Combine long-acting inhaled BDs;1 consider O2 tx, surgery/procedures, ventilation for COPD Group D2 pts

¹ Drugs limited to those available in U.S., listed in alpha order. LAMA+LABA combo reduces dyspnea [A] and reduces exac rate [B] vs single agent tx; if single agent used, LAMA preferred over LABA to &darr;exac rate [A], hospitalizations [B]. LAMA+LABA combo superior to ICS+LABA combo for exac prevention in COPD Group D pts [B]; such pts are @ increased pneumonia risk on ICS tx. ICS+LABA combos include: budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, mometasone/formoterol.<br><b>• Not recommended:</b> antitussives [C], long-term oral/inhaled steroid monotherapy [A], theophylline [B], vasodilators [B], benzodiazepines. Insufficient evidence for music or breath relaxation tx.<br>
<b>• Combo BDs</b> from different classes may &uarr;efficacy, &darr;side effects. Triple inhaled LAMA/LABA/ICS improves lung function, sx, health status [A] and reduces exac [B] vs ICS/LABA or LAMA mono-tx. Combo LAMA/LABA improved QoL vs placebo or individual components in those w/ highest sx burden, in 1 trial. Fixed triple tx bested tiotropium in certain pts w/ hx exac in 1 RCT; single-inhaler triple tx bested ICS/LABA in advanced COPD pts in 1 RCT.<br>
<b>• Roflumilast</b> Consider adding if FEV₁ <50% predicted in chronic bronchitis, esp if hospitalized for COPD exac in past year [A]. Improves lung function and reduces mod/severe exac in chronic bronchitis pts w/ severe (FEV₁ 30%-49% predicted) to very severe (FEV₁ <30% predicted) COPD 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 (500 mg bid) reduces exac over 1y [A]; azithromycin associated w/ increased bacterial resistance [A], hearing impairment [B]. No safety/efficacy data beyond 1y. Less benefit in active smokers, per 1 analysis.<br>
<b>• Opioids.</b> If severe dz (FEV₁ <50% predicted), low-dose long-acting (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-function decline long-term.
<br><br>
² <b>Group D</b>=more sx, high exac risk. <b>Exac</b>=acute worsening (beyond day-to-day variation) leading to change in medication.
<br><br>
³ If clinical signs of resp/heart failure: &#x2713;pulse ox; if O₂ sat <92%: &#x2713;blood gas.<br>
Long-term O₂ (≥15h/day) tx indications:<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%
<br><br>
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 @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.
<br><br>
⁴ LVRS improves survival in severe dz (FEV₁ <50% predicted) 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 lung-volume interventions (eg, valves [B], coils [B]) await further data to guide pt selection.
<br><br>
⁵ 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, BODE index 5-6, PCO₂ >50 mmHg and/or PaO₂ <60 mmHg, and FEV₁ <25% predicted.
<br><br>
GOLD BODE reference: Celli BR, et al. The Body-Mass index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease. <i>N Engl J Med.</i> 2004;350(10):1005-12. <a href=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021322>PDF</a> | <a href=http://www.ncbi.nlm.nih.gov/pubmed/14999112>PubMed® abstract</a>
<br><br>
⁶ Bullectomy in select pts [C], (eg, a large bulla in pts w/ relatively preserved underlying lung).
<br><br>
⁷ NPPV may improve hospital-free survival in select pts post-recent hospitalization, esp if daytime hypercapnia (PaCO₂ ≥52 mmHg) persists [B]. If COPD+OSA, CPAP has clear benefits.
<br><br>
⁸ 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.
<br><br>
⁹ Brief cessation counseling:<br>
<b>• Ask</b> about tobacco use @ 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
<br><br>
¹⁰ Common comorbidities include CV dz, skeletal muscle dysfxn, metabolic syndrome, osteoporosis, depression, anxiety, lung CA.