Quitting cigarette smoking

The most important treatment for COPD is quitting cigarette smoking. Patients who continue to
smoke have a more rapid deterioration in lung function when compared to others who quit.
Aging itself can cause a very slow decline in lung function. In susceptible individuals, cigarette
smoking can result in a much more dramatic loss of lung function. It is important to note that
when one stops smoking the decline in lung function eventually reverts to that of a non-smoker.

Unfortunately, only about one third of the patients can abstain from smoking long-term. Reasons
for difficulty in quitting include nicotine addiction, stress in the workplace and at home,
depression, peer pressure, and advertising from cigarette companies.

Nicotine in cigarettes is addictive and therefore cessation of smoking can cause symptoms of
nicotine withdrawal including anxiety, irritability, anger, depression, fatigue, difficulty
concentrating or sleeping, and intense craving for cigarettes. Patients likely to develop
withdrawal symptoms typically smoke more than 20 cigarettes a day, need to smoke shortly after
waking up in the morning, and have difficulty refraining from smoking in non-smoking areas.
However, some 25% of smokers can stop smoking without developing these symptoms. Even in
those smokers who develop symptoms of withdrawal, the symptoms will decrease after several
weeks of abstinence.

To help those patients with symptoms of withdrawal during the early weeks of smoking
cessation, nicotine chewing gum (Nicorette Gum), nicotine inhalers, and nicotine skin patches
(Habitrol, Nicoderm CQ, Nicotrol) are available in the United States. Nicotine replacement
therapy can deliver enough nicotine into the blood to reduce but not totally eliminate withdrawal
symptoms. Nicotine replacement methods in conjunction with intense patient education and
behavioral modification programs have improved the rates at which individuals quit smoking.
Nicotine skin patches are easy to use. They generally are used for four to six weeks, sometimes
with a tapering period of several additional weeks. The addiction potential of nicotine skin
patches is low. Sometimes combinations of several nicotine replacement therapies are utilized. It
is important to note, that patients that continue to smoke while on replacement therapy are at
increased risk for heart complications.

Bupropion (Zyban, Wellbutrin) is an antidepressant that has been found to decrease cravings for
cigarettes. It has been shown to be of benefit to patients who want to quit smoking.

Varenicline (Chantix) is a medication is to aid in smoking cessation and has been approved for
use in the US. Varenicline works in two ways; by cutting the pleasure of smoking and reducing
the withdrawal symptoms that lead smokers to light up again and again. This medicine is taken
over a 12 week course and can work in ways that bupropion does not.

In addition to nicotine withdrawal symptoms, quitting cigarette smoking also may lead to weight
gain of about 8-10 pounds on average though more in some patients. Quitting smoking also can
lead to depression and worsening of symptoms of chronic ulcerative colitis. Therefore quitting
smoking should be undertaken with a doctor's supervision. Nevertheless, the benefits of quitting
smoking (decreasing the rate of lung deterioration, decreasing risks of heart attack, lung cancer
and other cancers, decreasing the chance of developing stomach ulcers, etc.) far outweigh these
potential negative effects.
Bronchodilators

Treating airway obstruction in COPD with bronchodilators is similar but not identical to treating
bronchospasm in asthma. Bronchodilators are medications that relax the muscles surrounding the
small airways thereby opening the airways. Bronchodilators can be inhaled, taken orally or
administered intravenously. Inhaled bronchodilators are popular because they go directly to the
airways where they work. As compared with bronchodilators given orally, less medication
reaches the rest of the body, and, therefore, there are fewer side effects.

Metered dose inhalers (MDIs) are used to deliver bronchodilators. An MDI is a pressurized
canister containing a medication that is released when the canister is compressed. A standard
amount of medication is released with each compression of the MDI. To maximize the delivery
of the medications to the airways, the patient has to learn to coordinate inhalation with each
compression. Incorrect use of the MDI can lead to deposition of much of the medication on the
tongue and the back of the throat instead of on the airways.

Chlorofluorocarbons (CFCs) have been removed from all MDI inhalers because of the
environmental effects on the ozone layer. These have been replaced by a new propellant,
hydrofluoroalkane (HFA). Patients may notice that the jet they feel in the back of their throat is
less intense when compared with the CFC inhaler. They should be instructed that they are still
receiving the same amount of medication though it may feel different than their older inhaler.
Another very important point that patients must be aware of is that "floating" these new inhalers
does not help in determining the amount of medication left in the MDI. In the past, the CFC
devices could be floated in a bowl of water. With more medicine in the inhaler, the canister
would sink and gradually float as it emptied. This is not the case with the HFA inhalers. The
number of inhalations must be counted to determine if medication is still left in the inhaler.
Shaking the inhaler is not an effective method of determining how much medication is left. Often
propellant (HFA) will continue to come out of the inhaler even after the medication is used up.
At the present only one albuterol inhaler comes with a counter device and this is Ventolin-HFA.

Beta-agonists

Historically, one of the first medications used for asthma was adrenaline (epinephrine).
Adrenaline has a rapid onset of action in opening the airways. It is still used in certain emergency
situations for attacks of asthma. Unfortunately, adrenaline has many side effects including rapid
heart rate, headache, nausea, vomiting, restlessness, and a sense of panic. Therefore, it is not
used in the treatment of COPD.

Beta-2 agonists have the bronchodilating effects of adrenaline without many of its unwanted side
effects. Beta-2 agonists can be administered by MDI inhalers or orally. They are called
"agonists" because they activate the beta-2 receptor on the muscles surrounding the airways.
Activation of beta-2 receptors relaxes the muscles surrounding the airways and opens the
airways. Dilating airways helps to relieve the symptoms of dyspnea (shortness of breath). Beta-2
agonists have been shown to relieve dyspnea in many COPD patients, even among those without
demonstrable reversibility in airway obstruction. The action of beta-2 agonists starts within
minutes after inhalation and lasts for about 4 hours. Because of their quick onset of action, beta-2
agonists are especially helpful for patients who are acutely short of breath.
Because of their short duration of action, these medications should be used for symptoms as they
develop rather than as maintenance. Evidence suggests that when these drugs are used routinely,
their effectiveness is diminished. These are referred to as rescue inhalers.

Examples of beta-2 agonists include albuterol (Ventolin HFA, Proventil HFA, Proair),
metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethaire), isoetharine (Bronkosol),
and levalbuterol (Xopenex). Albuterol is a chemical that comes mixed in two forms, mirror
images of itself, a left and right hand. Levalbuterol is a purer form of albuterol, the left hand
component. There are some theoretical advantages to this form including possibly reduced side
effects.

Side effects of beta-2 agonists include anxiety, tremor, palpitations or fast heart rate, and low
blood potassium (hypokalemia).

Anti-cholinergic Agents

Acetylcholine is a chemical released by nerves that attaches to receptors on the muscles

surrounding the airway causing the muscles to contract and the airways to narrow. Anti-
cholinergic drugs such as ipratropium bromide (Atrovent) dilate airways by blocking the
receptors for acetylcholine on the muscles of the airways and preventing them from narrowing.
Ipratropium bromide (Atrovent) usually is administered via a MDI. In patients with COPD,
ipratropium has been shown to alleviate dyspnea, improve exercise tolerance and improve FEV1.
Ipratropium has a slower onset of action but longer duration of action than the shorter-acting
beta-2 agonists. Ipratropium usually is well tolerated with minimal side effects even when used
in higher doses. Tiotropium (Spiriva) is a long-acting and more powerful version of Ipratropium
and has been shown to be more effective.

In comparing ipratropium with beta-2 agonists in the treatment of patients with COPD, studies
suggest that ipratropium may be more effective in dilating airways and improving symptoms
with fewer side effects. Ipratropium is especially suitable for use by elderly patients who may
have difficulty with fast heart rate and tremor from the beta-2 agonists. In patients who respond
poorly to either beta-2 agonists or ipratropium alone, a combination of the two drugs sometimes
results in a better response than to either drug alone without additional side effects.

Methylxanthines

Theophylline (Theo-Dur, Theolair, Slo-Bid, Uniphyl, Theo-24) and aminophylline are examples
of methylxanthines. Methylxanthines are administered orally or intravenously. Long acting
theophylline preparations can be given orally once or twice a day. Theophylline, like a beta
agonist, relaxes the muscles surrounding the airways but also prevents mast cells around the
airways from releasing bronchoconstricting chemicals such as histamine. Theophylline also can
act as a mild diuretic and increase urination. Theophylline also may increase the force of
contraction of the heart and lower pressure in the pulmonary arteries. Thus, theophylline can help
patients with COPD who have heart failure and pulmonary hypertension. Patients who have
difficulty using inhaled bronchodilators but no difficulty taking oral medications find
theophylline particularly useful.

The disadvantage of methylxanthines is their side effects. Dosage and blood levels of
theophylline or aminophylline have to be closely monitored. Excessively high levels in the blood
can lead to nausea, vomiting, heart rhythm problems, and even seizures. In patients with heart
failure or cirrhosis, dosages of methylxanthines are lowered to avoid high blood levels.
Interactions with other medications, such as cimetidine (Tagamet), calcium channel blockers
(Procardia), quinolones (for example, ciprofloxacin [Cipro, Cipro XR, Proquin XR), and
allopurinol (Zyloprim) also can alter blood levels of methylxanthines.

