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2yr
Worsening COPD in a middle-aged woman

Angie

A 49-year-old woman with COPD complains of increasing dyspnea after physical exertion, including while taking walks in her hilly neighborhood or spending time with her active children. She is worried that her COPD, which was diagnosed 2 years ago, could be worsening. She has also been using her short-acting beta-agonist (SABA) inhaler more frequently, with little relief. She expresses a desire to return to her normal physical activities without experiencing shortness of breath (SOB).

She has no other comorbid conditions and only takes SABA PRN. She has a 20-year pack history and is trying to quit smoking cigarettes.

  • Her physical exam findings include the following.
  • No respiratory distress
  • BMI: 24 kg/m2 • BP: 118/72
  • Respiratory rate: 18 RPM
  • Lungs are clear on auscultation
  • Heart rate: 64 BPM
  • SpO2 at rest: 95%

Her mMRC (Modified Medical Research Council) Dyspnea Scale is Grade 1, which indicates SOB when hurrying on level ground or walking up a slight hill. She has experienced no COPD exacerbations and is GOLD Stage 1.

Based on the clinical picture, how would you escalate this woman’s treatment plan? What treatment would you initiate?

  • 2yr
    spirometry, chest xray, probably LAMA/LABA depending on result of spirometry, alpha 1 phenotype
  • 3yr
    Spirometry & alpha 1 antitrypsin testing
    smoking cessation
    LABA/LAMA daily, whichever the insurace will cover
  • 3yr
    add trelegy 100 one puff daily, arrange pulmonary rehab
  • 3yr
    spirometry
    chest xray
    alpha 1 antitryspin level
    start on trelegy 200 1puff aday
    smoking cessation with medication
    combivent prn
  • 3yr
    1. Tobacco cessation
    2. PFT/A1AT
    3. LAMA + PRN SABA
    4. Consider pulmonary rehab
    5. Consider TTE
  • 3yr
    1. Tobacco cessation
    2. PFT/A1AT
    3. LAMA + prn SABA
    4. Pulmonary rehab
    5. Consider TTE if not better clinically with above intervention.
  • 3yr
    Smoking cessation program.
    Start LAMA/LABA.
    Spirometry.
    Consider pulmonary rehab / exercise program.
  • 3yr
    Start smoking cessation therapy including Chantix and increase cardio exercises
  • 3yr
    stop smoking
    add LAMA/LABA
  • 3yr
    I would definitely discuss with her the importance of smoking cessation and would try to get her to implement a plan to stop. She would clearly benefit from a LAMA/LABA combination inhaler that would provide a LAMA to improve lung function and longer acting bronchodilation medicine to hopefully reduce SABA use.
  • 3yr
    Although there is data to suggest LAMA/LABA can result in more symptom improvement compared to single agent, I would start a LAMA while:
    1- consolidate a smoking cessation plan
    2- pulmonary rehab
    3- check spirometry (in the setting of her worsening symptoms, to compare to prior spirometry, which I assume was done 2 years' prior given the known GOLD classification)
    4- complete CAT
    5- check alpha-1 phenotype
  • 3yr
    Although there is data to suggest LAMA/LABA can result in more symptom improvement compared to single agent, I would start a LAMA while:
    1- consolidate a smoking cessation plan
    2- pulmonary rehab
    3- check spirometry (in the setting of her worsening symptoms, to compare to prior spirometry, which I assume was done 2 years' prior given the known GOLD classification)
    4- complete CAT
    5- check alpha-1 phenotype
  • 3yr
    I would add LAMA/LABA combination and albuterol to use as needed.
  • 3yr
    Combination anticholinergic with long acting bronchodilator covered by insurance
  • 3yr
    I would add LAMA/LABA combination whether it be anoro, stiolto or bevespi. The decision would be in part dictated by her insurance coverage pharmacy plan and her personal choice of inhaler preferences.

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