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TABLE9-3
BODYMASSINDEX,AIRFLOWOBSTRUCTION,DYSPNEA,ANDEXERCISECAPACITY
INDEX
Points
0 1 2 3
FEV1%predicted ≥65 50–64 36–49 ≤35
6MWT(m) 250 250–349 150–249 ≤149
mMRCdyspneascale 0–1 2 3 4
BMI(kg/m2) ≥21 <21
Atotalscoreiscalculatedbyaddingallthevariables.Theresultprovidesestimatesof4-yearsurvival:1point=80%,4points=
67%,7points=18%.6MWT,6-minutewalktest;BMI,bodymassindex;FEV1%,forcedexpiratoryvolumeinthefirstsecond
percentpredicted;mMRC,modifiedMedicalResearchCouncil.Intheabsenceofa6MWT,theBODEXindexcanbecalculated
substituting6MWTfornumberofexacerbationswithsimilarpredictivevalueuptoascoreof5.
AnoveldefinitionofCOPDiscurrentlybeingexaminedasintroducedthroughtheCOPDGeneStudy.
9
Theuseofenvironmentalexposures(e.g.,smoking),symptoms(e.g.,shortnessofbreath,chroniccough,
and phlegm production), structural abnormalities on CT scans (e.g., emphysema, gas trapping, and
airwaywallthickness),andlungfunction or spirometry(e.g.,FEV1,forcedvitalcapacity [FVC])are
usedincombinationtoidentifythosewithpossible,probable,ordefiniteCOPD.Inthisstudy,smokers
diagnosed with COPD, but who would not have previously met the definition of COPD based on
spirometryalone,weremorelikelytoexperiencelungfunctiondeclineanddeathwithin5years.
PHYSICALEXAMINATION
BythetimephysicalexaminationfindingsofCOPDarepresent,thediseaseisusuallyatanadvanced
stage(e.g.,FEV1<50%predicted).
Oninspection,pursedlipbreathing,barrelchestsecondarytohyperinflation,useofaccessorymuscles
ofrespiration,andcentralandperipheralcyanosiscanbepresent.
Palpationshouldfocusonsupraclavicularandaxillarylymphadenopathies,thepresenceofabdominal
hernias,abdominalaorticaneurysms,andthepresenceandqualityofperipheralpulses.
Percussionishyperresonantinadvancedemphysema.Diaphragmaticexcursioncanbereduceddueto
hyperinflation.
Auscultationin severe COPD mayexpose prolonged (i.e., >6 seconds) breathsoundson a maximal
forcedexhalationanddecreased breath sounds. Expiratorywheezingandrhonchi mayor maynotbe
present.
Signsofpulmonaryhypertensionandright-sidedheartfailuremaybepresent,andheartsoundsmaybe
muffledfromtheinterposedhyperinflatedlungs.
Clubbing is not a feature of COPD alone, so its presence should prompt an evaluation for other
conditions,especiallylungcancer.
Giventhehighincidenceofcardiovascularcomorbidities,anevaluation forsignsofarrhythmiasand
decompensated heart failure is also paramount. Abnormalities of cardiac auscultation or significant
lowerextremityedemashouldtriggerfurtherinvestigation.
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DifferentialDiagnosis
Obesity hypoventilation syndrome is commonly misdiagnosed as COPD in patients admitted to the
hospitalwithacutehypercapnicrespiratorysyndrome.
Debut presentation to the hospital with acute hypercapnic respiratory failure is common. In this
scenario, pulmonary function tests (PFTs) are often not available and a careful evaluation of the
clinicalhistory,physicalexaminationincludingbedsideultrasound,CT,andphysiologicmeasurements
while on mechanical ventilation (e.g., airway resistance, auto-PEEP [positive end-expiratory
pressure]) can help narrow the differential diagnosis.
9-11
On discharge, all such patients should be
referredforPFTs.
DiagnosticTesting
ConsiderthediagnosisofCOPDinanypatientwithchroniccough,dyspnea,orsputumproductionanda
historyofexposuretoCOPDriskfactors,especiallycigarettesmoking.
