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

COPD Treatment

COPD treatment should be stratified by disease severity and symptom burden, with smoking cessation as the absolute priority, followed by bronchodilator therapy as the pharmacological foundation, escalating from short-acting agents for mild disease to combination long-acting bronchodilators for moderate-severe disease. 1, 2

Non-Pharmacological Management (Essential First Steps)

Smoking Cessation

• Smoking cessation is mandatory at all stages and is the only intervention proven to slow disease progression. 3, 1
• Intensive support programs with nicotine replacement therapy achieve higher sustained quit rates than simple advice alone. 3
• All healthcare professionals should provide repeated encouragement at every consultation. 3

Pulmonary Rehabilitation and Exercise

• Pulmonary rehabilitation improves exercise performance and reduces breathlessness in moderate-to-severe disease (Groups B, C, D). 3, 1
• Exercise training should combine constant load or interval training with strength training. 1
• Exercise should be encouraged at all disease stages. 3

Vaccinations and Nutrition

• Influenza vaccination is recommended, especially for moderate-to-severe disease. 3
• Both obesity and poor nutrition require treatment. 3

Pharmacological Treatment Algorithm by Disease Severity

Mild COPD (Group A: Low Symptoms, Low Exacerbation Risk)

• No drug treatment if asymptomatic. 3, 2
• For symptomatic patients: Short-acting bronchodilator (SABA or SAMA) as needed. 1, 2
  • Options include inhaled β2-agonist OR anticholinergic via appropriate inhaler device. 3
  • If ineffective, discontinue the medication. 3

Moderate COPD (Group B: High Symptoms, Low Exacerbation Risk)

• Initial therapy: Single long-acting bronchodilator (LABA or LAMA). 1, 2
• Most patients controlled on monotherapy; few require combination treatment. 3, 2
• Treatment level depends on symptom severity and lifestyle impact. 3
• Consider corticosteroid trial in all moderate disease patients. 3

Severe COPD (Group D: High Symptoms, High Exacerbation Risk)

• LABA/LAMA combination therapy as initial treatment—superior for patient-reported outcomes and exacerbation prevention compared to monotherapy. 1, 2
• Long-acting muscarinic antagonists (e.g., tiotropium) are preferred over LABAs for exacerbation prevention. 2, 4
• Consider adding inhaled corticosteroids (ICS) for patients with persistent exacerbations. 2
• Assess for home nebulizer therapy using formal respiratory physician evaluation. 3, 2

Specific Medication Classes

Bronchodilators (Foundation of Treatment)

• Short-acting agents (SABA/SAMA): Provide symptom relief within minutes, lasting 4-5 hours; used as rescue therapy. 3, 2
• Long-acting agents: Tiotropium (once-daily LAMA) demonstrates consistent superiority to short-acting ipratropium and effectively prevents exacerbations. 4
• LABA/LAMA combinations: Provide complementary pharmacological actions with greater bronchodilation than either component alone. 5
• Beta-blocking agents (including eyedrop formulations) must be avoided. 3, 2

Inhaled Corticosteroids

• Add ICS to bronchodilator therapy for patients with persistent exacerbations. 2
• LABA/ICS combinations may be first-choice for patients with asthma-COPD overlap or high blood eosinophil counts. 2
• Critical caveat: ICS use increases pneumonia risk, especially in current smokers, older patients, those with prior exacerbations/pneumonia, low BMI, or severe airflow limitation. 1
• A positive corticosteroid response is defined as FEV1 increase by 200 ml AND 15% of baseline. 3
• Trial of oral corticosteroids (30 mg prednisolone daily for 2 weeks) indicated for assessing moderate-to-severe disease; 10-20% show objective improvement. 3

Theophyllines

• Only modest bronchodilators with variable effects; limited value in routine management. 3, 2
• Can be tried in severe disease but require monitoring for side effects. 2
• Sustained-release preparations preferred due to more predictable pharmacokinetics. 3

Long-Acting β2-Agonists

• Limited evidence for long-acting inhaled β2-agonists in COPD; use only with demonstrable bronchodilator response and monitor symptoms plus FEV1. 3
• No evidence supports sustained-release oral β2-agonists. 3

Phosphodiesterase-4 Inhibitors

• Consider for patients with FEV1 <50% predicted and chronic bronchitis who continue exacerbations despite LABA/LAMA/ICS therapy. 2

Inhaler Device Selection and Technique

• Metered-dose inhalers are cheapest but 76% of COPD patients make important errors; 10-40% make errors with dry powder inhalers. 3
• Inhaler technique must be demonstrated before prescribing and rechecked before changing treatments. 3, 2
• If patients cannot use metered-dose inhalers correctly, more expensive devices are justified. 3
• Most patients can be treated with bronchodilators via metered-dose inhalers with spacers or dry powder devices. 3

Home Nebulizer Therapy

• Only supply after full assessment by respiratory physician who can advise on risk/cost benefit. 3, 2
• Assessment must confirm: correct diagnosis, optimal use of other inhalers, patient response to nebulizer, and home trial with peak flow measurements. 3

Exacerbation Management

• Short-acting bronchodilators as first-line treatment. 1, 2
• Systemic corticosteroids (40 mg prednisone daily for 5 days) improve recovery time and lung function. 1, 2
• Antibiotics shorten recovery time and reduce early relapse risk when indicated. 2
  • Most common organisms: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, viruses. 3
  • Empirical 7-14 day course when sputum becomes purulent. 3
  • Common choices: amoxicillin, tetracycline derivatives, amoxicillin/clavulanic acid. 3
  • Patients may keep antibiotics in reserve and start when symptoms suggest infection. 3
• Non-invasive ventilation as first-line ventilatory support in acute respiratory failure. 1

Medications Without Proven Benefit

• No evidence supports: prophylactic antibiotics (continuous or intermittent), sodium cromoglycate, nedocromil sodium, antihistamines, or mucolytics. 3
• No role for antitussives. 1

Special Considerations

Long-Term Oxygen Therapy (LTOT)

• LTOT prolongs life in hypoxemic patients. 3
• Only prescribe if objectively demonstrated hypoxia (PaO2 <7.3 kPa) or high cylinder use (>2 per week). 3
• Continuous oxygen for severe hypoxemia (PaO2 <55 mmHg or oxygen saturation <88%). 6

Alpha-1 Antitrypsin Deficiency

• Augmentation therapy may be considered for patients with severe hereditary deficiency and established emphysema. 1

Surgical Options

• Indicated for recurrent pneumothoraces and isolated bullous disease. 3
• Lung volume reduction surgery may be considered in selected cases. 3

Critical Pitfalls to Avoid

• Never use LABA without ICS in asthma patients (contraindicated). 7, 8
• Do not discontinue LABA before initiating ICS—may precipitate exacerbations. 6
• Patients using combination LABA/ICS should not use additional LABA for any reason. 7
• Avoid more frequent administration than prescribed—higher doses increase adverse effects. 7
• Rinse mouth with water after inhalation to reduce oropharyngeal candidiasis risk. 7