Treatment and Medications for COPD

There are many medications and therapies available to help treat your COPD. Some treatments can decrease breathlessness, increase your ability to do activities, and reduce your risk of exacerbations (flare-ups). These treatments cannot repair the damage done to your lungs, but they can make it easier for you to breathe, feel better, do more, and stay out of the emergency department and hospital.

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COPD treatments include medication, pulmonary rehabilitation, smoking/vaping cessation support, immunizations, medical procedures, and other therapies. Let's learn more about the different treatment options for COPD.

COPD Medications

There are many different types of COPD medications, including short- and long-acting bronchodilators, inhaled and systemic corticosteroids, and antibiotics. For the first time in over 15 years two drugs of new classes have recently been approved for COPD by the FDA. All of these medications play a different role in the treatment of your COPD.

In the medication lists below, green text indicates an inhaled medication, blue text indicates an oral medication that is taken by mouth, and red text indicates an injectable medication.

Short-acting Bronchodilators: These medications work quickly to relax the muscles around your bronchial tubes, helping to relieve shortness of breath. They are inhaled into the lungs from an inhaler or nebulizer. When taking short-acting bronchodilators, you often begin to feel better within a few minutes of using your inhaler or nebulizer.

Some common short-acting bronchodilators include:

• Albuterol- inhaler and nebulizer
• ProAir® (Albuterol) inhaler
• Proventil® (Albuterol) inhaler
• Ventolin® (Albuterol) inhaler
• Xopenex® (Levalbuterol) inhaler and nebulizer

Long-acting Bronchodilators: Like short-acting bronchodilators, these medications are inhaled into the lungs through inhalers and nebulizers and relax the muscles in your lungs. However, long-acting bronchodilators do not work quickly. They are often used once or twice a day every day to help reduce the frequency and severity of your COPD symptoms.

Some common long-acting bronchodilators include:

• Brovana® (Aformoterol)- nebulizer
• Perforomist® (Formoterol Fumarate)- nebulizer
• Serevent® (Salmeterol)- inhaler
• Striverdi Respimat® (Olodaterol)- inhaler

Inhaled Corticosteroids: These medications reduce the inflammation in your lungs. They do not work quickly and may take up to a few weeks of continuous use before you begin to feel better. They need to be used every day as directed in order to improve your COPD symptoms. Like long- and short-acting bronchodilators, these medications are given via a nebulizer or inhaler. These inhaled corticosteroids are often a mainstay for asthma therapy and are not recommended as a single agent for COPD. They are only FDA approved for asthma.

Some common inhaled corticosteroids include:

• Alvesco® (Ciclesonide)- inhaler
• Arunity Ellipta® (Fluticasone Furoate)- inhaler
• Asmanex® (Mometasone)- inhaler
• Flovent® (Fluticasone Furoate)- inhaler
• Pulmicort® (Budesonide)- inhaler and nebulizer
• Qvar Redihaler® (Beclomethasone Dipropionate)- inhaler

Systemic Corticosteroids: These powerful medications reduce inflammation in your lungs. They are often used for a few days during an exacerbation, but they may also be used for more extended periods of time. Your health care provider will determine the dosage and duration of your systemic corticosteroid regimen. Be sure to carefully follow your health care provider's directions for the use of these medications. Often, you will have to wean off of systemic corticosteroids rather than stopping them abruptly. These medications are given via pill form or intravenous (IV) line.

Some common systemic corticosteroids include:

• Prednisone
• Medrol Dose Pack® (Methylprednisolone)
• Celestone
• Orapred® (Prednisolone Sodium Phosphate)
• DexPak® (Dexamethasone)
• Solu-medrol (Methylprednisolone)

Short-acting Anticholinergics: These medications work by reducing the bronchoconstriction in your lungs, helping you to breathe easier and feel less short of breath. They work quickly to help relieve your COPD symptoms. They last for 4-6 hours and are usually taken once or twice a day by inhaler or nebulizer.

