What is the best management approach for an older patient with emphysema, likely with a history of smoking?

Emphysema Management

Smoking cessation is the absolute first priority and the only intervention proven to slow disease progression and reduce mortality in emphysema, requiring immediate initiation of combination pharmacotherapy (varenicline or bupropion PLUS nicotine replacement therapy) alongside intensive behavioral counseling. 1

Immediate Smoking Cessation Strategy

• Abrupt cessation is superior to gradual reduction, as gradual withdrawal rarely achieves complete cessation 1
• Smoking cessation is the only treatment that modifies the natural decline in lung function, returning decline rates to those of healthy non-smokers after quitting 1
• Combination pharmacotherapy with behavioral support provides the best outcomes for long-term abstinence 2

Pharmacologic Bronchodilator Therapy

Initiate inhaled bronchodilator therapy immediately with either a long-acting β2-agonist (LABA) or long-acting anticholinergic (LAMA such as tiotropium) to reduce symptoms, prevent exacerbations, and improve exercise tolerance. 1

• For patients with high symptom burden and frequent exacerbations (GOLD Group D), baseline therapy should include LAMA, LABA/LAMA combination, or LABA/ICS with potential escalation to triple therapy (LABA/LAMA/ICS) 3
• LABA/LAMA combination provides greater improvements in pulmonary function than either agent alone and is preferred over LABA/ICS for frequent exacerbators due to pneumonia risk with inhaled corticosteroids 3, 4
• For patients with chronic bronchitis and frequent exacerbations despite optimal bronchodilator therapy, roflumilast (a phosphodiesterase-4 inhibitor) reduces moderate or severe exacerbation rates by 15-18% 5
• Theophylline is not recommended due to unfavorable risk-benefit ratio unless bronchodilators are inaccessible or unaffordable 3

Vaccinations to Reduce Mortality and Exacerbations

• Administer influenza vaccine annually to reduce serious illness, death, and total exacerbations 1, 2
• Pneumococcal vaccines (PCV13 and PPSV23) should be given to all patients 65 years and older, and to younger patients with emphysema 1, 2

Pulmonary Rehabilitation

Refer all patients to pulmonary rehabilitation regardless of disease severity to improve symptoms, quality of life, exercise capacity, and reduce breathlessness and hospitalizations. 1, 2

• Benefits occur across all disease severities and improve physical and emotional participation in everyday activities 1
• Programs should include cardiovascular fitness training, stress control, and self-confidence building 2

Assessment for Severe Disease Requiring Life-Prolonging Interventions

Evaluate for hypoxemia using arterial blood gas or pulse oximetry at rest, and perform spirometry to assess severity and determine need for additional therapies. 1

Long-Term Oxygen Therapy (LTOT)

• LTOT is the only treatment besides smoking cessation proven to improve survival in patients with severe COPD and hypoxemia 1, 2
• Prescribe LTOT for patients with resting oxygen saturation ≤88% or arterial oxygen partial pressure ≤55 mm Hg 3
• Also prescribe for patients with coexisting pulmonary hypertension, congestive heart failure, or polycythemia (hematocrit >55%) at arterial oxygen partial pressure between 55-60 mm Hg or SaO2 88-93% 3
• Target oxygen saturation of 88-92% if respiratory acidosis develops, and use >15 hours/day for survival benefit 1, 2
• Reevaluate need for and efficacy of prescription regularly 3

Surgical and Advanced Interventions

Lung Volume Reduction Surgery (LVRS)

• LVRS improves survival in selected patients with upper-lobe emphysema and low post-rehabilitation exercise capacity 2
• Refer patients with advanced emphysema or large bullae to a specialist for consideration of bullectomy, LVRS, or lung transplantation 3

Alpha-1 Antitrypsin Deficiency

• Intravenous augmentation therapy should be considered in patients with alpha-1 antitrypsin deficiency and progressive emphysema to slow disease progression 3, 2

Cardiovascular Risk Assessment

Screen for cardiovascular disease aggressively, as approximately 26% of deaths in moderate to severe COPD are cardiovascular, and COPD and CVD share common pathobiological pathways. 1

Monitoring and Follow-Up

• Schedule close follow-up within 2-4 weeks to assess smoking cessation progress and symptom response 1
• Perform spirometry regularly to monitor disease progression 1
• Reassess inhaler technique at each visit, as poor technique is a common pitfall that reduces treatment efficacy 1
• Monitor for depression and assess social circumstances, as depression should be identified and treated 3

Common Pitfalls to Avoid

• Delaying smoking cessation interventions is the most critical error, as it is the most important intervention to slow disease progression 1, 2
• Avoid prescribing inhaled corticosteroids without clear indication (frequent exacerbations or asthma-COPD overlap), as they increase pneumonia risk 3
• Do not prescribe statins, vasodilator therapy, or antitussives for COPD in the absence of other standard indications, as they lack evidence of benefit 3
• Avoid beta-blocking agents in all COPD patients 6