Respiratory Diseases and the Fire Service

have occasional side effects. The main side effects with beta-agonists include
increased heart rate, possible heart rhythm disturbances and a hand tremor.
The main side effects reported for anticholinergics are mouth dryness and a
bitter, metallic taste in the mouth.
Inhaled steroids are another mainstay in the treatment of stable COPD.
They do not modify the decline in lung function over time, however regular
treatment is appropriate for patients with severe and very severe COPD (stage
III and IV) to reduce inflammation in the bronchial tubes, exacerbations and
therefore improve quality of life. Combination inhalers containing steroids
and long-acting beta-agonists are more effective than using both components
individually. It is not recommended to use steroid pills to treat COPD on a
continuous basis, as effectiveness has not been definitively proven in clinical
trials and there are too many side effects, especially in the elderly patients.
The use of oral or intravenous steroids for exacerbations however is usually
necessary.
Patients with COPD have frequent exacerbations which can be associated
with viral and bacterial respiratory tract infections. Therefore an extremely
critical part of maintenance therapy is vaccination for influenza and pneumonia.
Pulmonary rehabilitation is another aspect of COPD management. This
consists of exercise training, nutrition counseling, and education. Some of the
benefits of pulmonary rehabilitation include: improving exercise tolerance and
quality of life, reducing breathlessness and the frequency of exacerbations, and
diminishing the occurrence of anxiety and depression associated with COPD.
There may be some benefit on survival, but the studies are somewhat lacking.
The only treatment which has been proven unequivocally to improve survival
is oxygen therapy when given on a long-term and continuous basis. Oxygen is
generally indicated when the blood oxygen level drops below a certain level
at rest or during exercise, or if congestive heart failure is present.
Surgery is a controversial issue in the treatment of COPD. Some studies
have reported success in removing damaged parts of the lungs but it was
limited to select patients. Much more information is required before surgery
is incorporated as a mainstay of COPD management. In patients with very
severe emphysema, lung transplantation can improve quality of life and
general ability to function, but survival benefit may disappear after two years.
Exacerbations are important events in the course of COPD. The most common
cause of an exacerbation is infection, bacterial or viral, and therefore antibiotics
are part of the treatment plan. Intravenous steroids are also beneficial because
they shorten recovery time and help to restore lung function more quickly. Sicker
patients often require oxygen during this time and for a few weeks to months
following the episode. Of course patients continue to take bronchodilators,
although they are usually administered in a humidified form. Finally, when
patients are in respiratory failure they may require placement on a mechanical
ventilator (discussed further in another chapter).
Chapter 2-5 • Chronic Obstructive Pulmonary Disease (COPD)
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