PULMONARYFUNCTIONTESTING
A definitive diagnosis of COPD requires the presence of expiratory airflow limitation on
postbronchodilator spirometry, measured using the FEV1/FVC ratio, after 400 μg of albuterol is
administered.Althougharatioof0.7istakenasthelowerlimitofnormalforalladults,withadvancing
age,the ratiomay decrease below0.7inindividualswhoareasymptomaticandhaveneversmoked.
Therefore,areducedratioshouldnotbeinterpretedautomaticallyasdiagnosticofCOPD.
ThepostbronchodilatorFEV1relativetothepredictednormaldefinestheseverityofexpiratoryairflow
obstruction(Table9-4)andisanindependentpredictorofCOPD-associatedmortality.
TABLE9-4
CLASSIFICATIONOFSEVERITYOFAIRFLOWLIMITATIONINCHRONICOBSTRUCTIVE
PULMONARYDISEASE(BASEDONPOSTBRONCHODILATORFEV1)
InPatientsWithFEV1/FVC<0.70:
GOLD1 Mild FEV1≥80%predicted
GOLD2 Moderate 50%≤FEV1<80%predicted
GOLD3 Severe 30%≤FEV1<50%predicted
GOLD4 Verysevere FEV1<30%predicted
ReprintedfromtheGlobalStrategyforDiagnosis,Management,andPreventionofCOPD;2021.©GlobalInitiativeforChronic
ObstructiveLungDisease(GOLD),allrightsreserved.Availablefromhttp://www.goldcopd.com
FEV1,forcedexpiratoryvolumein1second;FVC,forcedvitalcapacity;GOLD,GlobalInitiativeforChronicObstructiveLung
Disease.
Thetotallungcapacity,functionalresidualcapacity,andresidualvolumeoftenincreasetosupranormal
valuesinpatientswithCOPD,indicatinglunghyperinflationandairtrapping.
Thediffusingcapacityforcarbonmonoxide(DLCO)maybereducedinpatientswithemphysema.
The6-minutewalktestisasubmaximalexercisetest.Thedistancecoveredbythepatientisoneofthe
componentsofmanymultidimensionalmortalitypredictiontools.Itcanalsounmaskexercise-induced
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hypoxemiaandmuscledysfunction.Healthyindividualswillgenerallycover>450m.
LABORATORYSTUDIES
Abaselinearterialbloodgas(ABG)isrecommendedforpatientswithsevereCOPDtoassessforthe
presenceandseverityofhypoxemiaandhypercapnia.Annualmonitoringmaybeconsidered.
Elevatedvenousbicarbonatemaysignifychronichypercapnia.
Polycythemia mayreflect a physiologicresponse tochronic hypoxemia andinadequatesupplemental
oxygenuse.
Peripheraleosinophils>300cells/μLsupporttheinitialuseofaninhaledcorticosteroid(ICS).
A1ATlevels:Becauseofitsprognosticimplications,uniquesetofcomorbidities(e.g.,liverdisease),
andtheavailabilityofA1ATreplacementtherapy,allCOPDpatientsshouldbescreenedatleastonce
forA1ATdeficiency.
12
IMAGING
CXRs are not sensitive for determining the presence of COPD, but they are useful for evaluating
alternativediagnosesandtoestablishabaseline.
ChestCTwithoutcontrastcandetectemphysema,changesinairwaywallthickness,airtrapping,and
otherconditionsassociatedwithtobaccosmokingandCOPD,such as lungcanceroratherosclerosis
(see “Treatment” section). Symptomatic smokers with normal spirometry will often have CT
abnormalitiesaslistedabovetoexplaintheirsymptoms.
WithincreasingseverityofCOPD,patientsoftendevelopradiographicsignsofthoracichyperinflation,
including flattening of the diaphragm, increased retrosternal/retrocardiac air spaces, and lung
hyperlucencywithdiminishedvascularmarkings.Bullaemaybevisible.Inseveredisease,chestCTis
used to determine candidacy for lung volume reduction surgery (LVRS) (see “Maximizing lung
function”in“Treatment”section).
TREATMENT
Long-termmanagementofpatientswithCOPDaimstoimprovequalityoflife,decreasethefrequency
andseverityofacuteexacerbations,slowtheprogressionofdisease,andprolongsurvival.Thesegoals
are pursued by decreasing exposures to noxious agents; maximizing lung function;
maximizing/supplementing compensatory mechanisms; diagnosing and managing comorbidities; and
implementingexacerbationpreventionstrategies.
