How to manage worsening shortness of breath in a patient with COPD, hypertension, and hyperlipidemia?

Management of Worsening Shortness of Breath in COPD with Hypertension and Hyperlipidemia

This patient requires optimization of their existing Trelegy Ellipta therapy with proper inhaler technique assessment, consideration of pulmonary rehabilitation, and critical evaluation of their beta-blocker therapy which may be contributing to worsening dyspnea. 1

Immediate Assessment Priorities

Evaluate Current Medication Appropriateness

• Beta-blockers (including eye drops) should be avoided in COPD patients as they can cause bronchoconstriction and worsen respiratory symptoms 1, 2
• This patient is on both Metoprolol 23.75mg OD AND Metoprolol succinate 95mg OD - this appears to be duplicate therapy that needs urgent clarification and likely represents excessive beta-blockade
• The worsening SOB over the past month may be directly related to beta-blocker therapy interfering with bronchodilation 2

Verify Inhaler Technique

• Between 28-68% of patients do not use inhalers correctly, which can manifest as worsening symptoms rather than true disease progression 3
• The most problematic step is breathing out completely before inhalation (step 3 of proper technique), followed by the actual inhalation maneuver 4
• Directly observe the patient performing their Trelegy Ellipta technique at this visit, checking all five steps of proper application 4

Pharmacological Management

Optimize Current COPD Therapy

• Continue Trelegy Ellipta (contains LABA/LAMA/ICS combination) as this patient has moderate-to-severe disease based on spirometry showing mild-to-moderate airflow limitation 1
• The patient is already on appropriate triple therapy for their COPD severity 1
• Ensure the patient understands this is maintenance therapy, not rescue medication 5

Address Cardiovascular Medications

• Replace beta-blockers with calcium channel blockers (such as amlodipine) for hypertension management, as CCBs are safe in COPD and do not cause bronchoconstriction 2
• Note: Patient has documented leg swelling with CCBs previously, but this was likely dose-related; consider starting with lower doses or alternative CCB formulations
• Continue Perindopril (ACE inhibitor) and Doxazosin as these do not adversely affect respiratory function 2

Ensure Rescue Medication Availability

• Confirm the patient has a short-acting bronchodilator (SABA or SAMA) for acute symptom relief 5
• Trelegy Ellipta does not relieve sudden symptoms and extra doses should not be taken for acute dyspnea 5

Non-Pharmacological Management

Pulmonary Rehabilitation

• Pulmonary rehabilitation should be considered for this patient with moderate disease and high symptom burden 1
• Programs improve exercise performance and reduce breathlessness even in moderate-to-severe COPD 1
• Outpatient-based programs are effective and should be initiated 1

Exercise Encouragement

• Exercise should be encouraged within the limitations of airflow obstruction 1
• Breathlessness on exertion is distressing but not dangerous 1
• The patient can continue gardening and household activities with appropriate pacing and rest breaks 1

Assess for Oxygen Therapy Need

• With SpO2 of 94% at rest, formal assessment for long-term oxygen therapy (LTOT) is not currently indicated (requires PaO2 <7.3 kPa or ~55 mmHg) 1
• However, given worsening symptoms, arterial blood gas measurement should be obtained to objectively assess oxygenation and exclude hypercapnia 1

Additional Considerations

Screen for Comorbidities

• Screen for obstructive sleep apnea (OSA), which is common in COPD and can worsen dyspnea 2
• Assess for depression, which should be identified and treated as it affects outcomes 1
• The patient's social circumstances appear adequate (trying to reduce salt intake, engaged in activities) 1

Vaccination Status

• Ensure influenza vaccination is current, as it is recommended for all COPD patients and may reduce mortality by 70% in elderly patients 1
• Consider pneumococcal vaccination, though specific evidence in COPD is limited 1

Monitor for Pulmonary Hypertension

• While the patient has no clinical signs of cor pulmonale (no leg edema, normal cardiovascular exam), pulmonary hypertension can develop in moderate COPD 6
• The mild elevation in blood pressure (146/87) and bradycardia (pulse 55) may reflect beta-blocker effects rather than cardiac compensation 6

Critical Pitfalls to Avoid

• Do not increase Trelegy Ellipta dosing for worsening symptoms without first addressing beta-blocker therapy and inhaler technique 5
• Do not prescribe nebulized therapy without formal assessment per BTS guidelines 1
• Do not add theophyllines as they are of limited value and require monitoring for side effects 1
• Do not use pulmonary vasodilators for any pulmonary hypertension, as there is no evidence of benefit in COPD 1

Follow-Up Plan

• Reassess symptoms in 2-4 weeks after beta-blocker modification 2
• If symptoms persist despite medication optimization and confirmed proper inhaler technique, consider specialist referral for assessment of severe COPD and potential need for additional interventions 1
• Repeat spirometry if symptoms continue to worsen to document disease progression 1