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

COPD Treatment

Smoking cessation is the single most important intervention for all COPD patients and must be strongly encouraged at every clinical encounter, while bronchodilators form the cornerstone of pharmacological management with treatment intensity escalating based on disease severity and exacerbation risk. 1

Smoking Cessation - The Foundation

• Smoking cessation is essential at all stages of COPD and represents the only intervention proven to slow disease progression. 1, 2
• Nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions significantly increases quit rates. 1
• Active smoking cessation programs should be offered at every clinical encounter, as participation leads to higher sustained quit rates. 2

Pharmacological Management - Staged Approach

Mild COPD (Symptomatic)

• Patients with mild COPD and no symptoms require no drug treatment. 1, 2
• For symptomatic mild COPD, initiate short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device. 1, 2

Moderate COPD

• Regular long-acting bronchodilator monotherapy is recommended, with long-acting muscarinic antagonists (LAMAs) preferred for exacerbation prevention. 1
• LAMAs such as tiotropium (once daily), glycopyrronium (once daily), or aclidinium (twice daily) provide superior bronchodilation compared to short-acting agents. 3

Severe COPD

• Combination LABA/LAMA therapy is first-line treatment for severe COPD, providing optimal bronchodilation through complementary mechanisms. 1
• For severe COPD with high exacerbation risk, LABA + LAMA combination is the recommended initial approach. 1
• For severe COPD with low exacerbation risk, either LAMA monotherapy or ICS + LABA combination may be used. 1

When to Add Inhaled Corticosteroids (ICS)

• Add ICS to LABA + LAMA only if the patient meets specific criteria: FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR blood eosinophil count ≥150-200 cells/µL, OR asthma-COPD overlap syndrome. 1
• ICS may be added to bronchodilator therapy for patients with persistent exacerbations despite optimal bronchodilator use. 1
• LABA/ICS combinations (such as fluticasone/salmeterol 250/50 mcg twice daily) may be first-choice for asthma-COPD overlap or high eosinophil counts. 1, 4

Inhaler Technique - Critical for Success

• Inhaler technique must be demonstrated before prescribing and checked regularly, as 76% of patients make critical errors with metered-dose inhalers. 1
• After inhalation, patients should rinse their mouth with water without swallowing to reduce oropharyngeal candidiasis risk. 4
• Dry powder inhalers have lower error rates (10-40%) compared to metered-dose inhalers. 1

Pulmonary Rehabilitation

• Rehabilitation programs increase exercise tolerance and improve quality of life and should include physiotherapy, muscle training, nutritional support, and education. 1
• Pulmonary rehabilitation is recommended for moderate to severe disease and reduces breathlessness. 2

Long-Term Oxygen Therapy (LTOT)

• LTOT is recommended for patients with PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas, with the goal of maintaining SpO2 ≥90% during rest, sleep, and exertion. 1
• LTOT improves survival in hypoxemic patients and should only be prescribed with objectively demonstrated low oxygen levels. 1, 2
• Oxygen concentrators are the easiest mode for home use. 1

Acute Exacerbation Management

Bronchodilator Escalation

• Increase bronchodilator therapy during exacerbations and consider nebulizers if inhaler technique is inadequate. 1

Antibiotic Indications

• Antibiotics are indicated when ≥2 of the following are present: increased breathlessness, increased sputum volume, purulent sputum (7-14 day course). 1

Systemic Corticosteroids

• Systemic corticosteroids (30-40 mg prednisone daily for 5-7 days) improve lung function and shorten recovery time during acute exacerbations. 1

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients, especially those with moderate to severe disease. 1, 2
• Pneumococcal vaccination should be considered, with revaccination every 5-10 years. 1

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) must be avoided in COPD patients. 1, 2
• There is no evidence supporting prophylactic antibiotics given continuously or intermittently. 1, 2
• Patients using LABA/ICS combinations should not use additional LABA for any reason. 4
• LABA/ICS combinations are NOT indicated for relief of acute bronchospasm. 4
• Theophyllines have limited value in routine COPD management. 2

Advanced Disease Considerations

• Non-invasive ventilatory support should be considered for severe nocturnal hypoxemia or respiratory muscle weakness. 1
• Surgery may be indicated for recurrent pneumothorax and isolated bullous disease. 2
• Lung volume reduction surgery may be useful in selected patients. 2