Decreasingexposuretonoxiousagents
Smokingcessationasdetailedabove(prevention).
Avoidanceofbiomassfuelsathomeandatwork(e.g.,avoidingtheuseofcoalandwoodtoheatand
cook).
Usingpersonalprotectiveequipmentduringactivitiesthatproducedustandfumes.
Improvingventilationandavoidingtheuseofcausticchemicalsinhomecleaning,hobbies,etc.
Maximizinglungfunction
Bronchodilators
Theinhaledroutemaximizesdruglevelsintheairwaysandhelpsreducesystemictoxicities.
Inhaledbronchodilatorsworkprimarilybyrelaxingairwaysmoothmuscletone.Thisresultsina
reduction in expiratory airflow obstruction. Inhaled bronchodilators can be long-acting (e.g.,
muscarinic antagonists [LAMAs], β2-agonists [LABAs]) or short-acting (e.g., muscarinic
antagonistsandβ2-agonists[SABAs]).
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LAMAsandLABAsaloneandincombinationresultinimprovementsinlungfunction,reductions
inCOPDexacerbations,andimprovementsinquality oflife.
13,14
However,they do notslow the
rateoflungfunctiondeclineanddonotimprovesurvival.
ICS
ICSarenotrecommendedasmonotherapyinCOPD.InitialcombinationtherapywithICS/LABA
canbeconsideredinpatientswithperipheraleosinophilcounts>300cells/µL.
15
ICS can be used in patients already on LAMA/LABA who have continued frequent COPD
exacerbations,bloodeosinophilcounts>300cells/µL,orahistoryofasthma.
ICSwithdrawalshouldbeconsideredinpatientswithahistoryof<2exacerbationsinayear,no
COPD-relatedhospitalizations,andaneosinophilcount<300cells/µL.
16
Initialinhaledtherapy
In the latest GOLD statement, initial inhaled therapy is based on symptoms and history of
exacerbationsandnot onthe severityof airflow obstruction.Four groups, A, B, C, and D, are
definedasoutlinedinTable9-5.
TABLE9-5
REFINED ABCD ASSESSMENT TOOL FOR CHRONIC OBSTRUCTIVE LUNG
DISEASE
Group Description
A 0–1exacerbations,nohospitalizations,minimalsymptoms:mMRC0–1orCAT
<10
B 0–1exacerbations,nohospitalizations,moderatetoseveresymptoms:mMRC
≥2orCAT≥10
C >2exacerbationsor>1hospitalization,minimalsymptoms:mMRC0–1orCAT
<10
D >2exacerbationsor>1hospitalization,moderatetoseveresymptoms:mMRC
≥2orCAT≥10
DatafromtheGlobalStrategyforDiagnosis,Management,andPreventionofCOPD;2021.©GlobalInitiativeforChronic
ObstructiveLungDisease(GOLD).
CAT,COPDAssessmentTest;mMRC,modifiedMedicalResearchCouncilDyspneaScale.
Initiative forchronicobstructivelungdisease.Recommendedinitialtherapy: GroupA,a bronchodilator;GroupB,a long-
actingβ2-agonistorlong-actingmuscarinicantagonist;GroupC,along-actingmuscarinicantagonist;andGroupD,alongactingmuscarinicantagonist.ForGroupDwithCAT>20,combinationlong-actingβ2-agonistandlong-actingmuscarinic
antagonist.IfgroupDandeosinophils>300cells/μL,considerinhaledcorticosteroidpluslong-actingβ2-agonist.
Recommendedinitialtherapy:GroupA,abronchodilator;GroupB,aLABAorLAMA;GroupC,
aLAMA;andGroupD,aLAMA.ForGroupDwithCAT>20,combinationLABAandLAMAis
recommended.IfgroupDandeosinophils>300cells/µL,considerICSplusLABA.
Table9-6listscommonlyavailableinhaledbronchodilators.
