Research Synthesis
Chronic obstructive pulmonary disease (COPD) is understood as a progressive life-threatening illness characterized by an inflammatory component, a violation of bronchial patency at the level of the distal bronchi, and some structural changes in lung tissue and vessels. Modern scientists define COPD as an independent disease of lungs and distinguish it from several chronic respiratory system processes that occur with the obstructive syndrome such as chronic bronchitis, secondary emphysema, bronchial asthma, etc. (Garcia-Aymerich et al., 2011). According to the recent epidemiological data, COPD affects primarily men and women after the age of forty, occupying a leading position among the causes of disability, while five percent of the global population died from this disease in 2015 (“Chronic obstructive pulmonary disease (COPD),” 2016). Physiologically, it is characterized by breathlessness, gas exchange disturbance, hyperinflation of the lungs, and a decrease in the efficiency of the respiratory muscles.
Pathological changes during COPD are marked by an increase in the volume and number of submucosal glands, inflammation of the mucous membrane, emphysema, and the violation of the alveoli compound with small airways. As for obstruction, it is localized mainly in the small peripheral airways. Pathological changes in these airways are hardly noticeable but include loss of alveolar devices acting as tension cables to keep the airways open along with an increase in surface tension as a result of the replacement of surfactant with inflammatory exudates. Garcia-Aymerich et al. (2011) state that several mechanisms are responsible for the development of complex pathophysiology of COPD. The three main established mechanisms are the imbalance of protease-antiprotease, oxidative stress, and apoptosis.
There is important evidence that the increase in oxidative stress exists in smokers and causes some changes in the lungs in patients with COPD. Increased oxidative stress causes direct damage to the lungs by affecting proteins and deoxyribonucleic acid (DNA) as well as indirect harm through the activation of metabolic processes (Aoshiba, Zhou, Tsuji, & Nagai, 2012). Oxidative stress also affects the extracellular matrix and suppresses protective mechanisms such as surfactant and antiproteases. It leads to inflammation in the lungs, activating transcription factors such as nuclear factor-kappa B and the activator-1 protein (Aoshiba et al., 2012). In patients with COPD, the protective effects of intra- and extracellular antioxidant defense systems are suppressed by oxidative stress.
Smoking is the main cause of COPD. Cigarette smoke is a compound combination of several compounds, including high concentrations of free radicals and other oxidants. Components of the matrix of the lungs (for example, elastin and collagen) are damaged by oxidizers of cigarette smoke (Vestbo et al., 2013). Cigarette smoke hurts the function of alveolar epitheliocytes that is partially mediated by oxidants. It is now stated that cigarette smoke causes emphysema by triggering apoptosis of the epithelial cells of the alveoli due to blockade of the vascular endothelial growth factor receptor.
Among other factors causing COPD, which compose approximately five percent, scholars mention production hazards (inhalation of harmful gases and particles), respiratory infections of childhood, concomitant bronchopulmonary pathology, and the state of ecology (Vestbo et al., 2013). In less than one percent of patients, the underlying cause of COPD is a genetic predisposition expressed in the deficit of the alpha-1-antitrypsin protein that forms in the liver tissues and protects the lungs from damage by elastase enzyme. However, there is a need for exploring genomic issues associated with the disease regarding age, ethnicity, and living conditions. Among the occupational hazards, contacts with cadmium and silicon, processing of metals, and the harmful role of products formed during the combustion of fuel are leading in the number of causes of COPD development.
Because COPD develops slowly, it is most often diagnosed in people aged 40 years and older. However, this can also be explained by the aging of the body and the length of the smoking experience. The study by Aryal, Diaz-Guzman, and Mannino (2013) shows that now the level of morbidity among men and women is almost equal. The reason for this may be the spread of smoking among women as well as the increased sensitivity of the female body to passive smoking. When diagnosing COPD and determining the stage of chronic obstructive pulmonary disease, the following analyses are necessary: clinical blood test, spirometry, sputum examination, echocardiography, bronchodilator test, etc.
