COPD Management Recommendations
For patients with COPD, the recommended management should include LAMA/LABA combination therapy as first-line treatment to maximize bronchodilation, with escalation to triple therapy (LAMA/LABA/ICS) for patients with frequent exacerbations, alongside appropriate non-pharmacological interventions including pulmonary rehabilitation, smoking cessation, and vaccinations. 1
Pharmacological Management
Initial Therapy
- First-line treatment: LAMA/LABA combination therapy is recommended to maximize bronchodilation and reduce dyspnea 1
Escalation of Therapy
- For persistent symptoms: Continue LAMA/LABA combination 1
- For patients with FEV1 < 50% predicted and chronic bronchitis: Add roflumilast (PDE4 inhibitor) 1
- For patients with ≥2 moderate exacerbations or ≥1 severe exacerbation in the past year: Triple therapy with LAMA/LABA/ICS in a single inhaler 1
- Also indicated for patients with blood eosinophil count ≥300 cells/μL or history of asthma
- Note: Wixela Inhub® 250/50 (fluticasone/salmeterol) is indicated for twice-daily maintenance treatment of COPD and to reduce exacerbations in patients with a history of exacerbations 4
Exacerbation Management
- Increase bronchodilator therapy during exacerbations 1
- Consider antibiotics if increased sputum purulence, volume, or increased breathlessness 1
- Systemic corticosteroids for moderate to severe exacerbations 1
- Hospital admission for severe exacerbations or failure to respond to outpatient treatment 1
Oxygen Therapy
- Long-term oxygen therapy (LTOT) is fundamental for patients with chronic hypoxemia 1
- Target SaO₂ ≥90% without significantly increasing PaCO₂
- Administer for at least 15 hours/day to improve survival
- Consider ambulatory oxygen for patients with exercise desaturation
Non-Pharmacological Management
Essential Interventions
- Pulmonary rehabilitation: Improves exercise capacity and quality of life 1, 5
- Includes physical exercises, education, and psychosocial support
- Effective for improving symptoms and reducing exacerbations and hospitalizations
- Smoking cessation: Essential to prevent disease progression 1
- Vaccinations:
Monitoring and Follow-Up
- Regular spirometry to monitor disease progression 1
- Assessment of arterial blood gases for evaluating hypoxemia and hypercapnia 1
- Monitoring of symptoms, exacerbation frequency, and inhaler technique 1
- Evaluation for disease complications and comorbidities 1
Surgical Options
- Consider for appropriate candidates:
Comorbidity Management
- Screen and treat depression which contributes to symptom intensity 1
- Assess and manage pulmonary hypertension 1
- Address nutrition issues (obesity or poor nutrition) 1
- Discuss advance care planning with stable patients 1
Important Considerations
- Avoid beta-blockers (including eye drop formulations) as they can worsen bronchospasm 1
- ICS monotherapy is not recommended in COPD management 1
- Inhalation devices should be selected based on patient ability - some patients may benefit from pMDI with spacer if they cannot generate sufficient inspiratory flow for dry powder inhalers 6
- Tiotropium administered once daily has been shown to provide superior bronchodilation and symptomatic improvement compared to twice-daily salmeterol 3
COPD Severity Classification
| 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 |
Treatment should be adjusted based on disease severity, symptom burden, and exacerbation history to optimize outcomes and improve quality of life.