COPD: A step-care approach when FEV₁ is deteriorating

Early recognition of chronic obstructive pulmonary disease is particularly important because treatment of severe disease is often unsatisfactory and survival is strongly related to forced expiratory volume in 1 second (FEV₁) at the time of diagnosis. Smoking cessation is one of the few interventions that has been demonstrated to reduce the rate of decline in lung function. Ipratropium is the initial drag of choice, but patients may require as many as 24 to 32 puffs a day. β₂-Adrenergic agonists are also useful, although the optimum dosages have not yet been established. For selected patients, theophylline offers several benefits, including enhanced mucociliary clearance as well as bronchodilation. Inhaled corticosteroids may be a useful addition to ipratropium or β₂-adrenergic agonists, since they can improve FEV₁ and reduce bronchial hyperresponsiveness. Oral corticosteroids are not routinely recommended, but a 3- to 4-week trial of prednisone may be useful for managing acute exacerbations. Iodinated glycerol or supersaturated potassium iodide may benefit patients with excessive or thick mucus production. Continuous oxygen therapy is indicated for patients who have an oxygen saturation below 90% despite appropriate pharmacologic therapy.