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

Guidelines for Managing Chronic Obstructive Pulmonary Disease (COPD)

The management of COPD requires a structured approach based on disease severity, with pharmacological and non-pharmacological interventions tailored to improve lung function, reduce symptoms, prevent exacerbations, and ultimately reduce mortality and improve quality of life. 1

Diagnosis and Assessment

• Spirometric testing is essential for diagnosis, with persistent airflow limitation defined as post-bronchodilator FEV1/FVC < 0.7 1
• Chest radiography helps exclude other pathologies but cannot positively diagnose COPD 2
• Arterial blood gas measurement is necessary in severe COPD to identify persistent hypoxemia with or without hypercapnia 2
• More complex investigations are not normally indicated except in difficult cases 2

Pharmacological Management by Disease Severity

Mild Disease

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed for symptomatic relief 2, 1
• If these drugs are ineffective, they should be stopped 2

Moderate Disease

• Regular therapy with short-acting bronchodilators or a combination of both may be needed 2
• A corticosteroid trial should be considered in all patients 2
• Most patients will be controlled on a single drug, while some will need combination treatment 2

Severe Disease

• Combination therapy with regular β2-agonist and anticholinergic agents is recommended 2, 1
• Consider a corticosteroid trial 2
• Assess for home nebulizer using the BTS guidelines 2
• Theophyllines can be tried but must be monitored for side effects 2

Inhaler Considerations

• Optimize inhaler technique and select appropriate device to ensure efficient delivery 2, 1
• Inhaler technique must be demonstrated to the patient before prescribing and should be re-checked before changing treatments 2
• Home nebulizer therapy should only be supplied after full assessment by a respiratory physician 2

Non-Pharmacological Management

• Smoking cessation is essential at all stages of disease and can prevent accelerated lung function decline 2, 1
• Active participation in smoking cessation programs with nicotine replacement therapy increases quit rates 2
• Annual influenza vaccination is recommended, especially for moderate to severe disease 2, 1
• Exercise should be encouraged where possible 2, 1
• Address obesity and poor nutrition 2, 1
• Pulmonary rehabilitation improves exercise performance and reduces breathlessness in moderate/severe disease 2, 1

Management of Advanced Disease

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients (PaO2 <7.3 kPa) 2, 1
• Short burst oxygen is often prescribed for breathlessness but evidence supporting this practice is lacking 2, 1
• Surgery is indicated for recurrent pneumothoraces and isolated bullous disease 2
• Lung volume reduction surgery may benefit selected patients 2, 1
• Depression should be identified and treated 2
• Evaluate social circumstances and available support 2, 1

Management of Exacerbations

Key Symptoms of Exacerbation

• Increased sputum purulence
• Increased sputum volume
• Increased dyspnea
• Increased wheeze
• Chest tightness
• Fluid retention 2

Home Treatment

• Add or increase bronchodilators (consider if inhaler device and technique are appropriate) 2
• Antibiotics if two or more of: increased breathlessness, increased sputum volume, or development of purulent sputum 2
• Oral corticosteroids (30 mg per day for one week) in specific cases:
  • Patient already on oral corticosteroids
  • Previously documented response to oral corticosteroids
  • Airflow obstruction fails to respond to increased bronchodilator dose
  • First presentation of airflow obstruction 2

Hospital Admission Considerations

• Consider hospital admission based on:
  • Severity of symptoms
  • General condition
  • Oxygen requirements
  • Activity level
  • Social circumstances 2, 1

Indications for Specialist Referral

• Suspected severe COPD or onset of cor pulmonale 1
• Assessment for oxygen therapy or nebulizer use 1
• Assessment for oral corticosteroid treatment 1
• Bullous lung disease or consideration for surgery 1
• COPD in patients under 40 years or with < 10 pack-years smoking history 1
• Rapid decline in FEV1 1
• Uncertain diagnosis or symptoms disproportionate to lung function 1
• Frequent infections (to exclude bronchiectasis) 1

Common Pitfalls and Caveats

• Subjective improvement is not a satisfactory endpoint for corticosteroid trials; objective spirometric improvement must be documented 1
• Long-acting β2-agonists should only be used if objective evidence of improvement is available 2
• Theophyllines have limited value in routine COPD management 2, 1
• There is no role for other anti-inflammatory drugs such as sodium cromoglycate, nedocromil sodium, antihistamines, or mucolytics in COPD 2
• Beta-blocking agents (including eyedrop formulations) should be avoided 2
• There is no evidence to support the use of prophylactic antibiotics given either continuously or intermittently 2