Tuesday, 26 November 2013

Chronic obstructive pulmonary disease (COPD) Treatments In conventional medicine perspective

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United State.
 1. Emphysema, a type of Chronic obstructive pulmonary disease (COPD), is defined as a long term and progressive condition cause of shortness of breath but depending to the stage of lung function as a result of damage to tissues of the air sacs (alveoli) in the lungs. In the study of 63 patients with stable COPD (spirometric GOLD stages 2–4) and 17 age- and comorbidity-matched controls, researchers found that in contrast to asthma, COPD is characterised by elevated concentrations of both BDNF and TGF-beta1 in serum. The stage-dependent association with lung function supports the hypothesis that these platelet mediators may play a role in the pathogenesis of COPD(1). In some cases, but rarely, Emphysema is caused by Alpha-1 antitrypsin deficiency emphysema.
2. Chronic bronchitis
Chronic bronchitis is a chronic inflammation of the lung’s bronchi cause of the increased production of mucus in the lung of that leading to difficult breathing.
F. Treatments
F.1. In conventional medicine perspective
F1.1. Therapies
1. Incentive spirometry
In the study of a total of 27 consecutive patients (mean age, 68.4 +/- 7.9 years; 26 males) admitted for COPD exacerbations, found that the use of IS appears to improve arterial blood gases and health-related quality of life in patients with COPD exacerbations, although it does not alter pulmonary function parameters(36).
2. Oxygen therapy
Majority of patients in Oxygen therapy have chronic obstructive pulmonary disease (COPD). The multicenter Nocturnal Oxygen Therapy Trial and the smaller Medical Research Council study identified LTOT as an intervention that improved survival in patients with COPD or chronic respiratory failure, approximately doubling survival at 19 months in patients who were adherent to oxygen(37).
3. Bronchodilators
The aim of Bronchodilators is to decrease the resistance in the respiratory airway and increase airflow to the lungs
a. Short-acting bronchodilators 
In the study to clarify the additive efficacy of short-acting β(2)-agonists (SABA) or muscarinic antagonists (SAMA) on dynamic hyperinflation and exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) who had been treated with long-acting bronchodilators, showed that he additive efficacy of the two drugs was analyzed. Inhalation of SABA and SAMA improved airflow limitation and dynamic hyperinflation in stable COPD patients who had been treated with LAMA. Inhalation of SABA decreased respiratory resistance and the difference in respiratory resistance at 5 Hz and 20 Hz. On the whole, the additive efficacy of SABA on airflow limitation and dynamic hyperinflation was superior to that of SAMA(38).
b. Long-acting bronchodilators
In an overview of the clinical studies evaluating the safety and efficacy of inhaled aclidinium bromide, a novel long-acting anticholinergic bronchodilator, for the treatment of COPD, showed that clidinium bromide has effects on relevant COPD outcome measures, including level of FEV(1), similar to other long-acting bronchodilators, and therefore seems to have the potential for a significant role in the future management of moderate to severe COPD(35).
c. Side effects of Bronchodilators medicine are not limit to headache, Nervousness, Trembling and shaking, Etc., depending to types of medicine.
5. Phosphodiesterase-4 (PDE4) inhibitors 
a. Phosphodiesterases (PDE) are a family of enzymes responsible for the metabolism of the intracellular second messengers cyclic AMP and cyclic GMP. According to the study by GKT School of Biomedical Science, King’s College London, Targeting PDE with selective inhibitors may offer novel therapeutic strategies in the treatment of various conditions, and in the context of respiratory disease these include asthma and chronic obstructive pulmonary disease (COPD)(39). Other study indicated that While there is a wide distribution of these enzymes throughout the body, it is of interest that inflammatory cells thought to participate in the pathogenesis of inflammatory diseases including asthma and chronic obstructive pulmonary disease (COPD), preferentially express PDE4(40).
b. Side effects are not limit to Nausea, Emesis, and related general intestinal problems.
6. Corticosteroids  are most frequent used sontrollers in preventing inflammaory airways in asthma patients and COPD.
a. Inhaled corticosteroids
According to the study by University of Nevada School of Medicine, in the review of review is to compare and contrast the newer inhaled corticosteroid (ICS) ciclesonide with older ICSs, showed that once-daily administration of ICSs is generally not as effective as twice-daily. Continuous administration of ICSs does not change the natural history of asthma in either children or adults. Long-term administration of medium dose ICSs does not increase the risk of cataracts or osteopenia in children and young adults(41). Others in the study of  Dry powder inhaler (DPI) devices to assess the proportion of patients with asthma or chronic obstructive pulmonary disease (COPD) with significant bronchoobstruction who do not have inspiratory flows necessary for the adequate use of dry powder inhaler (DPI) devices Diskus and Turbuhaler. showed that significant proportion of patients with asthma or COPD with significant bronchoobstruction do not exhibit satisfactory inspiratory flows for the use of dry powder inhaler (DPI) devices (Diskus < Turbuhaler)(42).
b. Oral or intravenous corticosteroids
In the study of 47 patients, 30 females, 17 male, 24 received oral prednisolone and 23 received IV hydrocortisone. At baseline the oral and IV groups were similar (mean, SD) in age (38.3, 12.8 vs 37.3, 12.9, P=0.80) and initial percent predicted (PP) PEF (61, 16.7 vs 69, 13.0, P=0.11). After 72 h both groups had similar improvements in PEF (27%, 26 vs 27%, 19, P=0.96), researchers at the Department of Respiratory and Sleep Disorders Medicine, Western Hospital, found that Corticosteroids administered orally and IV had similar efficacy in the treatment of adults hospitalised with acute asthma(43).
