COPD Treatment Management
The recommended treatment for COPD should follow a staged approach with bronchodilators as the cornerstone of therapy, with treatment intensity increasing based on disease severity, symptom burden, and exacerbation risk. 1
Initial Assessment and Non-Pharmacological Interventions
- Smoking cessation is the single most important intervention for all COPD patients and should be strongly encouraged at every clinical encounter 1
- Pulmonary rehabilitation programs should be recommended for patients with high symptom burden (Groups B, C, and D), as they increase exercise tolerance and improve quality of life 1
- Annual influenza vaccination is recommended for all COPD patients 1
- Pneumococcal vaccination should be considered, with revaccination every 5-10 years 1
Pharmacological Treatment by Disease Severity
Group A (Low Symptoms, Low Exacerbation Risk)
- Start with a short-acting bronchodilator (SABA or SAMA) as needed for symptom relief 2
- Examples include albuterol (SABA) or ipratropium (SAMA) 3
Group B (High Symptoms, Low Exacerbation Risk)
- Initial therapy should be a long-acting bronchodilator 3
- Long-acting bronchodilators are superior to short-acting bronchodilators taken intermittently 3
- For patients with persistent breathlessness on monotherapy, the use of two bronchodilators is recommended 3
- For patients with severe breathlessness, initial therapy with two bronchodilators may be considered 3
Group C (Low Symptoms, High Exacerbation Risk)
- Start with a long-acting muscarinic antagonist (LAMA) as it is preferred for exacerbation prevention compared to LABAs 3, 2
Group D (High Symptoms, High Exacerbation Risk)
- LABA/LAMA combination is recommended as initial therapy because:
Escalation of Therapy
For patients who develop additional exacerbations on LABA/LAMA therapy, two alternative pathways are suggested:
- Escalation to LABA/LAMA/ICS (triple therapy) 3
- Switch to LABA/ICS. If this doesn't positively impact exacerbations/symptoms, add an LAMA 3
For patients with continued exacerbations on triple therapy:
- Consider adding roflumilast for patients with FEV1 < 50% predicted and chronic bronchitis, particularly if they experienced hospitalization for exacerbation in the previous year 3
- Consider adding a macrolide in former smokers, but factor in the risk of developing resistant organisms 3
Management of Exacerbations
- Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation 3
- Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 3
- Systemic corticosteroids improve lung function and shorten recovery time and hospitalization duration 3
- Antibiotics, when indicated (purulent sputum), shorten recovery time and reduce the risk of early relapse 3
Advanced Treatment Options
- For selected patients with severe emphysema, bronchoscopic or surgical lung volume reduction may be considered 3
- In selected patients with a large bulla, surgical bullectomy may be considered 3
- Lung transplantation may be considered for very severe COPD patients without relevant contraindications 3
Important Caveats
- Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1
- Inhaled corticosteroids (ICS) are not recommended as first-line monotherapy in COPD and increase the risk of pneumonia, especially in current smokers, older patients, and those with prior pneumonia 2
- Methylxanthines are not recommended due to side effects 3
- Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked, as 76% of COPD patients make important errors when using metered-dose inhalers 1