What are the guidelines for chronic treatment of pulmonary emphysema (Chronic Obstructive Pulmonary Disease - COPD)?

From the Guidelines

Chronic treatment for emphysema should prioritize LABD maintenance therapy in all symptomatic patients with COPD confirmed by spirometry, with a focus on single inhaler dual therapy LABD in those with moderate to severe dyspnea and/or poor health status. This approach is based on the most recent and highest quality study, the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1. The guideline recommends a step-up to single-inhaler triple therapy in those with persistent moderate to severe dyspnea and/or poor health status despite treatment with single inhaler dual therapy with LAMA/LABA or ICS/LABA.

Key components of emphysema management include:

• Smoking cessation, which is the most effective way to slow disease progression
• Bronchodilators, such as long-acting agents like tiotropium or salmeterol, for sustained symptom control
• Inhaled corticosteroids, like fluticasone, for patients with frequent exacerbations, often in combination inhalers with long-acting bronchodilators
• Pulmonary rehabilitation programs, which combine exercise training, education, and support to improve functional capacity
• Oxygen therapy for patients with resting oxygen saturation below 88%, typically starting at 1-3 liters per minute and adjusted to maintain saturation above 90%
• Vaccinations against influenza and pneumococcal pneumonia as important preventive measures

The 2023 guideline also suggests SITT in all patients at high risk of AECOPD, highlighting the need for targeted case-finding strategies to implement these therapeutic options effectively 1. In contrast, the 2017 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease report provides a more general overview of COPD management, emphasizing the importance of individualized treatment regimens and regular assessment of inhaler technique 1. However, the 2023 Canadian Thoracic Society guideline takes precedence due to its recency and focus on pharmacotherapy in stable COPD.

From the FDA Drug Label

Tiotropium bromide inhalation powder is indicated for the long-term, once-daily, maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. The recommended dose of tiotropium bromide inhalation powder is two inhalations of the powder contents of one tiotropium bromide inhalation powder capsule, once-daily, with the LupinHaler device.

Guidelines for Emphysema Chronic Treatment:

• The treatment involves the use of tiotropium bromide inhalation powder for the long-term, once-daily, maintenance treatment of bronchospasm associated with emphysema.
• The recommended dose is two inhalations of the powder contents of one tiotropium bromide inhalation powder capsule, once-daily, with the LupinHaler device 2.
• Tiotropium bromide is indicated to reduce exacerbations in COPD patients, including those with emphysema 2.
• It is essential to note that tiotropium bromide inhalation powder is intended as a once-daily maintenance treatment for COPD and should not be used for relief of acute symptoms 2.

From the Research

Emphysema Chronic Treatment Guidelines

• The primary goal of emphysema treatment is to improve dyspnea, reduce exacerbations, attenuate comorbidities, and improve quality of life 3.
• Surgical therapy, such as lung volume reduction surgery (LVRS), bullectomy, and lung transplantation, can be beneficial for a carefully selected subset of individuals 3.
• LVRS has been shown to improve exercise performance, quality of life, and pulmonary function in patients with upper lobe predominant emphysema 3.
• Long-acting bronchodilators, such as tiotropium and salmeterol, can improve airflow limitation, oxygenation, and respiratory impedance in patients with emphysema 4, 5.
• Tiotropium has been shown to be more effective than salmeterol in improving airflow limitation and dynamic hyperinflation in patients with emphysema dominant phenotype 4.
• The combination of salmeterol and tiotropium has been shown to be more effective than either drug alone in improving lung function in patients with moderate-to-severe COPD 6.
• New bronchodilating drugs, including long-acting muscarinic receptor antagonists (LAMA) and long-acting β2-adrenoreceptor agonists (LABA), are being developed for the treatment of COPD 7.
• LAMA/LABA fixed dose combinations (FDCs) provide the convenience of two bronchodilators with different mechanisms of action in a single inhaler and are likely to become a standard pharmacological strategy for COPD 7.