c. Side effects
a.1. psychiatric side effects include mania, depression and mood disturbances within the first two weeks of corticosteroid therapy(44).
2. Short side effects include cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects. and Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations(45).
7. Other medication
7.1. Expectorants
a. Expectorants is the types of medicine used to assist the clearance of mucus from the airways, lungs, bronchi, and trachea. In the study to to determine if treatment with mucolytics reduces the frequency of exacerbations, days of disability, or both, in participants with chronic bronchitis or chronic obstructive pulmonary disease, or both.Secondary objectives: to determine if mucolytics lead to an improvement in lung function or quality of life and to determine the frequency of adverse effects associated with mucolytics, showed that in participants with chronic bronchitis or COPD, treatment with a mucolytic may produce a small reduction in acute exacerbations, but may have little or no effect on the overall quality of life. The effects on exacerbations shown in early trials were larger than those found in the more recent studies(46).Others in the study of group 1 ascoril (10 ml tid), group 2 salbutamol (200 mcg two inhalations tid) plus bromhexin (8 mg tid) for 10 days.indicated that ascoril is most efficacious and safe for the treatment of mild or moderately severe COPD and elimination of its exacerbation. The early prescription of this therapy permits to avoid hospitalization and expensive therapy(47).
b. Side effects are not limit to Nausea, Gastrointestinal Distress, Sleep Complications,Drowsiness, Etc.
7.2. Methylxanthines
a. Methylxanthines represent a unique class of drugs for the treatment of asthma. At lower serum concentrations, theophylline is a weak bronchodilator but retains its capacity as an immunomodulator, anti-inflammatory, and bronchoprotective drug(48). In the study to evaluate the addition of methylxanthines to standard treatments in patients presenting with acute exacerbations of chronic obstructive pulmonary disease (COPD), researchers at the indicated that the available data do not support the use of methylxanthines for the treatment of exacerbations of chronic obstructive pulmonary disease. Potential benefits of methylxanthines for lung function and symptoms were generally not confirmed at standard levels of significance(49).
b, Side effects are not limit to nausea and vomiting, and non-significant increases in tremor, palpitations, and arrhythmias, etc.
F.1.2. Surgery
Surgeries may be the only options for  the patient with end-stage COPD, and suffering  severe  symptoms
1. Lung volume reduction surgery
In the study to to evaluate whether favorable short-term results in term of functional outcome and survival following lung volume reduction surgery persist for longer periods, showed that  LVRS can lead to a very long survival (10 years or more) in a small subgroup of patients, with improvement of pulmonary functional data. Some preoperative data (upper lobe distribution of emphysema and pulmonary arterial pressure) appear to predict survival. Lung transplantation can be offered to these patients, showing a trend to improved life expectancy(50).
2. Bullectomy
Bullectomy is the surgical removal of a bullae (greater than 1 cm) which is an air pocket in the lung with an aim to help COPD patients breathe better. A bullectomy may be considered for giant bullae, defined by a volume greater than a third of a hemithorax(51).
3. Lung Transplantation
Patients who are less than 65 years old with end-stage COPD but suffering severe symptoms with no other significant disease may be considered for lung transplant.  It offers the greatest functional benefits but also involves considerable risks(51)
According to the study Washington University, St Louis, Missouri, unfortunately, most emphysema patients are poor candidates for any surgical intervention. A meticulous selection process is favoured in which indications and contraindications are considered and the best solution is devised for each patient. Patients with giant bullae filling half the thoracic volume and compressing relatively normal adjacent parenchyma are offered bullectomy; those with hyperinflation, heterogeneous distribution of destruction, forced expiratory volume in 1 second (FEV(1)) >20%, and a normal carbon dioxide tension (PCO(2)) are offered LVRS; and patients with diffuse disease, lower FEV(1), hypercapnia, and associated pulmonary hypertension are directed towards transplantation. Using these criteria, few patients are serious candidates for surgical procedures. Combinations of LVRS and lung transplantation, either simultaneously or sequentially, are possible but rarely necessary(52).
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(1) http://respiratory-research.com/content/13/1/116/abstract
(36) http://www.ncbi.nlm.nih.gov/pubmed/15955148
(37) http://www.ncbi.nlm.nih.gov/pubmed/23229070
(38) http://www.ncbi.nlm.nih.gov/pubmed/23245993
(39) http://www.ncbi.nlm.nih.gov/pubmed/14636078
(40) http://www.ncbi.nlm.nih.gov/pubmed/11249575
(41) http://www.ncbi.nlm.nih.gov/pubmed/21720220
(42) http://www.ncbi.nlm.nih.gov/pubmed/22768682
(43) http://www.ncbi.nlm.nih.gov/pubmed/15707855
(44) http://www.ncbi.nlm.nih.gov/pubmed/10619339
(45) http://www.ncbi.nlm.nih.gov/pubmed/11588541
(46) http://www.ncbi.nlm.nih.gov/pubmed/22895919
(47) http://www.ncbi.nlm.nih.gov/pubmed/22690572
(48) http://www.ncbi.nlm.nih.gov/pubmed/20859807
(49) http://www.ncbi.nlm.nih.gov/pubmed/14500434
(50) http://www.ncbi.nlm.nih.gov/pubmed/23207566 
(51) http://www.ncbi.nlm.nih.gov/pubmed/16088435
(52) http://www.ncbi.nlm.nih.gov/pubmed/12832685

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