Missing Information
Disease prevention is a weak point in the evidence regarding COPD. For example, it is not stated widely that COPD is a preventable disease. The level of prevention of COPD must be very little dependent on physicians. The main measures should be taken either by the person himself or herself (smoking cessation) or by the state (anti-smoking laws, improvement of the environment, and promotion of a healthy lifestyle). It has been proved that the prevention of COPD is economically beneficial due to the reduction of morbidity and the reduction of disability of the able-bodied population (Vestbo et al., 2013). However, there are still no clear guidelines on COPD prevention strategies and techniques. The use of vaccines is another unanswered question. Some scholars believe that vaccination against influenza reduces the severity of exacerbations and the mortality of COPD patients by about 50 percent (Santos-Sancho et al., 2012). However, data on the effectiveness of the pneumococcal vaccine in COPD patients is not enough. There is also a lack of evidence regarding comorbidity with such diseases as asthma or diabetes mellitus.
Approaches to the Problem
The goals of COPD therapy are to prevent the progression of the disease along with its exacerbations, reduce the severity of clinical symptoms, achieve better tolerability of physical activity, and improve the quality of life of patients. The objective stated by the World Health Organization (WHO) is to “decrease risk factors of non-communicable diseases, such as tobacco smoking and exposure to second-hand smoke, indoor and outdoor air pollution, unhealthy diet and physical inactivity” (“Chronic obstructive pulmonary disease (COPD),” 2016, para. 8). There are two main approaches to the problem that will be discussed below.
Pharmacological Treatment
According to the medical approach, the following groups of drugs may be prescribed: bronchodilators (to eliminate dyspnea and block bronchospasm), glucocorticosteroids (have a pronounced anti-inflammatory effect), mucolytics (to dilute phlegm), and antioxidants (to reduce the duration and frequency of exacerbations of COPD) (Vestbo et al., 2013).
COPD is characterized by the formation of large cavities in the lungs – bullae filled with air or sputum. Their removal can alleviate the condition of the patient. Such surgery is called bullectomy. With a forced exhalation of 25 percent of lungs’ volume below normal, lung transplantation becomes necessary to maintain a patient’s life.
Non-Pharmacological Approaches
From the physiotherapeutic methods of treatment, intrapulmonary percussion ventilation is used. A special apparatus generates small volumes of air, which are delivered to the lungs by rapid shock acceleration. Such a pneumomassage enlarges the fallen bronchial tubes and improves the ventilation of the lungs. Oxygen therapy is prescribed in case the disease progresses, and the diagnosis of hypoxemia is made. The prolonged oxygen therapy (from 15 hours a day with a two-hour break) aims at increasing the oxygen concentration in the inspired air and the blood. For this purpose, special oxygen concentrators are used. Usually, these procedures are carried out at home. The positive effect of physical rehabilitation (training) is proved by several studies (Wedzicha et al., 2017). This method is under development, as far as there are no effective therapeutic programs. The easiest way to offer a patient is walking daily for 20 minutes.
Giving up smoking is another way to treat a patient with COPD. Even though this disease is considered chronic, smoking cessation is likely to improve one’s quality of life. The research conducted by Cunningham et al. (2016) indicates that quitting tobacco smoking has a significant effect on the course and prognosis of COPD. Even though the chronic inflammatory process is considered irreversible, smoking cessation slows its progression, especially in the early stages of the disease. Tobacco dependence is a serious problem that requires a lot of time and effort not only for the patient himself or herself but also for the care team and family. A special long-term study was conducted with a group of smokers, in which various measures were proposed to combat this dependence, including conversations, practical advice, psychological support, visualization, and so on (Cunningham et al., 2016). With such attention and time, it was possible to achieve quitting smoking in 25 percent of patients. The more often conversations are held, the greater is the probability of their effectiveness.
