TREATMENTS FOR COPD

PLEASE DO FAIL TO  GET YOUR VACCINATION AGAINST INFLUENZA - IN THE AUTUMN.

In what sequence/order should inhalants be taken?

Since the current postings on this subject I have found from patients that there are many different opinions among UK doctors on this issue. Drug manufacturers do not appear to have made any studies or issued guidelines - perhaps because they sell more of their products if the earlier approach is used. Even GP's sometimes do not offer advice when prescribing multiple inhalations of different drugs unless the patient asks - and this is truly unacceptable practice.

Among those that do offer advice, most UK doctors appear to be using the outdated sequence that tells patients to use short term relievers first, i. e., "to open up the airways so that the long term reliever can be more effective".

American experts say that recent research has shown this concept to be less effective than than the reverse sequence and in fact can cause more drug use than necessary. The first point they make is that there is no need to specially open up the airways as the receptor points in the lungs are 'networked' and if one area in the bronchia receives the inhaled chemical that causes them to relax and open up, the nearby ones will do so as well. The more remote ones will respond too, but their degree of saturation from the drug will be less depending on their distance from the areas receiving direct deposit of the drug particles.

The second, and most important point, is that the bronchia use the same receptor points to absorb and react to both the long and short term beta-agonist reliever drugs. This means that if the short term reliever is used first, the receptor points are already busy operating and if the long term drug is taken too soon afterwards, the receptor points are unable to react to more reliever drug. So very little of the long term one is able to be absorbed by the body.

The net result is that patients tend to use more short term inhalations for relief because too little of the long term one gets to work. It is best to take the long term one first.

It seems that this research and the logic that stems from it has so far failed to penetrate the UK medical scene and the internet has caused many patients to question their present advice. Personally I recommend all those who are still taking the short term relievers first, to talk to their doctors and ask whether they know about the recent work and whether, after considering it, their advice remains the same as before. If so, then the choice is up to you, but if you decide to experiment, it is highly unlikely that you will do yourself any harm - in fact I have seen several patients' postings on US and UK websites that claim significantly reduced short term drug usage from the new approach.

Since posting the compressed Version 2 of the drug sequence list below , I have had discussions with the list originator, Mark Mangus in the USA. The recommended wait for taking a short term beta-agonist reliever after taking the long term one, is as long as possible consistent with comfort, but should preferably be not be less than 30 minutes.

There is no harm likely if you do take it after less than 30 minutes, but its effect is likely to be negligible - unless your inhalation of the long term one was not quite as well performed as usual. It does happen sometimes !

David Boswell
The source of the work is understood to be accessed via :
Mark W. Mangus, Sr., BSRC, RRT, RPFT, FAARC
at the Pulmonary Rehabilitation Centre,
Christus Santa Rosa Health Care
San Antonio, Texas USA.

David Boswell

Lung damage from smoking is irreversible, which means that apart from a lung transplant. no treatment will as yet, replace all that damaged tissue. Before you throw your hands in the air and say "well that's it then, there's no point in stopping smoking and I might as well throw myself off the nearest cliff", there certainly is something you can do. 

Firstly you need to slow down the progression of the disease. Every year all healthy people lose a little lung power or put in medical terms a loss in FEV1. [Forced Expiratory Volume]. Patients with COPD who no longer smoke lose the same amount as people who have never smoked BUT if they continue to smoke (and 40% or so do) the rate of loss is TWICE as fast as patients who stop smoking .

 Putting it bluntly, that means if you have severe COPD and continue to smoke, you will probably die, for example, within 6 years instead of 12. This statement is not meant to be a forecast, but just figures to illustrate the point! The first real and only effective treatment for COPD is therefore to STOP SMOKING  see link.

You must also have an annual vaccination for influenza and it is also recommended that you consider a vaccination for the most common types of pneumonia. Most GP surgeries will arrange this automatically.  

And what about breathlessness?

There are certainly treatments to make breathing easier. There are also breathing techniques you can be taught on an Expert Patients Course or in Pulmonary Rehabilitation , and there is oxygen.  But on this page John deals with BRONCHODILATORS first.

What are  bronchodilators ?

Basically these are medicines delivered by inhalers which are pictured below. There are a number of types and some are called Turbohalers or Aurohalers that deliver powder and there are and others which deliver a spray. Both powders and sprays are drawn into your lungs, which require some effort on your part. You will be taught how to use them and it is important to learn and practise the techniques. If you are still having breathing difficulties you may be given a NEBULISER which delivers greater quantities over a period of five or ten minutes. However, there is some debate about its use. Besides being an expensive treatment, it may be no more effective than taking multi-bursts from your inhaler. However, if you have been hospitalised a few times or have suffered a number of exacerbations  it might be appropriate for you.

