What is the management of Chronic Obstructive Pulmonary Disease (COPD)?

Management of Chronic Obstructive Pulmonary Disease (COPD)

COPD management requires a structured approach based on disease severity, symptoms, and exacerbation history, with bronchodilators as the central pharmacologic treatment and smoking cessation as the primary intervention to modify disease progression.

Diagnosis and Assessment

• COPD is diagnosed by spirometry showing post-bronchodilator FEV1/FVC ratio <0.70 in clinically stable patients 1
• Assessment should determine:
  • Severity of airflow limitation (spirometry)
  • Impact of symptoms on daily life
  • Risk of exacerbations
  • Presence of comorbidities

Non-Pharmacological Interventions

Smoking Cessation

• Must be prioritized at all stages of disease as it's the only intervention proven to modify long-term decline in lung function 2
• Benefits include:
  • Reduced symptoms
  • Decreased exacerbation frequency
  • Improved health status
  • Reduced mortality

Vaccinations

• Influenza and pneumococcal vaccinations recommended for all COPD patients 1

Pulmonary Rehabilitation

• Should be offered to all patients with dyspnea, exercise intolerance, or activity limitations despite optimal pharmacotherapy 2
• Components include:
  • Exercise training (strength and endurance)
  • Educational support
  • Nutritional counseling
  • Psychosocial support
• Benefits:
  • Improved exercise capacity
  • Enhanced social reintegration
  • Increased autonomy
  • Reduced healthcare costs through fewer exacerbations and hospitalizations 2

Pharmacological Management

Bronchodilators

• Central to COPD pharmacological management 2

• Short-acting bronchodilators:

  • Used for mild intermittent symptoms (Group A patients) 1
  • Options include short-acting anticholinergics or short-acting beta2-agonists

• Long-acting bronchodilators:

  • Indicated as maintenance treatment when symptoms persist despite regular use of short-acting agents 2
  • Reduce exacerbation rate
  • Options include:
    • Long-acting anticholinergics (LAMA)
    • Long-acting beta2-agonists (LABA)
  • Choice between LAMA and LABA depends on patient's perception of symptom relief 2
  • Dual bronchodilation (LAMA + LABA) maximizes bronchodilation and significantly reduces exacerbations 3

Inhaled Corticosteroids (ICS)

• Only indicated in combination with LABA for:
  • Severe COPD with history of repeated exacerbations
  • Significant symptoms despite optimal bronchodilator therapy 2
• ICS + LABA reduces exacerbation rate 2
• Consider triple therapy (ICS + LABA + LAMA) for patients whose symptoms are not controlled with dual therapy 1

Oxygen Therapy

• Continuous oxygen therapy improves mortality in patients with severe hypoxemia (SpO2 <89%) 1, 4

Management Based on GOLD Classification

1. Group A (Low symptoms, Low risk):

   • Short-acting anticholinergic or short-acting beta2-agonist for intermittent symptoms 1

2. Group B (High symptoms, Low risk):

   • Long-acting anticholinergics or long-acting beta2-agonists 1
   • Consider pulmonary rehabilitation 1

3. Group C (Low symptoms, High risk):

   • Long-acting anticholinergic or ICS + LABA combination 1
   • Consider pulmonary rehabilitation 1

4. Group D (High symptoms, High risk):

   • Long-acting anticholinergic or ICS + LABA combination 1
   • Consider triple therapy if symptoms persist
   • Pulmonary rehabilitation strongly recommended 1

Exacerbation Management

Home Treatment of Mild Exacerbations

• Add or increase bronchodilators 5
• Prescribe antibiotics if two or more of the following are present:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 5
• Consider short course of corticosteroids (0.4-0.6 mg/kg daily) if marked wheeze is present 5
• Encourage:
  • Sputum clearance by coughing
  • Fluid intake
  • Home physiotherapy when appropriate 5
• Avoid sedatives and hypnotics 5
• Reassess within 48 hours 5

Hospital Management of Severe Exacerbations

• Increase dose/frequency of bronchodilators or combine beta2-agonist and anticholinergic 5
• Use air-driven nebulizers with supplemental oxygen by nasal cannulae
• Administer corticosteroids (oral or IV)
• Provide antibiotics (oral or IV)
• Consider subcutaneous heparin
• Monitor fluid balance and nutrition 5

Follow-up Care

• After home treatment: If patient deteriorates, reassess and consider hospital treatment
• After hospital discharge (4-6 weeks):
  • Assess patient's ability to cope
  • Measure FEV1
  • Reassess inhaler technique and understanding of treatment regimen
  • Evaluate need for LTOT and/or home nebulizer usage in severe COPD 5

Special Considerations

Air Travel

• Patients with chronic hypoxemia or borderline PaO2 (≤9.3 kPa/70 mmHg) may become more hypoxemic during air travel
• Consider testing to determine supplemental oxygen needs
• Relative contraindications to air travel include:
  • Current bronchospasm
  • Severe dyspnea
  • Severe anemia
  • Unstable cardiac disorders
  • Severely impaired pulmonary function 5

Surgical Options

• Lung volume reduction surgery can improve survival in patients with severe, upper lobe-predominant COPD with heterogeneous emphysema 1
• Bullectomy via thoracostomy or sternotomy can improve lung function in selected patients with large air cysts 5
• Lung transplantation may benefit patients <65 years with very poor exercise tolerance and lung function 5

Common Pitfalls to Avoid

• Underutilization of pulmonary rehabilitation despite proven benefits 4
• Inappropriate use of inhaled corticosteroids in patients without frequent exacerbations
• Failure to regularly assess and correct inhaler technique
• Not addressing comorbidities that contribute to symptoms and exacerbations 6
• Neglecting psychological symptoms which are highly prevalent in COPD 6