Treatment Options for Stage IV COPD

Doctor Auscultating a patient
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Chronic obstructive pulmonary disease (COPD) is an inflammatory disorder of the lungs that restricts airflow into and out of the lungs. COPD is classified by stages of disease which help determine the best course of treatment and predict the likely outcome (prognosis) of the disease.

Stage IV is considered the most severe form of COPD and is characterized by severe shortness of breath (dyspnea). At this stage, your medications won't work as well as they used to, simple tasks will leave you breathless, and you will have an increased risk of lung infection and respiratory failure.

Because COPD is irreversible, this stage of the disease is often referred to as "end stage COPD." This doesn't mean there aren't ways to treat the condition. The Global Initiative for Obstructive Lung Disease (GOLD) recommends the use of the following therapies and practices to best manage stage IV COPD.

No More Smoking

Quitting smoking is one way to live better.
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Even if you are diagnosed with advanced COPD, it's never too late to reap the rewards of smoking cessation. Not only does quitting help slow progression of the disease, the health benefits only continue to increase as time goes by.

After about two weeks, the worst of the nicotine withdrawal symptoms will begin to subside. Over the next few months, the risk of heart attack declines as your circulation improves.

After six to nine months, you'll start to feel less shortness of breath and have fewer problems with sinus congestion.

Flu and Pneumonia Vaccines

woman getting flu shot
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Flu and pneumonia vaccines are among the GOLD treatment guidelines for every stage of the disease. Annual flu shots help people reduce the risk of COPD exacerbation while the pneumonia vaccine significantly decreases your chance of getting bacterial pneumonia.

Studies have shown the annual flu shot alone lowers the risk of illness and death in people with COPD by as much as 50 percent.

Short-Acting Bronchodilators

Woman using a bronchodilator, France
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Rescue inhalers, containing short-acting bronchodilators like Proventil (albuterol), help people with COPD manage persistent or worsening symptoms of the disease. These medications are part of the standard of care for all stages of COPD.

Albuterol is a beta-agonist-class drug which helps the muscles around your airways relax. Proventil is most often used to treat sudden episodes of shortness of breath related to bronchospasm.

Long-Acting Bronchodilators

Senior man about to use asthma inhaler
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As your COPD progresses, your doctor may add one or more long-acting bronchodilators to help prevent or reduce the appearance of symptoms.

Long-acting beta-agonists (LABA) are one type of bronchodilator containing medications like salmeterol or formoterol. Long-acting anticholinergics or muscarinic antagonists (LAMA) are another type containing medications such as ipatropium, tiotropium, and aclidinium.

While using only one long-acting bronchodilator is safe, combination therapy is more effective with equal of fewer side effects. According to 2020 guidelines, people with moderate to severe COPD who experience either shortness of breath and/or exercise intolerance, should be treated with a combination of both a long-acting beta agonist (LABA) and a long-acting anticholinergic (LAMA).

Pulmonary Rehabilitation

Physical therapist working with a patient.
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Pulmonary rehabilitation is generally added during stage II COPD and continued as the disease progresses. It includes exercise, relaxation breathing techniquesnutritional advice, and emotional support to help people better cope with their condition.

Pulmonary rehab can help reduce ​disease symptoms, improve the quality of life, decrease social isolation, and increase survival time. The program uses a multidisciplinary team of nurses, physical and occupational therapists, dieticians, and counselors.

Steroid Medications

Man taking a pill.
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Treatment with glucocorticoids (commonly known as steroids) is controversial, both in the inhaled and oral forms. Oral steroids may be used to treat COPD when symptoms rapidly get worse. Inhaled steroids, by contrast, are typically used to treat stable symptoms or when symptoms are slowly getting worse.

In the past, GOLD recommended inhaled steroids once a person reached Stage III of the disease.

According to 2020 guidelines, however, inhaled corticosteroids should be used for COPD only when a person also has asthma, a high eosinophil count, or experiences one more more COPD exacerbations each year. If a person has not experienced an exacerbation in one year, the inhaled corticosteroid can be discontinued. While inhaled corticosteroids can reduce COPD exacerbations, they can also increase the risk of pneumonia.

Oral steroids are often needed during acute exacerbations and hospitalizations, though their routine use on a maintenance basis is now discouraged as they have been found to have little effect on hospitalizations or shortness of breath, but do increase complications such as high blood sugar and infections.

Oxygen Therapy and Opioids

Oxygen Therapy
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Oxygen therapy is recommended in stage IV on a continuous basis, during exercise, and/or to relieve sudden episodes of dyspnea.

Continuous oxygen is generally recommended for those whose PaO2 (as measured by arterial blood gases) is 55 mm HG or less or whose oxygen saturation levels are less than or equal to 88 percent.

While opioids have been discouraged in recent years due to the opioid crisis, they are now recommended for people who have severe shortness of breath despite optimal treatment of their disease (refractory symptoms). Opiate medications have been found to significantly improve shortness of breath and quality of life, while having minimal risk of falls/accidents or overdoses in this setting.

Lung Surgery

Surgeons performing surgery in operating room
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There are three types of lung surgery available to those who meet very specific criteria with stage IV COPD. They include a bullectomy used to treat large air spaces in the lung, lung volume reduction surgery (LVRS) used to remove a diseased lung, and lung transplantation.

Postoperative complications are common, particularly in those who are obese, in poor health, are elderly, or smoke.

Good Nutrition High in Calories

food from every food group on a table
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Good nutrition is especially important for people with stage IV COPD as the disease places enormous stress on the body and effectively burns up all of the fuel you get from eating. As such, people with COPD will need to increase their caloric intake, ideally with healthy foods rich in antioxidants and phytochemicals.

Eating right can also bolster your immune system and, in turn, help fight chest infections common in people with COPD.

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