DO NOT USE YOUR RESCUE INHALER ( BRICANYL, VENTOLIN etc) IMMEDIATELY AFTER EXERCISING. USE IT BEFORE OR WHEN YOU STOP FOR A WHILE. OTHERWISE YOU WILL NOT INHALE DEEPLY ENOUGH FOR THE LUNGS TO BENEFIT FROM THE MEDICINE. AFTER INHALING ALWAYS TRY TO HOLD YOUR BREATH FOR A FEW SECONDS TO ALLOW THE MEDICATION TO SETTLE IN THE LUNGS. IT IS NOT NECESSARY TO INHALE MORE THAN TWICE FROM ONE DOSE. SOME ELDERLY FOLK MIGHT FIND IT DIFFICULT TO USE AN INHALER - PLEASE SEE YOUR GP PRACTICE NURSE. ALSO IF YOU ARE HARD OF HEARING YOU MAY NOT HEAR THE CLICK OF THE POWDER INHALERS.

What type of medicines or drugs are delivered by inhalers?

The following is a description of the drugs John took - and why. This does not however mean they might be suitable for you!!! Remember that John  had severe COPD and you may never need all these.

John took SPIRIVA (otherwise known as Tiotropium).

This has recently been developed and established to be the drug of choice especially for those patients with moderate to severe COPD. It causes a slight but measurable improvement in your FEV1, health status and breathing. You breathe it in deeply (in powder form) from a special container into which you insert a  capsule. You press a button which pierces the capsule and then breathe in deeply and hold your breath a little. And the beauty of it is that you only have to do this once a day. The drug is known as a long acting bronchodilator and is also called an ANTICHOLINERGIC . Some patients take IPRATROPIUM  instead and the difference is ipratropium only lasts between 3 and 6 hours and is usually prescribed to be inhaled four times a day.

John also took short acting bronchodilators known as Beta2-agnonists !  Don’t worry about these medical terms! These affect your lungs differently that’s all and help your breathing. Some patients may get by with just these with the milder form of the disease and not have to take Spiriva (see above). He used to take just Ventolin or Salbutamol when heI felt breathless – this came as spray and you can see many asthma patients take it from a blue tube.  However, just to confuse you, he admitted that he then took Bricanyl which is a combination drug which he said he found more effective. But it is more expensive and some GPs may be reluctant to offer it depending upon the severity of the disease and your reaction to Ventolin or similar. It comes in powder form and when he breathed in deeply less of it ended up on the back of his throat. And for the enthusiasts amongst you this combination drug contains terbutaline sulphate (doesn’t mean  anything to us either!). Anyway, whichever of these short acting Beta2-agonists you use, you take them when you feel more breathless up to a limit set by your GP. They are also known as RELIEVERS or RESCUE MEDICINES. Not everybody gets on with say Bricanyl, so they just take Ventolin  instead or vice versa. Always discuss any side effects with your GP. It is important whichever inhaler you use to breathe it in as deeply as possible and then to hold your breath, ideally for 5 seconds or so. If you have difficulties you may be offered a SPACER which is a small chamber to hold the spray and you will have more time to breathe it in. With a powder inhaler there are aids for people with arthritis to make the inhaler easier to use.

Most patients with medium to severe COPD take some form of inhaled steroids. No, don't scream as they are not the same as those taken by some dumb athletes or body builders!! Your GP may refer to these inhaled steroids as CORTICOSTEROIDS. NICE (remember - see above) recommended in 2004 that all patients should take them if their FEV1 is less than 50%. It also recommends that these inhaled steroids be taken with long acting bronchodilators. But some patients have side effects with these combination drugs so report any side effects that are still present after a week or two. John used SYMBICORT (delivered by fine powder), twice a day, which contains budesonide (the steroid ) and formoterol - a long-acting Beta 2 agonist ).

This picture shows the drugs John took.

Well if you've followed all this you've done very well. Otherwise just pass on the page to your GP or rely on their judgement! In summary John took SPIRIVA, BRICANYL AND SYMBICORT. But a friend of his who has Severe COPD (emphysema) doesn't because she had some side effects using the last two so she just uses the corticosteroid FLIXOTIDE, [fluticasone  propionate], SPIRIVA and VENTOLIN. It's up to you to discuss these medicines and YOUR side effects with your GP. If you have a lot of sticky phlegm you may be offered mucolytics to reduce it. 

What about surgery?

Well this is a tricky subject. If you are a young patient with severe COPD and not long to live - say for example in your 40s then you might be offered a lung transplant. But John wasn'y offered one. In any case you will only be offered it if you have only a few months to live, and the rest of your body is in reasonable shape! If you are over 65, it is very rarely an option.

You might be eligible for what is called "volume reduction surgery". If your disease is confined to only part of your lungs, then surgery might remove this diseased part so allowing the remaining lungs perform better. John was not eligible because his disease had spread evenly throughout his lungs. Talk it over with your consultant not your GP.  

OTHERWISE

Some patients who are retainers of CO2 (carbon dioxide) may be offered Non-Invasive Ventilation machines to use at night. John had one one and has added a page about these machines.  

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Website Created by John Kirtley, BA.  Edited by Mol Smith and David Boswell B.Sc