Bronchodilators are used to relax the smooth muscles that surround the bronchioles, allowing the breathing tubes to dilate and air to flow more freely. These medications can be inhaled using an MDI (metered dose inhaler), powder inhaler devices, or a nebulizer machine These medications can either be short or long acting.
The short acting bronchodilators include the albuterol agents (Ventolin HFA, Proventil HFA, and Pro Air HFA) and the anticholinergic agent, ipratropium bromide (Atrovent).
As an aside, in the past patients have been instructed to count the number of puffs used from these devices or "float" the inhaler in water to determine the amount of remaining medicine available. The HFA devices cannot be floated, and counting of the number of puffs is the only available method of determining the continued presence of medication. One device, Ventolin HFA, has a built in counter. It is important to understand that the mere presence of propellant coming from the inhaler does not necessarily mean that medication is present.
The long acting agents include salmeterol (Serevent), formoterol (Foradil) and tiotropium (Spiriva). Often the long acting bronchodilator is used for controlling the symptoms of emphysema as maintenance therapy, and the short acting one is used when symptoms flare up (rescue therapy).
It is important that the patient know which medication is prescribed, since long acting inhalers cannot be used for rescue, because of their delayed onset of action. Sometimes, patients will seek medical care in an extremely ill state because they have been using the long-acting controller drug as their rescue inhaler. There are 120 or 200 puffs in a short acting MDI, and one puffer should last a significant amount of time. If not, the emphysema is not under control and the patient and health care professional will work on long acting solutions. Many patients with emphysema also have home nebulizers that can deliver albuterol and ipratroprium as part of their control regimen.
Since most patients do not have pure emphysema and usually also have other components of COPD, combined therapy is often prescribed which includes a long-acting bronchodilator and an inhaled corticosteroid. The inhaled corticosteroid (ICS) helps suppress the inflammatory components of COPD. While the bronchodilators work to relax the smooth muscle surrounding the breathing tubes, steroids decrease the inflammation within the walls of the tubes themselves.
These agents like Advair, which is a mixture of salmeterol (Serevent) and fluticasone (Flovent), an ICS, simplify treatment by combining both therapies into a single inhaler device. Another combination inhaler is formoterol and budesonide (Symbicort).
Many patients with emphysema need only take steroid inhalers when their symptoms flare, but others require daily therapy. Corticosteroids have direct action on the lung tissue and absorption of inhaled corticosteroids into the blood stream is minimal. Prednisone, an oral corticosteroid, can be taken in addition to the inhaled steroid should further anti-inflammatory effects be required. Moreover, these may be prescribed to be taken only during an acute flare of the emphysema, or may be required to be taken on a daily basis by those patients with more severe disease.
In emergency situations, corticosteroids may be injected intravenously.
Since patients with emphysema are at risk for infections like pneumonia, antibiotics may be prescribed when the usually clear sputum changes color, or when the patient presents with systemic signs of an infection (fever, chills, weakness).
As the disease progresses, patients may require supplemental oxygen to be able to function. Often it begins with nighttime use, then with exercise, and as the disease worsens, the need to use oxygen during the day for routine activities increases.
The decision to prescribe oxygen depends upon the patient's symptoms as well as results of other tests, including oximetry, pulmonary function tests, and arterial blood gas measurements.