Case-Based Review

Management of Stable Chronic Obstructive Pulmonary Disease

Journal of Clinical Outcomes Management. 2017 June;24(6)

Author(s):

References

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From the Division of Pulmonary Critical Care Medicine, University of Florida, Gainesville, FL.

Abstract

Objective:To review the management of stable chronic obstructive pulmonary disease (COPD).
Methods: Review of the peer-reviewed literature.
Results: Effective management of stable COPD requires the physician to apply a stepwise intensification of therapy depending on patient symptoms and functional reserve. Bronchodilators are the cornerstone of management. In addition to pharmacologic therapies, nonpharmacologic therapies, including smoking cessation, vaccinations, proper nutrition, and maintaining physical activity, are an important part of long-term management. Those who continue to be symptomatic despite appropriate maximal therapy may be candidates for lung volume reduction. Palliative care services for COPD patients, which can aid in reducing symptom burden and improving quality of life, should not be overlooked.
Conclusion: Successful management of stable COPD requires a multidisciplinary approach that utilizes various medical therapies as well as nonpharmacologic interventions.

Key words: chronic obstructive pulmonary disease; exacerbation; bronchodilator; lung volume reduction; cough.

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disease characterized by irreversible obstructive ventilatory defects [1–4]. It is a major cause of morbidity and mortality affecting 5% of the population in the United States and was the third leading cause of death in 2008 [5,6]. The goals in COPD management are to provide symptom relief, improve the quality of life, preserve lung function, and reduce the frequency of exacerbations and mortality. In this review, we will discuss the management of stable COPD in the context of 3 common clinical scenarios.

Case 1

A 65-year-old male with COPD underwent pulmonary function testing (PFT), which demonstrated an obstructive ventilatory defect (forced expiratory volume in 1 second/forced vital capacity ratio [FEV1/FVC], 0.45; FEV1, 2 L [65% of predicted]; and diffusing capacity of the lung for carbon monoxide [DLCO], 15 [65% of predicted]). He has dyspnea with strenuous exercise but is comfortable at rest and with minimal exercise. He has had 1 exacerbation in the last year that was treated on an outpatient basis with steroids and antibiotics. His medication regimen includes inhaled tiotropium once daily and inhaled albuterol as needed that he uses roughly twice a week.

What determines the appropriate therapy for a given COPD patient?

COPD management is guided by disease severity that is measured using a multimodal staging system developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The initial classification adopted by GOLD 2011 report encompassed 4 categories based on symptoms, number of exacerbations, and degree of airflow limitation on pulmonary function testing. However, in 2017 the GOLD ABCD classification was modified to consider only symptoms and risk of exacerbation in classifying patients regardless of performance on spirometry and FEV1 [7,8] ( Figure 1 ). This approach was intended to make therapy more individualized based on the patient clinical profile. The Table displays a summary of the recommended treatments according to classification based on the GOLD 2017 report.

The patient in our clinical scenario can be classified as GOLD category B.

What is the approach to building a pharmacologic regimen for the patient with COPD?