Dealing with Chronic Obstructive Pulmonary Disease (COPD) - Essay Example

DOES CURRENT PHARMACOLOGICAL AND NON PHARMACOLOGICAL THERAPEUTIC INTERVENTION FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) ACHIEVE GOOD OUTCOME FOR PATIENTS? DEBATE. Introduction: Chronic obstructive pulmonary disease (COPD) has become a significant health issue around the world due to the rising rates of morbidity and mortality associated with it. The pathogenesis demonstrated by COPD is very complex, wherein the characteristic occurrence of airflow limitation is in reality the final consequence of a cascade of events with initiation much in advance of any showing of clinical symptoms of the disease. This has led to under diagnosis and poor treatment outcomes for COPD. (1). Rationale for Selection of Topic: The first reason for the selection of COPD as the topic lies in its prevalence. Evaluation of Evidence from epidemiological studies shows that the prevalence varying from country to country between the range of 3% and 10% of the population. Meta-analysis of studies that have estimated the population-based prevalence of COPD from 1990 to 2004 in 28 countries gives the pooled prevalence of COPD as 7.5%. (2).The second reason lies in the severe health consequences that COPD poses. Present estimates of the World Health Organization (WHO) are that COPD is the twelfth commonest cause of morbidity and the fourth most common cause of death all around the world, estimated at 2.75 million. Future predictions of the WHO present an even more bleak picture, with the forecast by 2020 being that COPD is likely to become the fifth most common cause of morbidity and the third commonest cause of death, pushing its annual contribution of death rate to 4 million. (2). The third reason is the huge economic costs that the COPD poses to society. Analysis of data available on the economic costs of COPD on healthcare in the U.S. and the U.K. in 1996 show that in the U.S. the annual economic costs due to COPD were US$ 14.5 billion and in the U.K. it was 2.1 billion pounds. (2).The final reason is that COPD being a multi-component disorder no single approach or therapeutic agent has proven to be effective in arresting the decline of lung function and the progress of the disease. (3). Pharmacological Interventions for COPD: The result of the combined effort by the National Heart, Lung and Blood Institute (NHLBI) and the WHO in 2001 resulted in the development of a new generation of evidence-based guideline as a core resource in the management of COPD. This guideline is called the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Diseases (GOLD). (4). The European Respiratory Society (ERS) guidelines form the basis of the GOLD guidelines. The ERS guidelines take into consideration the varying severity of the disease and the symptoms of the disease, based on which is the recommendation for the use of medications for COPD. These recommendations are: A. “An inhaled anticholinergic or inhaled short acting beta 2 agonist. B. A combination of a short-acting beta 2 agonist and an anticholinergic. C. Increased does of both inhaled anticholinergics and short-acting beta 2 agonists. D. Adding other bronchodilators. E. Adding a corticosteroid”. (5). These ERS recommendations were amended in the GOLD guidelines to the recommended use of short-acting beta 2 agonists and anticholinergics in mild presence of COPD and gradual step-wise increase based on severity of the disease to include bronchodilators, the addition of theophylline and inhaled corticosteroids. (5). Therefore both these guidelines in essence call for a pharmacological approach that employs short-acting beta 2 agonists, anticholinergics in the early stages of the disease and the addition of bronchodilators as the disease progresses cortico-steroids as the disease continues to progress. The focus in this approach in the management of COPD is to reduce the impact of inflammation in the airway passages as a result of COPD. In the initial phases of the disease such a management technique improves the quality of life of the patient, but with COPD being a progressive disease and this approach only reducing the symptoms COPD, it becomes necessary to evaluate the pharmacological approach and its effectiveness in the later progressive stages of the disease. Furthermore, Bellamy and Smith, 2007, point out that more often COPD is diagnosed when the disease has moderately advanced. Exacerbations most often are made up of inflammatory events with severe airway and systemic markers. These exacerbations are heterogeneous events that are believed to result from complex interactions between the host, respiratory viruses, airway bacteria and pollution in the environment that increase the already present inflammatory burden in COPD. This has led to the use of vaccines and long-term antibiotic therapy as a part of the pharmacological approach to the