Short- and Long-term Monitoring
COPD worsens over time, so routine follow up and monitoring is essential. Perform spirometry yearly to identify patients who are experiencing a rapid decline. Ask specific questions about the patient’s well-being (e.g., by using a questionnaire such as the COPD Assessment Test) every three months. Assess symptoms (e.g., cough, sputum production, dyspnea, limitations of activity, and sleep disturbances) and smoking status at every visit. Exacerbation Management and Lung Function Smoking cessation is key for all patients who smoke and have COPD. Medications are used to reduce symptoms, reduce the frequency and severity of exacerbations, and improve exercise tolerance. Long-acting formulations are preferred. Current medications for COPD have not been shown to lessen the long-term decline in lung function. The most common cause of COPD exacerbations is viral or bacterial infection. The medication classes most commonly used to manage exacerbations are bronchodilators, steroids, and antibiotics. Short-acting β2 -agonists are preferred in the acute setting. Systemic steroids may shorten recovery time, improve FEV1, and improve hypoxemia, but long-term management of COPD with oral steroid medicines is not recommended due to steroid myopathy. An as-needed short acting β2 -agonist (SABA) alone is considered the first step in treatment for asthma. Regular, daily, low-dose ICS treatment, plus an asneeded SABA, is highly effective to reduce asthmarelated exacerbations, symptoms, hospitalizations, and mortality. For patients whose symptoms and/ or exacerbations persist in spite of management with low-dose ICS, plus an as needed SABA, a step up in treatment should be considered. However, patients should first be asked about treatment adherence, inhaler techniques, comorbidities, and level of exposure to allergens. Dual Bronchodilation For COPD, initial treatment should provide appropriate management of symptoms with bronchodilators or combination therapy, but not with ICS alone. Asthma should be managed with suitable controller therapy, including ICS, but not with long-acting bronchodilators alone. Bronchodilators increase FEV1 by alternating smooth muscle tone. The two classes of bronchodilators are β2 -agonists and anticholinergics. More recently, a combination of the long-acting anticholinergic umeclidinium and the long-acting β2 -agonist vilanterol became available in a once-daily inhaled preparation. Additionally, there are combinations of a longacting bronchodilator and anticholinergic, as well as long-acting anti muscarinic agents (LAMAs) on the market and in development.