TABLE9-6
INHALER PHARMACOTHERAPY FOR CHRONIC ASTHMA AND CHRONIC
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OBSTRUCTIVEPULMONARYDISEASE
A
Name Dose SideEffects
b
Short-Actingβ2-AgonistsandMuscarinicAntagonists(SABAandSAMA)
Albuterol(ProAir,Ventolin,Proventil) MDI:2inh
q4–6h
Nebulizer:
2.5mg
q6–8h
Palpitations,tremor,anxiety,
nausea/vomiting,throatirritation,
dyspepsia,tachycardia,arrhythmia,
hypertension
Levalbuterol(Xopenex) MDI:2inh
q4–6h
Nebulizer:
0.63–1.25
mgq6–8h
Cardiovasculareffectsmaybeless
commonwithlevalbuterol
Ipratropiumc(Atrovent) MDI:2inh
q4–6h
Nebulizer:
0.5mg
q6–8h
Xerostomia,cough,nausea/vomiting,
diarrhea,urinaryretention
Albuterol/ipratropium(Combivent
Respimat,DuoNeb)
SMI:1–2
inhq6h
Nebulizer:
1vial(3
mL)qid
Asaboveforeachindividual
medication
Long-Actingβ2-Agonists(LABA)
Salmeterol(SereventDiskus) DPI:1inh
bid
Headache,upperrespiratorytract
infection,cough,palpitations,fatigue,
diarrhea
Olodaterol(Striverdi) 2inhq24h
Long-ActingMuscarinicAntagonists(LAMA)
Umeclidinium(Incruse) DPI:1inh
q24h
Xerostomia,cough,nausea/vomiting,
diarrhea,urinaryretention
Tiotropium(Spiriva) DPI:1inh
q24h
CombinationInhaledCorticosteroid(ICS)/LABA
Fluticasone/salmeterol(Advair
Diskus,AdvairHFA,WixelaInhub,
AirDuo)
Advair
DPI:1inh
bid
Advair
HFA:1inh
bid
Asabove,pluslowerrespiratorytract
infection(pneumonia)andoral
candidiasis
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Wixela:1
inhbid
AirDuo:1
inhbid
Budesonide/formoterol(Symbicort) DPI:2inh
bid
Mometasone/formoterol(Dulera) HFA:2inh
bid
Fluticasone/vilanterol(Breo) DPI:1inh
q24h
CombinationLABA/LAMA
Umeclidinium/vilanterol(Anoro) DPI:1inh
q24h
Asaboveforeachindividual
medicationclass
Tiotropium/olodaterol(Stiolto) SMI:2inh
q24h
TripleCombination(ICS–LAMA–LABA)
Fluticasone/umeclidinium/vilanterol
(TrelegyEllipta
DPI:1inh
q24h
Asaboveforeachindividual
medicationclass
Budesonide/glycopyrrolate/formoterol
(Breztri)
MDI:2inh
bid
DPI,drypowderinhaler;inh,inhalation(s);MDI,metered-doseinhaler;SMI,softmistinhaler.
a
Table is not exhaustive and only lists some commonly prescribed inhalers. Inhaled corticosteroid (ICS) monotherapy
inhalersarelistedinthe“Asthma”sectioninTable9-14.
b
Onlythemostcommonsideeffectsarelisted.
c
Short-actinganticholinergic therapy(e.g.,ipratropium)is usually discontinuedwithinitiationof long-actinganticholinergic
therapy(e.g.,tiotropium),becauseminimaladditionalbenefitisexpected,sideeffectsmayincrease,anduseoftwoinhaled
anticholinergicagentshashadlimitedevaluation.
Providersshouldroutinelyassessapatient’sinhalertechniqueandprovideteaching.
BronchoscopicandLVRS
In selected patients, LVRS or bronchoscopic lung volume reduction (such as using a one-way
endobronchial valve) can improve FEV1, oxygenation, and functional outcomes. With these
procedures, total thoracic lungvolume is reduced,heathierlung is preferentiallyventilated and
perfused,andrespiratorymuscles may becomemore effective atventilation.Ina verycarefully
selectedgroupofpatients,LVRSmaybeassociatedwithasurvivalbenefit.
17
Lungtransplantation
Lungtransplantation in COPD is reserved for patientswith advanced disease (BODE>7) and
nonfatalcomorbidities.SingleanddoublelungtransplantprocedurescanbeperformedinCOPD
withbetterlong-termsurvivalfordouble-lungtransplantation.18Transplantationisrareinpatients
olderthan75years.
Qualityoflifeimprovessignificantlyforthevastmajorityofappropriatelyselectedpatients.
