The appropriate and optimal management of decompensated chronic airflow obstruction in an emergency department setting requires an appreciation of chronic day-to-day therapy. Specific management limits further insults to the respiratory system, treats reversible bronchospasm, and prevents or treats complications.
HEALTHY LIFESTYLE Elements include regular exercise, weight control, and smoking cessation. Smoking cessation is the only therapeutic intervention that can reduce the accelerated decline in lung function.15 Smoking cessation (along with long-term oxygen therapy) has been shown to reduce COPD mortality. -I8,9 and 1° Pulmonary rehabilitation can improve exercise capacity and quality of life and is recommended in those patients with moderate to severe COPD. 16 All COPD guidelines recommend yearly influenza vaccination.1,78,,9 and 1° Although there is some controversy regarding the pneumococcal vaccine in COPD patients, it is currently recommended by the ATS.1,789 and 1C,1I
OXYGEN Both the British Medical Research Council (MRC) study and the National Heart, Lung, and Blood Institute's Nocturnal Oxygen Study have demonstrated that long-term oxygen therapy reduces COPD mortality. Oxygen must be started after arterial blood gases document a Pa o2 of 55 mmHg or less, or a Pao2 between 56 and 59 mmHg when signs of cor pulmonale are present.1
PHARMACOTHERAPY There is no evidence that pharmacotherapy can alter the progression of COPD. Inhaled b 2-adrenergic agents used on an as-needed basis may be prescribed for mild to moderately obstructed patients with intermittent symptoms. In those patients with persistent symptoms or in those patients refractory to b2-adrenergic agents or bothered by side effects, ipratropium bromide is the drug of choice. With increasing symptoms, even after optimization of the above two classes of bronchodilators, theophylline may be helpful. Only about 20 to 30 percent of patients with COPD improve when given chronic oral steroids. 18 Initiating corticosteroid therapy requires careful analysis so as not to subject a nonresponder to the side effects unnecessarily. The European Respiratory Society Study on COPD showed no benefit of inhaled steroids—budesonide 400 pg twice daily—on the annual rate of decline of lung function. 19 Although some subgroups of patients with milder disease may benefit from inhaled steroids, even high doses were of no physiologic or functional benefit in patients with advanced COPD who were nonresponders to oral steroids.20 Results from other studies using inhaled steroids in COPD are pending. Although some studies support the use of theophylline in stable COPD patients, most current COPD guidelines consider it only an adjunct therapy. I7,8,9 and 19
MOBILIZATION OF SECRETIONS Assurance of generous oral fluid intake and atmospheric humidification, avoidance of antihistamine/decongestant agents, and limitation of antitussive use help mobilize respiratory secretions. The efficacy of specific expectorant products is dubious.
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