A common short-acting anticholinergic is:

• Atrovent® (Ipratropium Bromide)- inhaler and nebulizer

Long-acting Anticholinergics: Like short-acting anticholinergics, these medications work by reducing the bronchoconstriction in your lungs, helping you to breathe easier and feel less short of breath. However, long-acting anticholinergics do not work quickly. These medications may help prevent exacerbations in some people. They last for 12-24 hours and are usually taken once or twice a day by inhaler or nebulizer.

• Incruse Ellipta® (Umeclidinium)- inhaler
• Spiriva Handihaler® (Tiotropium Bromide)- inhaler
• Tudorza Pressair® (Aclidinium Bromide)- inhaler
• Lonhala Magnair® (Glycopyrrolate)- nebulizer
• Yupelri® (Revefenacin)- nebulizer

Combination Medications

Some inhalers and nebulizer treatments are available as combination therapy. This means that one inhaler or treatment contains more than one type of medication.

Short-Acting Anticholinergics plus Short-Acting Bronchodilators: These medications combine the actions of the two different types of bronchodilators into one inhaler or nebulizer solution. For some people, this combination of medications can be more effective than using only one type of quick reliever alone. If you don’t think your quick reliever is working well for you, ask your healthcare team to watch you use your inhaler. If you are using your inhaler correctly but are still having bothersome COPD symptoms, ask your health care team about these combination medications.

Some common short-acting anticholinergics and short-acting bronchodilators include:

• Duo-Neb® (Ipratropium Bromide/Albuterol)- nebulizer
• Combivent Respimat® (Ipratropium Bromide/Albuterol)- inhaler

Combination Long-Acting Bronchodilators and Long-acting Anticholinergics: These inhalers contain both a long-acting bronchodilator and a long-acting anticholinergic. These medications work by relaxing the muscles in your lungs and helping to relieve shortness of breath and prevent exacerbations. These medications usually last for 12 to 24 hours and can be used once or twice a day.

Some common combination long-acting bronchodilators and long-acting anticholinergics include:

• Anoro Ellipta® (Umeclidinium / Vilanterol)- inhaler
• Bevespi Aerosphere® (Glycopyrrolate / Formoterol Fumarate)- inhaler
• Stiolto Respimat® (Tiotropium / Olodaterol)- inhaler
• Duaklir® (Aclidinium Bromide/ Formoterol Fumarte)- inhaler

Combination Long-acting Bronchodilators and Inhaled Corticosteroids: These inhalers contain both a long-acting bronchodilator and an inhaled corticosteroid. These combination inhalers can be helpful for people who have frequent exacerbations (2 or more per year or one requiring hospitalization.) These medications last 12 to 24 hours and are taken once or twice a day. Be sure to rinse your mouth and gargle after using medications that contain inhaled corticosteroids.

Some common combination long-acting bronchodilators and inhaled corticosteroids include:

• Advair® (Fluticasone / Salmeterol)- inhaler
• AirDuo RespiClick® (Fluticasone / Salmeterol)- inhaler
• Breo Ellipta® (Fluticasone Furoate / Vilanterol)- inhaler
• Dulera® (Mometasone Furoate / Formoterol Fumarate Dihydrate)- inhaler
• Symbicort® (Budesonide / Formoterol)- inhaler

Combination Corticosteroid, Long-Acting Anticholinergic Bronchodilators, plus Long-Acting Bronchodilators (“Triple Therapy”): These medications contain three different medications, including an inhaled corticosteroid, long-acting bronchodilator, and long-acting anticholinergic. These medications relax the muscles around your bronchial tubes and decrease the inflammation in your lungs, reducing your COPD symptoms and helping to prevent exacerbations. Triple therapy can be helpful for people who have frequent exacerbations (2 or more per year or one requiring hospitalization.) Be sure to rinse your mouth and gargle after using medications that contain inhaled corticosteroids.

Some common triple therapy inhalers include:

• Trelegy Ellipta® (Fluticasone /Umeclidinium/ Vilanterol)- inhaler
• Breztri Aerosphere® (Budesonide/Glycopyrrolate/ Formoterol Fumarate)- inhaler

Phosphodiesterase 4 (PDE4) Inhibitors

This medication reduces airway inflammation. It helps to decrease COPD exacerbations (flare-ups) for patients with severe COPD. This medicine is an oral tablet lasting 24 hours.

