A 67-year-old man is in your clinic for a scheduled follow-up visit reporting continued dyspnea upon exertion, generalized weakness and fatigue, and chronic dry cough. He has had COPD without significant emphysema for the past 12 years. He quit smoking 6 years ago. His current therapy consists of oxygen by nasal cannula at 1.5 L/min, albuterol MDI, inhaled tiotropium, and inhaled salmeterol. He has tried inhaled corticosteroids in the past but stopped due to recurrent bouts of oral candidiasis.
His vital signs are normal. His SpO2 is 92% while on his usual NC flow rate. His physical exam is unchanged from previous visits and is only remarkable for the usual changes seen in long-standing COPD.
Three years ago his FEV1 was 47% and his symptoms are mostly unchanged since that time. A chest x-ray taken a month ago during a workup for acute bronchitis showed “changes typical of COPD”. A CT-scan 2 years ago for a PE workup did not reveal significant emphysematous changes.
You verify with the patient that his inhaler technique is good.
Of the following choices, which is the next most appropriate step in this patients COPD management?
A. Repeat pulmonary function testing
B. Refer for lung volume reduction surgery
C. Retry oral corticosteroid therapy
D. Refer for pulmonary rehab
E. No changes are required at this time
Correct answer: D – Refer for pulmonary rehab
Key Point: Pulmonary rehab should be considered for all patients with COPD and an FEV1 of <50% predicted.
Discussion: The management of COPD usually involves both pharmacologic as well as nonpharmacologic therapies. Pharmacologic options involve inhaled beta-agonists, anticholinergics, corticosteroid therapy and occasionally add-on therapy for persistent symptoms (methylxanthines and phosophodiesterase-4 inhibitors).
The most important nonpharmacologic method is tobacco cessation counseling and should be offered to all patients who continue to smoke. Oxygen therapy is also considered to be nonpharmacologic and should be offered to those who qualify based on SpO2 or PaO2 levels.
Another important nonpharmacologic therapy is pulmonary rehabilitation and can be considered for all symptomatic patients with an FEV1 less than 50% of predicted. It involves multiple encounters where education and counseling on nutrition and exercise as well as reinforcement for positive behaviors and techniques are provided. When used as add-on therapy for appropriately selected patients, it has been shown to improve objective measures of strength and endurance as well as symptoms of breathlessness and fatigue. Other factors, such as quality of life, participation in activities, and number of hospitalizations, may improve also. Potential drawbacks for patients include the requirement to be able walk at baseline and to engage in long-term therapy to maintain the beneficial effects.
Repeating pulmonary function tests is usually reserved for cases where new or changing symptoms are possibly due to another process. New PFTs can also be done to document FEV1 for severity categorization and selection of appropriate patients for advanced therapy. Lung volume reduction surgery is reserved for patients with FEV1 from 20 to 40 percent of predicted, with persistent symptoms despite maximal medical therapy, and with bilateral upper lobe emphysema. Oral corticosteroid therapy should be used periodically for exacerbations of COPD only and regular use should be avoided.
Reference:Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.