Pharmacotherapy for patient stabilization

A. Oxygen. Patients in respiratory distress should receive supplemental oxygen therapy. Oxygen therapy usually is initiated by nasal cannula to maintain an O2 saturation greater than 90%. Patients with hypercarbia may require controlled oxygen therapy using a Venturi mask in order to achieve more precise control of the FiO2.

B. Beta-agonists are first-line therapy for AECOPD. Albuterol is the most widely used agent.

Agent

MDI

(Proventil, Ventolin)

2-4 puffs q4h

0.5 cc (2.5 mg)

Pirbuterol (Maxair)

2 puffs q4-6h

Salmeterol (Serevent)

2 puffs q12h

C. Anticholinergic agents produce preferential dilatation of the larger central airways, in contrast to beta-agonists, which affect the peripheral airways. Ipratropium is a first-line therapeutic option for chronic, outpatient management of stable patients with COPD. The usual dose is 2-4 puffs every six hours. The inhalation dose is 500 mcg/2.5 mL solution nebulized 3-4 times daily.

D. Corticosteroids. Rapidly tapering courses of corticosteroids are effective in preventing relapses and maintaining longer symptom-free intervals in patients who have had AECOPD. Patients with an acute exacerbation of COPD should receive steroids as a mainstay of outpatient therapy. There is no role for inhaled corticosteroids in the treatment of acute exacerbations.

1. Oral steroids are warranted in severe COPD. Prednisone 0.5-1.0 mg/kg or 40 mg qAM. The dose should be tapered over 1-2 weeks following clinical improvement.

2. Aerosolized corticosteroids provide the benefits of oral corticosteroids with fewer side effects.

Triamcinolone (Azmacort) MDI 2-4 puffs bid. Flunisolide (AeroBid, AeroBid-M) MDI 2-4 puffs bid. Beclomethasone (Beclovent) MDI 2-4 puffs bid. Budesonide (Pulmicort) MDI 2 puffs bid.

3. Side effects of corticosteroids. Cataracts, osteoporosis, sodium and water retention, hypokalemia, muscle weakness, aseptic necrosis of femoral and humeral heads, peptic ulcer disease, pancreatitis, endocrine and skin abnormalities, muscle wasting.

E. Theophylline has a relatively narrow therapeutic index with side effects that range from nausea, vomiting, and tremor to more serious side effects, including seizures and ventricular arrhythmias. Dosage of long-acting theophylline (Slo-bid, Theo-Dur) is 200-300 mg bid. Theophylline preparations with 24-hour action may be administered once a day in the early evening. Theo-24, 100-400 mg qd [100, 200, 300, 400 mg].

F. Salmeterol (Serevent) is a long-acting beta-agonist, which may improve nocturnal dyspnea and reduce the frequency of beta-agonist rescue use. 2 puffs q12h.

G. Summary of therapeutic approaches

1. Acute exacerbations are treated with systemic steroids, antibiotics, and inhaled beta-agonists with combined ipratropium. Lack of improvement should prompt addition of theophylline, salmeterol, noninvasive ventilatory support (BIPAP), or intubation with mechanical ventilatory support.

2. Chronic and stable COPD is treated with scheduled doses of ipratropium in combination with albuterol. Salmeterol and theophylline are added when symptom control is difficult. Addition of an inhaled steroid may be beneficial in selected patients. Continuous oxygen therapy has clear benefits when indicated by a resting, exercise, or sleeping PaO2 <55 mm Hg.

H. Antibiotics. Amoxicillin-resistant, beta-lactamase-producing H. influenzae are common. Azithromycin has an appropriate spectrum of coverage. Levofloxacin is advantageous when gram-negative bacteria or atypical organisms predominate. Amoxicillin-clavulanate has in vitro activity against beta-lactamase-producing H. influenzae and M. catarrhalis.

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