Currently there is only one approved in the U.S.:

• Daliresp® (Roflumilast)

Inhaled Dual Phosphodiesterase Inhibitors:

This medication is an inhaled, steroid-free suspension that may be used as maintenance treatment for chronic obstructive pulmonary disease (COPD) in adults, to improve symptoms and reduce the number of flare-ups. It is used twice daily with a nebulizer. Currently there is only one approved in the U.S.:

• Ensifentrine (Ohtuvayre)

Biologics:

Biologic therapies target specific inflammatory pathways without the use of corticosteroids. Their use is related to the type of inflammation that is present.

• Dupilumab (Dupixent) is the first biologic therapy approved for COPD in the U.S. It is an an add-on maintenance treatment of adult patients with inadequately controlled COPD and an eosinophilic phenotype. It is administered with an injection every two weeks.

Biologics approved for asthma therapy that could have a role in selected patients with features of both asthma and COPD.

• Omalizumab (Xolair)
• Mepolizumab (Nucala)
• Benralizumab (Fasenra)
• Reslizumab (Cinquar)
• Dupilumab (Dupixent)
• Tezepelumab (Tezspire)

Antibiotics: These medications treat bacterial infections. They do not work on viruses. They are given for short periods of time through pill or IV form. They are often used to treat exacerbations that occur due to a bacterial lung infection.

Medication Delivery Devices

There are two main ways to deliver medication to your lungs. These include nebulizer treatments and inhalers. Sometimes people call inhalers “puffers.” Let’s learn more about these different delivery devices.

Nebulizers

Nebulizers are devices that change liquid medicine into a fine mist that can be inhaled into the lungs. This mist can be inhaled through a mouthpiece or face mask. There are different types of nebulizers including jet, vibrating mesh, and ultrasonic. Sometimes the vibrating mesh and ultrasonic types are called "electronic nebulizers."

Jet Nebulizers: These are the most commonly used nebulizers. When you use a jet nebulizer at home, pressurized gas from a small air compressor is combined with liquid medicine to create a mist or aerosol. The mist is then inhaled through a mask or mouthpiece. If you are using a jet nebulizer at a hospital or clinic, you may see the nebulizer attached to an oxygen outlet or tank instead of an air compressor.

Ultrasonic Nebulizers: In ultrasonic nebulizers, electric current is used to make high frequency vibrations. This movement turns the medication liquid into a mist or aerosol. The mist is then inhaled through a mask or mouthpiece.

Vibrating Mesh Nebulizers: These devices turn liquid medication into a fine mist or aerosol by forcing the liquid through a piece of vibrating mesh. The mist is then breathed in through a mask or mouthpiece.

For a demonstration on how to use different types of nebulizers, visit the COPD Foundation educational videos page.

A published review of different types of nebulizers is also available in the International Journal of Chronic Obstructive Pulmonary Disease.

Inhalers

There are several types of inhalers, including pressurized metered-dose inhalers (MDIs), dry powder inhalers (DPIs), and soft mist inhalers (SMIs). A useful chart of inhaler types can be found here.

Metered-Dose Inhalers (MDIs): These handheld devices release medicine in the form of a fine mist that is inhaled into the lungs. Each spray of mist has a precisely measured dose of medicine. Before using your MDI for the first time, you may need to “prime” it. Check your inhaler’s package insert for instructions on how to prime your inhaler. Often, you will need to spray your inhaler several times before using it. You must prime your inhaler the first time you use it. You may also have to prime it if you haven't used it for several days.

After your inhaler is primed, it is ready for use. MDI inhalers often require a spacer or holding chamber attachment. Ask your health care provider if you need to use a spacer with your inhaler.

To use your MDI with a spacer, follow these steps:

1. Shake the inhaler for several seconds, as directed in your medication's package insert.
2. Remove the cap of your MDI and attach the inhaler to the spacer.
3. Exhale completely, then put the inhaler up to your mouth. Make sure your lips are closed tightly around the mouthpiece.
4. Push down on the MDI canister and take a slow deep breath in. When you have finished inhaling, you should hold your breath for at least 5 seconds before exhaling.
5. If you need to take a second puff of medication, wait 30 to 60 seconds and then repeat the process.

