What are the management guidelines for patients with Chronic Obstructive Pulmonary Disease (COPD) who contract Coronavirus Disease 2019 (COVID-19)?

Management Guidelines for COPD Patients with COVID-19

COPD patients with COVID-19 should continue their regular COPD medications including inhaled corticosteroids and bronchodilators while receiving appropriate COVID-19 treatment based on disease severity, with special attention to respiratory support and infection control measures. 1

Risk Assessment and Disease Severity

COPD patients are at significantly higher risk of poor COVID-19 outcomes:

• 4.2 times higher odds of hospitalization 2
• 1.4 times higher odds of ICU admission 2
• 2.5 times higher odds of mortality 2

Disease severity classification (according to WHO guidelines) 3:

• Mild: Various symptoms without respiratory distress
• Moderate: Lower respiratory disease with SpO2 ≥94% on room air
• Severe: SpO2 <94% on room air
• Critical: Requires ICU admission or mechanical ventilation

COPD Medication Management During COVID-19

• Continue all regular COPD medications including inhaled corticosteroids (ICS), long-acting bronchodilators (LABA/LAMA), roflumilast, or chronic macrolides as previously prescribed 1
• Do not discontinue inhaled corticosteroids as they have not been associated with increased mortality in COPD patients with COVID-19 4
• For COPD exacerbations: Use systemic steroids and antibiotics according to usual indications, even during COVID-19 infection 1

COVID-19 Specific Management for COPD Patients

Respiratory Support

• Oxygen therapy: Maintain SpO2 ≥94% (or 90-96% in patients at risk of hypercapnic respiratory failure) 3

• Escalation pathway for respiratory support:

  1. Low-flow nasal cannula
  2. High-flow nasal cannula (HFNC) or CPAP
  3. Non-invasive ventilation (NIV)
  4. Invasive mechanical ventilation 3

• For mechanical ventilation: Use low tidal volume ventilation strategy 3

• Consider prone positioning for severe ARDS 3

Pharmacological Management

1. Corticosteroids:

   • Dexamethasone 6 mg daily for up to 10 days for patients requiring oxygen or ventilatory support 3
   • Do not use if not requiring oxygen 3

2. Antiviral therapy:

   • Remdesivir: 200 mg IV on Day 1, then 100 mg IV daily from Day 2 3
   • Nirmatrelvir-ritonavir: 300 mg nirmatrelvir with 100 mg ritonavir twice daily for 5 days for high-risk outpatients 3

3. Immunomodulators:

   • Consider tocilizumab (IL-6 receptor antagonist) for patients requiring oxygen with elevated inflammatory markers 3

4. Anticoagulation:

   • All hospitalized COPD patients with COVID-19 should receive thromboprophylaxis 3
   • Consider intensified prophylaxis for patients with additional risk factors 3

Managing Breathlessness

For patients with moderate to severe breathlessness, especially at end of life 5:

• Positioning techniques: Sitting upright, leaning forward with arms bracing
• Breathing techniques: Pursed-lip breathing, coordinated breathing training
• For severe distress: Consider opioids (morphine sulfate)
  • Opioid naive: Morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as required
  • Already on opioids: Increase dose appropriately
  • If eGFR <30 mL/min: Use oxycodone instead of morphine

Infection Control Measures

• Basic infection control:
  • Social distancing
  • Hand washing
  • Wearing masks or face coverings 1
• Avoid spirometry during periods of high community prevalence unless essential for diagnosis or pre-procedural assessment 1
• Vaccination: Ensure patients remain up to date with vaccinations, particularly annual influenza vaccination 1

Differentiating COVID-19 from COPD Exacerbation

• If symptoms suggest possible COVID-19, perform SARS-CoV-2 testing 1
• Be aware that eosinopenia is associated with COVID-19 in COPD patients and is a risk factor for mortality 4

Follow-up and Rehabilitation

• For mild/asymptomatic COVID-19: Follow usual COPD protocols 1
• For moderate-severe COVID-19: Monitor more frequently with particular attention to oxygen requirements 1
• Early rehabilitation: Include pulmonary rehabilitation, breathing exercises, and gradual increase in physical activity 3
• Schedule virtual follow-up 1-2 weeks after diagnosis 3

Common Pitfalls to Avoid

1. Do not discontinue regular COPD medications during COVID-19 infection
2. Do not delay treatment of COPD exacerbations due to COVID-19 concerns
3. Do not perform unnecessary spirometry during high community prevalence
4. Do not withhold corticosteroids in patients requiring oxygen
5. Be aware that many COPD patients may avoid seeking care due to concerns about cross-infection in hospitals 6

By following these guidelines, clinicians can optimize care for COPD patients with COVID-19, balancing the management of both conditions while minimizing risks.