Nonpharmacologic Treatment

Smoking Cessation

Regardless of the severity of COPD, smoking cessation is considered the most important intervention, and patients should receive education, support, and follow-up to facilitate this. Nicotine patches, gum, and lozenges can be recommended as a step-down approach to smoking cessation. The tobacco quit-line sponsored by the Centers for Disease Control and Prevention can be recommended. Medications that have been shown to decrease the urge to smoke include varenicline and bupropion.14

Oxygen Therapy

Prescription of supplemental oxygen should be according to the patient’s needs and best possible outcome. Patients with advanced COPD become desensitized to high CO2 levels and develop a hypoxic drive to breathe when oxygen levels diminish in the bloodstream. To avoid hypoxemia, titrated oxygen therapy to achieve an SaO2 of 88% to 92% is recommended for patients with severe COPD (Table 2).15

Table 2. Normal Ranges of Arterial Blood Gases

Blood pH 7.35 to 7.45
PCO2 35 to 45 mm Hg
PO2 90 to 100 mm Hg
HCO3 22 to 26 mEq/L
SaO2 95% to 100%

Lifestyle Modifications

Symptom management to reduce disease progression includes counseling about eating a healthy diet and obtaining regular exercise. Malnutrition coupled with advancing COPD can lead to worsening respiratory muscle function, dyspnea, and decreased exercise capacity. As a result, muscle mass decreases and respiratory muscles become overloaded during ventilation, which can lead to exacerbations or ultimately respiratory failure.16

Omega-3 fatty acids promote anti-inflammatory activities and are considered protective nutritional elements. Patients with COPD should increase their intake of dietary omega-3 fatty acids to help control inflammation. This can be achieved by incorporating more cold water fish — such as salmon, sardines, tuna, herring, halibut, and mackerel — into the diet. Soybeans, walnuts, flaxseeds, and canola oil are also rich in omega-3 fatty acids.17 

Patients with cachexia may benefit from consuming supplemental nutritional drinks with meals. Small, frequent meals dense in nutrient content with sufficient calories that meet basal energy expenditure requirements and induce weight gain, meals that require little preparation (eg, liquid nutritional supplements, microwaveable), resting before meals, and taking a daily dose of multivitamins are all recommended.18

Ambulatory patients should be encouraged to walk as tolerated. Patients should be advised to start slowly and see how far they can walk before becoming breathless. They should attempt to increase their walking distance by a few feet per day or by a minute or two per day. The goal is to engage in a brisk walk for 20 to 30 minutes 3 to 4 days per week. Patients should also be advised to exhale through pursed lips.17 Since cold air can irritate the lungs and trigger bronchospasm, patients who walk outdoors in cold weather should use a rescue inhaler 15 to 30 minutes prior to exercise and bring the rescue inhaler with them. On extremely cold days, exercising indoors is recommended.

Pulmonary Rehabilitation

Patients with COPD benefit from pulmonary rehabilitation and maintenance of physical activity. Pulmonary rehabilitation is generally recommended for all symptomatic patients, regardless of disease severity. It involves exercise training, patient education, nutritional advice, and psychosocial support. Early initiation of exercise training could reduce future disability by addressing the spiral of lung function decline, deconditioning, and inactivity associated with COPD progression.19,20 

Vaccinations

Vaccinations against influenza and pneumococci are necessary as patients with COPD are highly susceptible to lower respiratory infections. The injectable trivalent, inactivated influenza vaccine is composed of seasonal H3N2, H1N1, and influenza B and is available each year as an annual dose. It is effective in reducing hospitalizations in patients with COPD. The adult pneumococcal, 23-valent-polysaccharide vaccine (PPSV23), which includes the most serotypes, is recommended21, 22 and has been shown to decrease the incidence of community-acquired pneumonia in patients who have an FEV1 <40% predicted.23

Surgical and Nonsurgical Interventions

In patients with advanced disease, surgical intervention can be considered. In select patients with upper lobe emphysema, lung volume reduction surgery (LVRS) may be appropriate. In this procedure, nonfunctional alveoli are removed to decrease the nonventilated areas of the lung. In advanced emphysema, LVRS has been shown to improve lung and respiratory muscle function, exercise performance, quality of life, and mortality in select patients.24

Nonsurgical lung volume reduction coil treatment is a bronchoscopic procedure that can be implemented in patients with advanced emphysema. This procedure involves inserting coil-like devices into bronchioles, restoring elasticity to lung tissue.25

Lung transplantation is available to a limited number of patients, with end-stage COPD accounting for 40% of all adult lung transplantations performed worldwide.26 The prevalence of lung transplantation procedures is limited by organ availability and access to specialized tertiary care centers.24