For a demonstration on how to use different types of MDIs, visit the COPD Foundation educational videos page.

Soft Mist Inhalers (SMI): Soft mist inhalers are handheld devices that turn liquid medication into a mist. The soft mist comes out more slowly than the mist from an MDI. A spacer or holding chamber is not used with a soft mist inhaler.

When you receive your SMI from your pharmacy, you will have to put it together. You can ask the pharmacist to assemble it for you. If you get your medications by mail, be sure to read the instructions on how to get the inhaler ready to use.

Like MDIs, SMIs often need to be primed. Check your inhaler's package insert for instructions on how to prime your inhaler. Often, you will need to spray your inhaler several times before using it. You must prime your inhaler the first time you use it. You may also have to prime it if you haven't used it for several days. After your inhaler is primed, it is ready for use.

To use your SMI, follow these steps:

1. Hold the inhaler upright with the cap closed.
2. Turn the base of the inhaler towards the arrows found on the inhaler's label. Stop when you hear a click.
3. Open the cap and breathe out gently (away from inhaler).
4. Put the mouthpiece in your mouth and close your lips to form a good seal. Do not cover the air vents.
5. Start to breathe in slowly and deeply through your mouth while pressing down on the dose button.
6. When you have finished inhaling, you should hold your breath for at least 5 seconds before exhaling. Breathe out gently (away from inhaler) and close the cover. It should make a clicking sound when it's fully closed.
7. If you need a second dose of the medication, wait 30 to 60 seconds, and repeat the process.

For a demonstration on how to use different types of SMIs, visit the COPD Foundation educational videos page.

Dry-Powder Inhalers (DPIs): Dry Powder inhalers are handheld devices that contain a precise dose of medicine in a very fine powder. Some DPIs contain premeasured doses of the medication powder inside of the inhaler. Other DPIs require that you put a medication capsule into the inhaler each time you use it. DPIs do not release medications in a spray like metered dose inhalers and soft mist inhalers. Instead, you must “pull” the medication out of the device by taking a strong, deep breath in. Be sure to avoid shaking dry powder inhalers.

When using a DPI, first get the device ready for use. Refer to your medication's package insert for instructions on how to use your specific inhaler. Some inhalers can be used directly out of the package, while others require you to insert a capsule, puncture it by using the inhaler's dosing button or lever, and then inhaling the medication. If your inhaler requires you to insert a capsule, be sure to wait until you are ready to use the medication to insert it. Keep the capsules in their original pouch until it is time to use the inhaler.

To use your DPI, follow these steps:

1. Once the device is ready for use, exhale completely.
2. Put the inhaler up to your mouth and make a tight seal with your lips.
3. Take a strong, deep breath in through your mouth. You may taste the powder, but sometimes it is flavorless. When you have finished inhaling, you should hold your breath for at least 5 seconds before exhaling.
4. If you need a second dose of the medication, reload the inhaler (either by closing it and opening it again or by inserting another medication capsule), wait 30 to 60 seconds, and repeat the process.

Some people with COPD may not have the breathing strength to use a DPI. Your health care team may be able to check this by measuring your inspiratory flow rate in the clinic or hospital. If you find that your DPIs do not seem to be working as well as they did before, or if you don't feel that they are working well for you, be sure to check with your health care team. You may not be able to inhale enough of the medication. Other alternatives may be available if you are having trouble using your medications.

For a demonstration on how to use different types of DPIs, visit the COPD Foundation educational videos page.

Be sure to keep track of your medication doses and refill your medications before you run out. Many inhalers now have dose counters on them so that you know exactly how many puffs are left in the device. It is also important to know how to use your inhalers correctly, otherwise you may not be getting enough medication into your lungs. Ask your health care provider to watch you use your inhaler. They can point out any problems that might be happening, and they may have tips on how to get the most out of your inhalers. You can also visit our Educational Video Series, which contains videos showing the proper way to use, clean, and store many different kinds of inhalers and nebulizers. You can also find these videos in our free COPD Pocket Consultant Guide app in Apple's App Store and the Google Play Store.

