Our latest Clinical Practice, Outpatient Management of Severe COPD, comes from Dr. Dennis Niewoehner of the Veterans Affairs Medical Center in Minneapolis.
The sentinel clinical feature of severe chronic obstructive pulmonary disease (COPD) is dyspnea on exertion. Its onset is usually insidious, and it may progress to severe disability over a period of years or decades. Other common symptoms include cough, sputum production, wheezing, and chest congestion.
• When is oxygen therapy indicated in patients with severe COPD?
If the partial pressure of arterial oxygen is at or below 55 mm Hg, or if the arterial oxygen saturation is at or below 88%, home use of oxygen should be prescribed for at least 18 hours daily, including sleep time, with flow rates that maintain the oxygen saturation above 90%. There was an absolute reduction in death from any cause of about 20% in both multi-year trials of oxygen therapy.
• What bronchodilator treatment should be offered to patients with severe COPD?
Many patients with severe COPD obtain symptomatic relief from the use of inhaled bronchodilators. Short-acting (beta)2-adrenergic agonists (e.g., albuterol) and ipratropium bromide, a short-acting anticholinergic agent, are used singly and in combination. Long-acting bronchodilators are now commonly used, but a short-acting bronchodilator should be provided for rescue therapy. Both classes of drugs also reduce the risk of exacerbation by 15 to 20% (relative risk reduction), and this may be their most important clinical benefit.
Morning Report Questions
Q: What course of corticosteroid treatment is appropriate for severely symptomatic patients seen in an outpatient setting?
A: Severely symptomatic patients seen in an outpatient setting are also likely to benefit from systemic corticosteroids, although data from trials of outpatient corticosteroid therapy for severe symptoms are lacking. In most instances, 40 mg of prednisone taken once daily for 10 to 14 days should suffice.
Q: What is the role of pulmonary rehabilitation for patients with severe COPD?
A: Randomized, controlled trials of pulmonary rehabilitation consist mostly of small, single-center studies, generally involving patients with severe disease according to spirometric criteria (FEV1:FVC <0.70; FEV1, 30 to 49% of predicted value). A systematic review concluded that pulmonary rehabilitation significantly improved both functional exercise capacity (assessed by measuring the distance walked in 6 minutes) and respiratory quality of life.
Table 2. Medications Commonly Used in Outpatient Treatment of COPD.