What is the appropriate treatment for a patient with obstructive lung disease, FEV1 58% with +6% change postbronchodilator, normal FVC with +2% change postbronchodilator, FEV1/FVC 78%, and a history of COVID-19?

From the Guidelines

The patient with obstructive lung disease and a history of COVID-19 should be treated with a combination of a short-acting bronchodilator, such as albuterol (2 puffs every 4-6 hours as needed), and a long-acting bronchodilator, like tiotropium (18 mcg inhaled once daily), along with inhaled corticosteroids, such as fluticasone (250 mcg twice daily), to address both inflammation and bronchospasm. Given the patient's FEV1 of 58% with a significant bronchodilator response (+6%), this treatment approach is justified 1. The patient's moderate airflow obstruction with bronchodilator reversibility suggests asthma or a mixed pattern, which may be complicated by their COVID-19 history. The preserved FEV1/FVC ratio (78%) is atypical for pure COPD and may reflect post-COVID changes or a mixed obstructive pattern. Regular follow-up every 3-6 months is recommended to assess treatment response and adjust medications as needed. Additionally, the patient should receive pneumococcal and annual influenza vaccinations to prevent respiratory infections, and pulmonary rehabilitation would be beneficial to improve exercise capacity and quality of life 1. It's also important to consider the patient's COVID-19 history and the potential for long-term effects on lung function, as noted in recent studies 1. However, the most recent and highest quality study 1 provides the basis for the recommended treatment approach, prioritizing the patient's morbidity, mortality, and quality of life outcomes. Key considerations in the treatment plan include:

• Monitoring for potential side effects of medications
• Adjusting the treatment plan as needed based on the patient's response
• Encouraging the patient to adhere to the treatment plan and attend follow-up appointments
• Considering the potential impact of COVID-19 on the patient's lung function and overall health.

From the FDA Drug Label

The patients had a mean baseline percent of predicted forced expiratory volume in 1 second (FEV 1) of 66% (approximate range, 40 to 90%). The co-primary endpoints in these trials were FEV 1and daytime asthma symptoms In each placebo-controlled trial in adults, the treatment effect of montelukast sodium measured by daily diary card parameters, including symptom scores, “as-needed” β-agonist use, and PEFR measurements, was achieved after the first dose and was maintained throughout the dosing interval (24 hours)

The patient's FEV1 is 58% with a +6% change postbronchodilator, indicating some reversibility of airway obstruction. The FVC is normal with a +2% change postbronchodilator, and the FEV1/FVC ratio is 78%, which is consistent with obstructive lung disease. Given the patient's history of COVID-19, it is essential to consider the potential for ongoing respiratory issues.

• The patient's symptoms and lung function tests suggest mild to moderate obstructive lung disease.
• Montelukast sodium 2 may be considered as an add-on therapy to improve asthma control, but it is not a substitute for bronchodilators.
• Albuterol sulfate inhalation aerosol 3 may be used as a bronchodilator to help manage symptoms of obstructive lung disease. The most appropriate treatment for this patient would be to continue bronchodilator therapy, such as albuterol, and consider adding anti-inflammatory medications, such as inhaled corticosteroids, to control symptoms and prevent exacerbations. However, the specific treatment plan should be individualized based on the patient's response to therapy and medical history.

From the Research

Interpretation of Lung Function Test Results

• The patient's FEV1 is 58%, indicating obstructive lung disease, with a +6% change postbronchodilator, suggesting a mild response to bronchodilator therapy 4.
• The FVC is normal, with a +2% change postbronchodilator, indicating minimal response to bronchodilator therapy.
• The FEV1/FVC ratio is 78%, further supporting the diagnosis of obstructive lung disease.

Treatment Considerations

• Inhaled corticosteroids may be beneficial in reducing the risk of severe illness resulting from hyperinflammation in COVID-19, as suggested by a study on inhaled corticosteroids for the treatment of COVID-19 5.
• Montelukast, a leukotriene receptor antagonist, has been shown to have anti-inflammatory and bronchodilatory effects, and may be beneficial in COVID-19 patients to maintain the inflammatory/anti-inflammatory balance and prevent respiratory failure 6.
• Combined corticosteroid and long-acting beta-agonist therapy in a single inhaler may be effective in reducing exacerbations and improving lung function in patients with chronic obstructive pulmonary disease, although more data are needed to confirm its efficacy 4.

COVID-19 Considerations

• Inhaled therapy, including corticosteroids and other agents, may be an efficient approach for COVID-19 treatment, allowing for higher concentrations of the drug in the lung and reducing the risk of adverse side effects 7.
• Nebulized in-line endotracheal dornase alfa and albuterol may be beneficial in mechanically ventilated COVID-19 patients, reducing the fraction of inspired oxygen requirements and improving respiratory function 8.