Nebulizer or Inhaler- Which is Best for You?

Studies have shown that inhaled medicines used with a metered-dose inhaler (MDI), dry-powder inhaler (DPI) or soft mist inhaler (SMI) all work as well as nebulizers. However, that is only true if your inhaler is used with the proper technique, and you are able to take a big enough breath to get the medication deep into your lungs.

To decide which medication delivery device is best for you, talk with your health care professional. Some people may need to use a combination of inhalers and nebulizers. Here are some things to consider:

Potential Nebulizer Benefits

• These devices work well for patients with severe disease and frequent exacerbations.
• Nebulizers work well for patients with physical and/or cognitive limitations if they have a caregiver to help them.
• Nebulizers can be helpful during exacerbations of COPD, especially when higher drug doses are needed or the ability to take a deep breath is limited.
• A normal breathing pattern can be used with nebulizers. You don't have to breathe in deeply or your breath like you do with inhalers.
• Nebulizers deliver medication constantly for several minutes, which can be helpful during an exacerbation.
• Nebulizers are easier for people who have trouble coordinating a deep inhalation with activation of their inhaler.

Potential Nebulizer Drawbacks:

• Nebulizer treatments can take up to 20 minutes per treatment.
• Proper assembly and cleaning are required.
• Nebulizers are less portable than inhalers, although some new nebulizers are smaller and portable.
• There is the potential for the medication mist to get into the eyes, causing irritation.
• Some nebulizers can only be used with one type of medication. In these cases, you may need more than one nebulizer if you are using multiple types of medication.

Potential Inhaler Benefits:

• Inhalers are portable, light, and compact.
• The treatment time with an inhaler is shorter than with a nebulizer.
• Some inhalers contain multiple medicines in one device.

Potential Inhaler Drawbacks:

• Each inhaler is used differently than others. It is important to know how to use each of your inhalers properly.
• Inhalers are more dependent on proper technique, including inspiratory hold and coordination of inhalation with the device activation.
• It is more likely that some medication may deposit into your mouth and the back of your throat instead of getting deep into the lungs. A spacer can help, but it cannot be used with all inhalers. Ask your health care provider if a spacer is needed for your inhaler.
• Some devices may not work well for people who have trouble taking large, deep breaths, those who are having an exacerbation, or those who have more severe disease.

Discuss Your Medications With Your Health Care Professional

All medicines can have side effects. Tell your health care provider about all the medicines you take and be sure to ask about any side effects or problems you are having.

When visiting your health care provider, be sure to bring a list of all the medications you are currently taking, including supplements and vitamins. Bring your inhalers to your appointment and ask your health care team to watch you use your inhaler. They can watch for any problems and help you to learn how to use your inhalers correctly, if needed.

Sometimes the medication you are prescribed is changed at the pharmacy due to your insurance coverage. If the medication you receive is different than the one that was prescribed, ask the pharmacist to explain how to use it. Be sure to notify your health care provider's office of the change in your medication regimen. It is important for everyone on your healthcare team to know what medication you are using.

Download a free copy of our Medication and Immunization Wallet Card, fill it out, and keep it handy in case of emergencies. You should keep your wallet card updated and bring it with you to all of your medical appointments. You can also find an electronic wallet card in the COPD Foundation Pocket Consultant Guide mobile app. Download it from Apple's App Store and Google Play.

Medical Procedures for the Treatment of COPD

Lung Volume Reduction Surgery (LVRS)

Lung Volume Reduction Surgery is a surgical procedure that removes areas of damaged tissue in the lungs. Often, this procedure is performed with a minimally invasive technique called video assisted thoracoscopy (VAT.)

During the procedure, the surgeon removes the worst area of emphysema. This allows the remaining healthier portions of the lungs to work more efficiently. This surgery also reduces pressure on the diaphragm, making it easier to breathe.

LVRS is not right for everyone. To decide if LVRS is an appropriate option for you, extensive medical evaluations are required. This can include lung function testing, cardiac studies, and imaging studies. It is also important to quit smoking and complete a pulmonary rehabilitation program before the surgery to make healing as easy as possible.

