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1. Respiratory rehabilitation

2. ipratropium MDI (20 µg per puff) 40 µg, qid $15.75/200 puffs

3. If improvement is suboptimal with ipratropium, add short-acting beta-2 agonist using a metered-dose inhaler (MDI) or equivalent

salbutamol MDI (100 µg per puff)
200 µg, qid
$4.90/200 puffs

or pirbuterol (250 µg per puff)
500 µg,qid
$10.00/300 puffs

or terbutaline Turbuhaler® (500 µg per puff)
500 µg, qid
$14.30/200 puffs

4. If response is still suboptimal, add

theophylline slow release
10 mg/kg per day, divided bid, (maximum 300 mg/day); increase at 3-day intervals to16 mg/kg per day, divided bid (maximum 600 mg/day)
$0.01-0.03/kg per day

Second-line therapies:

1. Consider trial of oral corticosteroids:

prednisone
50 mg, once daily x 2 weeks
$0.70/week

2. If oral corticosteroids or high-dose inhaled corticosteroids produce an improvement in pulmonary function, consider long-term inhaled corticosteroids using an MDI or equivalent.

triamcinolone MDI (200 µg per puff)
200 µg, tid to qid
$0.20-0.27/day

or
400 µg bid
$0.27/day

or flunisolide
(250 µg per puff)
500 µg, bid
$0.64/day

or beclomethasone MDI (250 µg per puff)
500-1000 µg/day, divided bid to qid
$0.71-1.42/day

3. Consider long-acting beta-2 agonist in place of short-acting beta-2 agonists. Not to be used for acute exacerbations.

salmeterol MDI (25 µg per puff)
50 µg, bid
$1.66/day

or formoterol Aerolizer ™ (12 µg per puff)
12 µg, bid
$2.66/day

4. For exacerbations, use antibiotics

tetracycline
250 mg, qid x 7 days
$0.53/week

or trimethoprim/ sulfamethoxazole
160 mg/800 mg tablet, bid x7 days
$1.71/week

or amoxicillin
250 mg, qid x 7 days
$2.89/week

5. For PaO2 below 55 mm Hg, O2 saturation <90% or PaO2 between 55 and 59 mm Hg and evidence of cor pulmonale or polycythemia

oxygen
24 h/day, 2-4 L/minute

Additional instructions and notes

-Respiratory rehabilitation is defined as at least 4 weeks of exercise training with or without education, psychological support, or both. Respiratory rehabilitation relieves dyspnea and improves control over chronic airflow limitation. Compared with bronchodilators or oral theophylline, rehabilitation leads to a greater improvement in health-related quality of life and functional exercise capacity.

-There is little evidence of clinically important benefits from respiratory muscle training.

-Oxygen flow rates should be adjusted to keep O2 saturation between 90% and 92%.

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