From the Guidelines
Patients with moderate emphysema and upper lobe predilection on CT scan should be considered for lung volume reduction surgery (LVRS) as it has been shown to improve survival, exercise capacity, and quality of life in selected patients, particularly those with upper lobe-predominant emphysema and low exercise capacity after pulmonary rehabilitation, as demonstrated in the National Emphysema Treatment Trial (NETT) 1.
Management of Moderate Emphysema
The management of moderate emphysema with upper lobe predilection on CT scan involves a multifaceted approach, including:
- Immediate smoking cessation if the patient still smokes, as this is the only intervention proven to slow disease progression
- Pharmacotherapy with bronchodilators such as long-acting beta-agonists (LABAs) like salmeterol (50mcg twice daily) or formoterol (12mcg twice daily), often combined with long-acting muscarinic antagonists (LAMAs) like tiotropium (18mcg once daily)
- Pulmonary rehabilitation to improve exercise capacity and quality of life
- Vaccination against influenza annually and pneumococcal pneumonia
- Oxygen therapy if resting oxygen saturation is ≤88% or PaO2 ≤55 mmHg
Role of CT Scan
CT scans play a crucial role in the diagnosis and management of emphysema, as they can estimate the degree of emphysema and its distribution, identify bronchial wall thickening and gas trapping, and detect pulmonary and non-pulmonary comorbidities 1.
Importance of Pulmonary Rehabilitation
Pulmonary rehabilitation is essential in the management of moderate emphysema, as it can improve exercise capacity, quality of life, and survival, particularly in patients undergoing LVRS 1. It should be considered as part of the comprehensive management plan for these patients.
From the Research
Moderate Emphysema with Upper Lobe Predilection on CT
Treatment Options
- The use of combination inhaled steroid and long-acting beta(2)-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease (COPD) has been studied 2, 3.
- The results suggest that the addition of combination treatment to tiotropium has shown improvements in average health-related quality of life and lung function 2, 3.
- However, the benefits and risks of using tiotropium and combination therapy together for the treatment of COPD are unclear 2, 3.
Comparison of Treatment Outcomes
- A study comparing tiotropium plus LABA/ICS versus tiotropium alone found no statistically significant differences in mortality, but a reduction in all-cause hospitalisations with the use of combined therapy 3.
- Another study found that the addition of LABA to tiotropium resulted in a slightly larger improvement in mean health-related quality of life and lung function compared to tiotropium alone 4, 5.
- A comparison of combination inhaled steroid and long-acting beta2-agonist versus tiotropium for COPD found that there were more deaths on tiotropium than on fluticasone/salmeterol, but the number of withdrawals from each arm was large and imbalanced 6.
Key Findings
- The results of these studies indicate that the addition of combination treatment to tiotropium may improve health-related quality of life and lung function in patients with COPD 2, 3, 4, 5.
- However, the evidence is not sufficient to support the benefit of tiotropium + LABA/ICS for mortality and exacerbations 3.
- Further large, long-term randomised controlled trials comparing combination therapy to tiotropium are required to determine the relative efficacy and safety of these treatments 6.