What are the treatment guidelines for Chronic Obstructive Pulmonary Disease (COPD)?

COPD Treatment Guidelines

COPD treatment should follow a stepwise approach based on disease severity, with combination therapy of LAMA/LABA recommended as first-line treatment for patients with persistent symptoms, regardless of exacerbation history. 1

Diagnosis and Assessment

• Objective measurement via spirometry is required for COPD diagnosis
• Post-bronchodilator FEV1/FVC <0.70 confirms persistent airflow limitation 1
• COPD severity classification based on FEV1:
  • Mild: >80% predicted
  • Moderate: 50-80% predicted
  • Severe: 30-50% predicted
  • Very Severe: <30% predicted 1

Pharmacological Treatment

Mild COPD

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

Moderate COPD

• Regular therapy with short-acting bronchodilators or combination of both 2
• Consider a corticosteroid trial in all patients 2
• Consider LAMA/LABA combination for persistent symptoms 1

Severe COPD

• Combination therapy with regular β2-agonist and anticholinergic 2
• Consider a corticosteroid trial 2
• Assess for home nebulizer using BTS guidelines 2
• LAMA/LABA combination is strongly recommended for patients with dyspnea or exercise intolerance 3
• Consider adding 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

Medication Considerations

• Fluticasone propionate/salmeterol (Wixela Inhub® 250/50) is indicated for twice-daily maintenance treatment of airflow obstruction and reducing exacerbations in COPD patients 4
• Theophyllines have limited value in routine COPD management 2
• Long-acting bronchodilators are more effective and convenient than short-acting bronchodilators 5
• Once-daily bronchodilators (tiotropium, indacaterol) may offer superior bronchodilation compared to twice-daily agents 5

Non-Pharmacological Management

Smoking Cessation

• Essential at all stages of disease 2, 1
• Participation in active smoking cessation programs leads to higher sustained quit rates, especially with nicotine replacement therapy 2
• Cannot restore lost lung function but prevents accelerated decline 2

Pulmonary Rehabilitation

• Cornerstone of management for symptomatic patients 1
• Improves exercise performance and reduces breathlessness 2, 1
• Reduces readmissions and mortality after recent exacerbations 1

Preventive Measures

• Annual influenza vaccination recommended, especially for moderate to severe disease 2, 1
• Pneumococcal vaccination recommended 1
• Encourage exercise where possible 2
• Address obesity and poor nutrition 2

Advanced Disease Management

Oxygen Therapy

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 2
• Prescribe only if objectively demonstrated hypoxia (PaO2 <7.3 kPa) or high cylinder use (more than two per week) 2
• Short-burst oxygen for breathlessness lacks evidence 2

Surgical Options

• Consider surgery for recurrent pneumothoraces and isolated bullous disease 2
• Lung volume reduction surgery may benefit selected patients 2, 1
• Bronchoscopic lung volume reduction (BLVR) for select patients with upper-lobe predominant emphysema 1
• Lung transplantation for end-stage disease in patients <65 years with very poor exercise tolerance and lung function 1

Comprehensive Care

• Assess and treat depression 2
• Focus on relief of dyspnea, pain, anxiety, fatigue, and poor nutrition 1
• Consider advance care planning to reduce anxiety and avoid unwanted invasive therapies 1

Common Pitfalls and Caveats

• Do not use LABA monotherapy due to increased risk of serious asthma-related events 4
• Do not initiate treatment during acute exacerbations 4
• Monitor for Candida albicans infection of mouth and pharynx; advise patients to rinse mouth with water after inhalation 4
• Increased risk of pneumonia in COPD patients on ICS; monitor for signs and symptoms 4
• Poor inhaler technique correlates with poor symptom control; ensure proper device selection and technique optimization 1
• Consider referral to specialist care for diagnostic uncertainty, rapid disease progression, severe symptoms despite optimal therapy, or consideration for advanced therapies 1