What is the treatment for a 61-year-old patient with emphysema who smokes?

Treatment of Emphysema in a 61-Year-Old Active Smoker

Smoking cessation is the absolute priority and the only intervention proven to slow disease progression, reduce mortality, and improve outcomes in emphysema—this must be addressed immediately with combination pharmacotherapy (varenicline or bupropion PLUS nicotine replacement therapy) alongside intensive behavioral counseling. 1

Immediate Smoking Cessation Strategy

The most critical intervention is aggressive smoking cessation using combination therapy:

• Start varenicline, bupropion, or nortriptyline PLUS nicotine replacement therapy (patch combined with rapid-acting form like gum or nasal spray) 1, 2
• Combination pharmacotherapy with behavioral support achieves up to 24% quit rates at 1 year compared to only 3-5% with willpower alone 3
• Provide intensive behavioral counseling—this significantly increases quit rates over self-initiated strategies and is essential alongside medication 1
• Advise abrupt cessation rather than gradual reduction, as gradual withdrawal rarely achieves complete cessation 4

Why this matters for mortality and morbidity: Smoking cessation is the only treatment that modifies the natural decline in lung function in COPD 1. When smokers quit, their subsequent FEV1 decline returns to rates similar to healthy non-smokers 1. In smokers who cannot stop, life expectancy is less than 20 years after diagnosis 1. Smoking cessation reduces exacerbation risk (adjusted HR 0.78) with greater benefit the longer abstinence is maintained 4.

Common pitfall: Do not recommend gradual smoking reduction as the primary strategy—it rarely works 4. Expect multiple quit attempts as recidivism is high (approximately 80% are still smoking at 1 year), requiring repeated intensive intervention 2.

Pharmacologic Bronchodilator Therapy

Initiate inhaled bronchodilator therapy immediately to reduce symptoms, prevent exacerbations, and improve exercise tolerance:

• Start with either a long-acting β2-agonist (LABA) or long-acting anticholinergic (LAMA like tiotropium) 1, 5
• Pharmacologic therapy reduces COPD symptoms, decreases frequency and severity of exacerbations, and improves health status and exercise tolerance 1
• Assess and verify proper inhaler technique at every visit—incorrect technique is a major cause of treatment failure 1

Important caveat: No existing medication modifies the long-term decline in lung function 1. Bronchodilators provide symptomatic relief and reduce exacerbations but do not alter disease progression—only smoking cessation does that 1.

Vaccinations to Reduce Mortality

Administer vaccinations immediately to prevent life-threatening infections:

• Influenza vaccine annually—reduces serious illness, death, risk of ischemic heart disease, and total exacerbations 1
• Pneumococcal vaccines (PCV13 and PPSV23)—recommended for all patients 65 years and older; this patient at 61 should receive them given emphysema 1

Pulmonary Rehabilitation

Refer to pulmonary rehabilitation program:

• Improves symptoms, quality of life, and physical and emotional participation in everyday activities 1
• Benefits occur regardless of disease severity 1

Assessment for Severe Disease Requiring Additional Interventions

Evaluate for hypoxemia and severe airflow limitation to determine if additional life-prolonging therapies are needed:

• Check arterial blood gas or pulse oximetry at rest—if severe resting chronic hypoxemia is present (PaO2 ≤55 mmHg or SpO2 ≤88%), long-term oxygen therapy improves survival 1, 5
• Perform spirometry to assess severity—if FEV1 <35% predicted, mortality increases exponentially and additional interventions may be needed 1
• In select patients with advanced emphysema refractory to optimized medical care, surgical interventions (lung volume reduction, bullectomy) or bronchoscopic interventions may be beneficial 1

Critical point: Long-term oxygen therapy is the only treatment besides smoking cessation known to improve prognosis in patients with severe COPD and hypoxemia 1, 5. Target oxygen saturation of 88-92% if respiratory acidosis develops 5.

Screen for Comorbidities That Impact Mortality

Assess for cardiovascular disease and lung cancer:

• Approximately 26% of deaths in moderate to severe COPD are cardiovascular, 21% are cancer-related, and only 35% directly attributable to COPD 5
• Address cardiovascular risk factors aggressively as COPD and CVD share common pathobiological pathways 5

Monitoring and Follow-Up

• Schedule close follow-up within 2-4 weeks to assess smoking cessation progress and symptom response 4
• Perform spirometry regularly to monitor disease progression 4
• Reassess inhaler technique at each visit 1

Critical pitfall to avoid: Do not rely on physical examination alone to assess severity—absence of wheezing does not exclude significant disease 4. Spirometry is essential for diagnosis and monitoring 5.