Patients in GOLD groups C and D should be prescribed a long-acting anticholinergic or a combination of an inhaled corticosteroid and long-acting beta 2 agonist. 3 Compared with tiotropium alone, fluticasone/salmeterol (Advair) improved daily symptom scores and decreased mortality (number needed to treat = 40), but increased the incidence of pneumonia (number needed to harm = 25) and did not change the rate of exacerbations. 33 Patients with poorly controlled symptoms should start triple therapy with an inhaled corticosteroid, long-acting anticholinergic, and long-acting beta 2 agonist. The data for triple therapy are inconsistent, with studies showing improvement in lung function and symptom scores but conflicting results regarding reduction in exacerbation rates compared with tiotropium alone. 28 , 34 A summary of initial treatment options and common medications is presented in Table 4 8 and Table 5 , 35 and patient instructions for inhaler use are reviewed in eFigure B .
To apply foam, invert canister; dispense a small amount (up to a maximum of a golf-ball-sized dollop or 1 1/2 capfuls) of foam into the cap of the canister, onto cool surface (., saucer), or directly on the lesion, taking care to avoid contact with the eyes. 88 Foam will begin to melt immediately upon contact with warm skin; do not dispense directly onto hands (unless the hands are the affected area). 88 If the canister seems warm to the touch or the foam seems runny, place the canister under cold running tap water. 88 Using clean, dry fingertips, gently massage foam into the affected area; repeat until the entire affected area has been treated. 88 Avoid exposure to flames or smoking during and immediately after application. 88