Top Papers Of The Month

COPD: Inhaler Use, a How-To on Inpatient Care, and a Primary Care Primer

Gregory W. Rutecki, MD

This is a second “mining” of a Top Paper addressing exacerbations of chronic obstructive pulmonary disease (COPD).1 When a patient with COPD recovers from an ambulatory exacerbation, prevention of future episodes is key to management. When such a patient is admitted for inpatient care, issues specific to hospital management of COPD should be reviewed.

Inhaler use is the cornerstone of prevention of COPD exacerbations. But what do we know about using them? A combination of a long-acting β2-agonist with a corticosteroid is better than using either as a single agent. In the TORCH (Towards a Revolution in COPD Health) study,2 moderate to severe exacerbations of COPD were decreased by 25% in the combination therapy group compared with the single-agent group. It also should be noted, however, that corticosteroid inhalation was associated with a higher risk of pneumonia.

Another important piece of evidence is that a long-acting muscarinic agent is better at preventing COPD exacerbations than is placebo. In the UPLIFT (Understanding Potential Long-Term Impacts on Function with Tiotropium) study,3 exacerbations with tiotropium were reduced 14% more than with administration of a placebo. Muscarinic agents might be better than β2-agonists in this regard, as well.1

Data to support “triple therapy”—that is, a corticosteroid, a muscarinic agent, and a β2-agonist combination—is limited.1 Also, use caution when removing an inhaled corticosteroid from a patient’s COPD regimen.1

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines4 recommend mucolytic agents for patients with severe COPD and exacerbations when inhaled corticosteroids are not being used.1 The role of macrolide antibiotics in the prevention of COPD exacerbations remains unclear.1

For inpatients with a COPD exacerbation, short courses of oral prednisone (40 mg for 5 days) are appropriate.1 However, for inpatients requiring ventilator support, intravenous corticosteroids should be utilized.1 Lower-dose parenteral therapy (100 mg/d) is preferred.1

In the primary care office, there is still work to be done after inpatient or ambulatory care of a COPD exacerbation. Referral to pulmonary rehabilitation helps, smoking cessation should be an iterative topic for discussion, and do not forget about influenza and pneumococcal vaccines in your unvaccinated patient population.1

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.


  1. Hatipoglu US, Aboussouan LS. Treating and preventing acute exacerbations of COPD. Cleve Clin J Med. 2016;83(4):289-300.
  2. Calverley PMA, Anderson JA, Celli B, et al; TORCH Investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356(8):775-789.
  3. Tashkin DP, Celli B, Senn S, et al; UPLIFT Study Investigators. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. 2008;​359(15):1543-1554.
  4. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease.​-​​copd-2016/. Accessed July 19, 2016.