Management of refractory chronic obstructive pulmonary disease
- Gary T Ferguson, MD
Gary T Ferguson, MD
- Director, Pulmonary Research Institute of Southeast Michigan
- Barry Make, MD
Barry Make, MD
- Professor of Medicine, University of Colorado Denver School of Medicine
- Co-Director, COPD Program, National Jewish Health
Chronic obstructive pulmonary disease (COPD) is a common condition with an estimated global prevalence of almost 12 percent in adults over age 30 [1-3]. COPD is the fourth leading cause of death among adults worldwide and is expected to become the third leading cause of death by 2020 [2,4-6].
In the majority of patients with COPD, symptoms and exacerbations can be controlled with interventions such as smoking cessation, vaccinations against influenza and pneumococcal infections, pulmonary rehabilitation, and one or more inhaled medications (eg, bronchodilators and glucocorticoids). In a minority of patients, COPD symptoms and exacerbations are persistent despite these interventions. While refractory COPD has not been defined, the context for this diagnostic category is patients with severe, persistent symptoms or high risk for exacerbations in spite of appropriate care, or advanced disease.
The management of refractory COPD will be reviewed here. The clinical manifestations, diagnosis, and management of stable COPD and COPD exacerbations are discussed separately. (See "Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging" and "Management of stable chronic obstructive pulmonary disease" and "Management of exacerbations of chronic obstructive pulmonary disease".)
Some patients with COPD have refractory symptoms of dyspnea, exercise limitation, and cough over a period of months or continue to have exacerbations despite therapy with appropriate long-acting muscarinic agent (LAMA, also known as a long-acting anticholinergic agent), long-acting beta agonist, and inhaled glucocorticoid therapies.
In the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification, these patients comprise a small portion of patients in COPD categories B, C, or D . In addition to dyspnea, cough, sputum production, wheezing, and chest tightness, patients with severe and very severe COPD often report fatigue, weight loss, sleep disturbance, and anorexia.
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- REASSESS COPD
- ASSESS FOR COMPLICATING DISEASES
- PHARMACOLOGIC AGENTS
- Optimizing triple inhaler therapy
- - Adherence
- - Technique
- - Medication selection
- Phosphodiesterase inhibitors
- Chronic antibiotic therapy
- Rarely used medications
- - Mucoactive agents
- - Systemic glucocorticoids
- SUPPORTIVE MEASURES FOR ADVANCED COPD
- Nocturnal noninvasive ventilation
- Lung volume reduction surgery
- Bronchoscopic LVRS
- Lung transplantation
- PALLIATIVE CARE IN COPD
- Symptom management and goals of care
- Advance care planning
- Hospice and end-of-life care
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS