What is the step-by-step approach for managing Chronic Obstructive Pulmonary Disease (COPD), including medication and doses?

Step-by-Step Approach for COPD Management

The management of COPD requires a systematic approach based on disease severity, with pharmacological therapy progressing from short-acting bronchodilators to combination therapy as the disease worsens, while always prioritizing smoking cessation as the most essential intervention. 1

Initial Assessment and Classification

1. Confirm diagnosis with spirometry:

   • FEV1/FVC ratio < 0.7 confirms airflow limitation
   • Classify severity based on FEV1 (% predicted):
     • Mild: 60-80%
     • Moderate: 40-59%
     • Severe: <40% 1

2. Assess symptoms and exacerbation risk:

   • Symptoms: Use validated tools (mMRC dyspnea scale or CAT score)
   • Exacerbation history: Number of exacerbations in past year
   • Categorize patients into groups A-D based on combined assessment 1

Pharmacological Management by Severity

Mild COPD (Group A)

• First-line therapy: Short-acting bronchodilator as needed
  • Short-acting β2-agonist (SABA): Salbutamol 100-200 μg as needed
  • OR Short-acting muscarinic antagonist (SAMA): Ipratropium 20-40 μg as needed 2, 1

Moderate COPD (Group B)

• First-line therapy: Long-acting bronchodilator
  • Long-acting β2-agonist (LABA): e.g., formoterol 12 μg twice daily
  • OR Long-acting muscarinic antagonist (LAMA): e.g., tiotropium 18 μg once daily 2, 1
• If symptoms persist: Consider LABA/LAMA combination 1

Severe COPD (Groups C and D)

• First-line therapy: LAMA (preferred for Group C) 1
• Second-line therapy: LABA/LAMA combination 1
• If exacerbations persist with eosinophil count ≥300 cells/μL: Add inhaled corticosteroid (ICS) 1
• Triple therapy: LABA/LAMA/ICS for patients with continued exacerbations despite dual therapy 1

Management of Exacerbations

1. Bronchodilator therapy:

   • For mild exacerbations: Increase dose/frequency of current bronchodilators 2
   • For moderate-severe exacerbations: Nebulized salbutamol (2.5-5 mg) or terbutaline (5-10 mg) or ipratropium bromide (500 μg) every 4-6 hours 2
   • Consider combination therapy: β2-agonist (2.5-10 mg) with ipratropium bromide (250-500 μg) for severe cases 2

2. Corticosteroids:

   • Prednisone 30-40 mg orally daily for 5-14 days
   • No taper needed for short courses (5-7 days) 1

3. Antibiotics:

   • Initiate if two or more of: increased breathlessness, increased sputum volume, purulent sputum
   • First-line options: amoxicillin, doxycycline, or macrolides for 5-7 days 1

4. Oxygen therapy:

   • Target SpO2 of 88-92% to prevent tissue hypoxia while avoiding CO2 retention
   • Use controlled oxygen delivery devices (e.g., Venturi masks) 1

5. Non-invasive ventilation (NIV):

   • Initiate if respiratory acidosis (pH < 7.35 with PaCO2 > 45 mmHg)
   • Also indicated for severe dyspnea with signs of respiratory muscle fatigue 1

Essential Non-Pharmacological Interventions

1. Smoking cessation (highest priority for all COPD stages):

   • Participation in active cessation program with nicotine replacement therapy 2, 1

2. Vaccinations:

   • Annual influenza vaccination for all COPD patients
   • Pneumococcal vaccination as recommended 1

3. Pulmonary rehabilitation:

   • Recommended for moderate to severe disease
   • Improves exercise capacity, reduces breathlessness, and enhances quality of life 2, 1

4. Long-term oxygen therapy (LTOT):

   • For persistent hypoxemia (PaO2 < 7.3 kPa or < 60 mmHg)
   • Prolongs life in hypoxemic patients 2, 1

Common Pitfalls to Avoid

• Overuse of inhaled corticosteroids in patients without frequent exacerbations or eosinophilia
• Improper inhaler technique leading to suboptimal drug delivery
• Neglecting smoking cessation as the primary intervention
• Inadequate attention to comorbidities that can worsen COPD outcomes
• Failure to assess and address nutritional status in advanced disease 1

Monitoring and Follow-up

• Review medication adherence and inhaler technique at each visit
• Assess symptom control and exacerbation frequency
• Monitor lung function (FEV1) periodically
• Consider early discharge planning during hospitalizations with follow-up within 4-6 weeks 1

Bold text indicates the most important recommendations for COPD management, emphasizing the stepwise approach based on disease severity and the critical importance of smoking cessation as the cornerstone of treatment.