Management of Stable Chronic Obstructive Pulmonary Disease

There is no consistent evidence of beneficial role of mucolytics in COPD patient [7,56]. The PANTHEON trial showed decreased exacerbations with N-acetylcysteine (1.16 exacerbations per patient-year compared to 1.49 exacerbations per patient-year in the placebo group; risk ratio 0.78, 95% CI 0.67–0.90; P = 0.001) but had methodologic issues including high drop-out rate, exclusion of patients on oxygen, and a large of proportion of nonsmokers [57].

Chronic Antibiotics

There is no role for chronic antibiotics in the management of COPD [7]. Macrolides are an exception but are used for their anti-inflammatory effects rather than their antibiotic effects. They should be reserved for patient with frequent exacerbations on optimal therapy and will be discussed later in the review [58].

• What nonpharmacologic treatments are recommended for COPD patients?

Smoking cessation, oxygen therapy for severe hypoxemia (resting O ₂ saturation ≤ 88 or PaO ₂ ≤ 55), vaccination for influenza and pneumococcus, and appropriate nutrition should be provided in all COPD patients. Pulmonary rehabilitation is indicated for patients in GOLD categories B, C, and D [7]. It improves symptoms, quality of life, exercise tolerance and health care utilization. Beneficial effects last for about 2 years [59,60].

• What other diagnoses should be considered in patients who continue to be symptomatic on optimal therapy?

Other diseases that share the same risk factors as COPD and can contribute to dyspnea, including coronary heart disease, heart failure, thromboembolic disease, and pulmonary hypertension, should be considered. In addition, all patients with refractory disease should have a careful assessment of their inhaler technique, continued smoking, need for oxygen therapy, and associated deconditioning.

Case 2

A 70-year-old male with severe COPD on oxygen therapy and obstructive sleep apnea treated on nocturnal CPAP was seen in the pulmonary clinic for evaluation of his dyspnea. He was symptomatic with minimal activity and had chronic cough with some sputum production. He had been hospitalized 3 times over the past 12 months and had been to the emergency department (ED) the same number of times for dyspnea. Pertinent medications included as-needed albuterol inhaler, inhaled steroids, and tiotropium 18 mcg inhaled daily. He demonstrated good inhaler technique. On examination, his vital signs were pulse 99 bpm, SpO ₂ 94% on 2L/min oxygen by nasal cannula, blood pressure 126/72 mm Hg, respiratory rate 15, and BMI 35 kg/m ². He appeared chronically ill but in no acute distress. No wheezing or rales were heard. He had no lower extremity edema. The remainder of the exam was within normal limits. His last pulmonary function test demonstrated moderate obstruction with significant bronchodilator response to 2 puffs of albuterol. The side effects of chronic steroid therapy were impressed upon the patient and 500 mg of roflumilast was started daily. Over the course of the next 3 months, he had no further exacerbations. Roflumilast was continued. He has not required any further hospitalizations, ED visits, or oral steroid use since the last clinic visit.

• What is the significance of acute exacerbations of COPD?

Acute exacerbation of COPD (AECOPD) is a frequently observed complication for many patients with COPD [61,62]. AECOPD is associated with accelerated disease progression, augmented decline in health status and quality of life, and increased mortality [63]. Exacerbations account for most of the costs associated with COPD. Estimates suggest that the aggregate costs associated with the treatment of AECOPDs are between $3.2 and $3.8 billion, and that annual health care costs are 10-fold greater for patients with COPD associated with acute exacerbations than for patients with COPD but without exacerbations [64]. Hence, any intervention that could potentially minimize or prevent this complication will have far-reaching benefits to patients with COPD as well as provide significant cost saving.