Corticosteroids

When airway inflammation (which causes swelling) contributes to airflow obstruction,

antiinflammatory medications (more specifically, corticosteroids) may be beneficial. Examples
of corticosteroids include prednisone and prednisolone (Pediapred Oral Liquid, Medrol). Twenty
to thirty percent of patients with COPD show improvement in lung function when given
corticosteroids by mouth.

Unfortunately, high doses of oral corticosteroids over prolonged periods can have serious side
effects including:

 osteoporosis,
 bone fractures,
 diabetes mellitus,
 high blood pressure,
 thinning of the skin and easy bruising,
 insomnia,
 emotional changes, and
 Weight gain.

Therefore, many doctors use oral corticosteroids as the treatment of last resort. When oral
corticosteroids are used, they are prescribed at the lowest possible doses for the shortest period of
time to minimize side effects. When it is necessary to use long term oral steroids, medications
are often prescribed to help reduce the development of the above side effects.

Corticosteroids also can be inhaled. Inhaled corticosteroids have many fewer side effects than
long term oral corticosteroids.

Examples of inhaled corticosteroids include:

 beclomethasone dipropionate (Beclovent, Qvar, and Vanceril),

 triamcinolone acetonide (Azmacort),
 fluticasone (Flovent),
 budesonide (Pulmicort),
 mometasone furoate (Asmanex), and
 flunisolide (Aerobid).

Inhaled corticosteroids have been useful in treating patients with asthma, but in patients with
COPD, it is not clear whether inhaled corticosteroids have the same benefit as oral
corticosteroids. Nevertheless, doctors are less concerned about using inhaled corticosteroids
because of their safety. The side effects of inhaled corticosteroids include hoarseness, loss of
voice, and oral yeast infections.
To decrease the deposition of medications on the throat and increase the amount reaching the
airways, spacers can be helpful. Spacers are tube-like chambers attached to the outlet of the MDI
canister. Spacer devices can hold the released medications long enough for patients to inhale
them slowly and deeply into the lungs. A spacing device placed between the mouth and the MDI
can improve medication delivery and reduce the side effects on the mouth and throat.Rinsing out
the mouth after use of a steroid inhaler also can decrease these side effects. It is less clear
whether spacing devices help with deposition or side effects of other inhaled medications.

Advair, a powered inhaler device, contains both salmeterol (a long acting beta-agonist) and
fluticasone (an inhaled steroid). This medication has shown to be effective in COPD patients
with chronic bronchitis. Its major side effects include the possible development of thrush (oral
candidiasis) and hoarseness. Another combination medication available in an MID device is
budesonide and formoterol (Symbicort).

Herbal Treatments for COPD:

1. Olive leaf - Olive leaf is one herb that eases symptoms of COPD. Olive leaf reduces
inflammation and aids in the treatment of COPD-related infection. Olive leaf is a natural
antibiotic with anti-inflammatory, anti-viral and anti-bacterial properties.

2. Serrapeptase - Research suggests that Serrapeptase is also helpful. There are many success
stories using this miracle natural enzyme. According to Robert Redfern, "Serrapeptase is a
naturally occurring, physiological agent with no inhibitory effects on prostaglandins and is
devoid of gastrointestinal side effects."

3. Cayenne - Cayenne is used because it has the ability to increase circulation and improve
breathing. A recipe for blood clearance: 1 cup of water, 1/4 teaspoon of cayenne, 1 tablespoon of
apple vinegar and 2 teaspoons of honey. Drink this slowly throughout the day.

4. Other herbs that help ease COPD symptoms include astragalus, enchinacea, ginseng,
quercetin, thyme, milk thistle, eucalyptus and lobelia.

Surgery

In rare cases, surgery may benefit some people who have COPD. Surgery usually is a last resort
for people who have severe symptoms that have not improved from taking medicines.

Surgeries for people who have COPD that's mainly related to emphysema include bullectomy
(bul-EK-to-me) and lung volume reduction surgery (LVRS). A lung transplant may be done for
people who have very severe COPD.

Bullectomy

When the walls of the air sacs are destroyed, larger air spaces called bullae form. These air
spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove
one or more very large bullae from the lungs.
Lung Volume Reduction Surgery

In LVRS, surgeons remove damaged tissue from the lungs. This helps the lungs work better. In
carefully selected patients, LVRS can improve breathing and quality of life.

Lung Transplant

A lung transplant may benefit some people who have very severe COPD. During a lung
transplant, your damaged lung is removed and replaced with a healthy lung from a deceased
donor.

A lung transplant can improve your lung function and quality of life. However, lung transplants
have a high risk of complications. These include infections and death due to the body rejecting
the transplanted lung.

If you have very severe COPD, talk with your doctor about whether a lung transplant is an
option. Discuss with your doctor the benefits and risks of this type of surgery.