Long acting inhaled BD combo 1 consider additional interventions in select pts for COPD Group B2 pts

By vgreene, 7 April, 2023

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1 Drugs limited to those available in U.S., listed in alpha order. Regular and prn SAMA or SABA use improves FEV1 and sx [A]; SABA+SAMA combos more effective than mono-tx [A]. LABAs and LAMAs improve dyspnea, reduce exac rate [A]. LAMAs reduce exac [A] and hospitalizations [B] more than LABAs; combos more effective than mono-tx [B]. Triple inhaled tx (ICS/LAMA/LABA) improves lung fxn, reduces exac compared w/ ICS/LABA, LABA/LAMA, or LAMA mono-tx [A]. 
• Not recommended: antitussives [C]; long-term oral/inhaled steroid mono-tx [A]; theophylline, unless other bronchodilators unavailable/unaffordable [B]; vasodilators [B]; benzodiazepines. Insufficient evidence for music or breath relaxation tx. 
• Combo BDs from different classes may ↑efficacy, ↓side effects. Combo LAMA/LABA improved QOL vs placebo or individual components in those w/ highest sx burden, in 1 trial. 
• Vitamin D: Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM). 
• Opioids: If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B]. 
• No existing COPD med has conclusively been shown to modify lung-fxn decline long-term. However, a systematic review combining data from 9 studies showed a 5.0 mL/yr reduction in rate of FEV1 decline compared w/ placebo.
 
2 Group B=more sx, low exac risk. Exac=dyspnea and/or cough and sputum that worsen over <14 days.
 
3 If clinical signs of resp/R heart failure: check pulse ox; if O2 sat <92%: check blood gas. 
Long-term O2 (≥15h/day) tx indications: 
• Sat ≤88% (or PaO2 ≤55 mmHg) (w/ or w/o hypercapnia) 2x in 3wk, or 
• Sat 88% (or PaO2 55-60 mmHg) w/ pulm HTN, edema suggesting CHF, or Hct >55%
 
Prescribe O2 for severe resting hypoxemia [A]. If stable COPD w/ only moderate resting/exercise-induced desaturation, don’t routinely prescribe O2 [A]; however, consider individual factors. If placed on long-term O2, titrate to keep sat ≥90%; re-eval at 60-90 days w/ pulse ox/ABG. Air travel: If resting sat >95% w/ 6-min-walk sat >84%, air travel OK w/o further assessment; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
 
4 NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO2 >53 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
 
5 Procedural interventions: 
• Lung volume reduction surgery. Consider LVRS in select pts. LVRS improves survival in severe dz w/ upper lobe emphysema + low post-rehab exercise capacity [A]; however, LVRS shows higher mortality vs medical mgmt in pts w/ FEV1 ≤20% predicted w/ either homogeneous dz on HRCT or DLCO ≤20% predicted. 
• Bronchoscopic interventions (eg ,valves [A], coils [B], vapor ablation [B]) ↓end-exp lung volume and ↑exercise tolerance, health status, and lung fxn at 6-12mo in select pts. 
• Bullectomy may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance. 
• Txp. In pts w/ very severe progressive dz, consider lung txp. Txp improves functional capacity, QOL in select pts w/ very severe COPD (FEV1 <30% predicted) [C]. Refer for txp eval if progressive COPD, noncandidate for endoscopic/surgical LVRS, w/ <a href=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021322>BODE Index</a> 5-6, PCO2 >50 mmHg and/or PaO2 <60 mmHg, and FEV1 <25% predicted. Txp-list criteria (any 1 of): BODE >7, FEV1 <15%-20% predicted, ≥3 exac/past yr, severe exac w/ hypercapnic resp failure, mod/severe pulm HTN. 
• Alpha-1 antitrypsin IV augmentation may slow emphysema progression [B] in pts w/ genetic deficiency.
 
6 When community prevalence of COVID-19 high, restrict spirometry to pts requiring test for COPD dx and/or assessment of lung fxn for interventional/surgical procedures.
 
7 Rehab improves SOB, health status, exercise tolerance in stable COPD [A]; reduces hospitalization in pts w/ recent exac [B]. Optimum benefits seen from 6-8wk program; no evidence supports 12wk. Twice-weekly supervised exercise recommended. Rehab can be done at a range of sites, including home programs.
 
8 Brief cessation counseling: 
• Ask about tobacco use at every visit for tobacco users; use office-wide identification system 
• Advise quitting in a clear, strong, personalized manner 
• Assess willingness to quit, determine when (eg, w/in next 30 days) 
• Assist w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources 
• Arrange f/u in person or via phone, etc
 
9 Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA. 
10 COVID-19 mitigation strategies: 
• Follow basic infxn control measures 
• Wear a face covering in public 
• Consider sheltering in place
 
11 Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.

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Prescribe rescue short acting BD SABA or SAMA to all pts for immediate sx relief SABA options albuterol levalbuterol MDI NEB SAMA ipratropium MDI NEB

Start LABA LAMA 1 o LABA options arformoterol formoterol olodaterol salmeterol o LAMA options aclidinium glycopyrrolate revefenacin tiotropium DPI MDI umeclidinium o LAMA LABA combo options aclidinium formoterol glycopyrrolate formoterol tiotropium olodat

If LABA LAMA not considered appropriate No evidence favors LABA vs LAMA mono tx choice depends on pt s perception of sx relief

Eval response De escalate tx when appropriate Check inhaler technique every visit

Consider for select pts If hypoxemic per O2 sat ABG 3 assess for long term O2 tx 3 For select pts consider noninvasive ventilation 4 procedural interventions5 6

Pulmonary rehab7 recommended A Encourage physical activity No demonstrated benefit for integrative care or telehealth B

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Long-acting inhaled BD combo;1 consider additional interventions in select pts for COPD Group B2 pts

Long acting inhaled BD combo 1 consider additional interventions in select pts for COPD Group B2 pts

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