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

Management of Chronic Obstructive Pulmonary Disease (COPD)

The management of COPD requires a comprehensive approach including smoking cessation, pharmacological therapy with bronchodilators, pulmonary rehabilitation, and oxygen therapy for hypoxemic patients, with treatment intensity escalating based on disease severity. 1

Assessment and Diagnosis

• 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 1
• Arterial blood gas measurement is necessary in severe COPD to identify persistent hypoxemia 1
• A trial of oral corticosteroids (30 mg prednisolone daily for two weeks) is indicated in moderate to severe disease, with objective improvement seen in 10-20% of cases 2, 1

Pharmacological Management by Disease Severity

Mild Disease

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed for symptomatic relief 2, 1
• Smoking cessation is the only intervention proven to reduce the rate of progression of COPD 2, 3

Moderate Disease

• Regular therapy with short-acting bronchodilators or a combination of both may be needed 2, 1
• Long-acting bronchodilators (LABAs and LAMAs) are effective for symptomatic management 4
• Consider a corticosteroid trial to identify potential responders 2, 1

Severe Disease

• Combination therapy with regular β2-agonist and anticholinergic agents is recommended 2, 1
• Dual bronchodilation (LAMA/LABA combination) is superior to monotherapy for symptom control and exacerbation prevention 4
• Triple therapy (adding inhaled corticosteroids to LABA and LAMA) provides further reduction in exacerbations, especially in patients with higher blood eosinophil counts 4
• For COPD exacerbations, antibiotics are recommended when sputum becomes purulent 2

Medication Selection and Administration

• Optimize inhaler technique and select appropriate device to ensure efficient delivery 2, 1
• Theophyllines have limited value in routine COPD management 2, 1
• For COPD maintenance, the recommended dosage for Wixela Inhub® (fluticasone/salmeterol) is 250/50 mcg, 1 inhalation twice daily, approximately 12 hours apart 5
• Common pathogens in COPD exacerbations include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2

Non-Pharmacological Management

• Smoking cessation is crucial at all stages of disease and reduces the rate of lung function decline 2, 1
• Active participation in smoking cessation programs with nicotine replacement therapy increases quit rates 2, 1
• Annual influenza vaccination is recommended, especially for moderate to severe disease 2, 1
• Pulmonary rehabilitation improves exercise performance, reduces breathlessness, and enhances quality of life 2, 1, 6
• Exercise should be encouraged where possible 2, 1
• Address obesity and poor nutrition when present 2, 1

Management of Advanced Disease

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients (PaO2 < 7.3 kPa) 2, 1, 7
• Surgery may be indicated for recurrent pneumothoraces and isolated bullous disease 2, 1
• Lung volume reduction surgery may benefit selected patients 2, 1
• Opiates can be effective for relief of intractable breathlessness in end-stage disease 3
• Assess for depression and provide appropriate treatment 1
• Evaluate social circumstances and available support 1

Exacerbation Management

• Home treatment includes increasing bronchodilators and considering antibiotics if increased breathlessness, increased sputum volume, or purulent sputum is present 1
• Consider hospital admission based on severity of symptoms, general condition, oxygen requirements, and social circumstances 1
• Knowledge of local resistance patterns is helpful in directing empirical antibiotic therapy 2

Common Pitfalls and Caveats

• Subjective improvement is not a satisfactory endpoint for corticosteroid trials; objective spirometric improvement must be documented 2, 1
• Short burst oxygen is often prescribed for breathlessness but evidence supporting this practice is lacking 1
• Air travel may be hazardous if PaO2 breathing air is < 6.7 kPa; check oxygen availability on flights 2, 1
• Inhaled corticosteroids alone do not modify the natural history of COPD and should not be used as standalone therapy 8