Management Advanced Disease

• Long-term oxygen therapy (LTOT)

  • Indications

    • PaO2 ≤ 55 mm Hg or SaO2 ≤ 88% at rest despite optimal medication

    • OR PaO2 55–60 mm Hg in patients with pulmonary hypertension, CHF, or polycythemia

  • Target oxygen saturation: > 90%

  • Recommended duration: continuous oxygen therapy for ≥ 15 hours/day

  • Reevaluate after 60–90 days (with ABG or pulse oximetry).

• Ventilatory support

  • Continuous positive airway pressure is useful in patients with COPD and obstructive sleep apnea.

  • Long-term noninvasive positive-pressure ventilation may be considered in select patients with severe chronic hypercapnia.

LTOT Increases survival in patients with COPD.

• Surgical bullectomy: indicated in severe emphysema with hyperinflation and large bullae

• Lung volume reduction

  • Indicated for severe emphysema and hyperinflation without large bullae

  • Severely affected emphysematous areas of the lung are removed either surgically (lung volume reduction surgery) or endoscopically

• Lung transplantation: may be indicated for very severe COPD, patients not eligible for bullectomy or lung volume reduction, and those with surgical contraindications

Palliative measures (e.g., low-dose opiates, fans blowing onto the patient's face, or acupuncture) can be used if distressing breathlessness persists despite optimal medical therapy.