COPD Management Strategies
The cornerstone of COPD management includes smoking cessation, bronchodilator therapy (starting with short-acting agents and progressing to long-acting bronchodilators), pulmonary rehabilitation, and appropriate vaccination, with treatment escalation based on symptom severity, exacerbation history, and lung function. 1
Disease Classification and Assessment
COPD severity should be classified into four groups based on:
- Spirometry results: FEV1 as percentage of predicted
- Symptoms: Breathlessness severity
- Exacerbation history
- Presence of respiratory failure
| Severity | FEV1 (% predicted) | Key Clinical Features |
|---|---|---|
| Mild | >80% | Few symptoms, normal activities |
| Moderate | 50-80% | Breathlessness on moderate exertion |
| Severe | 30-50% | Breathlessness on minimal exertion |
| Very Severe | <30% | Breathlessness at rest, respiratory failure |
Pharmacological Management
Bronchodilator Therapy
- Initial therapy: Short-acting bronchodilators (SABA or SAMA) as needed for intermittent symptoms 1
- Persistent symptoms: Progress to long-acting bronchodilators
Anti-inflammatory Therapy
- LABA/LAMA/ICS triple therapy: For patients with blood eosinophil count ≥300 cells/μL or history of asthma 1
- Fluticasone propionate/salmeterol (Wixela Inhub® 250/50): Indicated for twice-daily maintenance treatment of airflow obstruction in COPD and to reduce exacerbations in patients with a history of exacerbations 3
- Roflumilast: Consider for patients with FEV1 < 50% predicted and chronic bronchitis 1
Exacerbation Management
- Systemic corticosteroids: For acute exacerbations 1
- Antibiotics: For exacerbations with increased sputum purulence or requiring mechanical ventilation 1
Non-Pharmacological Management
Oxygen Therapy
- Long-term oxygen therapy (LTOT): Prolongs life in hypoxemic patients (PaO₂ ≤55 mm Hg or SaO₂ ≤88%) 1
- Should be given for at least 15 hours daily
- Flow rate adjusted to maintain PaO₂ >8 kPa
- Regular reassessment every 6 months
Pulmonary Rehabilitation
- Essential component for improving exercise capacity and quality of life 1
- Includes:
- Exercise training
- Breathing techniques
- Energy conservation strategies
- Nutritional counseling
Vaccination
- Influenza vaccination: Recommended annually for all COPD patients 1
- Pneumococcal vaccinations (PCV13 and PPSV23): Recommended for patients ≥65 years 1
Surgical Options
- Lung volume reduction surgery: For selected patients with emphysema 1
- Lung transplantation: For end-stage disease in patients <65 years with:
- Very poor exercise tolerance
- Poor lung function (FEV1 <25% predicted)
- PaO₂ <7.5 kPa and PaCO₂ >6.5 kPa 1
Management of Comorbidities
- Depression: Screen and treat as it contributes to symptom intensity 1
- Pulmonary hypertension: Assess and manage appropriately 1
- Nutrition: Address obesity or poor nutrition 1
Monitoring and Follow-up
- Regular spirometry: To track disease progression 1
- Oxygen saturation monitoring
- Assessment of exercise capacity
- Evaluation for disease progression and complications
Common Pitfalls to Avoid
- Overreliance on short-acting bronchodilators: Progress to long-acting agents for persistent symptoms
- Inappropriate ICS use: Reserve for patients with eosinophilia or asthma history
- Inadequate exacerbation management: Consider both corticosteroids and antibiotics when appropriate
- Neglecting non-pharmacological therapies: Pulmonary rehabilitation is essential
- Missing comorbidities: Screen for and treat depression and other common comorbidities
- Delaying LTOT: Implement promptly when criteria are met
Remember that more frequent administration or a greater number of inhalations of prescribed LABA-containing medications is not recommended, as some patients are more likely to experience adverse effects with higher doses 3.