What are the management options for Chronic Obstructive Pulmonary Disease (COPD)?

COPD Management

The cornerstone of COPD management includes smoking cessation, pharmacological therapy with bronchodilators (starting with LAMAs), pulmonary rehabilitation, and appropriate oxygen therapy for those with hypoxemia, with treatment escalation based on symptom severity and exacerbation frequency. 1

Diagnosis and Assessment

• Confirm diagnosis with spirometry showing FEV1 <80% of predicted and FEV1/VC ratio <70% 1
• Chest radiography helps exclude other pathologies but cannot positively diagnose COPD 2
• Assess disease severity based on spirometry results:
  • Mild: FEV1 >80% predicted
  • Moderate: FEV1 50-80% predicted
  • Severe: FEV1 30-50% predicted
  • Very Severe: FEV1 <30% predicted 1
• Arterial blood gas testing is necessary in severe COPD to identify persistent hypoxemia 2

Pharmacological Management

Bronchodilator Therapy

1. Mild Disease

   • Short-acting bronchodilators as needed (β2-agonist or anticholinergic) 2
   • Optimize inhaler technique and select appropriate device 2

2. Moderate Disease

   • Regular LAMA (e.g., tiotropium) as first-line therapy 1, 3
   • If symptoms persist, add LABA (e.g., salmeterol) 1, 4
   • Consider LAMA/LABA combination for persistent symptoms 1

3. Severe Disease

   • LAMA/LABA combination therapy 1
   • Consider triple therapy (LAMA/LABA/ICS) for patients with blood eosinophil count ≥300 cells/μL or history of asthma 1
   • Consider roflumilast for patients with FEV1 <50% predicted and chronic bronchitis 1

Corticosteroid Therapy

• Consider corticosteroid trial in moderate to severe disease 2
• Inhaled corticosteroids recommended for patients with:
  • Frequent exacerbations
  • Blood eosinophil count ≥300 cells/μL
  • History of asthma 1
• For high doses of inhaled corticosteroids (≥1,000 μg/day), use large-volume spacer or dry-powder system 2

Non-Pharmacological Management

Smoking Cessation

• Essential at all stages of disease 2
• Most effective strategy for slowing disease progression and reducing mortality 5
• Combine counseling with pharmacotherapy (NRT, bupropion, varenicline) 5, 6, 7
• Participation in active smoking cessation program leads to higher sustained quit rate 2

Pulmonary Rehabilitation

• Improves exercise performance and reduces breathlessness in moderate/severe disease 2
• Increases patients' sense of control 8
• Effective for improving symptoms and reducing exacerbations and hospitalizations 8

Oxygen Therapy

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 2
• Should be prescribed if objectively demonstrated hypoxia (PaO₂ <7.3 kPa) 2
• Administer for at least 15 hours/day to improve survival 1
• Target SaO₂ ≥90% without significantly increasing PaCO₂ 1

Management of Exacerbations

Assessment of Severity

• Mild: Treated with short-acting bronchodilators only
• Moderate: Requires short-acting bronchodilators plus antibiotics and/or oral corticosteroids
• Severe: Requires hospitalization or emergency room visit 1

Home Management

1. Bronchodilators: Increase dose or frequency of short-acting agents 2
2. Antibiotics: Indicated if two or more of:
   • Increased breathlessness
   • Increased sputum volume
   • Development of purulent sputum 2
3. Oral Corticosteroids: Consider in select cases (30 mg daily for one week) 2
4. Airway Clearance: Encourage sputum clearance by coughing 2
5. Hydration: Encourage fluid intake 2
6. Monitoring: Instruct patient on symptoms of worsening and when to seek help 2

Hospital Management

• Indicated for severe exacerbations with:
  • Marked increase in intensity of symptoms
  • Severe baseline COPD
  • New physical signs (cyanosis, peripheral edema)
  • Failure to respond to initial medical management
  • Significant comorbidities
  • Frequent exacerbations
  • Older age
  • Insufficient home support 1

Surgical Options

• Consider surgery for:
  • Recurrent pneumothoraces
  • Isolated bullous disease
  • Lung volume reduction in selected patients 2
• Lung transplantation for end-stage disease in patients <65 years with very poor exercise tolerance and lung function 1

Additional Considerations

• Assess and manage comorbidities (depression, anxiety, cardiovascular disease) 2, 1
• Vaccinate against influenza, especially for moderate to severe disease 2
• Provide nutritional support for patients with obesity or poor nutrition 1
• Discuss advance care planning with stable patients 1

By following this comprehensive approach to COPD management, clinicians can help improve symptoms, reduce exacerbations, and potentially slow disease progression in patients with COPD.