COPD Management Strategies
The management of COPD should be based on a comprehensive approach including smoking cessation, pharmacological therapy with bronchodilators (starting with SABA/SAMA for intermittent symptoms and progressing to LABA/LAMA combinations for persistent symptoms), pulmonary rehabilitation, oxygen therapy for hypoxemic patients, vaccination, and treatment of exacerbations and comorbidities. 1
Classification and Assessment
COPD severity should be classified into four groups based on:
- Spirometry results (FEV1)
- Symptom burden
- 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
- First-line therapy: Short-acting bronchodilators (SABA or SAMA) for intermittent symptoms 1
- For persistent symptoms: Progress to long-acting bronchodilators
- For patients with persistent symptoms despite single agent: LAMA + LABA combination 1
- For patients with blood eosinophil count ≥300 cells/μL or history of asthma: LABA/LAMA/ICS triple therapy 1
Inhaled Corticosteroids (ICS)
- Fluticasone propionate/salmeterol (Wixela Inhub 250/50) is indicated for twice-daily maintenance treatment of airflow obstruction in COPD and to reduce exacerbations in patients with a history of exacerbations 2
- The recommended dosage for COPD patients is 1 inhalation of Wixela Inhub 250/50 twice daily, approximately 12 hours apart 2
Additional Pharmacological Options
- For patients with FEV1 < 50% predicted and chronic bronchitis: Consider roflumilast 1
- For acute exacerbations: Systemic corticosteroids and antibiotics (if 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 without unacceptable rise in PaCO₂
- Regular reassessment every 6 months
- Consider ambulatory oxygen for patients with exercise desaturation
Pulmonary Rehabilitation
- Essential component for improving exercise capacity and quality of life 1
- Includes:
- Exercise training
- Breathing techniques
- Energy conservation strategies
- Nutritional counseling
- Should be encouraged at all stages of disease
Preventive Measures
- Smoking cessation: Essential to prevent disease progression 1
- Vaccinations:
- Annual influenza vaccination for all COPD patients
- Pneumococcal vaccinations (PCV13 and PPSV23) for patients ≥65 years 1
Management of Exacerbations
- Increase bronchodilator therapy
- Consider antibiotics if two or more of: increased breathlessness, increased sputum volume, or purulent sputum
- Consider oral corticosteroids for select cases
- Reassess if not improved within two weeks
- Consider chest radiography and hospital referral if not improving
Surgical Options
- Consider lung volume reduction surgery, bullectomy, or lung transplantation in selected patients 1
- Lung transplantation should be considered for patients <65 years with very poor exercise tolerance, poor lung function (FEV1 <25% predicted), and respiratory failure
- Long-term survival after lung transplantation is approximately 50% at 5 years
Management of Comorbidities
- Screen and treat depression which contributes to symptom intensity and social isolation 1
- Assess and manage pulmonary hypertension appropriately
- Address nutrition issues (both obesity and poor nutrition)
- Assess social circumstances and support
- Discuss advance care planning with stable patients
Monitoring and Follow-up
- Regular spirometry to track disease progression
- Monitor oxygen saturation
- Assess exercise capacity
- Evaluate for disease progression and complications
- Consider specialist referral for:
- Suspected severe COPD
- Onset of cor pulmonale
- Assessment for oxygen therapy, nebulizer therapy, or oral corticosteroid need