What occurs in a patient with a history of Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Patients with a history of Chronic Obstructive Pulmonary Disease (COPD) are at high risk of developing progressive airflow limitation, exacerbations, and long-term complications, and therefore require comprehensive management to prevent severe acute exacerbations, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1. The disease is characterized by chronic inflammation of the airways, lung parenchyma, and pulmonary vasculature, leading to symptoms such as persistent cough with sputum production, dyspnea (especially with exertion), and recurrent respiratory infections. As COPD progresses, patients develop hyperinflation of the lungs, gas exchange abnormalities, and eventually respiratory failure. Common physical findings include barrel chest, prolonged expiration, wheezing, and decreased breath sounds. Patients often experience exacerbations triggered by respiratory infections or environmental factors that worsen their baseline symptoms. Long-term complications include cor pulmonale (right heart failure), pulmonary hypertension, weight loss, and skeletal muscle dysfunction. The disease is primarily caused by cigarette smoking, though occupational exposures, air pollution, and genetic factors (such as alpha-1 antitrypsin deficiency) can also contribute. Some key points to consider in the management of COPD include:

• Education and case management to prevent severe acute exacerbations, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1
• The use of bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy when indicated, and smoking cessation to slow disease progression, as discussed in the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1
• The importance of addressing comorbidities, such as ischemic heart disease, lung cancer, and diabetes, which can significantly impact patient outcomes, as highlighted in the American Journal of Respiratory and Critical Care Medicine 1
• The need for regular monitoring and follow-up to prevent hospitalizations and improve health-related quality of life, as emphasized in the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1. The most effective intervention to slow disease progression remains smoking cessation, and patients with COPD should be encouraged to quit smoking as part of their comprehensive management plan, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

From the FDA Drug Label

Subjects treated with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg had greater improvements in FEV1 (113 mL, 10%) compared with fluticasone propionate 500 mcg (7 mL, 2%), salmeterol (15 mL, 2%), and placebo (-60 mL, -3%) Exacerbations were defined as worsening of 2 or more major symptoms (dyspnea, sputum volume, and sputum purulence) or worsening of any 1 major symptom together with any 1 of the following minor symptoms: sore throat, colds (nasal discharge and/or nasal congestion), fever without other cause, and increased cough or wheeze for at least 2 consecutive days In the 1-year trial, the group receiving fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg had a significantly lower rate of moderate and severe exacerbations compared with placebo (25.4% reduction compared with placebo [95% CI: 13.5,35.7]) Increased risk of pneumonia in patients with COPD. Monitor patients for signs and symptoms of pneumonia.

Key Points:

• Patients with a history of Chronic Obstructive Pulmonary Disease (COPD) may experience improvements in lung function with salmeterol.
• Exacerbations of COPD may be reduced with the use of fluticasone propionate and salmeterol inhalation powder.
• Patients with COPD are at an increased risk of pneumonia and should be monitored for signs and symptoms.
• FEV1 improvements were seen in patients treated with fluticasone propionate and salmeterol inhalation powder.

2

From the Research

COPD Overview

• Chronic Obstructive Pulmonary Disease (COPD) is a progressive condition involving chronic inflammation and parenchymal destruction with resulting airflow limitation 3
• COPD is associated with worsening airflow limitation over time and increased frequency of COPD exacerbations, leading to increased mortality and morbidity 3

Exacerbations in COPD

• COPD exacerbations are associated with a rapid worsening of baseline symptoms that requires prompt management and may necessitate hospitalization in the case of a severe episode 3
• Exacerbations are mainly triggered by respiratory infections and environmental factors 4
• The goals of COPD treatment include recognizing the impact that both symptoms and exacerbations have on patients' lives when considering optimal patient-focused management 4

Treatment of COPD

• Treatment guidelines recommend the use of inhaled long-acting bronchodilators to alleviate symptoms and reduce the risk of exacerbations in patients with moderate-to-very-severe COPD 5
• Tiotropium is more effective than salmeterol in preventing exacerbations in patients with moderate-to-very-severe COPD 5
• Roflumilast, a potent and selective inhibitor of the enzyme phosphodiesterase-4, reduces moderate to severe exacerbations, with the benefit most well established in patients with severe disease 3
• Pulmonary rehabilitation (PR) improves exercise tolerance in COPD patients, and the combination of tiotropium and PR augments exercise tolerance benefits 6

Management Strategies

• COPD management strategies should include both pharmacologic and non-pharmacologic approaches 4
• Novel treatment strategies including precision medicine and point-of-care testing are also discussed 4
• Maintenance therapy should be initiated before a substantial decline in lung function has occurred, as early treatment may be associated with improvements in lung function, symptoms, exercise tolerance, exacerbations of COPD, and quality of life 7