Q:I am trying to encourage a patient with chronicobstructive pulmonary disease (COPD) to quitsmoking. He began smoking at age 14 years and hassmoked 1 pack of cigarettes a day for 35 years. His lungfunction is moderately decreased (forced expiratoryvolume in 1 second [FEV1], 65% of predicted). What othermeasures can I recommend to help restore lung functionso that he has more stamina and less shortness ofbreath on exertion?
Q:I am trying to encourage a patient with chronicobstructive pulmonary disease (COPD) to quitsmoking. He began smoking at age 14 years and hassmoked 1 pack of cigarettes a day for 35 years. His lungfunction is moderately decreased (forced expiratoryvolume in 1 second [FEV1], 65% of predicted). What othermeasures can I recommend to help restore lung functionso that he has more stamina and less shortness ofbreath on exertion?A:COPD develops in 1 of 5 smokers. This results inpremature loss of ventilatory function as measuredby spirometry.1 Prognosis is based on the rate of declineof FEV1 over the course of the disease (generally 30 to 40years).2The Lung Health Study demonstrated that smokingcessation in the early stages of COPD results in improvedpulmonary function initially, followed by a muchslower decline over 5 years, compared with the acceleratedrate of decline in persistent smokers.3 In some patients,smoking cessation may even be associated withsome unexpected restoration of lung function.Moreover, bronchodilators may be more effectivefollowing smoking cessation, particularly in the earlystages of disease. This is because airway inflammationmay subside so that beta receptors and anticholinergicreceptors are more responsive to inhaled agents, whetherused alone or in combination.It is also possible that lung damage may be healedwith retinoic acid derivatives.4 This effect has been demonstratedin animal studies5; whether the same response willbe seen in patients with COPD is currently under investigation.Regardless of the study results, however, it still iscritical for patients to stop smoking.Finally, shortness of breath may be greatly reducedby exercise training in a pulmonary rehabilitation program.6 Walking outdoors for 20 minutes twice a day maybe helpful. A more elaborate exercise program is outlinedin the Table. Thus, even if the lungs have been damaged by 35 years of heavy smoking, dyspneacan be reduced and quality oflife improved.Many long-term smokers feeldiscouraged after repeated attemptsto quit have failed. Tell them theyshould not give up. It is never too lateto quit smoking,7 although it is betterto quit early on, before the lungs aretoo severely damaged. Nevertheless,there is a survival benefit even for those who quit late inlife, when lung function has been drastically reduced.8Smoking cessation is the key to optimal managementat all stages of COPD. The future promises drugs that willtarget the basic inflammatory processes and other mechanismsof COPD9 and thus perhaps modify the course ofthe disease.
Burrows B, Knudson RJ, Camilli AE, et al. The “horse-racing effect” and predictingdecline in forced expiratory volume in one second from screening spirometry.
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Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking interventionand the use of an inhaled anticholinergic bronchodilator on the rate of decline ofFEV1. The Lung Health Study.
Belloni PN, Garvin L, Mao CP, et al. Effects of all-trans-retinoic acid in promotingalveolar repair. Chest. 2000;117(5, suppl 1):235S-241S.
Massaro GD, Massaro D. Retinoic acid treatment abrogates elastase-inducedpulmonary emphysema in rats.
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Petty TL. It’s never too late to stop smoking. But how old are your lungs?
Peto R, Speizer FE, Cochrane AL, et al. The relevance in adults of air-flow obstruction,but not of mucus hypersecretion, to mortality from chronic lung disease.Results from 20 years of prospective observation.
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