management of COPD. (6). Limitations of the Pharmacological Intervention in COPD: The pharmacological approach in the management of COPD is a judicious use of appropriate pharmacological agents to provide symptomatic relief to the inflammation of the airway passages, which progressively increases as the disease progresses coupled with long-term antibiotics and vaccines to prevent the onset of infection that could lead to exacerbations. Is this sufficient to bring about good outcomes for patients with COPD is the important question. The answer is no, as there are several aspects to COPD and its impact on the body, which are not addressed by the pharmacological approach of targeting the inflammation of the airway passages in COPD. For example weight loss has been a part of the progress of the disease in COPD. There is ample evidence to show the linkage between systemic inflammations in the development of tissue depletion in patients with COPD. Several factors of the disease play a role in the muscle depletion associated with the weight loss in COPD. Nutritional depletion in COPD acts as a means to predict mortality in a COPD patient and morbidity with the advance of the disease. Addressing nutritional depletion in COPD thus becomes essential for better outcomes in COPD, which the pharmaceutical approach fails to achieve. (3). What should be the outcome objectives in COPD? An evaluation of this provides a clear picture of the outcome objectives achieved through a pharmacological approach and those that are not. The outcome objectives that need to be achieved in COPD are multi-factorial, which include decrease and control of respiratory symptoms, increase in physical capacity, improvements in health status, reduction of the psychological influence of physical impairment and disability, prevention of complications and exacerbations and finally extending the life of the patient to the maximum possible. (3).The pharmacological approach attempts only two of these outcome objectives in the form of decrease and control of respiratory symptoms and prevention of complications and exacerbations. This brings into the picture non-pharmacological interventions in the management of COPD with its more holistic approach to the management of COPD. Non-pharmacological Interventions for COPD: There is ample evidence to suggest that multi-dimensional approach that includes exercise training, education and appropriate nutritional support provides anti-inflammatory and other functional benefits to COPD patients (7). Pulmonary rehabilitation provides a multi-dimensional approach to the management of COPD patients. Pulmonary rehabilitation takes into consideration the individual needs of the patient and the program is made out tailored to each individual patient. Being a multi-disciplinary, it combines exercise, self-management and psychosocial supports to provide benefits to COPD patients. There is evidence to show that the benefits derived from pulmonary rehabilitation include functional exercise capacity, quality of life and dyspnoea, reduction in exacerbations that lead to hospitalization and length of stay in hospital. As such pulmonary rehabilitation addresses in a broader way the outcomes objectives that need to be achieved in the management of COPD than in the case of the pharmacological approach with its limited scope to address the required objectives in the management of COPD. (8). Pulmonary rehabilitation programs consist of supervised exercise and education normally over a period of eight weeks that contribute to improved functional exercise capacity and quality of life. However, these benefits normally extend only up to a period of nine months subsequent to the rehabilitation program and in a year’s time there is evidence to show decline, as a result of failure to adhere to exercise program. For the benefits derived through the rehabilitation program to be sustained greater adherence to the exercise program needs to be achieved and this may call for extended supervision in the exercise program (7). Supervision thus becomes a key element in the extension of benefits derived from a pulmonary rehabilitation program. This supervision needs to be through the interaction of health-care providers in sharing information, building partnerships and providing emotional support. This has led to the WHO noting that for pulmonary rehabilitation to be really successful in achieving the required outcomes in the management of COPD the approach has to be truly collaborative in its follow-up to ensure that there is greater partnership among health-care providers and the COPD patients. In short maintenance of the rehabilitation program is the key issue in its continued benefit to COPD patients. (9). While there is evidence to support the benefits that pulmonary rehabilitation could provide COPD patients, there is limited evidence to suggest that extension of these programs outside