What are the diagnosis and treatment options for Chronic Obstructive Pulmonary Disease (COPD)?

Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease (COPD)

COPD should be diagnosed with post-bronchodilator spirometry showing a FEV1/FVC ratio less than 0.70, and treatment should be based on symptom severity and exacerbation risk, with smoking cessation, bronchodilators, pulmonary rehabilitation, and in advanced cases, oxygen therapy forming the cornerstones of management. 1

Diagnosis of COPD

When to Suspect COPD

• Consider COPD in any patient with dyspnea, chronic cough, sputum production, or history of exposure to risk factors (especially smoking, occupational dusts, and indoor/outdoor air pollution) 1
• COPD often develops decades before symptoms appear, with impaired lung growth during childhood/adolescence potentially contributing to disease development 1

Diagnostic Testing

• Spirometry is required to make the diagnosis and should be performed in all suspected cases 1, 2
• Diagnostic criterion: post-bronchodilator FEV1/FVC ratio less than 0.70 confirms persistent airflow limitation 1
• Other pulmonary function tests can provide additional information about disease consequences such as hyperinflation 2

Severity Classification

COPD severity is classified based on spirometry results 1:

• Mild COPD: FEV1/FVC < 0.7 and FEV1 ≥ 80% predicted
• Moderate COPD: FEV1/FVC < 0.7 and FEV1 50-80% predicted
• Severe COPD: FEV1/FVC < 0.7 and FEV1 30-50% predicted
• Very severe COPD: FEV1/FVC < 0.7 and FEV1 < 30% predicted

Additional Assessment

• Comprehensive medical history including exposure to risk factors, past respiratory infections, family history, and impact on quality of life 1
• Evaluation of symptoms (dyspnea, cough, sputum production, wheezing, fatigue) 1
• Assessment of exacerbation history and comorbidities 1

Treatment of COPD

Non-Pharmacological Interventions

Smoking Cessation

• Highest priority for primary prevention and slowing disease progression 1
• Reduces rate of lung function decline and may produce small initial increase in FEV1 1
• Success rates of up to 30% with appropriate support; may require multiple attempts 1

Pulmonary Rehabilitation

• Strongly recommended for symptomatic patients with FEV1 < 50% predicted 1
• Consider for symptomatic or exercise-limited patients with FEV1 > 50% predicted 1
• Improves health status, dyspnea, exercise capacity, and reduces hospitalizations 1, 3

Oxygen Therapy

• Strongly recommended for patients with severe resting hypoxemia (PaO2 ≤ 55 mmHg or SpO2 ≤ 88%) 1
• Improves survival, exercise capacity, sleep and cognitive performance in hypoxemic patients 1
• Goal is to maintain SpO2 > 90% during rest, sleep, and exertion 1

Pharmacological Treatment

Initial Treatment Based on Severity

• For patients with respiratory symptoms and FEV1 between 60-80% predicted: consider inhaled bronchodilators 1
• For patients with respiratory symptoms and FEV1 < 60% predicted: inhaled bronchodilators are recommended 1

Bronchodilator Options

• Monotherapy with either long-acting anticholinergics (e.g., tiotropium) or long-acting β-agonists (e.g., salmeterol) is recommended for symptomatic patients with FEV1 < 60% predicted 1, 4, 5
• Choice between agents should be based on patient preference, cost, and adverse effect profile 1
• Tiotropium is indicated for long-term, once-daily maintenance treatment of COPD 4
• Salmeterol (in combination with fluticasone) is indicated for twice-daily maintenance treatment of airflow obstruction in COPD and to reduce exacerbations 5

Combination Therapy

• Consider combination therapy (long-acting anticholinergics, long-acting β-agonists, or inhaled corticosteroids) for symptomatic patients with FEV1 < 60% predicted 1
• Combining medications of different classes can provide better lung function improvement and symptom relief 1
• Greatest benefits in terms of exacerbations and health status are seen in patients with FEV1 < 50% predicted 1

Inhaled Corticosteroids

• May produce small increases in post-bronchodilator FEV1 and reduce bronchial reactivity 1
• In advanced disease (FEV1 < 50% predicted), can reduce number of exacerbations per year and rate of health status deterioration 1
• No effect on rate of FEV1 decline in any COPD severity 1

Surgical Options

• Bullectomy, lung volume reduction surgery, and lung transplantation may improve spirometry, lung volumes, exercise capacity, and quality of life in highly selected patients 1
• Lung volume reduction surgery shows benefits for patients with non-homogeneous emphysema, particularly with upper lobe predominance 1, 3

Management of Exacerbations

• Shorter courses of antibiotics and corticosteroids are now recommended for exacerbations 6
• For immediate relief of symptoms during exacerbations, short-acting bronchodilators should be used 5

Common Pitfalls and Caveats

• COPD is substantially underdiagnosed, with diagnosis typically delayed until the condition is advanced 7
• Spirometry is essential for diagnosis but often underutilized in clinical practice 7
• Inhaled medications are not indicated for relief of acute bronchospasm 4, 5
• Patients using combination inhalers should not use additional long-acting β-agonists for any reason 5
• Weight loss and muscle wasting contribute significantly to morbidity in COPD; nutritional screening is recommended 1