What is the protocol treatment for a patient with Chronic Obstructive Pulmonary Disease (COPD) presenting with cough and wheezing?

From the Guidelines

For a patient with COPD experiencing cough and wheezing, the initial treatment should focus on bronchodilators, with short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as the recommended initial bronchodilators to treat an acute exacerbation, as stated in the 2017 GOLD executive summary 1. The treatment protocol for a patient with COPD complaining of cough and wheezing should prioritize minimizing the negative impact of the current exacerbation and preventing subsequent events.

• The initial treatment should include short-acting beta-agonists (SABA) like albuterol (2-4 puffs every 4-6 hours as needed) and short-acting muscarinic antagonists (SAMA) like ipratropium bromide (2 puffs four times daily) to relax airway smooth muscles and reduce mucus production.
• For maintenance therapy, prescribe a long-acting beta-agonist (LABA) such as formoterol (12 mcg twice daily) or salmeterol (50 mcg twice daily), along with a long-acting muscarinic antagonist (LAMA) like tiotropium (18 mcg once daily), as recommended by the 2017 GOLD report 1.
• If symptoms persist, add an inhaled corticosteroid (ICS) like fluticasone (250-500 mcg twice daily) to reduce airway inflammation, considering the benefits of combination therapy as suggested in guidelines from 2015 1.
• For acute exacerbations, a short course of oral corticosteroids (prednisone 40 mg daily for 5 days) may be necessary, as systemic corticosteroids improve lung function and oxygenation, and shorten recovery time and hospitalization duration, as noted in the 2017 GOLD executive summary 1.
• Antibiotics are indicated if there are signs of infection, as they shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration, also from the 2017 GOLD report 1. Encourage proper inhaler technique, smoking cessation, pulmonary rehabilitation, and annual influenza and pneumococcal vaccinations to improve overall management of COPD.

From the FDA Drug Label

1. 2 Maintenance Treatment of Chronic Obstructive Pulmonary Disease Wixela Inhub® 250/50 is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. The recommended dosage for patients with COPD is 1 inhalation of Wixela Inhub® 250/50 twice daily, approximately 12 hours apart. If shortness of breath occurs in the period between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief

The protocol treatment for a patient with COPD complaining of cough and wheezing would be:

• Wixela Inhub® 250/50 twice daily, approximately 12 hours apart, for the maintenance treatment of airflow obstruction.
• If shortness of breath occurs between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief 2.

From the Research

Treatment Protocol for COPD Patients with Cough and Wheezing

The treatment protocol for COPD patients complaining of cough and wheezing involves the use of bronchodilators, which are the mainstay of pharmacological management of COPD 3, 4, 5. The Global Initiative for Chronic Obstructive Lung Disease strategy recommends the use of a combination of long-acting β₂-agonist/long-acting muscarinic antagonists (LABA/LAMA) as the first-line treatment option in the majority of symptomatic patients with COPD 3.

Recommended Treatment Options

• Long-acting β₂-agonist (LABA) and long-acting muscarinic antagonist (LAMA) combination therapy is recommended for patients with COPD and dyspnea or exercise intolerance 6.
• LABA/LAMA fixed-dose combinations (FDCs) provide greater benefits compared with placebo and similar or greater benefits compared with tiotropium and salmeterol/fluticasone in improving lung function, dyspnea, health-related quality of life, reducing rescue medication use, and preventing exacerbations 3.
• Inhaled muscarinic acetylcholine receptor antagonists, such as tiotropium bromide, are effective in improving lung function and reducing symptoms in COPD patients 5.

Comparison of Treatment Options

• LAMA+LABA combination therapy is similar to LABA+ICS in terms of exacerbations and quality of life, but offers a larger improvement in FEV1 and a slightly lower risk of pneumonia 7.
• LAMA+LABA combination therapy may have a higher risk of all-cause death compared to LABA+ICS, but the absolute risk is low 7.

Key Considerations

• The choice of treatment should be based on individual patient needs and factors such as inhaler devices and potential biomarkers 3.
• Physicians should consider the efficacy gradient that exists among LABA/LAMA FDCs when choosing the optimal bronchodilator treatment for long-term management of patients with COPD 3.