Approaches to the Treatment of Condition
The presented information was collected from reliable scholarly sources such as peer-reviewed journals and official websites (CDC and WHO). PubMed, CINAHL, Web of Knowledge, and other databases were used. The search was conducted according to the following keywords: COPD, chronic obstructive pulmonary disease, COPD treatment, pharmacological and non-pharmacological approaches, and COPD prevention. The results of the electronic clinical tools and screenings were used to reflect the relevant statistics regarding COPD frequency and severity. It should be noted that the evidence about COPD is rather extended and detailed. The majority of research articles are devoted to the treatment options and the analysis of their effectiveness. In general, data is available and comprehensible. Nevertheless, there are still some questions to be answered in further research as was indicated earlier in this paper. The attention is to be paid to patient awareness and disease prevention based on patient education.
It seems essential to consider both pharmacological and non-pharmacological treatment options. Considering the literature review, it is possible to state that drug treatment based on inhalers and end of life (EOL) care. It should be emphasized that currently, bronchodilators take the leading place in the complex therapy of patients with COPD. All categories of bronchodilators increase exercise tolerance even in the absence of increased FEV1 (Tiffeneau-Pinelli index) values (Melani & Paleari, 2016). At this point, the preference is to be given to inhalation therapy (level of evidence A). The inhalation way of administration of the drugs provides the direct entry of the drug into the respiratory tract and, thus, contributes to more effective medication. Also, the inhalation of administration reduces the potential risk of adverse systemic effects.
Particular attention should be paid to teaching patients the right technique of inhalation to increase the effectiveness of this therapy. Melani and Paleari (2016) state that m-anticholinergics and beta2-agonists are used mainly by metered-dose inhalers. To increase the effectiveness of drug delivery to the place of pathological reactions, namely, to the lower respiratory tract, spacers can be used, which can increase the intake of the drug into the airways by 20 percent. In patients with severe and extremely severe COPD, bronchodilator therapy is to be performed according to special solutions through a nebulizer (Melani & Paleari, 2016). Nebulizer therapy is also preferred along with the use of a dosed aerosol with a spacer in patients with cognitive impairment and the elderly.
EOL care is a multidisciplinary program of individualized care for COPD patients designed to improve their physical state, social adaptation, and autonomy. Its components are physical training, patient education, psychotherapy, and rational nutrition (Safka & McIvor, 2015). Pulmonary rehabilitation should be prescribed with COPD of moderate severity, severe, and extremely severe categories. EOL improves the working capacity, quality of life, and survival of patients, reduces shortness of breath, hospitalization rates, and duration, and suppresses anxiety and depression. The effect of EOL remains continuous. For example, it is recommended to organize classes with patients in small groups with the participation of specialists of various profiles for several weeks.
In recent years, much attention has been paid to rational nutrition, since weight loss and especially muscle loss in COPD patients is associated with high mortality (Safka & McIvor, 2015). Such patients should be recommended a high-calorie diet with high protein content and physical doses with an anabolic effect. The long-term treatment program fits patients with a strong desire to quit smoking and those who plan to do it shortly. The program consists of periodic interviews between the doctor and the patient (more frequent in the first two months of smoking cessation), and the patient receiving nicotine-containing drugs (NSPs). Duration of drug intake is determined individually and depends on the degree of nicotine dependence of the patient.
The rationale for the Selected Treatment Option
Drug therapy is used to prevent complications and reduce the severity of symptoms, their frequency, and exacerbations. The inhalation way of administration of the drugs ensures the direct entry of the drug into the respiratory tract. Also, it reduces the risk of side effects. According to the evidence provided by the Centers for Disease Control and Prevention (CDC), “certain vaccines, such as flu and pneumococcal vaccines, are especially important for people with COPD” (“Chronic obstructive pulmonary disease (COPD)”, 2017, para. 12). Therefore, it is essential to include vaccination in EOL care, thus minimizing the risk of morbidity and any complications. EOL presents a comprehensive care approach, the use which seems to provide the most appropriate care for patients suffering from COPD. As stressed by Safka and McIvor (2015) in their study, there is also a rehabilitation program for COPD patients, which helps them to learn how to manage COPD. Specialists advise and teach patients the technique of proper breathing in COPD to facilitate it, show physical exercises and how to eat properly, etc.
