What is Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

IECOPD should be treated with a combination of bronchodilators, corticosteroids, and antibiotics, prioritizing the reduction of morbidity, mortality, and improvement of quality of life. For acute management, the most recent and highest quality study 1 suggests that a comprehensive approach to COPD management is essential, including confirming a diagnosis of COPD with spirometry, evaluating symptom burden, health status, and risk of exacerbations over time.

Key Interventions

• Start with short-acting bronchodilators like albuterol (2-4 puffs every 4-6 hours) and ipratropium (2 puffs every 6 hours) to improve airflow.
• Add a 5-7 day course of oral corticosteroids such as prednisone 40mg daily to reduce airway inflammation, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.
• Antibiotic therapy should include amoxicillin-clavulanate 875/125mg twice daily, doxycycline 100mg twice daily, or azithromycin 500mg on day 1 followed by 250mg daily for 4 days, depending on local resistance patterns and patient allergies, to fight bacterial infection.
• Supplemental oxygen should be provided to maintain oxygen saturation above 88-92%, as this is crucial for preventing respiratory failure and improving outcomes.
• Patients should increase fluid intake, continue maintenance inhalers, and use airway clearance techniques to further improve symptoms and prevent complications.

Rationale

The interventions outlined above are based on the most recent and highest quality evidence, including the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1, which emphasizes the importance of a comprehensive approach to COPD management. The European Respiratory Society/American Thoracic Society guideline 1 also provides recommendations for the treatment of COPD exacerbations, including the use of oral corticosteroids and antibiotics. By prioritizing the reduction of morbidity, mortality, and improvement of quality of life, these interventions can help resolve the acute exacerbation and prevent respiratory failure.

From the Research

Definition and Treatment of COPD

• Chronic obstructive pulmonary disease (COPD) is a respiratory disorder characterized by largely irreversible changes in air flow due to irritants such as tobacco smoke 2.
• Patients with COPD experience acute exacerbations, and severe disease may progress to chronic respiratory failure.
• The first measure in COPD is to eliminate exposure to the irritant, most often tobacco 2.

Medications for COPD

• Regular medication is not necessary for patients who do not have recurrent symptoms 2.
• Inhaled short-acting beta-2 agonists, such as salmeterol and formoterol, have been shown to improve dyspnoea and reduce breathlessness and acute exacerbations 2, 3.
• Long-acting beta-2 agonists, such as salmeterol and formoterol, have been extensively evaluated in symptomatic patients and have been shown to reduce breathlessness and acute exacerbations 2, 4.
• Inhaled corticosteroids, such as fluticasone, can be added to a long-acting beta-2 agonist to prevent exacerbations in patients with a history of frequent or severe exacerbations 2, 4, 5.

Combination Therapies

• Combination of an antimuscarinic with an inhaled beta-2 agonist improves symptoms in 7% to 10% of patients 2.
• An inhaled combination therapy with a long-acting beta2-agonist and an inhaled corticosteroid appears to be effective in improving airway limitation after acute administration in patients suffering from COPD 3.
• Triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA may be recommended over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year 5.

Stepwise Management of COPD

• Treatment guidelines recommend a stepwise approach to managing COPD, with the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma 6.
• The use of add-on therapies with LABA/LAMA for different patient phenotypes, including patients still symptomatic despite LABA/LAMA treatment, patients still exacerbating despite LABA/LAMA treatment with high blood eosinophil counts, and patients still exacerbating despite LABA/LAMA treatment without high blood eosinophils or concomitant asthma 6.