Internal Medicine

0521779407-C02 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

342 Chronic Obstructive Pulmonary Disease

➣Titrate flow to PaO 2 60–80

➣Most patients require increased flow for exercise, sleep

■Bronchodilators:

➣Ipratropium or short-acting beta 2 or long-acting beta 2 or com-

bination

➣Nebulization usually not necessary with proper inhaler tech-

nique and dose

➣Theophylline may be useful as additional therapy

➣Long-acting anticholinergics and PDE4 inhibitors look promis-

ing for the near future

■Inhaled corticosteroids (ICS):

➣4 recent, large, multinational studies:

➣ICS do not slow progression of disease

➣May reduce exacerbations and visits

➣Increased risk of osteoporosis, skin thinning

■Oral steroids effective in exacerbations

■Treat infectious exacerbations:

➣Unclear when antibiotics needed; meta-analysis suggests pos

effect

➣Treat empirically forS pneumonia,H influenza,M catarrhalis,

Legionella,Mycoplasma; considerPseudomonas, AFB

■Vaccination:

➣Pneumococcal q 5–10 y

➣Influenza q 1 y

■Pulmonary rehabilitation improves quality of life, not survival

■Lung volume reduction surgery controversial; benefits may be short-

lived; multicenter NIH trial underway

■Lung transplant: COPD most common indication; 1-y survival,

∼90%; 5-y,∼50%

■Opiates help relieve dyspnea in some patients

follow-up

■Routine, periodic spirometry best objective measure to assess

status

■Evaluate frequently for comorbid conditions (CHF, poor nutrition)

complications and prognosis

Complications

■Exacerbation (S pneumoniae, H influenzae up to 80%)

■Pneumonia

■Hemoptysis