroid use is associated with oral candidiasis (a yeast infection of the mouth or throat, often called thrush), a hoarse
 voice, skin bruising, and an increased risk of pneumonia. Some of these side effects can be minimized and even prevented by rinsing your mouth after using your inhaler. The National Institutes for Health provide these instructions regarding inhaler use, for example: “When you are finished, place the cover back on the inhaler and twist shut. Rinse your mouth with water and spit out the water. Do not swallow the water. This helps prevent hoarseness, throat irritation, and infections in the mouth.”

Chart 5: Phosphodiesterase-4 Inhibitors

Category: Phosphodiesterase-4 inhibitors reduce inflammation. They do not have a bronchodilating effect and are generally used in combination with long-acting bronchodilators.

Drug Types: Phosphodiesterase-4 inhibitor such as Daliresp (roflumilast)

Side Effects: Phosphodiesterase-4 inhibitors have more adverse effects than other inhaled medications for COPD, including nausea, reduced appetite, abdominal pain, diarrhea, sleep disturbances, and headache. However, these side effects diminish over time the longer you use the drug.

Phosphodiesterase-4 inhibitors have more adverse effects than other inhaled medications for COPD, including nausea, reduced appetite, abdominal pain, diarrhea, sleep disturbances, and headache. However, these side effects diminish over time the longer you use the drug.

Newer COPD Medications

In the past 4 or 5 years, several new drugs — or drug combinations — for COPD have come on the market. What’s the significance of these newer drugs? “These agents provide more options for patients, but none represents a ‘dramatic’ breakthrough. With the exception of Daliresp, there are similar drugs on the market.” says Philip Diaz, MD, director of Pulmonary Rehabilitation Services and medical director of Respiratory Therapy at The Ohio State University Wexner Medical Center, in Columbus, OH. Dr. Diaz notes, however, that options are always good: “Some patients have excellent responses to some of these new drugs, where they didn’t have such a response to similar drugs previously.”

Chart 6: Combination Drugs

Category: Combination drugs, in which 2 drugs are combined in one inhaler, may offer some benefits over 1 drug taken alone or 2 drugs taken separately.
Drug Types:

–Combination long-acting beta2-agonists plus corticosteroid such as budesonide/formoterol (Symbicort)
–Anoro Ellipta (umeclidinium/vilanterol) combines an anticholinergic with a long-acting beta-agonist
–Breo Ellipta (fluticasone/vilanterol): combines an inhaled corticosteroid and a long-acting beta-agonist
Side Effects: Generally the same as the original drugs in the mixes.

Combination drugs, in which 2 drugs are combined in one inhaler, may offer some benefits over 1 drug taken alone or 2 drugs taken separately:

  • Studies have shown that combining drugs from different classes may improve symptoms without causing more — or more severe — side effects, compared to increasing the dose of a single drug.
  • People may find it easier to manage their medications when only 1 inhaler is needed to take 2 drugs — rather than 2 inhalers to take 2 drugs.
  • When treatment is easier and it reduces symptoms better, people may be more likely to follow their treatment plan as prescribed.

Ultimately, the choice of drug therapy should be individualized and should take into consideration the severity of a person’s symptoms and the frequency of exacerbations, or flare-ups, of the disease.

“In general,” says Dr. Diaz, COPD drugs “are fairly well-tolerated.”

More Drug Options On the Horizon

At least 3 new COPD drugs are currently in development. One called RPL554 is being developed by Verona Pharma in London and is both a phosphodiesterase-3 and phosphodiesterase-4 inhibitor.

“It’s interesting as it may offer a unique combination of bronchodilating properties and anti-inflammatory effects in a nebulized form,” says Dr. Diaz. That means it can address COPD on 2 fronts:  bronchoconstriction and inflammation.

2 other drugs are being developed by Novartis: QVA149, which combines a long-acting beta-agonist with an anticholinergic; and NVA237, which is just the anticholinergic portion. While these two may not be all that different from current drugs, says Dr. Diaz, they will at least provide more options for patients.

Other Treatment Options

For people with severe COPD and low blood oxygen levels, continuous or intermittent oxygen therapy can help. In addition to surgery using the lung volume reduction coils presently in clinical trials, there are a number of surgical approaches to treating COPD, including bullectomy, in which large air spaces in the lungs called bullae are removed; other forms of lung volume reduction surgery, in which damaged lung tissue is removed; and lung transplantation.

Pulmonary Rehabilitation

When used in combination with drug therapy, pulmonary rehabilitation can also significantly improve quality of life for people with COPD. Rehabilitation programs may include:

  • Exercises to increase endurance
  • Strategies for preserving energy by simplifying physical activities
  • Breathing techniques
  • General education about COPD
  • Nutrition counseling
  • Psychological support

Orlan Holmes, 63, who had COPD for 10 years before having a double lung transplant, had pulmonary rehab, and he speaks highly of the treatment’s benefits. “I invested in a pulse oximeter [a device that measures the oxygen level, or oxygen saturation, in the blood], so I could track when I was having problems. I could monitor my heart rate as well as my oxygen level. If my heart rate became too fast or my O2 level dropped below 89, then I needed to rest and do pursed lip breathing. I learned to do things more efficiently by monitoring my results.”

In pursed lip breathing, you inhale slowly through the nose, pursing your lips as if you were going to whistle, and breathe out slowly through your mouth while counting to 4. This technique helps to slow your breathing and relieve shortness of breath.

A number of so-called airway clearance devices can also be helpful to some COPD patients. These aid in removing mucus from the airways and improving lung function. Some require a person to both inhale and exhale through the device, while others require only exhaling, or blowing into, the device.

The use of such devices is strictly patient-specific, says respiratory therapist Andrea Yagodich, who oversees the COPD education program at The Ohio State University Wexner Medical Center.

“If a COPD patient has an underlying case of pneumonia, then [an airway clearance device] may be beneficial,” Yagodich says. “The airway clearance devices we use here at OSUWMC are easy to use and generally well-received by the patients.”

Ingrid Strauch is a freelance writer and editor in Brooklyn, NY.

For more information:

Global Strategy for Diagnosis, Management, and Prevention of COPD (The Global Initiative for Chronic Obstructive Lung Disease)

Inhaled corticosteroids in COPD and the risk of serious pneumonia (Thorax)

Current devices of respiratory physiotherapy (Hippokratia)

Pulse Oximetry (PDF. American Thoracic Society)

Pursed Lip Breathing (Cleveland Clinic)

Additional Resources:

COPD Foundation

American Thoracic Society

American Lung Association


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