Answers

Short answers

1 Increasing breathlessness is a feature of the inexorable progression of chronic obstructive pulmonary disease, especially in patients who continue to smoke. Other common comorbidities need to be considered—especially heart failure and lung cancer.

2 Although she has moderate COPD, she is not having frequent exacerbations so is unlikely to benefit from inhaled steroids. Reverting to her previous treatment of a long acting β agonist and adding a long acting anticholinergic might be a better option.

3 Pulmonary rehabilitation could improve her exercise tolerance. Consider the possibility of depression, which is common in people with COPD.

Long answers
Increasing breathlessness
Assess progression of the disease. Breathlessness is a primary symptom of COPD and gets worse as the disease progresses.^{1 2} Comparison with previous readings showed that the FEV₁ at diagnosis, about five years before, had been 1.71 litres: an average loss of 53 ml/year. People with moderate COPD lose up to 60 ml per year,^{3 4} and a loss of more than 500 ml over five years suggests rapid progression of disease, which would warrant specialist referral for further investigation.¹ Although severity is assessed on the basis of post-bronchodilator FEV₁,^{1 2} lung function does not correlate well with functional disability,^{5 6 7} and it is important to make specific enquiry about symptoms such as breathlessness and impact on activities.⁸

Review smoking status. Apart from the general health benefits of smoking cessation, quitting is the only intervention that will significantly affect the prognosis.⁹ The patient’s quit attempt last year was the most successful to date and she had not smoked for nearly five months when she relapsed during the stress of a family crisis. Most smokers make several attempts to quit before finally succeeding, and she should be offered further advice and support.^{10 11 12} Her increasing disability and the impact this is having on her work may be useful in motivating another quit attempt. Practical guidance on supporting smoking cessation is available from the International Primary Care Respiratory Group (www.theipcrg.org/smoking/index.php).

Consider other causes for her increasing breathlessness. Smoking is a risk factor for lung cancer and ischaemic heart disease, and these comorbidities are common in people with COPD.^{2 13} A reduced FEV₁ is an independent risk factor for lung cancer, especially in women.¹⁴ Only a third of patients with severe COPD will die of respiratory causes: heart failure and cancer are each responsible for about a quarter of deaths.¹⁵ A full blood count would exclude anaemia as a cause of breathlessness. If the patient is overweight dietary advice would be appropriate, while a recent loss of weight would prompt investigation for underlying causes. Her general fitness will also affect breathlessness, and she should be advised that exercise is safe and may help to reverse or prevent the physical deconditioning that is associated with exercise limitation in people with COPD.^{1 2}

Treatment
Inhaled steroids do not reduce the rate of decline of lung function in COPD.^{1 2 3 9 16 17} They can, however, reduce the number of exacerbations from 1.32 per year to 0.99 per year,³ though the effect is significant only in patients with moderate or severe COPD (FEV₁ <50% of predicted). This is clinically meaningful only if patients are experiencing two or more exacerbations each year.^{1 2} Some patients with COPD need courses of oral corticosteroids or antibiotics several times a year, but others rarely have exacerbations.^{3 18} Although this patient has moderate COPD (FEV₁=40% predicted), she had had only two exacerbations over five years, so inhaled steroids are unlikely to be of benefit.¹⁷ Despite this, withdrawal of inhaled steroids should be monitored carefully as about a third of patients from a primary care population will experience worsening of symptoms on stopping treatment—especially women, older patients, and those on higher dose therapy.²⁰

The hope that the effect of inhaled steroids on exacerbations might result in a reduction in mortality has been explored in a four arm randomised controlled trial.¹⁵ The effect on mortality did not quite reach statistical significance.

If inhaled steroids had been indicated it would have been necessary to give a larger dose than had been prescribed for the patient (trials have used daily doses of 1000 µg fluticasone^{3 15}) to overcome the antagonistic effects of the smoking and steroid resistance in COPD.²¹ The patient’s concerns about side effects may therefore be justified, as trials using high dose inhaled steroids in COPD have confirmed an increase in both local effects (sore mouth, hoarseness) and systemic effects (especially bruising of the skin and loss of bone density).^{3 17 22} A recently recognised concern is the excess risk of pneumonia in patients taking inhaled steroids for COPD. Nearly 20% of the patients taking inhaled steroids in the TORCH trial had pneumonia, compared with 12% in the placebo group (number needed to harm=13 over three years).¹⁵

The mainstay of symptom relief for COPD is long acting bronchodilators, which are indicated to ameliorate symptoms.^{1 2} As she is becoming increasingly breathless it would be appropriate to offer the patient a trial of the long acting anticholinergic tiotropium in addition to her regular treatment with salmeterol. In the recent UPLIFT trial, participants using tiotropium had better lung function throughout the trial and improved quality of life, and they experienced fewer exacerbations than the control group, although the rate of decline of lung function was not affected.⁴ Apart from the anticipated occurrences of a dry mouth and constipation, side effects did not increase significantly, and serious cardiac and pulmonary adverse events were less common in the tiotropium group. Tiotropium has a long half life, and the patient should be advised that it will take several days to reach peak effect.^{1 2}

Ensuring that patients are able to use the inhalers they are prescribed is crucial to successful treatment.^{1 2} Inhaler technique should be checked regularly and a suitable device selected.²³

Other options
Dyspnoea should be assessed with a validated instrument such as the MRC (Medical Research Council) dyspnoea score.²⁴ This defines five grades of breathlessness related to normal activities and patients are asked to select the level that best describes how breathlessness affects them. The five levels are:

1 Not troubled by breathlessness except on strenuous exercise

2 Short of breath when hurrying or walking up a slight hill

3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace

4 Stops for breath after walking about 100 metres or after a few minutes on level ground

5 Too breathless to leave the house, or breathless when dressing or undressing.

Five years ago, when the diagnosis of COPD was made, the patient had assessed herself at level 2. At this review, for the first time, she acknowledged that she was no longer able to walk as fast as her colleagues even on the flat and this was becoming an important problem for her job.

• The patient should be offered pulmonary rehabilitation, which has been shown to improve exercise tolerance and enhances patients’ sense of control over their condition.^{1 2 25} Although the format, duration, and setting of pulmonary rehabilitation varies, core content includes optimisation of treatment, an exercise programme, and education. A key benefit is support and encouragement from the group. Despite the potential benefits, some patients (especially smokers and patients with poor social support) will not accept referral to, or adhere to, a course of pulmonary rehabilitation.²⁶ Offering the opportunity to discuss concerns may encourage acceptance.
  
• The threat that the increasing breathlessness poses to her job may be causing anxiety and may need to be discussed. Depression is common in patients with COPD and can contribute to a downward spiral of increasing symptoms and inability to cope.²⁶
  

Outcome of the review

Careful history and examination showed no signs of other disease, so the approach was to optimise COPD treatment to relieve the breathlessness and arrange follow-up to assess response. Relieved that the inhaled steroids were unlikely to be the best treatment for her, the patient reduced and stopped the combination inhaler and reverted to using salmeterol, without any ill effects. She started a daily dose of tiotropium, and when she was reviewed four weeks later she reported some improvement in her exercise tolerance.

After discussion, she accepted the offer of a referral to the pulmonary rehabilitation group and was delighted not only with the improvement in her well being, but with all that she learnt about her condition and the helpful management strategies.

Having completed the pulmonary rehabilitation course, she joined the local Breath-Easy group, which helped maintain her sense of well being despite her reduced lung function. Together with a friend she met at the group, she determined to make another quit attempt and six months later was still not smoking.

Cite this as: BMJ 2009;338:b70