Most patients with moderate to very severe COPD will benefit from a pulmonary rehabilitation program, which typically includes measures to reverse exercise de-conditioning, optimize psychological well-being, and maintain weight and muscle mass. Such programs have been found helpful in inpatient, outpatient, and home settings.
Exercise training programs appear to be of particular benefit. Evidence shows that these regimens improve exercise tolerance and reduce dyspnea and fatigue.
Long-term supplemental oxygen can improve survival, exercise capacity, lung function, and mental state in patients with very severe disease and chronic respiratory failure.
Symptoms that worsen beyond normal day-to-day variation to the extent that medical management must be changed represent an exacerbation and demand close attention. The most common causes of worsening symptoms are lower-respiratory infection and air pollution.
Adjustments in bronchodilator therapy, short-term systemic glucocorticosteroids, and antibiotics are likely to have a role in managing exacerbations. But while some episodes can be cared for at home, the threshold for a hospital assessment should be low, according to Dr. Anzueto. “COPD can be a lethal disease, and there is little room for error.”
The GOLD guidelines urge hospital assessment when the worsening of symptoms (particularly dyspnea) is marked; new physical signs (i.e., cyanosis or peripheral edema) or arrhythmias emerge; or the episode does not respond to initial medical management.
Older patients and those who have significant comorbidity or a history of frequent exacerbations should go to the hospital sooner rather than later.
It may take several weeks after an exacerbation for patients to recover function fully and for symptoms to return to their prior level. Follow-up should include an assessment four to six weeks after hospital discharge.
If the episode included hypoxemia, arterial gases should be monitored for the following three months and supplemental oxygen considered. Adjustments in pharmacotherapy and lifestyle (e.g., reducing exposure to lung irritants) should be made with an eye toward preventing future episodes.
The GOLD Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease is available online.