19
Mediansurvivalaftertransplantationisapproximately6years.Importantly,survivalisimproved
forsomebutnotallpatientswithCOPDafterlungtransplantation.
20
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Maximizing/supplementingcompensatorymechanisms
Exercisetraining
When possible, exercise should be performed in the setting of a pulmonary rehabilitation
program.
AllpatientsbeingdischargedfromthehospitalforaCOPDexacerbation,atinitialdiagnosis,and
priortoLVRSorlungtransplantationshouldbereferredtoapulmonaryrehabilitationprogram.
Exercise training consistsof aerobic exercise at 60%–80% ofmaximal exercise capacity. High
intensityintervaltrainingcanhelpachievesimilarworkloadsinpatientswithlimitedmobilityand
exercisetolerance.Upperextremitystrengthtraininghelpsimproveupperextremityspecifictask
performance(e.g.,laundry,doingdishes).
21
Supplementaloxygen
Oxygensupplementationimprovessurvivalandqualityoflifeandreducesexacerbations.
ThecurrentindicationsforoxygentherapyinCOPDareasfollows:
□ PaO2≤55mmHgorSpO2≤88%atrest.
□ PaO2 56–59 mm Hg or SpO2 <89% if there is right heart failure, cor pulmonale, or
erythrocytosiswithahematocrit>55%.
In patients with moderate resting desaturation (i.e., SpO2 89%–93%) or exercise-induced
desaturation(i.e.,SpO2≥80%for≥5minutesand<90%for≥10seconds),oxygentherapydidnot
improvemortalityinarecentclinicaltrial.
22
Inpatientswithnocturnaldesaturationsbutwithoutsleep-disorderedbreathingorseveredaytime
hypoxemia,nocturnaloxygentherapydoesnotimprovesurvival.
23
Noninvasivepositivepressureventilation
The useofnocturnal noninvasive positive pressure ventilationin patientswitha resting paCO
2
≥52 mm Hg improves dyspnea, exercise capacity, time to hospital readmission, and possibly
survivalinsmallrandomizedcontrolledtrialsanduncontrolledcaseseries.
24,25
Nutritionalsupplementation
Malnutrition, usually measured by the body mass index (BMI), is associated with increased
mortality. Nutritional advice can be obtained as a part of most pulmonary rehabilitation
programs.
Smallfrequentmealsandrestingbeforeeatingcanalleviatemeal-induceddyspnea.
Supplementationwith120mLofdietarysupplementsthreetimesdailycanimproveBMI,exercise
tolerance,andqualityoflifeinadvancedCOPD.
26
Managementofcomorbidities
Population-basedstudiesrevealadiagnosisofCOPDasamajoreventinapatient’strajectory,that
is often followed by the occurrence of multiple complications and the diagnosis of many
comorbidities.
Providers should screen for and manage frequently encountered comorbidities following general
guidelineswithoutsignificantdeviation.
β-Blockers,usedinthe managementofheartfailureandcoronaryarterydiseaseamongothers,are
notcontraindicatedinpatientswithCOPD.
Thepresenceofatrialarrhythmiasshouldnotgenerallyalterinhalerselectionwiththeexceptionof
avoidinghigh-doseSABAandsystemictheophylline.
Intermittentclaudicationsecondarytoperipheralvascular diseaseis acommon contributortolow
exercisecapacity.
CoronaryarterydiseaseandheartfailurecanmimicCOPDexacerbations.
Lungcancerscreening
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Updated USPreventiveServicesTaskForce guidelinesin2021 recommend currentsmokers or
thosewhoquitduringthepast15years,haveacumulativesmokinghistoryof≥20pack-years,and
arealsobetweentheagesof50and80yearsundergolow-doseCTlungcancerscreeningasithas
beenassociatedwithimprovedsurvival.
27
Screening CTs should be discontinued once a person has not smoked for 15 years or if they
developahealthproblemthatlimitslifeexpectancyortheabilitytotoleratetreatmenttargetedat
adiagnosedlungcancer.
Overlapwithotherrespiratorydiseases:
Patients with clinical, historical, and spirometric evidence of an asthma overlap (e.g.,
bronchodilator response >15% or 400 mL for FEV1, personal history of asthma, peripheral
eosinophilia)maybeconsideredtohaveasthma–COPDoverlap(ACO)andshouldhavetreatment
that addresses the predominant disease entity (e.g., if they have predominant asthma, treat as
asthma;ifpredominantCOPD,treatas COPD;andiffeatures of both,starttreatmentasasthma
pendingfurtherinvestigation).
