What is the recommended treatment for a patient with moderate Chronic Obstructive Pulmonary Disease (COPD) and Forced Expiratory Volume in 1 second (FEV1) of 75%, presenting with increased cough and shortness of breath, without noticeable change in sputum purulence and volume, after exposure to a smoker?

From the Guidelines

For a patient with moderate COPD (FEV1 of 75%), the appropriate daily medication in addition to a short-acting beta2-agonist would be a low-dose inhaled corticosteroid. This helps reduce airway inflammation and prevent exacerbations in patients with moderate COPD, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

When the patient returns with increased cough and shortness of breath but without changes in sputum purulence or volume, no antimicrobial therapy is needed at this time. The worsening symptoms are likely related to environmental factors (exposure to secondhand smoke from the brother) rather than a bacterial infection. According to the global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report, antibiotics are indicated when there are signs of bacterial infection such as increased sputum purulence, fever, or other systemic symptoms 1.

Instead, management should focus on:

• Reducing exposure to the irritant (secondhand smoke)
• Ensuring proper use of prescribed inhalers
• Possibly temporarily increasing bronchodilator therapy until symptoms improve Antibiotics like azithromycin, amoxicillin-clavulanate, or moxifloxacin would be considered if there were clear signs of a bacterial infection, but in this case, the symptoms suggest an exacerbation likely triggered by environmental factors rather than a bacterial cause.

From the FDA Drug Label

Azithromycin Tablets, USP are indicated for the treatment of patients with mild to moderate infections (pneumonia: see WARNINGS) caused by susceptible strains of the designated microorganisms in the specific conditions listed below Acute bacterial exacerbations of chronic obstructive pulmonary disease due to Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae

The patient Donnie has moderate COPD and is experiencing increased cough and shortness of breath. Given that his sputum purulence and volume have not noticeably changed, it is unclear if this is a bacterial exacerbation. However, the NP should consider the patient's symptoms and the fact that his brother, a smoker, has been staying at his home, which may have triggered the exacerbation. The FDA drug label for azithromycin 2 and 2 indicates that it is used to treat acute bacterial exacerbations of chronic obstructive pulmonary disease due to Haemophilus influenzae, Moraxella catarrhalis or Streptococcus pneumoniae. Since the patient's symptoms have worsened, the NP may consider initiating antimicrobial therapy. Given the information provided, the most appropriate recommendation would be to initiate oral azithromycin as it is indicated for the treatment of acute bacterial exacerbations of chronic obstructive pulmonary disease.

From the Research

Initial Treatment for Donnie

• The NP prescribes daily use of an inhaled long-acting beta2-agonist for Donnie, which is supported by the study 3 that shows inhaled long-acting beta2-agonists are effective in improving quality of life and reducing exacerbations in patients with moderate to severe COPD.
• Another study 4 also supports the use of inhaled combination therapy with long-acting beta2-agonists and corticosteroids in stable COPD patients, which can improve airflow obstruction and provide clinical benefits.

Follow-up Treatment for Donnie

• Donnie returns 4 weeks later complaining of increased cough and shortness of breath, and the NP needs to decide on the next course of treatment.
• The study 5 compares different classes of long-acting inhalers for people with COPD and finds that combination inhalers (LABA and ICS) improve quality of life and lung function the most.
• However, there is no clear evidence from the provided studies to support the use of antimicrobial therapy in this case, as Donnie's sputum purulence and volume have not noticeably changed, and his symptoms may be related to his brother's smoking.
• Therefore, the NP may recommend no antimicrobial therapy needed at this time, and instead focus on optimizing Donnie's current treatment regimen and providing guidance on how to manage his symptoms and reduce his exposure to secondhand smoke.

Rationale for Treatment Decisions

• The treatment decisions for Donnie are based on the evidence from the studies 3, 4, and 5, which support the use of inhaled long-acting beta2-agonists and combination therapy with corticosteroids in patients with COPD.
• The study 6 also provides scientific rationale for combining long-acting beta2-agonists and muscarinic antagonists in COPD, which may be considered as an alternative treatment option for Donnie.
• The study 7 provides a benefit-risk assessment of inhaled long-acting beta2-agonists in the management of obstructive pulmonary disease, which supports the safety and efficacy of these medications in patients with COPD.