K. Consultation with a Pulmonary Specialist

One of the premises of this monograph is that the primary care physician should be able to diagnose and manage the great majority of patients with COPD throughout the course of their illness. There are several clinical circumstances, however, in which consultation with a pulmonary specialist is indicated. Patients with very severe disease accompanied by complications might best be managed in conjunction with a consultant.

Indications for Consultation

1. Particularly severe disease, including:

a. persistent dyspnea with activities of daily living despite therapy, or

b. frequent recurrent exacerbations.

Consultation on these patients may address:

• evaluation of other etiologies of dyspnea.
• review of the therapeutic regimen and recommendations for revisions or additional therapy.
• consideration of additional therapy for intractable dyspnea including possible use of codeine or narcotics (to partially blunt excessive respiratory drives).
• second opinion or discussion of advance directives, especially for subsequent severe exacerbations with acute respiratory failure, including discussion of withholding and/or withdrawing life support measures.

2. Evaluation for and initiation of maintenance oxygen therapy.

• This includes consideration of nocturnal oxygen therapy for nocturnal hypoxemia and consideration of transtracheal oxygen therapy.

3. Failure to successfully taper the patient from systemic corticosteroids.

4. Consideration of and preoperative assessment for thoracic surgery and other surgery placing the patient at high risk for pulmonary complications.

5. Failure to respond after two courses of antibiotics for an acute exacerbation.

6. Presence of severe purulent chronic bronchitis or bronchiectasis for consideration of long-term intermittent or continuous antibiotic therapy.

7 Persistent pulmonary infiltrate(s) on chest radiograph unresponsive to a course of antibiotics.

• This includes evaluation for tuberculosis, atypical mycobacterial disease, fungal disease, and lung cancer.

8. Evaluation of sleep disturbances, including suspected obstructive sleep apnea.

9. Management of severe acute respiratory failure. ¦ This is particularly indicated if treatment with mechanical ventilation is a consideration.

10 . Cor pulmonale with clinical right heart failure that is unresponsive to usual therapy.

11 . Consideration of new techniques in lung volume reduction surgery.

12. Consideration for alpha-1- antitrypsin (Prolastin ®) augmentation therapy.