The National Emphysema Treatment Trial (NETT), a large multicentered trial sponsored by the National Institutes of Health and The Centers for Medicaid & Medicare Services, found that in carefully selected patients, LVRS can improve lung function, exercise capacity, quality of life, and even survival. LVRS is the first therapy since oxygen to show improved survival in advanced COPD. Because this is surgery in patients with limited lung reserve, there are risks that must be weighed. Centers with extensive experience in LVRS have documented decreased surgical risks and often long-term benefits.

Bronchoscopic Lung Volume Reduction (BLVR)

For some people living with severe emphysema, bronchoscopic lung volume reduction (BLVR) might be an option for treatment. In this procedure, a bronchoscope (a flexible tube with lights and tools attached) is used to place one-way endobronchial valves in the airways. These valves allow air to leave the diseased tissue but will not let air back into those areas. The damaged area begins to take up less space, giving the healthy lung tissue an opportunity to work better. The valves can be removed at any time, if necessary.

As with LVRS, smoking cessation and pulmonary rehabilitation are very important prior to the procedure. Even though this treatment is less invasive than LVRS, there are risks. Careful evaluation is important to ensure that you are a good candidate for the procedure. Your health care provider may need to refer you to a specialist to see if BLVR is right for you.

Additional Treatments for COPD

Supplemental Oxygen

Severe COPD reduces your lungs' ability to release oxygen into your blood, which is then carried throughout your body. The amount of oxygen in your blood can be measured by using a pulse oximeter. This is a small device that fits snugly on your finger. It measures how well your red blood cells are carrying oxygen. If the level of oxygen in your blood is too low, it can be confirmed by performing an arterial blood gas (ABG) test. If your oxygen levels are too low, your health care provider may prescribe oxygen therapy.

Shortness of breath does not necessarily mean you need to use supplemental (extra) oxygen. While some patients who have severe shortness of breath do not have low oxygen levels in their blood, others can have low oxygen levels without feeling short of breath at all. Supplemental oxygen is usually ordered if your oxygen level is low during level is low during sleep, at rest, and/or while you are active.

Learn more about Oxygen Therapy

Pulmonary Rehabilitation

Pulmonary rehabilitation is one of the best treatments we have for COPD. It helps with many of the problems people with COPD experience. These programs provide exercise training, education about COPD, tips on how to complete everyday activities without becoming so short of breath, and advice on how to live better with your condition. You'll also learn how to improve your stamina, use your medications properly, reduce anxiety and depression, and help prevent exacerbations and hospitalizations.

Many different types of medical professionals will work with you in pulmonary rehab. These include doctors, nurses, physical therapists, exercise specialists, dietitians (people who teach you about healthy food choices) and more. You will work with this team to create a special program tailored to your specific needs. Pulmonary rehab programs are available in many communities and often paid for by insurance. Some programs are found in a clinic or hospital, while others can take place in your home or via video conferencing over the internet. If you have not been to pulmonary rehab, talk to your healthcare team and ask how you can be referred to a program near you.

Learn more about Pulmonary Rehabilitation

The COPD Pocket Consultant Guide Mobile App

The COPD Foundation offers an important resource to help you manage your COPD. The free COPD Foundation's COPD Pocket Consultant Guide mobile app includes section such as:

• My Wallet Card to keep track of your important health information
• My COPD Action Plan that gives you instructions to follow on good days and bad
• Activity Tracking which helps you to improve your stamina and identify patterns in your activity level
• Calendar that lets you track your COPD symptoms over weeks or months
• Inhaler and nebulizer videos that show you how to use and clean your inhalers and nebulizers
• Exercise videos that show you some simple exercises you can do while seated
• For my next visit which offers suggested questions to ask at your next clinic visit and lets you add you own questions
• COPD Digest which is a blog that covers timely topics in COPD management
• Links to other COPD Foundation resources such as our educational materials which include booklets, forms, and flyers

You can download the COPD Pocket Consultant Guide app for free in Apple's App Store and Google Play.

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