New treatments for early and late COPD. Part 2: Drug and nondrug therapies

Bronchodilators, preferably inhaled, are reconanended for all patients with chronic obstructive pulmonary disease; ipratropium, with a 6- to 8-hour duration of action, is effective maintenance therapy. Tiotropium is currently being reviewed by the FDA for release in the United States; its once-daily dosing schedule may facilitate adherence. Criteria for long-term oxygen therapy are severe hypoxemio (PaO 2 , 55 mm Hg or lower) or a PaO 2 of 60 mm Hg or lower with signs of cor pulmonale or secondary polycythemia (hematocrit higher than 55%). When symptoms are disabling despite optimal medical management, referred for pulmonary rehabilitation is the next step. Patients with upper lobe-predoiminant emphysema and low exercise capacity may benefit most from lung volume redaction surgery. Consider transplantation if the patient has severe lung disease that is refractory to medical therapy and survival is expected to be less than 2 to 3 years.