Management of Obstructive Lung Disease: COPD

Conference Coverage: ACP Internal Medicine 2014

Sola Olopade, MD, MPH, presented a series of case studies on patients with asthma, severe asthma, and COPD at the Academy of College Physician’s pulmonary session.

A Case Study

History. A 64-year-old smoker presents with progressive shortness-of-breath. His history includes a recent hospital discharge for acute exacerbation. He completed a course of antibiotics in the hospital and is currently on inhaled corticosteroid/long-acting beta agonist (ICS/LABA), tiotropium bromide inhalation powder (Spiriva), short-acting beta2-antagonist (SABA), and a tapering dose of steroids.
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The patient’s history also includes many emergency department visits and admissions over the past 2 years, and he completed a pulmonary rehab 2 months prior. He has a 40-pack a year history and admits to still smoking a quarter pack a day.

Physical examination. The patient was a frail-appearing man with vitals within normal limits. Oxygen saturation was 96% in the right atrium, decreased base saturation with expiratory wheezing, and FEV₁ 35% predicted and FEV₁/FVC 56%. Chest x-ray showed hyperinflation and centrilobular emphysema.

Discussion

Olopade said COPD patients who continue to smoke are not uncommon. To these patients, he said he equates treating COPD while smoking with putting a fire out while pouring gasoline on the flames. No pulmonologist can make a difference if the patient doesn’t first agree to quit smoking.

Diagnosis. In order to make a diagnosis of COPD, Olopade said to start by assessing appropriate risk factors, especially smoking or exposure to smoke from burning biomass. Next, note compatible symptoms, such as exertional and progressively worsening dyspnea and cough. The spirometry post-brochodilator test should be FEV₁/FVC <70%. Finally, note gas exchange abnormalities and hyperinflation usually present on pulmonary function testing.

In patients with FEV₁/FVC <70%, COPD can be graded on four levels: GOLD 1 (mild, FEV₁ ≥80% predicted), GOLD 2 (moderate, 50% ≤FEV₁ ≤80% predicted), GOLD 3 (severe, 30% ≤FEV₁ ≤50% predicted), and GOLD 4 (very severe, FEV₁ <30% predicted).

Treatment. The goals of treatment to stabilize COPD include reducing symptoms (relief symptoms, improve exercise tolerance, and improve health status) and reducing risk (prevent disease progression, prevent exacerbation, and reduce mortality).

Management of stable COPD includes:

• Reduction of exposure to risk factors (eg, smoking)
• Bronchodilators
• Anticholinergics
• Inhaled corticosteroids/LABAs
• Supplemental oxygen
• Vaccinations
• Pulmonary rehabilitation
• Phosphodiesterase inhibitors

Exacerbation. COPD exacerbation is the worsening of respiratory symptoms that is beyond the usual day-to-day variations and requires a change in medication. Viral upper respiratory infection (URI) and infection of tracheobronchial tree are the most common etiology.

To assess, physicians should use a pulse oximetry and/or arterial blood gas (ABG), treatment setting, chest radiograph, EKG, complete blood count, sputum purulence, and biochemical and electrolyte abnormalities.

Management includes antibiotics, corticosteroids (for no more than 10 days), and respiratory support (supplemental oxygen, ABG, bronchodilators, and noninvasive mechanical ventilation.