Plan for Follow-Up and Referrals
The scheme of follow-up therapy should be selected individually, taking into account the severity of the course, the patient’s commitment to long-term treatment, the availability and cost of medications for each particular patient. According to clinical guidelines provided by a European Respiratory Society and American Thoracic Society, a constant intake of medication prescribed by a doctor is obligatory (Wedzicha et al., 2017). A chronic inflammatory process characterizes COPD. Therefore, it is not necessary to be limited only to preparations for bronchial dilatation (except the early stages), rather it is critical to use the anti-inflammatory drugs continuously. The proper use of inhalers should also be involved in the follow-up care plan.
It is strongly recommended to give up smoking. Vaccines are to be used to prevent the exacerbation of COPD during epidemic outbreaks of influenza. For patients with COPD, physical training programs are effective at all stages of the process, increasing exercise tolerance and reducing dyspnoea and fatigue. Another point is participation in patient education programs, where experts tell about the features of the disease in a form accessible to the patients, give recommendations on the regime, physical activity. They introduce the spectrum of medicines and the subtleties of their intake and teach rules for using inhalers. In the case of exacerbation or the newly revealed severe symptoms, the patient is to be hospitalized in a specialized pulmonology department and referred to his or her pulmonologist. Thus, the outpatient pulmonary rehabilitation should be designed in a comprehensive manner and referral of the patient to the relevant specialist.
References
Aoshiba, K., Zhou, F., Tsuji, T., & Nagai, A. (2012). DNA damage as a molecular link in the pathogenesis of COPD in smokers. European Respiratory Journal, 39(6), 1368-1376.
Aryal, S., Diaz-Guzman, E., & Mannino, D. M. (2013). COPD and gender differences: An update. Translational Research, 162(4), 208-218.
Chronic obstructive pulmonary disease (COPD). (2016). Web.
Chronic obstructive pulmonary disease (COPD). (2017). Web.
Cunningham, T. J., Eke, P. I., Ford, E. S., Agaku, I. T., Wheaton, A. G., & Croft, J. B. (2016). Cigarette smoking, tooth loss, and chronic obstructive pulmonary disease: Findings from the behavioral risk factor surveillance system. Journal of Periodontology, 87(4), 385-394.
Garcia-Aymerich, J., Gómez, F. P., Benet, M., Farrero, E., Basagaņa, X., Gayete, Ā.,… Roca, J. (2011). Identification and prospective validation of clinically relevant chronic obstructive pulmonary disease (COPD) subtypes. Thorax, 66(5), 430-437.
Melani, A. S., & Paleari, D. (2016). Maintaining control of chronic obstructive airway disease: Adherence to inhaled therapy and risks and benefits of switching devices. COPD: Journal of Chronic Obstructive Pulmonary Disease, 13(2), 241-250.
Safka, K. A., & McIvor, R. A. (2015). Non-pharmacological management of chronic obstructive pulmonary disease. The Ulster Medical Journal, 84(1), 13-21.
Santos-Sancho, J. M., Jimenez-Trujillo, I., Hernández-Barrera, V., López-de Andrés, A., Carrasco-Garrido, P., Ortega-Molina, P., & Jimenez-Garcia, R. (2012). Influenza vaccination coverage and uptake predictors among Spanish adults suffering COPD. Human Vaccines & Immunotherapeutics, 8(7), 938-945.
Vestbo, J., Hurd, S. S., Agustí, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A.,… Stockley, R. A. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187(4), 347-365.
Wedzicha, J. A., Calverley, P. M., Albert, R. K., Anzueto, A., Criner, G. J., Hurst, J. R.,… Sliwinski, P. (2017). Prevention of COPD exacerbations: a European Respiratory Society / American Thoracic Society guideline. European Respiratory Journal, 50(3), 1-12.