A 68-year-old woman is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (COPD). She responds well to treatment and is discharged. At her follow-up appointment, she states that she has been compliant with treatment but has had 2 acute exacerbations in the last 9 months. In addition to COPD, her medical history is significant for hypertension, hyperlipidemia, and atrial fibrillation. She takes hydrochlorothiazide, simvastatin, diltiazem, and salmeterol. She also takes inhaled albuterol and ipratropium as needed. She does not smoke, is up to date with the appropriate vaccinations, and is undergoing pulmonary rehabilitation. Her vitals are taken: blood pressure 132/86 mmHg, heart rate 87 beats per minute, respiratory rate 16 breaths per minute, and oxygen saturation 94% on room air.
Which of the following is the most appropriate next step in management?A) Add theophylline
Add inhaled fluticasone. This patient’s COPD is progressively worsening and she suffered another acute exacerbation, which makes it necessary to step up her treatment to the next level. Treatment of COPD progresses in a stepwise fashion based on symptoms, number of exacerbations, and GOLD staging criteria, which relies on forced expiratory volume in 1 second (FEV1) for staging. For the shelf examination, the most important task is to recognize when a patient requires a step-up in therapy and then to know what the next step in therapy is. The first step in all of these patients is to decrease risk factors: smoking cessation and vaccinations to prevent lung infections (pneumococcal vaccine and annual influenza vaccine). Pulmonary rehabilitation is another supplemental therapy that is useful in patients with at least moderate symptoms. The treatment steps in pharmacologic therapy are summarized in below in a stepwise fashion; when a patient is experiencing worsening of symptoms or acute exacerbations, the next step should be added to the current regimen. Other complicated treatments for advanced disease, such as lung volume reduction surgery, are not typically tested on the shelf examination. This patient’s regimen includes short-acting bronchodilators and a LABA, and therefore the next step in management is an inhaled corticosteroid.
(A) Theophylline blocks phosphodiesterase and increases intracellular cAMP, leading to increased catecholamine release. It is not a first-line therapy, but it may be used in severe COPD for refractory disease. As a sympathomimetic, it can exacerbate tachyarrhythmias and therefore is not a good option in this patient with atrial fibrillation. (C) Oral corticosteroids are used for acute exacerbations but not in chronic disease due to the negative side-effect profile as well as an increase in mortality. (D) This patient does not meet criteria for home oxygen therapy at this time (criteria explained later). (E) The patient has worsening symptoms and the next step in therapy is warranted.
Step-Up Therapy for COPD: