A patient has stage 2 chronic obstructive pulmonary disease. How should the appointment be managed?

Correct answer: A. Schedule short, early-morning appointments with the patient seated upright

• A. CORRECT. Short appointments limit fatigue, morning scheduling avoids the accumulation of secretions and the fatigue that builds through the day, and an upright or semi-supine position is essential because a fully supine position compromises diaphragmatic excursion and worsens dyspnoea.
• B. Supine positioning is exactly what these patients cannot tolerate.
• C. Opioids and other respiratory depressants — including benzodiazepines and barbiturates — should be avoided or used with great caution in COPD.
• D. High-flow oxygen is specifically avoided in patients with severe COPD who retain carbon dioxide, since their respiratory drive may be hypoxic. Low-flow supplemental oxygen at 2 to 3 L/min is the appropriate approach if oxygen is needed at all.

Note: Additional considerations: ask the patient to bring their rescue inhaler and use it before the appointment; avoid the rubber dam if it worsens their breathing, or use a nasal hood carefully; avoid nitrous oxide in severe disease; and remember that many COPD patients are on theophylline, which interacts with erythromycin and ciprofloxacin, and on chronic corticosteroids, which raises adrenal suppression and candidiasis considerations.