Theophylline

1. Theophylline has utility in patients with significant side effects from high dose beta agonists as well as in patients with nocturnal symptoms. It has been shown to improve airflow, decrease dyspnea, and improve ventilation, arterial blood gases, exercise tolerance, and respiratory muscle function.

2. It should be used after adequate doses of ipratropium and beta2-agonists have been tried. A dosage that yields a serum drug level ranging from 8 to 12 ug/mL is recommended. Evening dosing may control decreased nighttime airflows and improve morning respiratory symptoms. Adverse drug interactions occur with ciprofloxacin, erythromycin, cimetidine, and zileuton.

3. Dosage of long-acting theophylline. 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]. E. Corticosteroids

1. Corticosteroids produce a favorable response during acute COPD exacerbations, improving symptoms and reducing the length of hospitalization. Short courses of corticosteroids should be considered in patients with acute exacerbations who are unresponsive to aggressive inhaled bronchodilator therapy.

2. Long-term use of corticosteroids should be considered only in patients who have continued symptoms or severe airflow limitation despite maximal therapy with other agents. Only 20% to 30% of patients show objective benefits from long-term corticosteroid administration.

3. 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 2-5 puffs bid. Budesonide (Pulmicort) MDI 2 puffs bid.

4. 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.

5. 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.

IV.Surgical treatment. Lung volume reduction surgery (LVRS) consists of surgical removal of an emphysematous bulla. This procedure can ameliorate symptoms and improve pulmonary function. Lung transplantation is reserved for those patients deemed unsuitable or too ill for LVRS. It is effective for severe emphysema.

V. Treatment of complications of COPD A. Infection

1. Infection frequently causes bronchitis exacerbations and is associated with increased or purulent sputum, increased cough, chest congestion and discomfort, and increased dyspnea and wheezing. Chills and fever suggest pneumonia. Acute bacterial episodes tend to be seasonal, appearing more frequently in the winter.

2. Gram stain a. Gram stain is a useful guide in the selection of an empiric antibiotic. The presence of more than 25 neutrophils and fewer than 10 epithelial cells per low-power field indicates that the specimen is sputum.

b. The presence of bacteria on high-power examination of such a specimen is presumptive evidence of infection. Although patients with COPD may be colonized by Hemophilus influenzae and Streptococcus pneumoniae, these organisms should not be present in sufficient numbers to be seen on a Gram stain.

3. Sputum culture and sensitivity testing are generally not necessary but may be required if the patient is very ill or if the infection is hospital-acquired.

4. A chest film is helpful in ruling out pneumonia or other disorders.

5. Pathogens for COPD exacerbations include H. influenzae, parainfluenzae, S. pneumoniae, and Moraxella catarrhalis. Mycoplasma pneumoniae or Chlamydia may be present. Other less common pathogens are staphylococci, Neisseria, Klebsiella, and Pseudomonas.

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