THERAPEUTIC ALGORITHM FOR CHRONIC OBSTRUCTIVE PULMONARY-DISEASE

It would be foolhardy to offer an inflexible step-care protocol for the management of chronic obstructive pulmonary disease, given its heterogeneity and our uncertainty about its pathogenesis. Instead, the following outline might be regarded as a statement of principles to guide individual treatment plans. Smoking cessation is an essential, if difficult, first step, which is necessary to slow the accelerated rate of decline in pulmonary function that is characteristic of this disease. There is a compelling rationale for the use of influenza and pneumococcal vaccination, although proof of efficacy is lacking. If airways obstruction is present, inhaled quaternary anticholinergic bronchodilators seem to offer the greatest benefit with fewest side effects, making them the obvious first choice in bronchodilator therapy. In some patients, the addition of beta-agonists, theophylline, or both may augment bronchodilation. If significant airways obstruction persists despite the foregoing, an oral steroid trial is required. Some carefully selected patients whose exercise capacity has been limited despite optimal medical therapy may respond to a supervised exercise rehabilitation program. If hypoxemia is present, supplemental oxygen improves survival. Additional therapeutic modalities, ranging from preventive antioxidant administration to lung transplantation, remain investigational.