the hospital environment without adequate support and supervision of health providers and is beneficial to COPD across all populations and therefore recommending this approach becomes difficult till such evidence emerges. (10). Limitations of the Non-pharmacological Interventions: The non-pharmacological interventions are meaningful only as COPD progresses to demonstrate severe symptoms in the patients. Even the GOLD guidelines recommend the use of pulmonary rehabilitation in all stages of COPD except stage 1. Pulmonary rehabilitation thus is indicated in COPD patients with manifested functional deficit even after optimum pharmaceutical intervention. Thus pulmonary rehabilitation is not a replacement for pharmacological interventions in the beginning stage of COPD, but an augmentation in the management of COPD in the presence of manifested functional deficits subsequent to the pharmacological intervention. (3). Furthermore sustaining the benefits of pulmonary rehabilitation programs beyond A period of one year has not been satisfactory and calls for greater efforts in the development of collaboration between the health-service provider and the patient towards achieving optimum outcomes in COPD patients. (10). Implication for Practice in Clinical Settings: Exacerbations in COPD lead to hospitalization and could progress to mortality. A patient admitted into a hospital with exacerbations needs to be managed well in the hospital first to overcome the immediate crisis situation and then prepared for taking the necessary actions and precautions to prevent further episodes of exacerbations. COPD exacerbations are known to be linked with increased upper and lower airway systemic inflammation. There is an enhancement of systemic inflammation during events of exacerbation and the causes still remain unclear, it is possible that there is a spill-over of inflammatory markers from the lungs. The issue with uncontrolled systemic inflammation is that it could lead to cardiac events or increased risk of cardiovascular events in the patient. The result of the airway inflammatory responses is seen in oedema, bronchospasms and an increase in sputum production, which all together contribute to further deterioration in the airflow limitation and development of hyperinflation. In the normal course the more severe the underlying COPD at the time of exacerbation, the greater is the extent of physiological change during the exacerbation event causing a worsening of airflow limitation and the increased risk of respiratory failure. (6). Controlling the impact of exacerbations in COPD is of primary importance in a patient admitted in hospital and this calls for targeting the airway and systemic responses to exacerbation aggressively as a means to prevent the risk of respiratory or cardiac failure in the patient. It is the pharmacological intervention that is of importance at this stage and consists of using combined and increased dosages of anticholinergics, short-acting beta 2 agonists, bronchodilators and corticosteroids. (5). This aggressive approach could provide stabilization of a patient with exacerbations and lead to discharge of the patient after a stay in the hospital. There is evidence to suggest that nearly 30% of the percent of patients discharged from hospitals after am exacerbation event are likely to be readmitted into hospitals with a recurrent exacerbation within 8 weeks. The cause of frequent exacerbations in such patients is still unclear. However it becomes clear that prevention of the frequency of exacerbations is essential to retard the progress of the disease and reduce morbidity and mortality due to the disease. Influenza and pneumococcal vaccines, long-term antibiotics, inhaled corticosteroids, long acting bronchodilators and mucolytic agents are pharmacological interventions that are used in the prevention of exacerbations. (6). COPD exacerbations have functional consequences like peripheral muscle weakness, which gets enhanced during exacerbations and contributes to reduced functionality and poor physical condition. There is evidence to suggest that unless this poor functionality and physical condition unless addresses will lead to increased frequency of exacerbations and hospitalization. (6). Pharmacological interventions do not address this poor functionality and physical condition, which needs to be addressed through pulmonary rehabilitation. This requires educating and informing the patient about the condition and the needs for proper pulmonary rehabilitation and initiating a supervised nutritional and exercise regimen. Even after discharge of the patient there is the requirement for support of the pulmonary rehabilitation program to prevent discontinuation of the pulmonary rehabilitation program. (9). Did the debate answer the focus question? Yes the debate did answer the focus question of whether pharmacological and non pharmacological