What are the recommended treatments for Chronic Obstructive Pulmonary Disease (COPD)?

COPD Treatment Management

The 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

Assessment and Classification

• Spirometric testing is preferred to peak expiratory flow (PEF) recordings for diagnosis and assessment of COPD severity 2
• A positive spirometric response to bronchodilators or corticosteroids is considered present when FEV1 increases by 200 ml and 15% of baseline value 2
• Estimation of arterial blood gas tensions is necessary in severe COPD to identify persistent hypoxemia with or without hypercapnia 2

Pharmacological Management

Mild COPD

• Patients with no symptoms require no drug treatment 1
• For symptomatic patients, use short-acting bronchodilators as needed:
  • Short-acting β2 agonist OR
  • Short-acting inhaled anticholinergic 2, 1
• Discontinue these medications if ineffective 2

Moderate COPD

• Regular bronchodilator therapy is recommended:
  • Continue short-acting agents as in mild disease but with regular therapy 2
  • Long-acting muscarinic antagonists (LAMAs) are preferred for exacerbation prevention 1, 3
  • Consider a trial of oral corticosteroids to identify potential responders 2
• Most patients will be controlled on a single drug, while some may need combination treatment 2

Severe COPD

• Combination therapy is recommended:
  • Regular β2 agonist AND anticholinergic 2
  • Consider LABA/LAMA combinations for optimal bronchodilation 1, 4
  • Consider corticosteroid trial if not previously done 2
  • Assess for home nebulizer using BTS guidelines 2
• Tiotropium (a LAMA) provides significant improvement in spirometry and lung volumes with once-daily dosing 3, 4

Inhaled Corticosteroids (ICS)

• Add ICS to bronchodilator therapy for patients with persistent exacerbations 1
• LABA/ICS combinations (like fluticasone/salmeterol) are indicated for maintenance treatment of airflow obstruction and reducing exacerbations 5

Delivery Devices and Technique

• Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked 2, 1
• If patients cannot use a metered dose inhaler correctly, alternative devices are justified 2
• Studies show 76% of COPD patients make important errors with metered-dose inhalers, while 10-40% make errors with dry powder inhalers 2, 1
• For patients who cannot generate sufficient inspiratory flow rates for dry powder inhalers, consider pMDI with spacer 6

Non-Pharmacological Management

• Smoking cessation is essential at all stages of disease and is the single most important intervention 2, 1
• Participation in active smoking cessation programs leads to higher sustained quit rates, especially with nicotine replacement therapy 2
• Exercise should be encouraged where possible 2
• Pulmonary rehabilitation programs improve exercise performance and reduce breathlessness in moderate/severe disease 2, 1
• Annual influenza vaccination is recommended, especially for moderate to severe disease 2, 1
• Address obesity and poor nutrition when present 2

Advanced Disease Management

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 2, 7
• LTOT should only be prescribed with objectively demonstrated hypoxia (PaO2 <7.3 kPa) 2
• Consider pulmonary rehabilitation for patients with moderate to severe disease 1
• Surgery may be indicated for recurrent pneumothoraces and isolated bullous disease 2
• Lung volume reduction surgery may be useful in selected patients 2
• Identify and treat depression; assess social circumstances and available support 2

Common Pitfalls and Considerations

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 2
• There is no evidence supporting prophylactic antibiotics given continuously or intermittently 2
• Theophyllines have limited value in routine COPD management 2
• There is no role for other anti-inflammatory drugs such as sodium cromoglycate or nedocromil sodium 2
• Regularly assess inhaler technique as errors are common and can significantly impact treatment efficacy 2, 1