page194
Indacaterol (section 3.1.1.1) is a long-acting beta
2
ago-
nist licensed for the maintenance treatment of chronic
obstructive pulmonary disease.
In patients with severe chronic obstructive pulmonary
disease associated with chronic bronchitis and a history
of frequent exacerbations, roflumilast (section 3.3.3) is
licensed as an adjunct to existing bronchodilator treat-
ment.
A mucolytic drug (section 3.7) may be considered for a
patient with a chronic productive cough.
Long-term oxygen therapy (section 3.6) prolongs survi-
val
in patients with severe chronic obstructive pulm-
onary disease and hypoxaemia.
During an exacerbation of
chronic obstructive pulm-
onary disease,
bronchodilator therapy can be adminis-
tered through a nebuliser if necessary and oxygen given
if
appropriate.
Aminophylline can be given intrave-
nously
if
response
to nebulised bronchodilators
is
poor.
A short
course of
oral
corticosteroid (section
6.3.2),
such as prednisolone 30 mg daily for 7–14 days,
should be given if
increased breathlessness interferes
with daily activities.
Antibacterial
treatment (Table 1,
section 5.1) is required when sputum becomes purulent
or if there are other signs of infection.
Patients who have had an episode of hypercapnic resp-
iratory failure should be given a 24% or 28% Venturi
mask and an
oxygen alert
card
(see below)
endorsed
with the oxygen saturations required during previous
exacerbations.
Patients
and their
carers
should be
instructed to show the card to emergency healthcare
providers
in the event
of
an exacerbation,
see also
section 3.6.
Oxygen alert card
Name: ________________________________
I am at risk of type II respiratory failure with a raised CO
2
level.
Please use my ____% Venturi mask to achieve an
oxygen saturation of _____% to _____% during
exacerbations.
Use compressed air to drive nebulisers (with nasal oxygen
at 2 litres/minute). If compressed air not available,
limit
oxygen-driven nebulisers to 6 minutes.
Oxygen alert card based on British Thoracic Society guideline
for emergency oxygen use in adult patients (October 2008);
available at
www.brit-thoracic.org.uk
Croup
Mild croup is largely self-limiting,
but treatment with a
single dose of
a corticosteroid (e.g.
dexamethasone
150 micrograms/kg) by mouth may be of benefit.
Use of inhaled therapies in chronic obstructive pulmonary disease
Breathlessness and exercise limitation
Short-acting beta
2
agonist as required
(may continue at all stages)
or
short-acting muscarinic antagonist
as required
Exacerbations or
persistent breathlessness
FEV
1
>
50%
FEV
1
< 50%
Long-acting
beta
2
agonist
Long-acting
muscarinic antagonist
Discontinue
short-acting muscarinic antagonist
Offer long-acting muscarinic
antagonist in preference to regular
short-acting muscarinic antagonist
four times a day
Long-acting beta
2
agonist
plus
inhaled corticosteroid
in a combination inhaler
Consider long-acting beta
2
agonist plus
long-acting muscarinic antagonist if
inhaled corticosteroid declined
or not tolerated
Long-acting
muscarinic antagonist
Discontinue
short-acting muscarinic antagonist
Offer long-acting muscarinic
antagonist in preference to regular
short-acting muscarinic antagonist
four times a day
Persistent exacerbations
or breathlessness
Long-acting beta
2
agonist
plus
inhaled corticosteroid
in a combination inhaler
Consider long-acting beta
2
agonist plus
long-acting muscarinic antagonist if
inhaled corticosteroid declined
or not tolerated
Long-acting
muscarinic antagonist
plus
long-acting beta
2
agonist
plus
inhaled corticosteroid
in a combination inhaler
Advice on the use of inhaled therapies in chronic obstructive pulmonary disease is based on the recommendations of the National Institute for Health and Clinical
Excellence (2010). Management of chronic obstructive pulmonary disease in adults in primary and secondary care. London: NICE.
Available from www.nice.org.uk/CG101 Reproduced with permission
Offer therapy (strong evidence)
Consider therapy (less strong evidence)
174
3.1 Bronchodilators
BNF 61
3
Respiratory system