From the Guidelines
For a patient with COPD and chronic cough who has a normal LDCT and oxygen saturation of 93% on room air while taking Tiotropium 100mcg (Durla), the next steps should include optimizing bronchodilator therapy by adding a long-acting beta-agonist (LABA) such as salmeterol or formoterol, preferably in a combination inhaler with tiotropium, as recommended by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1.
Optimizing Bronchodilator Therapy
The patient is already taking Tiotropium, a long-acting anticholinergic, which is a good starting point. Adding a LABA can help further improve symptoms and reduce the risk of exacerbations. The combination of a LABA and a long-acting anticholinergic has been shown to be effective in reducing symptoms and improving health status in patients with COPD 1.
Evaluating Potential Triggers of Cough
The patient should also be evaluated for potential triggers of cough, including:
- Gastroesophageal reflux disease
- Post-nasal drip
- ACE inhibitor use These conditions can exacerbate cough and should be treated accordingly.
Pulmonary Rehabilitation
Pulmonary rehabilitation should be recommended to improve exercise capacity and quality of life. This can include a combination of exercise training, education, and behavioral modification.
Smoking Cessation
Smoking cessation must be strongly encouraged if the patient continues to smoke. Smoking is a major risk factor for COPD and can exacerbate symptoms.
Vaccination
Vaccination against influenza and pneumococcal disease is essential to prevent exacerbations. These vaccines can help reduce the risk of respiratory infections and exacerbations.
Inhaler Technique and Adherence
The patient should be taught proper inhaler technique and adherence should be assessed at follow-up visits. This can help ensure that the patient is using their medications correctly and consistently.
These interventions aim to reduce symptoms, prevent exacerbations, and slow disease progression by targeting airway inflammation and bronchoconstriction, which are the underlying pathophysiological mechanisms in COPD. By following these steps, the patient can expect to see an improvement in their symptoms and quality of life.
From the Research
Patient Profile
- Chronic Obstructive Pulmonary Disease (COPD) with chronic cough
- Normal Low-Dose Computed Tomography (LDCT)
- Oxygen saturation (O2 sat) at 93% on Room Air (RA)
- Currently taking Durla (Tiotropium) 100mcg
Current Treatment and Guidelines
- The patient is currently on Tiotropium, a long-acting muscarinic antagonist (LAMA), which is recommended as initial treatment for Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D 2
- Guidelines recommend starting monotherapy with an inhaled bronchodilator, stepping up to combination therapy as needed, and/or adding inhaled corticosteroids as symptom severity and airflow obstruction progress 3
Next Steps
- Consider stepping up to combination therapy with a long-acting β2-agonist (LABA) and LAMA, as recommended by the American Thoracic Society for patients with COPD and dyspnea or exercise intolerance 4, 5
- Assess the patient's symptom severity and exacerbation history to determine the need for triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA 4, 6
- Continue to monitor the patient's oxygen saturation and adjust treatment as needed to maintain adequate oxygenation
Treatment Options
- LABA/LAMA combination therapy: recommended for patients with COPD and dyspnea or exercise intolerance 4, 5
- Triple therapy with ICS/LABA/LAMA: recommended for patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year 4, 6
- Tiotropium: safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations 2