Approach to patients with COPD and persistent dyspnea despite inhaled therapies

6MWD: six-minute walk distance; 6MWT: six-minute walk test; ABG: arterial blood gas; BMI: body mass index; COPD: chronic obstructive pulmonary disease; echo: echocardiography (ie, cardiac ultrasound); FEV₁: forced expiratory volume in one second; HgB: blood hemoglobin level; HRCT: high-resolution computed tomography; ICS: inhaled glucocorticoid (aka inhaled corticosteroid); LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; mMRC: modified Medical Research council; PaCO₂: arterial partial pressure of carbon dioxide; PaO₂: arterial partial pressure of oxygen; PAP: positive airway pressure; PASP: pulmonary artery systolic pressure; PFTs: pulmonary function tests; PH: pulmonary hypertension; RV: residual volume; SpO₂: hemoglobin oxygen saturation, as assessed by pulse oximetry; TLC: total lung capacity.

* Palliative approaches may be used to manage refractory breathlessness, cough, fatigue, weakness, anxiety, and depression arising from refractory lung disease. Palliative care does not necessitate specialist referral, hospice referral, or limit additional interventions such as lung volume reduction or lung transplantation. Regardless of referral to palliative specialist for symptom management, advanced care planning is appropriate for patients with refractory COPD who are at risk for intensive care unit admissions, intubation, and respiratory arrest.

¶ The most appropriate procedural intervention will depend upon the details of the above work-up, anatomic features (eg, fissural integrity, emphysema distribution), and detailed discussion with the patient about the risks and benefits of the intervention. Please refer to UpToDate content on "Bronchoscopic treatment of emphysema" and "Lung volume reduction surgery in COPD" for additional details.

Δ For patients who do not want, do not qualify for, or have persistent dyspnea despite or while awaiting surgical or bronchoscopic interventions, a trial of theophylline is reasonable. When we use theophylline, we target a peak serum level of 5 to 12 mcg/mL. We initiate therapy with a total daily dose of 10 mg/kg ideal body weight per day or 300 mg per day, whichever is lower. Refer to UpToDate content and the UpToDate Lexidrug drug monograph for detail on product selection and dosing frequency. Peak levels should initially be obtained after three days on therapy, three to five days after each dose adjustment, if toxicity is suspected, or if changes to the patient's condition or medication regimen are expected to impact theophylline clearance. Assess efficacy after four to six weeks at therapeutic levels and promptly discontinue if ineffective. Refer to UpToDate content on refractory COPD for further discussion of dose titration and monitoring.