Patient Care and Monitoring

1. Assess the patient's symptoms and history of exposure to risk factors. For new patients, obtain a detailed medical history including:

• Medical conditions, especially history of respiratory disorders

• Immunization status (pneumococcal and influenza)

• Family history of COPD or other chronic respiratory disease

• History of exacerbations or previous hospitalizations for respiratory disorders

• Impact of disease on the patient's life, including limitation of activity, missed work, and feelings of depression or anxiety

2. Obtain spirometry measurements to assess airflow limitation and aid in severity classification and treatment decisions. Measure arterial blood gases if FEVi is less than 40% predicted or if the patient has clinical signs suggestive of respiratory failure or right heart failure.

3. Obtain a thorough history of prescription, nonprescription, and dietary supplement use. Assess inhaler technique and adherence to the medication regimen. Ask the patient about effectiveness of medications at controlling symptoms and adverse effects.

4. Ask current tobacco users about daily quantity, past quit attempts, and current readiness to quit.

5. Design a therapeutic plan including lifestyle modifications (e.g., smoking cessation) and optimal drug therapy. Consider need for pulmonary rehabilitation, oxygen therapy, and/or surgery.

6. Provide patient education about the disease state and therapeutic plan:

• What COPD is, and what its natural course is like

• Smoking cessation counseling

• Role of regular exercise and healthy eating

• How and when to take medications; importance of adherence to the medication plan; adverse effects and how to minimize them

• Signs and symptoms of an exacerbation and what to do if one occurs

• Advanced directives and end-of-life issues for patients with more severe disease

7. Determine the follow-up period based on patient status and needs (typically 3-6 months).

8. Follow-up visits should include:

• Assessment of tobacco use and/or quit attempts

• Assessment of change in symptoms. Obtain spirometry if there is a substantial increase in symptoms or a complication

• Review of drug therapy (dosages, adherence, inhaler technique, effectiveness, adverse effects, and drug interactions)

• Evaluation of exacerbation frequency, severity, and likely causes

9. Perform spirometry at least annually to assess disease progression.

10. Provide annual influenza vaccination.

11. Assess inhaler technique at every visit. Have the patient demonstrate proper use of each device using a placebo inhaler or personal inhaler. Proper use of these devices is critical for therapeutic success.

Abbreviations Introduced in This Chapter




Arterial blood


A mcrica o T horaci c S ocie I y


Hotly mass index


Cyclic adenosine monophosphate


Chronic obsl rue live pulmonary disease


Extraocular movements imact


1 vii ropea n Re$pi ra (ory Sei tlety


Forced expiratory volume in 1 second


Forced vital capacity


Global Initiative for Chronic Obstructive l ung



Jugular venous distention


Self-assessment questions and answers are available at ht-tp://www. mhpharmacotherapy. com/pp.html.

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