How to manage Chronic Obstructive Pulmonary Disease (COPD)?

Comprehensive Management of COPD

The management of COPD requires a structured approach based on disease severity, with pharmacological therapy including bronchodilators as first-line treatment, supplemented by non-pharmacological interventions such as smoking cessation, pulmonary rehabilitation, and appropriate vaccinations.

Diagnosis and Assessment

• Confirm COPD diagnosis with post-bronchodilator spirometry showing FEV1/FVC < 0.7 1
• Assess symptom burden using validated tools like COPD Assessment Test (CAT) or Modified Medical Research Council (mMRC) dyspnea scale 1
• Categorize patients according to GOLD ABCD assessment tool based on symptoms and exacerbation risk 1
• Obtain chest radiograph to exclude other pathologies 2
• Estimate arterial blood gas tensions in severe COPD to identify persistent hypoxemia 2

Pharmacological Management by Disease Severity

Mild COPD

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed for symptom relief 2
• Discontinue if ineffective 2

Moderate COPD

• Regular inhaled bronchodilators for symptomatic patients 2
• Most patients can be controlled on a single drug, though some may need combination treatment 2
• Consider a corticosteroid trial in all patients 2

Severe COPD

• Combination therapy with regular β2-agonist and anticholinergic bronchodilators 2, 1
• Consider adding theophyllines with careful monitoring for side effects 2
• Consider a corticosteroid trial 2
• Assess for home nebulizer therapy according to BTS guidelines 2
• For patients with history of exacerbations, consider LABA/ICS combination such as salmeterol/fluticasone (Wixela Inhub 250/50) twice daily 3

Important Medication Considerations

• Optimize inhaler technique and select appropriate delivery device 2
• Tiotropium (LAMA) is more effective than salmeterol (LABA) in preventing exacerbations in moderate-to-very-severe COPD 4
• Triple therapy (LABA/LAMA/ICS) for patients with continued exacerbations and high blood eosinophils 1
• Consider roflumilast if FEV1 < 50% predicted and patient has chronic bronchitis 1

Non-Pharmacological Interventions

Smoking Cessation

• Smoking cessation is essential at all stages of disease and is the only intervention proven to reduce disease progression 2, 1, 5
• Participation in active smoking cessation programs leads to higher sustained quit rates, especially with nicotine replacement therapy 2

Pulmonary Rehabilitation

• Recommended for moderate to severe disease 2, 1
• Improves exercise performance and reduces breathlessness 2, 1
• Should include aerobic conditioning, strength training, educational lectures, nutritional interventions, and psychosocial support 1

Oxygen Therapy

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 2
• Indicated for patients with PaO2 ≤ 55 mmHg or SaO2 ≤ 88%, confirmed twice over 3 weeks 1
• Should only be prescribed if objectively demonstrated hypoxia (PaO2 <7.3 kPa) or high cylinder use (more than two per week) 2

Other Important Interventions

• Annual influenza vaccination recommended, especially for moderate to severe disease 2, 1
• Consider pneumococcal vaccination 1
• Encourage exercise within limitations of airways obstruction 2
• Address nutritional status - weight reduction for obese patients, nutritional support for malnourished patients 2

Management of Exacerbations

• Antibiotics recommended for patients with purulent sputum (7-14 day course) 1
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1
• First-line antibiotic options include amoxicillin, tetracycline derivatives, and amoxicillin/clavulanic acid 1
• Maximizing bronchodilation through appropriate maintenance therapy can significantly reduce exacerbations 6

Surgical Options for Selected Patients

• Consider lung volume reduction procedures in selected patients with severe hyperinflation 1
• Bullectomy may improve pulmonary function in patients with large air cysts 1
• Consider lung transplantation for very severe COPD without contraindications 1

Follow-up and Monitoring

• Regularly assess symptoms, exacerbation frequency, and inhaler technique 1
• Address comorbidities such as cardiovascular disease, depression, and osteoporosis 1
• Consider palliative care approaches for symptom management in advanced disease 1

Common Pitfalls to Avoid

• Relying solely on subjective improvement after corticosteroid trial (objective improvement seen in only 10-20% of cases) 2
• Prescribing home nebulizer treatment without proper assessment 2
• Using prophylactic antibiotics continuously or intermittently 2
• Failing to optimize inhaler technique before changing or modifying treatment 2
• Using high-dose bronchodilator therapy without formal assessment 2