“OK. He’s a 49-year-old builder and was a 40-a-day smoker and a moderately heavy drinker. He didn’t address either until one day he collapsed unable to breathe and ended up in ITU. A severe respiratory infection was diagnosed – which was treated with antibiotics – and COPD.
“He was discharged from hospital on ipratropium 20mcg plus salbutamol 100mcg inhalers, to use up to four times daily. He stopped smoking immediately following the shock of the episode.
“He’s just been back for his first review and he says that he still gets breathless with the slightest exertion and is using his salbutamol inhaler up to six times a day. We’ve checked his inhaler technique and there’s nothing wrong with it.
“I think I know where to go from here but I’d just like to check it out with you before I write the script.”
1. What are the recommendations for prescribing in COPD, and what is the source of this advice?
2. What is Lauren likely to be prescribing as the next step? And which conditions should David check that the patient is not suffering from before supplying this medication, and why?
3. If a patient came to you for advice about persistent respiratory symptoms, what factors would make you suspect that he or she had COPD rather than asthma?
1. Step 1, for breathlessness at rest or on exertion: a short-acting inhaled beta2 agonist and and/or short-acting inhaled muscarinic antagonist, prn. Step 2, if there is exacerbation of or persistent breathlessness and FEV1 ≥ 50 per cent, a long-acting beta2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA); if FEV1 ≤ 50 per cent, a LAMA or LABA + inhaled corticosteroid (ICS) [or LABA + LAMA if ICS is declined or not tolerated]. Step 3, if Step 2 ineffective: LABA + ICS or LABA + LAMA + ICS.
If symptoms persist or the patient is unable to use an inhaler, oral modified-release aminophylline or theophylline. A mucolytic may be considered for a patient with chronic productive cough. Long-term oxygen therapy prolongs survival in patients with severe chronic obstructive pulmonary disease and hypoxaemia.
Source: BNF 60, based on 2010 NICE COPD guidelines.
2. Tiotropium (inhalation powder). Prostatic hyperplasia, bladder outflow obstruction, angle-closure glaucoma, as antimuscarinics can exacerbate these conditions.
3 Nearly always a smoker or ex-smoker rather than non-smoker; usually aged over 35; commonly, a chronic productive cough; persistent and progressive, rather than variable, breathlessness; not normally awoken by night time breathlessness or wheezing; and no significant variability of symptoms during the day or from day to day, whereas both are common with asthma.