Nonpharmacologic Therapy

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Smoking Cessation

Smoking cessation slows the rate of decline in pulmonary function in patients with COPD.6'7 Stopping smoking can also reduce cough and sputum production and decrease airway reactivity. Therefore, it is a critical part of any treatment plan for patients with COPD. Unfortunately, achieving and maintaining cessation is a major challenge. A clinical practice guideline from the U.S. Public Health Service recommends a specific action plan depending on the current smoking status and desire to quit (Fig. 15-2).8 Brief interventions are effective and can increase cessation rates significantly. The five As and the five Rs can be used to guide brief interventions (Table 15-3).

Table 15-2 Treatment Algorithm for Stable COPD

GOLD Stage

Recommended Therapy

I: Mild

I: Moderate

I: Severe

IV: Very severe

Avoidance of risk factors), especially through smoking cessation; influenza vaccination Short-acting inhaled bronchodilator when needed (e.g.. ipratropium, albuterol, or combination inhaler) ADD

Pulmonary rehabilitation Inhaled LABDon scheduled basis i

Inadequate response to LABD?

1 Yes

Use alternative class or combine classes of inhaled LABD 1

Inadequate response to LABD?

1 Yes

Add/substitute oral theophylline ADD

Inhaled corticosteroids if repeated exacerbations'1

Long-term oxygen if chronic respiratory failure

Consider surgical treatment

LABD, long acting bronchodilator (tioiropium6. salmeterol, or

All tobacco users should be assessed for their readiness to quit and appropriate strategies implemented. Those who are ready to quit should be treated with a combination of counseling on behavioral and cognitive strategies and pharmacotherapy (nicotine replacement therapy, sustained-release bupropion, or varenicline; refer to Smoking Cessation in Chap. 36). In COPD patients, the likelihood of sustained abstinence is higher with nicotine replacement therapy than that with sustained-release bupropion.9

Pulmonary Rehabilitation

Pulmonary rehabilitation results in significant and clinically meaningful improvements in dyspnea, exercise capacity, ( health status, and health care utilization.10 It should be considered for patients with COPD who have dyspnea or other respiratory symptoms, reduced exercise capacity, a restriction in activities because of their disease, or impaired health status. A comprehensive pulmonary rehabilitation program should include exercise training, nutrition counseling, and education. It should cover a range of nonpulmonary problems including exercise deconditioning, relative social isolation, altered mood states (especially depression), muscle wasting, and weight loss.

floes patient now use tobacco?

FIGURE 15-2. Algorithm for routine assessment of tobacco use status. (From Ref. 8.)

Rehabilitation programs may be conducted in the inpatient, outpatient (most common), or home setting. The minimum length of an effective program is 2 months; the longer the program, the more sustained the results.10 It is important for patients to continue with a home exercise program to maintain the benefits gained from the pulmonary rehabilitation program.

Table 15-3 Components of Brief Interventions for Tobacco Users

The 5 As for Brief Intervention

Ask: Identify and document tobacco-use status for every patient at every visit Advise: Urge every tobacco user to quit

Assess: Is the tobacco user willing to make a quit attempt at this time?

Assist: Use counseling and pharmacotherapy to help patients willing to make a quit attempt

Arrange: Schedule follow-up contact, preferably within the first week after the quit date

The 5 Rs to Motivate Smokers Unwilling to Quit at Present

Relevance: Tailor advice and discussion to each smoker

Risks: Help the patient identify potential negative consequences of tobacco use Rewards: Help the patient identify the potential benefits of quitting Roadblocks: Help the patient identify barriers to quitting Repetition: Repeat the motivational message at every visit

Long-Term Oxygen Therapy

Long-term administration of oxygen (greater than 15 hours per day) to patients with chronic respiratory failure has been shown to reduce mortality and improve quality of life.1,2 Oxygen therapy should be initiated in stable patients with very severe COPD (GOLD stage IV) who are optimized on drug therapy and meet one of the following criteria: (a) A resting PaO2 at or below 55 mm Hg (7.32 kPa) or oxygen saturation (SaO2) at or below 88%; or (b) PaO2 between 55 and 60 mm Hg (7.32 and 7.98 kPa) or SaO2 of 89% and evidence of pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia.1,

The dual-prong nasal cannula is the standard means of delivering continuous flow of oxygen. The goal of therapy is to increase the baseline oxygen saturation to at least 90% and/or PaO2 to at least 60 mm Hg (7.98 kPa), allowing adequate oxygenation of vital organs. The flow rate, expressed as liters per minute (L/min), must be increased during exercise and sleep and can be adjusted based on pulse oximetry. Hypoxemia also worsens during air travel; patients requiring oxygen should generally increase their flow rate by 2 L/min during flight.1

Oxygen therapy should be continued indefinitely if it was initiated while the patient was in a stable state (rather than during an acute episode). Withdrawal of oxygen because of improved PaO2 in such a patient may be detrimental.


Bullectomy, lung volume reduction surgery, and lung transplantation are surgical options for very severe COPD. These procedures may result in improved spirometry, lung volumes, exercise capacity, dyspnea, health-related quality of life, and possibly survival. Patient selection is critical because not all patients benefit. Refer to the ATS/ ERS COPD standards for a detailed discussion of appropriate selection of surgical candidates.1

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