Patient I

The following is a patient described in New England Journal of Medicine, 2010; 362:1407-1416.

A 67-year-old man presents with a history of dyspnea, which has progressed for the past several years. He began smoking cigarettes at 15 years of age and continues to smoke one pack per day. Worsening breathlessness forced him to retire as a laborer, and he has sought emergency care for what he calls bronchitis twice in the past year. His physical examination is notable for diminished breath sounds on auscultation, with a prolonged expiratory phase.

Spirometry reveals a ratio of forced expiratory volume in 1 second [FEV1] to forced vital capacity [FVC] of 0.43, with the FEV1 34% of the predicted value).

QUESTION: Why is the prolonged expiratory phase of ventilation significant?


QUESTION: Based on the spirometry, would you rate this mild, moderate or severe?


QUESTION: When is an inhaled cholinergic antagonist used in COPD?


The patient has typical clinical manifestations of advanced COPD, with severe airflow obstruction confirmed by spirometry. Education is important during the patient's initial visit to the doctor, including information about the signs and symptoms of a severe exacerbation and the need for prompt treatment.

Smoking cessation is the most important element in the management of his disease and should be addressed at every visit, as long as the patient continues to smoke.

Many patients of this type have been on an an inhaled long-acting beta2-agonist (LABA) and plus an inhaled corticosteroid, or alternately on a long acting anticholinergic (LAMA). But according to the results of a trial published last year (NEJM, June 9, 2016), because he has had recent exacerbations, it would be better to treat him with the LABA indacaterol plus the LAMA glycopyrronium. A short-acting bronchodilator would be provided for rescue use.

Even if symptoms do not abate, he should be urged to continue taking the medications, because they reduce the risk of a severe exacerbation. Like all patients, he should receive instruction in inhaler technique.

If the patient's arterial oxygen saturation is 88% or lower at rest in a stable clinical state, long-term oxygen therapy should be prescribed and used for at least 18 hours each day.

In the absence of a contraindication, he should receive influenza vaccination each autumn, as well as pneumococcal vaccination (with revaccination as needed). Pulmonary rehabilitation should be considered if it is accessible to the patient and if he has no medical contraindications.

QUESTION: What does the "M" in LAMA stand for?


QUESTION: If he becomes stable, and he doesn't feel the LABA and LAMA are making him feel any better, why should he keep taking them?