28
InpatientswithILDoverlap,theprognosisisusuallydeterminedbytheunderlyingILD.
Overlapwithbronchiectasismaybenefitfromtherapiesaimedatimprovingairwayclearanceand
avoidanceofICSs.
Exacerbationpreventionstrategies
Consistentuseofinhaledtherapies,avoidanceofnoxiousexposures,diagnosis andmanagement of
comorbidities,exercisetraining,nutritionalsupport,oxygenandventilatorysupportarenecessaryto
preventexacerbationsandtheircomplications.
Vaccinations
AllpatientswithCOPDshouldreceiveinfluenzavaccinationyearlypreferablywithkilledorlive
inactivatedviruses.
Onedoseofpneumococcalvaccine(PPSV23)shouldbeadministeredbeforetheageof65years
andaseconddoseaftertheageof65years(andatleast5yearsafterthefirstdose).
Pneumococcal vaccines (PCV13) are recommended for all patients older than 65 years or in
youngerpatientsinthepresenceofimmunocompromisingconditionsorimmunosuppression.
29
PCV13andPPSV23shouldnotbeadministeredduringthesamevisit.
IfbothPCV13andPPSV23aretobeadministered,PCV13shouldbeadministeredfirst.
PCV13 and PPSV23 should be administered at least 1 year apart unless they are being
administeredtoanimmunocompromisedpatientinwhichcasetheycanbeadministered8weeks
apart.
30
COVID-19vaccinationisrecommendedtoallpatientswithCOPD.
31
Macrolideantibiotics(e.g.,azithromycin250mgdaily)
Itmayfunctionasananti-infectiveordirectanti-inflammatoryinCOPD.
In patientswithpreviousexacerbations,thefrequency ofsubsequentexacerbationsisdecreased
by19%;however,improvementinclinicalsymptomswasmodest.
32
The benefit maybe absentincurrent smokers andgreaterinolder individuals (>65 years) and
thosewithmilderdisease(FEV1>50%).
Hearing loss in the absence of tinnitus was reported, suggesting routine monitoring with
audiometryshouldbeconsideredwithchronictherapy.
Phosphodiesterase-4inhibitors(e.g.,roflumilast500μgdaily)
The US Food and Drug Administration (FDA) approved for a relatively narrow indication of
severeCOPD(FEV1<50%)andchronicbronchitiswithfrequent exacerbations,demonstratinga
17%reductioninexacerbations.
33
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Itappearstobesafewhenusedasadditionaltherapytochronicbronchodilators.
Itdidnotresultinimprovementsinclinicalsymptomspossiblyduetoahigherfrequencyofside
effects,particularlygastrointestinal,whichlimitthedosetolerated.
Limited long-term data and the possibility of weight loss and increased psychiatric symptoms
suggestthatclosemonitoringisindicated.
Theophylline(200–300mgtwicedailyinsustainedreleasetablets)
Theophylline is a xanthine derivative with bronchodilator properties. High-risk patients not
responding adequately to dual inhaled bronchodilator therapy may benefit from the additionof
theophylline.
Theophyllineisgenerallynotrecommendedduetolimitedefficacy,anarrowtherapeuticmargin,
andmultipledruginteractions.
Patients with severe COPD may experience clinical deterioration with discontinuation of
theophylline.
Theophyllineclearanceis increased incurrentsmokers and reduced in theelderlyand patients
withliverdiseaseorcongestiveheartfailure.
Systemiccorticosteroidsarenotrecommendedforthelong-termmanagementofCOPDowingtoan
unfavorable side effectprofile andlimitedefficacy.However,theyare sometimes usedinpatients
withseverediseasewhoarenotrespondingtoothertherapies.Ifused,chronicoralsteroidtherapy
should be administered at the minimum effective dose and discontinued as soon as is feasible.
Routine bone mineral density assessment to prevent complications of osteoporosis should be
incorporated.
IV A1AT augmentation therapy may benefit select patients with severe A1AT deficiency and
COPD.34Weeklyinfusionof60mg/kgisthestandardtreatment.
