What treatment is recommended for an elderly female with pulmonary emphysema?

Treatment of Pulmonary Emphysema in Elderly Females

Initiate tiotropium bromide 18 mcg once daily via HandiHaler as first-line maintenance therapy, combined with short-acting beta-agonists (salbutamol 200-400 mcg) or anticholinergic agents (ipratropium 250-500 mcg) as needed for symptom relief. 1

First-Line Maintenance Bronchodilator Therapy

Long-acting anticholinergic agents are particularly important in elderly patients with emphysema:

• Tiotropium bromide 18 mcg once daily is the preferred long-acting bronchodilator, demonstrating superior efficacy in improving lung function, reducing exacerbations, and improving quality of life compared to placebo and ipratropium. 2, 3, 4, 5

• With advancing age, the response to beta-agonists declines more rapidly than the response to anticholinergics, making anticholinergic treatment especially appropriate for elderly patients. 1

• Tiotropium provides 24-hour bronchodilation with once-daily dosing, improving trough FEV1 by 79-113 mL compared to placebo, with greatest improvements in patients with FEV1 50-70% predicted. 2

• This agent reduces COPD exacerbations (14.6% vs 19.9% with placebo) and prolongs time to first exacerbation. 2

Short-Acting Bronchodilators for Symptom Relief

For breakthrough symptoms, use either beta-agonists or anticholinergics:

• Ipratropium bromide 250-500 mcg four times daily via nebulizer or metered-dose inhaler is preferred in elderly patients due to better preserved response with aging. 1

• Alternatively, salbutamol 200-400 mcg or terbutaline 500-1000 mcg via hand-held inhaler every 4-6 hours as needed. 1

• Use caution with high-dose beta-agonists in elderly patients with ischemic heart disease, as they are especially likely to cause tremor and may precipitate cardiac events; first dose may require ECG monitoring. 1

Inhaler Device Selection for Elderly Patients

Device selection is critical in elderly females who may have physical limitations:

• A relatively high proportion of elderly patients cannot use metered-dose inhalers satisfactorily due to impaired cognitive function, memory loss, weak fingers, or poor coordination. 1

• Alternative devices to consider include: metered-dose inhaler with spacer and tight-fitting face mask, Haleraid or breath-activated inhaler, dry powder inhaler, or nebulizer. 1

• When using anticholinergics in elderly patients, deliver via mouthpiece rather than face mask to avoid risk of acute glaucoma or blurred vision, as prostatism and glaucoma are more common in the elderly. 1

• Formal instruction should be given in device use with the first dose under supervision, and technique should be checked periodically. 1

Smoking Cessation

Smoking cessation is the single most important intervention:

• Smoking is the single most important cause of COPD and emphysema. 1

• When the smoker stops smoking, in 90% of cases sputum production will cease, and subsequent lung function decline returns to that of healthy non-smokers. 1

• Provide explanation of smoking effects, benefits of stopping, and encouragement to quit; consider nicotine replacement therapy (gum or transdermal) and behavioral intervention to increase success rates. 1

Management of Acute Exacerbations

For acute exacerbations characterized by increased dyspnea, cough, or purulent sputum:

• Add or increase bronchodilators (ensure appropriate inhaler device and technique). 1

• Prescribe antibiotics if two or more of the following are present: increased breathlessness, increased sputum volume, development of purulent sputum. 1

• First-line antibiotics include amoxicillin or tetracycline; for more severe exacerbations or lack of response, use broad-spectrum cephalosporin or newer macrolides. 1

• Oral corticosteroids (30 mg daily for one week) should be used for acute exacerbations in specific circumstances: patient already on oral corticosteroids, previously documented response to corticosteroids, airflow obstruction fails to respond to increased bronchodilator dose, or first presentation of airflow obstruction. 1

Long-Term Oxygen Therapy

Assess for hypoxemia and consider long-term oxygen therapy:

• Long-term oxygen therapy is the only treatment known to improve prognosis in patients with severe COPD and hypoxemia. 1

• Supplemental oxygen should be used in patients with desaturation during exercise. 1

• Initiate long-term oxygen if severe hypoxemia is present according to established criteria. 1

Additional Considerations for Elderly Patients

Address comorbidities and complications common in elderly emphysema patients:

• Depression and panic disorders occur frequently; treat depression with selective serotonin reuptake inhibitors (preferred over tricyclic antidepressants in patients with chronic sputum production), and panic with short-acting benzodiazepines or buspirone. 1

• Pulmonary rehabilitation combining cardiovascular fitness, self-confidence, and stress control improves endurance, reduces dyspnea, and reduces hospitalizations. 1

• Weight loss and malnutrition are common; recommend smaller, more frequent meals to reduce dyspnea from abdominal bloating. 1

• Monitor for development of cor pulmonale and peripheral edema, which indicate poor prognosis. 1

Common Pitfalls to Avoid

• Do not use high-dose beta-agonists as first-line therapy in elderly patients due to increased risk of tremor and cardiac effects. 1

• Avoid face masks when delivering anticholinergics to elderly patients to prevent acute glaucoma. 1

• Do not continue oral corticosteroids long-term after acute exacerbations due to effects on bone loss, which contributes to loss of spine height and lung volume. 1

• Ensure proper inhaler technique is taught and regularly assessed, as many elderly patients cannot use standard metered-dose inhalers effectively. 1