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

COPD Treatment Guidelines

COPD treatment should follow a stepwise approach based on disease severity, with bronchodilators as the cornerstone of pharmacological management and smoking cessation as the most essential non-pharmacological intervention. 1, 2

Assessment and Diagnosis

• Spirometric testing is essential for diagnosis, with persistent airflow limitation defined as post-bronchodilator FEV1/FVC < 0.7 1
• A positive bronchodilator response is present when FEV1 increases by 200 ml and 15% of baseline value 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

Pharmacological Management by Disease Severity

Mild COPD

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed for symptomatic relief 3, 2
• No regular medication needed if patient remains asymptomatic 2

Moderate COPD

• Regular therapy with short-acting bronchodilators or a combination of both 3
• Consider long-acting bronchodilators (LABAs or LAMAs) for more consistent symptom control 2, 4
• A corticosteroid trial should be considered in all patients 3

Severe COPD

• Combination therapy with regular β2-agonist and anticholinergic agents 3
• Long-acting bronchodilators provide superior clinical outcomes compared to short-acting agents 4, 5
• Consider a corticosteroid trial and assess for home nebulizer use 3
• Wixela Inhub® 250/50 (fluticasone propionate/salmeterol) twice daily is indicated for maintenance treatment of airflow obstruction and reducing exacerbations 6

Non-Pharmacological Management

• Smoking cessation is crucial at all stages of disease and is the single most important intervention 1, 2
• Active participation in smoking cessation programs with nicotine replacement therapy increases quit rates 1
• Exercise should be encouraged where possible 3, 1
• Pulmonary rehabilitation improves exercise performance and reduces breathlessness in moderate to severe disease 1, 2
• Annual influenza vaccination is recommended, especially for moderate to severe disease 1, 2
• Address obesity and poor nutrition when present 3, 1

Management of Advanced Disease

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients (PaO2 < 7.3 kPa) 1, 7
• LTOT should only be prescribed if objectively demonstrated hypoxia or with high oxygen cylinder use (more than two per week) 3, 1
• Surgery may be indicated for recurrent pneumothoraces and isolated bullous disease 1
• Lung volume reduction surgery may benefit selected patients 1
• Assess for depression and provide appropriate treatment 1

Common Pitfalls and Considerations

• Subjective improvement is not a satisfactory endpoint for corticosteroid trials; objective spirometric improvement must be documented 1
• Short burst oxygen is often prescribed for breathlessness but evidence supporting this practice is lacking 1
• Theophyllines have limited value in routine COPD management 3, 2
• Long-acting β2-agonists should only be used if objective evidence of improvement is available 3
• Regularly assess inhaler technique as errors are common and can significantly impact treatment efficacy 1, 2
• Air travel may be hazardous if PaO2 breathing air is < 6.7 kPa; check oxygen availability on flights 3

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