Introduction

What is COPD?

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition characterised by persistent breathing difficulties due to restricted airflow. This reduced airflow is often caused by inflammation, lung damage, or an accumulation of mucus (phlegm) in the airways, making it harder to breathe and decreasing overall lung function.¹

COPD is responsible for 30% of deaths in the UK, and 85-90%1 of the time, it is caused by smoking. However, COPD can also be caused by exposure to secondhand smoke, polluted air and industrial dusts.² The disease is divided into four distinct stages: mild, moderate, severe and very severe,³ categorised according to lung function, which is assessed through a breathing test called spirometry. This test measures how much air you can inhale and exhale, as well as how easily you can breathe out. 

COPD is an irreversible disease, but its symptoms can be managed through pharmacological interventions, lifestyle changes, and specialised treatments like respiratory therapy.² The most common symptoms of COPD include shortness of breath, chronic cough, and fatigue. These symptoms can worsen during flare-ups, which often require additional treatment.¹ Moreover, COPD can lead to secondary conditions such as lung cancer, lung infections, cardiovascular problems, and depression. As a leading cause of morbidity and mortality, COPD significantly impacts quality of life, making its treatment essential.

Overview of respiratory therapy in COPD management

The purpose of respiratory therapy is to improve lung function, increase oxygenation and ventilation and ultimately improve COPD symptoms and quality of life. This line of treatment encompasses a variety of techniques and interventions,⁴ categorised as: pharmacological, non-pharmacological and advanced respiratory therapies.⁴

Pharmacological respiratory therapies

Effective management of COPD often involves pharmacological interventions. Classes of respiratory medication include:

Bronchodilators

Bronchodilators are a common treatment for COPD, they work by relaxing your smooth muscles around your airways and improving airflow by decreasing bronchoconstriction. Bronchodilators are categorised into short-acting bronchodilators (SABAs) and long-acting bronchodilators (LABAs).⁵

SABAs rapidly dilate the bronchi within a few minutes and provide rapid relief. Therefore they are mainly used to address acute symptoms. Some examples of SABAs include levalbuterol and albuterol.⁵

LABAs have a prolonged duration of action and can maintain bronchodilation for 12 hours or more. Therefore, they are mainly used to consistently control symptoms and decrease frequency of flare ups. Some examples of LABAs include formoterol and salmeterol. 

Inhaled corticosteroids (ICS)

Examples of inhaled corticosteroids (ICS) include fluticasone and budesonide. They are crucial in reducing inflammation in the airway, a hallmark of COPD, by inhibiting the inflammatory cascade. ICS also reduces hyperresponsiveness, and consequently frequency and severity of flare-ups.⁶ ICS is often used in patients with moderate or severe COPD and combined with LABAs. 

Combination inhalers

Combined inhaler, as its name suggests, contains both bronchodilator and corticosteroid, meaning you get both bronchodilation and anti-inflammation effects. Therefore, simplifying treatment regimens and providing effective management of symptoms if you have severe COPD. The main combined inhalers are Symbicort and advair.⁷ 

Mucolytics

Mucolytics clear the airways by breaking down the structure of mucus and decreasing mucus viscosity. This is particularly important because COPD causes hypersecretion of mucus and impairs clearance of airways, which can result in constriction. Some examples include acetylcysteine and carbocysteine.⁸

Antibiotics and vaccinations

If you have COPD, respiratory infections can worsen your symptoms, leading to exacerbations and hospitalisation. Therefore, treating or preventing bacterial infection is crucial. Prophylactic antibiotics can be used to treat infections, and vaccinations are recommended to reduce the risk of respiratory infections. 

Non-pharmacological respiratory therapies

Non-pharmacological respiratory therapies take into account different aspects of COPD, such as lifestyle, physical and psychological and are an integral part of managing COPD. Different non-pharmacological respiratory therapies include:

Pulmonary rehabilitation

Pulmonary rehabilitation is a multidisciplinary program aimed at improving overall quality of life. It includes an exercise regimen, a nutritional guide, counselling and any other support that you may need. With a tailored exercise program, you focus on improving your respiratory muscles, or in other words, getting fitter. Meanwhile, the nutritional guide facilitates weight management but also a healthy lifestyle. 

Oxygen therapy

Oxygen therapy is used if you have severe COPD. It provides supplemental oxygen and has numerous ways of delivery - facial mask, ventilator, nasal cannula. Oxygen therapy helps you maintain sufficient blood oxygen levels and can also relieve some symptoms you may be experiencing.¹⁰

Smoking cessation programs

Given that COPD is mainly caused by smoking, these programs focus on helping you quit smoking. It is, therefore, one of the most effective treatments for slowing down the progression of COPD. The smoking cessation program involves behavioural counselling to address your addiction to nicotine by identifying triggers and teaching you coping strategies. Furthermore, by pharmacotherapy, you control withdrawal symptoms of quitting nicotine and decrease cravings. Some examples include nicotine replacement therapy (NRT) and bupropion.¹¹ Smoking cessation programs coupled with pharmacological interventions are one of the most common treatments for COPD.

Advanced respiratory therapies for severe COPD

Advanced respiratory therapies are used when we do not achieve adequate results with other therapies or if COPD is severe-very severe. Some examples include:

Non-invasive ventilation (NIV)

NIV provides you with positive pressure ventilation through a mask in order to help you breathe easier and decrease fatigue of your respiratory muscles. NIV also increases gas exchange in the lungs, meaning the oxygen in your blood increases while the carbon dioxide decreases. Due to the effectiveness of NIV, you get an overall decrease in flare-ups and hospitalisations. 

Lung volume reduction surgery (LVRS)

LVRS is a procedure that removes the damaged section of your lungs, which will open space for the healthy parts of your lungs to expand more. The increase in expansion of the lungs enhances lung function and overall relief of symptoms. Although LVRS is an extremely effective procedure, it is associated with high risks of complications.¹²

Lung transplantation

Lung transplantation is for end-stage COPD patients who require one or both lungs to be replaced with donor lungs. Lung transplantation can significantly impact quality of life and relieve symptoms, however, great risks are associated with it. Long-term survival rate in lung transplantation is varied, and you will have to remain on immunosuppressive therapies for life to prevent organ rejection.¹³

Conclusion

COPD is a progressive lung disease that is highly prevalent, with smoking being its primary cause. It is also an irreversible condition; therefore, respiratory therapies focus on slowing down the progress of this disease and relieving symptoms. There are three main types of respiratory therapies: pharmacological, non-pharmacological and advanced treatment. The most effective treatment is a multidisciplinary approach focusing on improving airflow with pharmacological intervention and lifestyle change,s with non-pharmacological treatments. In the case of severe COPD where other treatments are ineffective, advanced respiratory therapies are considered, which are often effective but high-risk. 

FAQs

Q: What is the main focus of respiratory therapies?

A: Improve overall quality of life, relieve symptoms and slow down the progression of your disease.

Q: What are some challenges in managing COPD by respiratory therapy?

A: The most common challenge is ensuring that patients stick to the treatment plans and are transparent about them. Furthermore, access to pulmonary rehabilitation programs and managing comorbid conditions is also challenging.

Q: Are there any advancements being made in respiratory therapy for COPD?

A: Yes, the most recent focus of the healthcare system has been improving the pharmacological interventions of COPD, which includes researching more effective medications. Advancement of non-invasive ventilation devices is also another focus. 

Q: Why is smoking cessation the most effective treatment for COPD?

A: The program focuses on helping you stop smoking, given that smoking is the main cause of COPD, quitting can help improve symptoms, and also increase the effectiveness of other treatments you may be involved in.