Tailored treatment improves COPD management

Primary care physicians can devise an integrated treatment plan based on recommendations on how to manage chronic obstructive pulmonary disease (COPD) and tailor treatment to their individual patient's needs.

Effective management of COPD begins with an accurate diagnosis. Primary care physicians should consider COPD in all long-term smokers with shortness of breath or dyspnea, as well as in smokers with cardiovascular disease, Barbara Yawn MD, adjunct professor of family and community health at the University of Minnesota, recently told Medical Economics.

“When primary care physicians see patients who are short of breath, they usually think heart disease. I want them to think heart disease and lung disease, especially if the patient is a current or former smoker,” said Yawn. “If the patient has heart disease, still consider spirometry, an objective test for COPD.”

Spirometry is the best method for diagnosing COPD and distinguishing between COPD, asthma and cardiovascular diseases. Airway obstruction is fully reversible in asthma, but not in COPD, and can be confirmed when the post-bronchodilator ratio of forced expiratory volume in one second to forced vital capacity is <0.7.

Once the diagnosis of COPD is confirmed, appropriate management includes both non-pharmacological and pharmacological therapy. Non-pharmacological therapy begins with smoking cessation methods.

“Patients may not be ready to quit smoking yet, but keep offering it,” she said.

Next: Improtance of immunizations

Immunizations for influenza and pneumococcal disease are also important. “Only 75% of lung disease patients get the flu vaccine, and a lower percentage the pneumococcal vaccine,” said Yawn, who also may add in pertussis vaccine “because no one wants a COPD patient to be coughing for six weeks.”

Pulmonary rehabilitation is now a well-recognized modality that should also be offered to all symptomatic patients at all stages of the disease, she said.

Drug interventions

Pharmacological therapy includes drugs for smoking session, when appropriate. Almost all COPD patients are symptomatic when diagnosed and need daily medication, usually long-acting bronchodilator therapy. “If a patient is significantly impaired, start with a long-acting, beta2-agonist or a long-acting muscarinic antagonist. If you start with a bronchodilator and the patient becomes more short of breath, add in another one,” said Yawn, adding that dual, maximal bronchodilation improves symptoms and reduces the risk of exacerbation.

If symptoms become worse, the patient may also need a short-acting bronchodilator. With exacerbations, oral corticosteroids and possibly antibiotics may be indicated. A patient who has two or more exacerbations per year needs an inhaled corticosteroid, she said.

Once patients have been accurately diagnosed with COPD and received a suitable treatment plan, they need to be regularly monitored, with their therapy adjusted as needed. Patients not controlled with drugs and with chronic hypoxemia may require long-term oxygen therapy.

Next: Follow-up care

Management of stable COPD and prevention of exacerbations are important components of follow-up care. In addition, patients should be evaluated for complications of COPD, such as chronic respiratory failure, spontaneous pneumothorax, and chronic cor pulmonale.

For patients with chronic bronchitis three months a year for two consecutive years, prescribe a phosphodiesterase-4 inhibitor, said Yawn. These drugs have many gastrointestinal side effects, leading to low compliance, so she suggests asking a pulmonologist for help, if need be.

Antibiotics can be an option if there are signs of infection-an increase in sputum volume and purulence and/or fever. Close monitoring of response to therapy is required.  If the severity of symptoms increases (marked dyspnea) or new physical signs arise, the patient should be hospitalized. Again, the primary care physician may ask the aid of a pulmonologist in the use of daily antibiotics for frequent exacerbations, she said.

Although most COPD cases can be managed in primary care, referral to a pulmonary specialist should be considered if the diagnosis is unclear, the patient is younger than 40 years of age, does not respond to treatment, has an accelerated decline in lung function, suffers from frequent exacerbations despite treatment and/or the patient needs to be evaluated for surgery, advised Yawn.

COPD is preventable and treatable, and available management options can have a positive impact.

“To improve symptoms and quality of life of COPD patients requires tailored treatment to each patient's individual needs, as well as regular monitoring to ensure optimal drug delivery, and integrated care,” said Yawn.