Inhaled corticosteroids for chronic obstructive pulmonary disease

A 65 year old female former smoker presents to your practice with gradually worsening shortness of breath while walking up a flight of stairs and a daily cough, productive of small amounts of white phlegm. She has a smoking history of 20 cigarettes a day for 20 years and chronic obstructive pulmonary disease (COPD). Her breathlessness had gradually worsened since an influenza-like illness six months ago, which was treated with a two week course of oral prednisolone and antibiotics. Since the illness she has used inhaled tiotropium 18 µg once daily and inhaled salbutamol as needed. Spirometry at the general practice shows a forced expiratory volume in one second (FEV₁) of 63% predicted and a ratio of FEV₁ to forced vital capacity of 0.65 after use of a bronchodilator. These values have not changed significantly over the previous year. As she is still symptomatic, her general practitioner recommends stopping tiotropium and starting a combination inhaler of a corticosteroid and a long acting β₂ agonist.