SPECIALCONSIDERATIONS
AcuteExacerbationofCOPD
ACOPDexacerbationisdefinedasincreaseddyspnea,oftenaccompaniedbyincreasedcough,sputum
production, sputum purulence, wheezing, chest tightness, or other symptoms (and signs) of acutely
worsenedrespiratorystatus,intheabsenceofanalternativeexplanation.
35
Respiratoryinfections(viralandbacterial)andairpollutioncausemostexacerbations.
The differential diagnosis includes pneumothorax, pneumonia, pleural effusion, congestive heart
failure,cardiacischemia,andpulmonaryembolism.
In additionto thehistoryand physical examination, assessmentofa patientwith a suspectedCOPD
exacerbationshouldincludeoxyhemoglobinsaturation,ABG,ECG,andCXR.
Criteria forhospital admissionincludea significantincrease insymptom severity, severe underlying
COPD, significant comorbidities, failure to respond to initial medical management, diagnostic
uncertainty,andinsufficienthomesupport.
Criteria foradmissiontoanintensivecare unitincludethe needforinvasivemechanical ventilation,
hemodynamic instability, severe dyspnea that does not adequately respond to therapy, mental status
changes, and persistent or worsening hypoxemia, hypercapnia, or respiratory acidosis despite
supplementaloxygenandnoninvasiveventilation(NIV).
Pharmacotherapy(Table9-7)
SABAs are the first-line therapy forCOPDexacerbations. Short-acting anticholinergic agents
canbeaddedintheeventofinadequateresponsetoSABAs.
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TABLE9-7
PHARMACOTHERAPY FOR ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE
PULMONARYDISEASE
MedicationName Dose
Albuterol MDI:twotofourpuffs
q1–4h
Nebulizer:2.5mgq1–4h
Ipratropium MDI:twopuffsq4h
Nebulizer:0.5mgq4h
Prednisone 40mg/d×5d
Antibiotics
a
PatientCharacteristics PathogenstoConsider Antibioticb(OneoftheFollowing)
Noriskfactorsforpoor
outcomeordrugresistantpathogen
c
Haemophilus
influenzae
Streptococcus
pneumoniae
Moraxellacatarrhalis
Macrolide,second-orthird-generation
cephalosporin,doxycycline,
trimethoprim/sulfamethoxazole
Riskfactorspresent Asabove,plusgram-
negativerods,including
Pseudomonas
Antipseudomonalfluoroquinoloneorβlactam
MDI,metered-doseinhaler.
a
ReprintedfromtheGlobalStrategyforDiagnosis,Management,andPreventionofCOPD;2021.©GlobalInitiativeforChronic
ObstructiveLungDisease(GOLD),allrightsreserved.Availablefromhttp://www.goldcopd.com.
1
b
Treatfor3–7days.Ifrecentantibioticexposure,selectanagentfromanalternativeclass.Takelocalresistancepatternsinto
account.
c
Riskfactors:age>65years,comorbidconditions(especially cardiacdisease),forcedexpiratoryvolumein1second(FEV1)
<50%,morethanthreeexacerbations/year,andantibiotictherapywithinthepast3months.
Many patients experiencing an acute exacerbation of COPD have difficulty performing optimal
metered-dose inhaler (MDI) technique. Therefore, numerous clinicians opt to deliver
bronchodilatorsvianebulization.
Long-actingbronchodilatorsshouldbeconsideredoncestable.
Owing to the risk of serious side effects, clinicians typically avoid using methylxanthines (e.g.,
theophylline) for acute exacerbations. However, if a patient uses methylxanthines chronically,
discontinuationduringanexacerbationisdiscouragedbecauseoftheriskofdecompensation.
Systemic corticosteroids produce improvement in hospital length of stay, lung function, and the
incidenceofrelapse.Theyarerecommendedforallinpatientsandmostoutpatientsexperiencingan
exacerbation of COPD. A prednisone dose of 40 mg for 5 days is recommended over longer
regimens.
36
Antibiotictherapyisroutinelyadministeredbutmostoftenbenefitspatientswithsputumpurulence
aswellaspatientswithaneedformechanicalventilation.Durationoftherapyshouldbe5–7days.
Antibiotic choice should be guided by local resistance patterns, previous patient exposures, and
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