What is the initial management for a patient with emphysema (chronic obstructive pulmonary disease, COPD)?

From the Guidelines

The initial management for a patient with emphysema (COPD) should prioritize smoking cessation, bronchodilator therapy, and pulmonary rehabilitation, as these interventions have been shown to improve symptoms, reduce exacerbations, and slow disease progression. According to the most recent and highest quality study, the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1, a comprehensive approach to COPD management is essential to improve symptoms and health status, prevent acute exacerbations, and reduce mortality.

Key components of this approach include:

• Smoking cessation, which is the most effective intervention to slow disease progression
• First-line pharmacotherapy with a short-acting bronchodilator such as albuterol (2 puffs every 4-6 hours as needed) for symptom relief
• Maintenance therapy with a long-acting bronchodilator like tiotropium (18 mcg inhaled once daily) or salmeterol (50 mcg inhaled twice daily)
• Combination therapy with a long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) for patients with frequent exacerbations or more severe symptoms
• Inhaled corticosteroids for patients with frequent exacerbations despite optimal bronchodilator therapy
• Pulmonary rehabilitation to improve exercise capacity and quality of life
• Oxygen therapy for patients with resting hypoxemia (SpO2 ≤88% or PaO2 ≤55 mmHg)
• Vaccinations against influenza and pneumococcal disease as essential preventive measures, as recommended by the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report 1.

These interventions work by reducing airway inflammation, improving airflow, strengthening respiratory muscles, and preventing complications, ultimately aiming to improve symptoms, reduce exacerbations, and slow disease progression.

From the FDA Drug Label

STIOLTO RESPIMAT is a combination of tiotropium bromide and olodaterol indicated for long-term, once-daily maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. The initial management for a patient with emphysema (chronic obstructive pulmonary disease, COPD) includes the use of long-term, once-daily maintenance treatment with medications such as STIOLTO RESPIMAT, a combination of tiotropium bromide and olodaterol.

• The recommended dosage of STIOLTO RESPIMAT is two inhalations once-daily at the same time of the day.
• Key considerations for the initial management of emphysema include:
  • The use of STIOLTO RESPIMAT for maintenance treatment, not for the relief of acute symptoms.
  • The importance of monitoring patients with moderate to severe renal impairment for anticholinergic effects.
  • The need to prescribe an inhaled, short-acting beta2-agonist for symptomatic relief of acute respiratory symptoms. 2

From the Research

Initial Management for Emphysema

The initial management for a patient with emphysema, a type of chronic obstructive pulmonary disease (COPD), involves various approaches.

• Lung volume reduction surgery (LVRS) is considered for patients with severe pulmonary emphysema, as it has been shown to improve pulmonary function and quality of life in selected patients 3, 4.
• The National Emphysema Treatment Trial (NETT) Research Group found that LVRS carries a considerable risk for death in patients with homogenous emphysema and low forced expiratory volume in one second (FEV1) 3.
• Computed tomography (CT) scans are used to assess the severity of emphysema and to identify the major anatomic subtypes of emphysema, which is critical in the assessment of patients for lung volume reduction surgery 5.
• Emerging imaging techniques like dynamic or functional magnetic resonance imaging (MRI), scintigraphy, and the implementation of radiomics and artificial intelligence are being used to evaluate, diagnose, and quantify lung emphysema 6.

Diagnosis and Quantification

• Chest CT scans offer more sensitive estimates of emphysema progression than lung function tests, such as forced expiratory volume in first second (FEV1) 7.
• The standard CT densitometric score of emphysema is the relative area of voxels below a threshold (RA), which reflects the overall emphysema progression 7.
• Local emphysema progression can be estimated from longitudinal chest CT scans using a framework that computes local image dissimilarities in corresponding anatomical locations 7.

Treatment Planning

• Quantification and evaluation of the distribution of lung emphysema are crucial in treatment planning, and imaging plays a central role in this process 6.
• The aim of treatment is to reduce symptoms, improve quality of life, and slow disease progression.
• Treatment options, including LVRS, should be considered on a case-by-case basis, taking into account the patient's overall health, disease severity, and other factors 3, 4.