Target dyspnea sx w additional tx assess for interventions mitigate risks

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].<br>
• <b>Not recommended:</b> 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.<br>
• <b>Vitamin D:</b> Supplementation of vitamin D decr hospital admission episodes (by 50%) among pts w/ severe deficiency (<10 ng/mL or <25 nM).<br>
• <b>Roflumilast:</b> Consider adding if FEV₁ <50% in chronic bronchitis, esp if hospitalized for COPD exac in past yr [A]. Improves lung fxn and reduces mod/severe exac in chronic bronchitis pts w/ FEV₁ <50% w/ hx exac [A]. Benefits greater in pts previously hospitalized for acute exac.<br>
• <b>Antibiotics:</b> Consider macrolides in former smokers w/ exac despite appropriate tx [B]. Azithromycin (250 mg/day or 500 mg 3x/wk) or erythromycin (250 mg bid) reduces exac over 1y [A]; azithromycin assoc w/ incr bacterial resistance [A], hearing impairment [B], and long QTc. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.<br>
• <b>Opioids:</b> If severe dz, low-dose, long-acting opioid (PO/parenteral) may be considered for SOB [B].<br>
• <b>If severe A1AT deficiency w/ emphysema:</b> Consider A1AT replacement tx [B].<br>
• 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.
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² If clinical signs of resp/R heart failure: check pulse ox; if O₂ sat <92%: check blood gas.
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<b>Long-term O₂ (≥15h/day) tx indications:</b><br>
• Sat ≤88% or PaO₂ ≤55 mmHg w/ or w/o hypercapnia 2x in 3wk, or<br>
• Sat 88% or PaO₂ 55-60 mmHg w/ pulm HTN, edema suggesting CHF, or Hct >55%
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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; however, severe hypoxemia in air travel may occur despite sea-level sat [C].
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³ 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.
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⁴ 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.
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⁵ <b>Procedural interventions:</b><br>
• <b>Lung volume reduction surgery.</b> 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.<br>
• <b>Bronchoscopic interventions</b> (eg ,valves [A], coils [B], vapor ablation [B]) &darr;end-exp lung volume and &uarr;exercise tolerance, health status, and lung fxn at 6-12mo in select pts.<br>
• <b>Bullectomy</b> may be considered in select pts [C]; assoc w/ decr dyspnea, improved lung fxn and exercise tolerance.<br>
• <b>Txp.</b> 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><u>BODE Index</u></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.<br>
• <b>Alpha-1 antitrypsin IV augmentation</b> may slow emphysema progression [B] in pts w/ genetic deficiency.
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⁶ <b>Brief cessation counseling:</b><br>
• <b>Ask</b> about tobacco use at every visit for tobacco users; use office-wide identification system<br>
• <b>Advise</b> quitting in a clear, strong, personalized manner<br>
• <b>Assess</b> willingness to quit, determine when (eg, w/in next 30 days)<br>
• <b>Assist</b> w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources<br>
• <b>Arrange</b> f/u in person or via phone, etc
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⁷ 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.
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⁸ Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.
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⁹ <b>COVID-19 mitigation strategies:</b><br>
• Follow basic infxn control measures<br>
• Wear a face covering in public<br>
• Consider sheltering in place
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¹⁰ Pts w/ COVID-19 should continue taking oral and inhaled resp meds for COPD.