improving the patient’s health thesis
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e also vital for improving the patient’s health after discharge and include education regarding proper inhaler technique, and avoidance of second-hand smoke (and other respiratory irritants). Patient education regarding the ability to recognize the symptoms of an exacerbation should be emphasized.
Pulmonary rehabilitation is an important part of outpatient COPD care after an admission for AECOPD, and should be considered at the time of discharge for all patients with chronic lung disease with the goal of alleviating symptoms and optimizing functional capacity. Evidence supports that entering pulmonary rehabilitation within 10 days of hospital discharge is safe. Furthermore, patients enrolled in early pulmonary rehabilitation experienced improved exercise tolerance and health status at 3 months. Beyond functional capacity, pulmonary rehabilitation programs often focus on establishing social support and care networks that are most appropriate for the patient and can have quality- of-life benefits beyond physical improvements.
Evidence supports that entering pulmonary rehabilitation within 10 days of hospital discharge is safe, and patients enrolled in early pulmonary rehabilitation experience improved exercise tolerance and health status at 3 months.
SURGICAL TREATMENT OPTIONS AND TRANSPLANT EVALUATION
Surgical treatment options for COPD include lung volume reduction surgery (LVRS), bullectomy, lung transplantation and investigational approaches. LVRS involves bilateral removal of 25% to 30% of total lung volume. The National Emphysema Treatment Trial, published in 2003, demonstrated that LVRS improved exercise capacity but not survival among all patients with severe emphysema. This trial did, however, identify subgroups that had a survival advantage. The best candidates for LVRS are patients with predominantly upper-lobe disease and a low exercise capacity after pulmonary rehabilitation. Bullectomy has not been well studied in randomized trials, but it may be considered for patients with at least one-third of the thorax occupied by bullae.
For patients with advanced disease another therapy to consider is lung transplantation. Lung transplant referral is indicated for younger patients with COPD that have progressive symptoms despite maximal medical therapy, including smoking cessation. Lung transplant for COPD has been shown to improve quality of life, but effect on mortality has not been clearly demonstrated and is more controversial. For further analysis of trials addressing treatment strategies in COPD, please refer to the key references (Table 232-10).
TABLE 232-10 Evidence-based Medicine: Key References for Chronic Obstructive Pulmonary Disease
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Reference Methodology Results Limitations Bottom Line Calverely P, et al. N Engl J Med. 2007;356:775- 789. TORCH trial
Randomized, double-blind, placebo- controlled trial of placebo vs salmeterol alone vs fluticasone alone vs salmeterol plus fluticasone inhaled twice daily for 3 y. 6112 patients were active or former smokers with diagnosis of COPD, FEV1 < 60% predicted and no significant bronchodilator response
Comparing combination therapy to placebo, there was nonstatistically significant reduction in mortality (OR, 0.825; CI 0.681- 1.002). Compared to placebo, combination therapy reduced exacerbations. There were higher levels of pneumonia in both groups receiving fluticasone when compared to placebo
There was a large drop-out rate (as might be expected in a COPD trial with a placebo arm)
There is insufficient data to suggest that inhaled corticosteroids decrease mortality in patients with COPD, but addition of inhaled corticosteroid may reduce exacerbations for patients on LABAs that have recurrent exacerbations. For monotherapy in COPD, LABA should be used rather than an ICS