What are the steps for medical management of Chronic Obstructive Pulmonary Disease (COPD)?

Medical Management of COPD: A Stepwise Approach

The medical management of COPD should follow a stepwise approach based on disease severity, symptom burden, and exacerbation risk, with smoking cessation as the primary intervention across all stages to slow disease progression and improve outcomes. 1, 2

Initial Assessment and Classification

• Confirm COPD diagnosis with post-bronchodilator spirometry showing FEV1/FVC < 0.7 2
• Assess symptom burden using validated tools (CAT or mMRC dyspnea scale) 2
• Evaluate exacerbation history (frequency and severity) 2
• Categorize patients according to the GOLD ABCD assessment tool based on symptoms and exacerbation risk 1, 2
• Consider chest radiograph to exclude other pathologies 1
• Estimate arterial blood gas tensions in severe COPD to identify persistent hypoxemia 1

Non-Pharmacological Interventions

For All COPD Patients:

• Smoking cessation - highest priority intervention to reduce rate of lung function decline 1, 2

  • Provide explanation of smoking effects and benefits of stopping
  • Consider nicotine replacement therapy (gum or transdermal) and behavioral support
  • Multiple attempts may be needed; abrupt cessation is most successful 1

• Vaccinations

  • Annual influenza vaccination 1, 2
  • Pneumococcal vaccinations (PCV13 and PPSV23) for patients >65 years or with significant comorbidities 2

• Physical activity

  • Encourage regular exercise for all patients 1
  • Consider pulmonary rehabilitation for patients with moderate to severe disease 1, 2

• Self-management education

  • Provide basic information about COPD
  • Teach strategies to minimize dyspnea
  • Advise on when to seek help 1

Pharmacological Management by Disease Severity

Group A (Low Symptoms, Low Risk):

• Short-acting bronchodilator (SABA or SAMA) as needed 1, 2
• Consider long-acting bronchodilator if symptoms persist 1, 2

Group B (High Symptoms, Low Risk):

• Long-acting bronchodilator (LAMA preferred over LABA) 1, 2
• Consider dual bronchodilation (LAMA + LABA) if persistent symptoms 1, 3

Group C (Low Symptoms, High Risk):

• LAMA as first choice (better than LABA for exacerbation prevention) 1, 2
• Consider roflumilast if FEV1 < 50% predicted and patient has chronic bronchitis 1

Group D (High Symptoms, High Risk):

• Start with LAMA or LAMA+LABA 1
• Consider triple therapy (LABA/LAMA/ICS) for patients with continued exacerbations and high blood eosinophils 1, 2, 3
• Consider macrolide (in former smokers) for frequent exacerbations 1

Management of Exacerbations

• Antibiotics for purulent sputum (7-14 day course) 1
  • Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
  • First-line options: amoxicillin, tetracycline derivatives, amoxicillin/clavulanic acid
  • Consider local resistance patterns when selecting therapy 1
• Culture sputum when response to initial therapy is poor 1

Advanced Disease Management

Oxygen Therapy

• Long-term oxygen therapy indicated for:
  • PaO2 ≤ 55 mmHg (7.3 kPa) or SaO2 ≤ 88%, confirmed twice over 3 weeks 1
  • PaO2 between 55-60 mmHg with evidence of pulmonary hypertension, peripheral edema, or polycythemia 1

Surgical Options

• Consider lung volume reduction procedures in selected patients with severe hyperinflation 1, 2
• Consider lung transplantation for very severe COPD without contraindications 1

Monitoring and Follow-up

• Regularly assess symptoms, exacerbation frequency, and inhaler technique 2
• Monitor for common pitfalls:
  • Inadequate inhaler technique (check and correct regularly) 2
  • Overuse of inhaled corticosteroids in patients without exacerbations (increases pneumonia risk) 2
  • Undertreatment of comorbidities that can worsen COPD outcomes 2

Important Cautions

• Long-acting bronchodilators are not indicated for relief of acute symptoms 4, 5
• Formoterol and salmeterol should not be used as monotherapy in patients with asthma 4, 5
• Monitor for development of pneumonia in patients using inhaled corticosteroids 5
• Consider de-escalation of ICS in patients without exacerbations and low eosinophil counts 2

By following this stepwise approach to COPD management, clinicians can effectively address both symptoms and exacerbation risk while improving patients' quality of life and potentially slowing disease progression.