What is the assessment and plan for a patient with panlobular emphysema, chronic and poorly controlled, not adhering to controller medication regimen, using albuterol (salbutamol) daily, and recommended to use oxygen as needed (PRN)?

From the Guidelines

The patient should immediately resume their prescribed controller medications, including inhaled corticosteroids and long-acting bronchodilators, and use oxygen therapy as needed, to improve symptoms, reduce exacerbations, and slow disease progression, as recommended by the most recent guidelines 1. The patient has panlobular emphysema that is poorly controlled due to non-adherence to controller medications while relying on daily albuterol rescue therapy.

• The prescribed controller medications typically include inhaled corticosteroids (such as fluticasone) combined with long-acting bronchodilators (such as salmeterol or formoterol).
• The patient should use these controllers consistently, usually twice daily, to reduce inflammation and maintain airway patency.
• Additionally, oxygen therapy should be used as prescribed when needed (PRN), particularly during exertion or sleep if oxygen saturation drops.
• The patient should limit albuterol use to true rescue situations rather than daily maintenance.
• Controller medications work by reducing underlying inflammation and preventing airway constriction, while rescue medications only provide temporary symptom relief without addressing the disease progression.
• Consistent use of controllers can significantly reduce exacerbations, improve lung function, and slow disease progression, whereas relying solely on rescue medication allows the underlying inflammatory process to continue unchecked, potentially accelerating lung damage, as supported by previous studies 1.
• The most recent guidelines from 2023 1 emphasize the importance of personalized management plans, including pharmacological and nonpharmacological treatments, to improve symptoms and health status, prevent acute exacerbations, and reduce mortality.

From the FDA Drug Label

The precise function of these receptors, however, is not yet established. Albuterol has been shown in most controlled clinical trials to have more effect on the respiratory tract in the form of bronchial smooth muscle relaxation than isoproterenol at comparable doses while producing fewer cardiovascular effects Controlled clinical studies and other clinical experience have shown that inhaled albuterol, like other beta-adrenergic agonist drugs, can produce a significant cardiovascular effect in some patients, as measured by pulse rate, blood pressure, symptoms, and/or electrocardiographic changes Clinically significant improvement in pulmonary function (defined as maintenance of a 15% or more increase in FEV1 over baseline values) continued for 3 to 4 hours in most patients and in some patients continued up to 6 hours

The patient is using his rescue medication (albuterol) daily, which may indicate that his Panlobular emphysema is not well-controlled. The drug label suggests that albuterol can produce cardiovascular effects in some patients.

• The patient's daily use of albuterol may lead to cardiovascular effects such as increased heart rate and blood pressure.
• The patient's poor control of his Panlobular emphysema may be due to non-adherence to his controller medications.
• The recommendation to use Oxygen PRN may help alleviate symptoms, but the underlying issue of poor control needs to be addressed 2.

From the Research

Assessment and Plan for Panlobular Emphysema

• The patient has panlobular emphysema, a type of chronic obstructive pulmonary disease (COPD), which is not well-controlled and requires adjustment of the treatment plan.
• The patient is not using controller medications as instructed and is relying on rescue medication (albuterol) daily, indicating poor adherence to the current treatment regimen.
• The use of oxygen as needed (PRN) has been recommended, but the patient's current oxygen usage is not specified.

Treatment Options

• According to 3, long-acting beta-agonists (LABAs) and inhaled corticosteroids (ICS) are commonly used in the treatment of COPD, and combination therapy may provide additional benefits.
• 4 suggests that triple therapy, which includes LABA, LAMA, and ICS, may reduce the rate of moderate-to-severe COPD exacerbations and improve health-related quality of life, but may also increase the risk of pneumonia.
• 5 provides an overview of pharmacotherapies for COPD, including short-acting beta agonists, long-acting beta agonists, and inhaled corticosteroids, and highlights the importance of individualized treatment plans.
• 6 presents a pooled post-hoc analysis of the ENHANCE-1/2 studies, which suggests that ensifentrine, a novel PDE3/PDE4 inhibitor, may improve lung function and reduce exacerbations in patients with moderate to severe COPD.
• 7 discusses the role of long-acting beta-agonists in the management of COPD and highlights the potential benefits of once-daily LABAs, including improved efficacy and compliance.

Potential Adjustments to the Treatment Plan

• Consider adding a LABA or LAMA to the patient's treatment regimen to improve bronchodilation and reduce symptoms.
• Evaluate the patient's adherence to the current treatment plan and provide education on the importance of proper medication use.
• Consider recommending a combination inhaler that includes a LABA and an ICS to simplify the treatment regimen and improve efficacy.
• Monitor the patient's oxygen usage and adjust the treatment plan as needed to ensure adequate oxygenation.