What is the best course of action for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is experiencing wheezing despite receiving standard care?

From the Guidelines

For a COPD patient experiencing persistent wheezing despite standard care, the best course of action is to step up therapy with additional bronchodilators or anti-inflammatory medications, prioritizing the use of long-acting muscarinic antagonists (LAMA) or a combination of LAMA and long-acting beta-agonist (LABA) as recommended by the 2017 European Respiratory Society/American Thoracic Society guideline 1. This approach is supported by the most recent and highest quality evidence, which emphasizes the importance of preventing exacerbations and improving symptoms in COPD patients. The patient's current treatment regimen should be reviewed to ensure proper use of short-acting beta-agonists (such as albuterol) and long-acting bronchodilators (like tiotropium or salmeterol), with consideration for adding a combination inhaled corticosteroid/LABA (like fluticasone/salmeterol) if necessary, as suggested by the 2015 American College of Chest Physicians and Canadian Thoracic Society guideline 1. Key considerations include:

• Evaluating the patient for exacerbation triggers such as respiratory infections or environmental irritants
• Reviewing proper inhaler technique to ensure effective medication delivery
• Considering pulmonary rehabilitation, smoking cessation if applicable, and oxygen therapy assessment as adjunctive measures
• Using oral corticosteroids (like prednisone) for immediate relief if necessary, as part of a comprehensive management plan that prioritizes morbidity, mortality, and quality of life outcomes. The 2016 review of national guidelines for COPD management in Europe 1 provides a framework for understanding the various treatment options and their applications, but the most recent guideline from 2017 1 takes precedence in informing the best course of action for managing wheezing in COPD patients.

From the FDA Drug Label

If symptoms get worse, medical consultation should be sought promptly. The best course of action for a patient with Chronic Obstructive Pulmonary Disease (COPD) who is experiencing wheezing despite receiving standard care is to seek medical consultation promptly.

• The patient should not increase the dose or frequency of medication without medical consultation.
• Other anti-asthma medicines should not be used unless prescribed. 2

From the Research

Management of COPD Exacerbations

• For a patient with Chronic Obstructive Pulmonary Disease (COPD) who is experiencing wheezing despite receiving standard care, the best course of action involves assessing the severity of the exacerbation and adjusting treatment accordingly 3, 4.
• Current guidelines recommend inhaled pharmacologic therapy as the preferred route of administration for treating COPD, with bronchodilators (β2-agonists and antimuscarinics) being the mainstay of pharmacologic therapy 3.
• Nebulized drug delivery may be considered for patients who are not responding to standard therapy, as it provides benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life 3, 4.

Treatment Options

• The use of inhaled corticosteroids (ICS) may be considered to prevent acute exacerbations of COPD, but the evidence is debated and should be evaluated on a case-by-case basis 5.
• Combination therapy with a long-acting beta agonist (LABA) and a long-acting muscarinic antagonist (LAMA) may be considered for patients with moderate to severe COPD 6.
• For rescue medication, both short-acting beta agonists (SABA) and combination SABA/Ipratropium bromide have been shown to be safe and efficacious 7.

Patient Assessment

• A thorough assessment of the patient's symptoms, lung function, and medical history is necessary to determine the best course of action 6.
• The patient's ability to use inhalation devices correctly should also be assessed, as poor inhaler technique can compromise symptom relief 4.