Board Review

A 58-year-old man is evaluated for chronic cough, occasional wheezing, and shortness of breath associated with frequent stops to catch his breath when walking one to two blocks on level ground. His medical history is notable for an episode of bronchitis, for which he underwent outpatient treatment 6 months ago. He is a current smoker with a 30-pack-year smoking history.

On physical examination, vital signs are normal. Examination of the lungs shows mildly decreased breath sounds throughout both lung fields and occasional scattered expiratory wheezes. The remainder of the physical examination is normal. Spirometry shows an FEV₁ of 70% of predicted and a postbronchodilator FEV₁/FVC ratio of 62%. His modified Medical Research Council (mMRC) symptom score is 2.

In addition to smoking cessation, which of the following is the most appropriate treatment?

A) Combination inhaled glucocorticoid and a long-acting bronchodilator

B) Phosphodiesterase-4 inhibitor and combination inhaled glucocorticoid and long-acting bronchodilator

C) Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation

D) Short-acting bronchodilator as needed and an inhaled glucocorticoid

Answer: C - Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation

Objective: Treat COPD in a patient with risk category B disease.

Key Point

The recommended therapy for stable patients with symptomatic (Global Initiative for Chronic Obstructive Lung Disease risk category B) COPD consists of a short-acting bronchodilator as needed and regular use of a long-acting bronchodilator, as well as with pulmonary rehabilitation.

The most appropriate treatment for this patient with COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] risk category B) is a short-acting bronchodilator as needed, regular use of a long-acting bronchodilator, and pulmonary rehabilitation. The new GOLD risk stratification can be used to classify risk and help make management decisions.

Risk category A COPD is characterized by an FEV₁/FVC ratio less than 70%, an FEV₁ greater than or equal to 50% of predicted, and zero to one exacerbation(s) in the past year. These patients have mild or infrequent symptoms. Symptoms can be objectively quantified using either the Modified Medical Research Council (mMRC) Questionnaire or the COPD Assessment Test (CAT) score. Patients in risk category A have a mMRC score of 0 to 1 or CAT score less than 10. Therapy for category A COPD is an inhaled bronchodilator as needed; a short-acting bronchodilator is preferred.

Patients in risk category B have all the same spirometry measurements and exacerbation frequency as in category A but are more symptomatic, often having to walk slowly or stop owing to breathlessness (mMRC score of ≥2 or CAT score ≥10). These patients are also treated with bronchodilators, typically a short-acting bronchodilator as needed and regular use of a long-acting bronchodilator, as well as with pulmonary rehabilitation. Combinations of a long-acting β₂-agonist (LABA) and long-acting anticholinergic (also known as long-acting muscarinic agent [LAMA]) bronchodilators can be used as alternative therapy.

Risk category C COPD is characterized by an FEV₁/FVC ratio less than 70%, an FEV₁ less than 50% of predicted, or two or more exacerbations per year or one or more hospitalizations for an exacerbation. Otherwise, patients have mild or infrequent symptoms (mMRC score of 0-1 or CAT score <10). Regular treatment with a combination inhaled glucocorticoid plus a LABA or monotherapy with a LAMA is preferred. Alternatives may include dual combination therapy with a LAMA plus an inhaled glucocorticoid or a LABA, or a phosphodiesterase-4 (PDE-4) inhibitor and a long-acting bronchodilator.

Patients in risk category D have all the same spirometry measurements and exacerbation frequency as category C, but they are more symptomatic (mMRC score of ≥2 or CAT score ≥10). Preferred therapy includes a short-acting bronchodilator as needed and regular use of combination therapy with an inhaled glucocorticoid and a LABA and/or a LAMA, and pulmonary rehabilitation. Alternative therapy includes triple combinations of two long-acting bronchodilators and an inhaled glucocorticoid; an inhaled glucocorticoid plus a LABA and PDE-4 inhibitor; or double combinations of two long-acting bronchodilators, or a LAMA and PDE-4 inhibitor.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. . Updated 2015. Accessed April 2, 2015. Link Out