therapeutic interventions achieve good outcomes for patients with COPD. Given that the outcome objectives to be achieved in COPD patients is decrease and control of respiratory symptoms, increase in physical capacity, improvements in health status, reduction of the psychological influence of physical impairment and disability, prevention of complications and exacerbations and finally extending the life of the patient to the maximum possible we find that pharmacological interventions or non pharmacological interventions by themselves do provide all the necessary outcomes. (3). Judicious use of pharmacological interventions provides satisfactory outcomes in addressing the airway inflammatory responses in COPD and provides decrease in control and of respiratory systems and prevention of complications and exacerbations, thereby contributing to extension of the life of the patient. (5). On the other hand, non pharmacological interventions addresses the other aspects of the outcomes of increase in physical capacity, improvement in health status reduction of the psychological influence of physical impairment and disability and also contributes to prevention of complication and exacerbations. (8). Thus the combined use of pharmacological and non pharmacological interventions becomes essential for achieving the good outcome objectives in the interventions for the management of patients with COPD. Conclusion: COPD is a disease that is highly prevalent in all parts of the world. Of even more concern is the high rate of morbidity and associated with this disease for which a cure is yet to be found. Frequent exacerbations in the disease lead to frequent hospitalizations and high economic costs to society. It is a multifaceted disease with focus on the inflammation of the airway passages contributing to poor functional capacity and physical abilities. This causes the outcomes that need to be achieved by any intervention or combination or interventions to be several too and include decrease and control of respiratory symptoms, increase in physical capacity, improvements in health status, reduction of the psychological influence of physical impairment and disability, prevention of complications and exacerbations and finally extending the life of the patient to the maximum possible. Evaluation of the pharmacological interventions that are recommended and in use shows that these interventions do not address all the required outcomes in COPD and therefore are deficient in some aspects. The non pharmacological interventions mainly address the outcomes that are not done by the pharmacological interventions. This being the status of the pharmacological and non pharmacological interventions with regards to good outcomes that needs to be achieved with interventions in COPD, it is the combined use of both pharmacological and non pharmacological interventions that are capable of achieving the desired objectives in the management of COPD. Works Cited 1. Moretti, Maurizio. “Pharmacology and Clinical Efficacy of Erdosteine in Chronic Obstructive Pulmonary Disease”. Expert Review of Respiratory Medicine 1.3 (2007): 307-316. 2. Bellamy, D. & Smith, J. “Role of Primary Care In Early Diagnosis and Effective Management of COPD”. International Journal of Clinical Practice 61.8 (2007): 1380-1389. 3. Wouters, E. “Management of severe COPD”. Lancet 364.9437 (2004): 883-895. 4. Foster, A. Jill, Yawn, P. Barbara, Abdolrasulnia Maziar, Jenkins Todd, Rennard, I. Stephen & Casebeer, L. “Enhancing COPD Management in Primary Care Settings”. Medscape General Medicine 9.3 (2007): 22 May 2008. . 5. Tsagarika V., Markantonis, S.L. & Amfilochiou, A. “Pharmacotherapeutic management of COPD patients in Greece – adherence to international guidelines”. Journal of Clinical Pharmacy and Therapeutics 31.4. (2006): 369-374. 6. Wedzicha, A. Jadwiga & Seemungal, A.R. Terrence. “COPD exacerbations: defining their cause and prevention” Lancet 370.9589 (2007): 786-796. 7. “Garrod, R. Ansley, P. Canavan, J. & Jewell, A. “Exercise and the inflammatory response in chronic obstructive pulmonary disease (COPD)-Does training confer anti-inflammatory properties in COPD?” Medical hypotheses 68.2 (2007): 291-298. 8. Spencer, M. Lissa, Alison, A. Jennifer & McKeogh, J. Zoe. “Do supervised weekly exercise programs maintain functional exercise capacity and quality of life, twelve months after pulmonary rehabilitation in COPD?” BMC Pulmonary Medicine 7.7 (2007). 22 May 2008. . 9. Moullec, G. Ninot, G. Varray, A. Desplan, J. Hayot, M. & Prefaut, C. “An innovative maintenance follow-up program after a first inpatient pulmonary rehabilitation”. Respiratory Medicine 102.4 (2008): 556-566. 10. Garcia-Aymerich, J. Hernandez, C. Alonso, A. Casas, A. Rodriguez-Roisin, R. Anto, J.M. & Roca, J. “Effects of an integrated care intervention on risk factors of COPD readmission”. Respiratory Medicine 101.7 (2007): 1462-1469. Read More