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

COPD Management

COPD management requires a stepwise pharmacological approach based on disease severity, combined with non-pharmacological interventions including smoking cessation, oxygen therapy when indicated, and pulmonary rehabilitation to reduce mortality and improve quality of life.

Stable COPD: Pharmacological Management by Severity

Mild Disease (FEV1 ≥60% predicted)

• Initiate short-acting bronchodilators (β2-agonists or anticholinergics) as needed for symptom relief 1
• Consider adding long-acting bronchodilators if symptoms persist despite short-acting agents 1
• Reassess FEV1, symptom relief, and inhaler technique at follow-up visits 1

Moderate to Severe Disease (FEV1 <60% predicted)

• Combine β2-agonists and anticholinergics to maximize bronchodilation 1
• Add theophylline (target serum level 5-15 μg/L) if bronchodilators alone are insufficient, or substitute with long-acting oral/inhaled β2-agonists if theophylline is not tolerated 1
• Consider inhaled corticosteroids if FEV1 decline exceeds 50 mL/year or if frequent exacerbations occur 1
• For high-dose inhaled corticosteroids (≥1,000 μg/day), use large-volume spacer or dry-powder delivery systems 1

Combination Therapy

• Fluticasone/salmeterol combination is FDA-approved for COPD maintenance treatment at 250/50 mcg twice daily, which reduces exacerbations in patients with exacerbation history 2
• The 500/50 mcg strength shows no efficacy advantage over 250/50 mcg for COPD and is not recommended 2
• Patients using combination therapy should not use additional long-acting β2-agonists 2

Exacerbation Management

Severity Assessment

• Immediate hospital evaluation is required for loss of alertness, severe dyspnea, significant clinical deterioration, or when severity is uncertain 1, 3
• Mild exacerbations without these features can be managed at home 1, 3

Mild Exacerbations (Home Management)

• Initiate or increase bronchodilators (β2-agonists and/or anticholinergics) in dose or frequency 1, 3
• Prescribe antibiotics if bacterial infection is suspected (purulent sputum) 1, 3
• Consider short-course corticosteroids (0.4-0.6 mg/kg daily) if marked wheeze is present 1
• Encourage sputum clearance by coughing and adequate fluid intake 1
• Avoid sedatives and hypnotics which worsen respiratory depression 1, 3
• Reassess within 48 hours; refer to hospital if symptoms worsen 1

Severe Exacerbations (Hospital Management)

• Provide controlled oxygen therapy via air-driven nebulizers with supplemental O2 by nasal cannulae to maintain appropriate saturation 1, 3
• Administer systemic corticosteroids (prednisolone 30 mg/day for 7-14 days), oral or intravenous 1, 3
• Combine β2-agonist and anticholinergic bronchodilators via nebulizer or spacer devices 1
• Prescribe antibiotics (oral or intravenous) if infection is present 1
• Consider non-invasive ventilation for patients with severe respiratory acidosis who fail initial therapy 3
• Consider subcutaneous heparin for thromboembolism prophylaxis 1
• Monitor fluid balance and nutrition 1
• Reassess within 30-60 minutes and adjust therapy based on PaO2, symptoms, and clinical signs 1

Post-Exacerbation Management

• Continue nebulized bronchodilators for 24-48 hours until clinical improvement 3
• Transition to usual inhaler therapy 24-48 hours before discharge 3
• Measure FEV1 before discharge to establish new baseline 3
• Check arterial blood gases on room air before discharge in patients who presented with respiratory failure 3

Non-Pharmacological Interventions

Oxygen Therapy

• Long-term oxygen therapy (LTOT) is the only treatment besides smoking cessation proven to modify survival in severe COPD 4
• Indicated for patients with PaO2 <7.5 kPa (56 mmHg) 1

Surgical Options

• Bullectomy may improve lung function and exercise tolerance in selected patients with large unilateral or bilateral air cysts, demonstrated collapsed parenchyma on CT, and preserved transfer factor 1
• Lung transplantation benefits patients <65 years with FEV1 <25% predicted, PaO2 <7.5 kPa (56 mmHg), and PaCO2 >6.5 kPa (49 mmHg), with approximately 50% survival at 5 years 1
• Single lung transplantation is contraindicated with chronic bronchial infection or bronchiectasis in the remaining lung 1

Pulmonary Rehabilitation

• Assess exercise capacity and respiratory muscle function to identify candidates for general body or respiratory muscle training 1
• Rehabilitation programs reduce hospitalizations and improve quality of life 5

Critical Monitoring Parameters

Regular Assessment

• Check dose and frequency of medications, symptom relief, and inhaler technique at each visit 1
• Monitor FEV1 and vital capacity to track disease progression 1
• Reinforce smoking cessation at every encounter 1
• Objective response to therapy is defined as FEV1 improvement ≥10% predicted and/or >200 mL 1

Corticosteroid Safety

• For long-term oral corticosteroids, provide osteoporosis protection with calcium, vitamin D, hormone replacement, or bisphosphonates 1
• Add inhaled corticosteroids to minimize oral corticosteroid dose 1

Common Pitfalls

• Do not delay hospital evaluation when exacerbation severity is uncertain 3
• Avoid using additional long-acting β2-agonists when patients are already on combination therapy 2
• Do not use higher than recommended doses of combination inhalers, as adverse effects increase without additional benefit 2
• Consider alternative diagnoses (pneumonia, pulmonary embolism, heart failure, pneumothorax) that may mimic COPD exacerbation 3
• Patients with PaCO2 ≥6.7 kPa (50 mmHg) or PaO2 ≤6.7 kPa (50 mmHg) should avoid air travel without supplemental oxygen 1