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

Treatment Options for Chronic Obstructive Pulmonary Disease (COPD)

The optimal management of COPD requires a staged approach with bronchodilators as the cornerstone of therapy, with treatment intensity increasing based on disease severity, symptom burden, and exacerbation risk. 1

Smoking Cessation

• Smoking cessation is the single most important intervention for all COPD patients and should be strongly encouraged at every clinical encounter 2
• Nicotine replacement therapy (gum or transdermal patches) and behavioral interventions can increase success rates 2
• Health professionals should provide personal example by not smoking and promoting smoke-free environments 2

Bronchodilator Therapy Based on Disease Severity

Mild COPD

• Patients with no symptoms require no drug treatment 2, 1
• Symptomatic patients should receive a trial of short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device 2, 1
• If these medications are ineffective, they should be discontinued 2

Moderate COPD

• Regular use of long-acting bronchodilator monotherapy is recommended 2, 1
• Most patients can be controlled on a single drug, with long-acting muscarinic antagonists (LAMAs) preferred for exacerbation prevention 1
• The level of treatment depends on symptom severity and impact on lifestyle 2
• Oral bronchodilators are not usually required at this stage 2

Severe COPD

• Combination of long-acting β2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) is recommended 2, 1
• Fixed-dose combinations provide convenience of two bronchodilators with different mechanisms of action in a single inhaler 3
• Theophyllines (methylxanthines) can be tried but must be monitored closely for side effects 2

Inhaled Corticosteroids (ICS)

• ICS may be added to bronchodilator therapy for patients with persistent exacerbations 1
• LABA/ICS combinations may be first-choice initial therapy for patients with asthma-COPD overlap or high blood eosinophil counts 1
• The recommended ICS/LABA dosage for COPD is one inhalation twice daily 4

Delivery Devices

• Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked 2, 1
• 76% of COPD patients make important errors when using metered-dose inhalers, while 10-40% make errors with dry powder inhalers 2
• Home nebulizer therapy should only be prescribed after formal assessment by a respiratory physician 2
• Most patients can be effectively treated with metered-dose inhalers with spacers or dry powder devices 2

Management of Exacerbations

• Antibiotics should be used when sputum becomes purulent (7-14 day course) 2
• Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2
• Inexpensive antibiotics like amoxicillin, tetracycline derivatives, and amoxicillin/clavulanic acid are sufficient in most cases 2
• Systemic corticosteroids (40mg prednisone daily for 5 days) improve lung function and shorten recovery time 1

Oxygen Therapy

• Long-term oxygen therapy (LTOT) is indicated for patients with severe hypoxemia and is the only treatment besides smoking cessation shown to modify survival rates 5
• Oxygen concentrators are the easiest mode of treatment for home use 2
• In end-stage COPD, short bursts of oxygen may help intractable dyspnea 2

Pulmonary Rehabilitation

• Rehabilitation programs have been shown to increase exercise tolerance and improve quality of life 2
• Programs should include physiotherapy, muscle training, nutritional support, and education 2
• Walking is generally preferred for exercise reconditioning, but stair-climbing, treadmill, or cycling can also be used 2
• Benefits disappear rapidly if exercise is discontinued, so maintenance is essential 2

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients 2
• Pneumococcal vaccination may be considered, with revaccination every 5-10 years 2

Common Pitfalls and Caveats

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 2, 1
• There is no evidence supporting the use of prophylactic antibiotics given continuously or intermittently 2
• Mucolytic drugs have produced variable results in trials and require further study before recommendation 2
• Pulmonary vasodilators have no established role in COPD with pulmonary hypertension 2
• Non-invasive ventilatory support should be considered for patients with severe nocturnal hypoxemia or respiratory muscle weakness 2