What is the recommended treatment approach for Chronic Obstructive Pulmonary Disease (COPD) and asthma?

Treatment of COPD and Asthma

Diagnostic Differentiation First

Before initiating treatment, confirm the diagnosis with post-bronchodilator spirometry: FEV1/FVC <0.70 with minimal reversibility indicates COPD, while significant reversibility (>12% and >200 mL improvement) suggests asthma. 1

Key Diagnostic Features:

• COPD: Develops after age 40, significant smoking/occupational exposure history, persistent airflow limitation not fully reversible, emphysema on imaging 1
• Asthma: Variable airflow limitation often reversible spontaneously or with therapy, can begin at any age (often childhood), associated with atopy, marked bronchodilator response 1
• Asthma-COPD Overlap: Requires ≥2 major criteria (FEV1 increase ≥15% and ≥400 mL, sputum eosinophilia ≥3%, history of asthma) OR 1 major + 2 minor criteria (elevated IgE, atopy, positive bronchodilator test ≥12% and ≥200 mL) 2

Treatment Algorithm for COPD

Step 1: Initial Bronchodilator Therapy

Start with long-acting muscarinic antagonist (LAMA) or long-acting beta-agonist (LABA) monotherapy for all symptomatic COPD patients. 1, 3 LAMAs are preferred over LABAs for exacerbation prevention 3.

• Mild COPD (intermittent symptoms): As-needed short-acting beta-agonist (salbutamol 2.5-5 mg) or short-acting anticholinergic 3
• Moderate COPD (Group B): LAMA or LABA monotherapy 3
• Severe COPD: LABA + LAMA combination if increased benefit demonstrated 3

Step 2: When to Add Inhaled Corticosteroids (ICS)

Add ICS to bronchodilator therapy ONLY for patients with: 1, 3

• Frequent exacerbations (≥2 per year) despite optimal bronchodilator therapy
• Blood eosinophil count ≥300 cells/µL 4
• Sputum eosinophilia
• Features of asthma-COPD overlap

Critical caveat: ICS overuse in COPD increases pneumonia risk significantly 4. Do not prescribe ICS routinely in COPD without these specific indications.

Step 3: Triple Therapy

For patients with persistent exacerbations despite LABA + LAMA, add ICS to create triple therapy (LABA + LAMA + ICS), but only if blood eosinophils ≥300 cells/µL 4.

Treatment Algorithm for Asthma

Step 1: Controller Medication

Initiate low-dose inhaled corticosteroid (ICS) as first-line controller medication for all patients with persistent asthma. 1, 3 This is fundamentally different from COPD—the threshold for ICS use is much lower in asthma 3.

• Short-acting beta-agonist (SABA) as needed for symptom relief 1
• Mild persistent asthma: Low-dose ICS 3

Step 2: Add Long-Acting Bronchodilator

For persistent symptoms despite ICS, add LABA to create ICS/LABA combination therapy. 1, 5

• Moderate persistent asthma: Low to medium-dose ICS + LABA 3
• Severe persistent asthma: High-dose ICS + LABA 3

Step 3: Add-On Therapies

For difficult-to-control asthma despite ICS/LABA: 1

• Consider adding tiotropium (LAMA)—this reduces exacerbation risk by 35% compared to increasing ICS dose 6
• Alternative: Leukotriene modifiers 1

Important: Adding tiotropium is superior to simply increasing ICS/LABA dose, with 64-73% lower exacerbation rates, 47% fewer ED visits, and 48% fewer hospitalizations 6.

Treatment Algorithm for Asthma-COPD Overlap

Start immediately with ICS/LABA combination therapy regardless of symptom severity—this is mandatory for overlap patients. 2, 1, 7 This differs from pure COPD where ICS is reserved for specific indications.

Initial Therapy:

• ICS/LABA combination (e.g., fluticasone/salmeterol 250/50 mcg twice daily) 2, 5

Escalation for Persistent Symptoms:

• Add LAMA to create triple therapy (ICS + LABA + LAMA) 2, 1

Rationale:

Overlap patients have mixed inflammatory patterns (both eosinophilic and neutrophilic) requiring the asthma treatment paradigm 7. They experience higher exacerbation burden, worse quality of life, and potentially higher mortality than either disease alone 7.

Acute Exacerbation Management

COPD Exacerbation:

• Bronchodilators: Nebulized salbutamol 5 mg or terbutaline 10 mg, repeat 4-6 hourly 3
• Systemic corticosteroids: Prednisone 40 mg daily for 5 days 3
• Antibiotics: Only if increased sputum purulence or mechanical ventilation required 3
• Oxygen: Target saturation 88-92% 3

Asthma Exacerbation (Severe):

• Severity criteria: Cannot complete sentences, respiratory rate >25/min, heart rate >110/min, peak flow <50% best 2, 3
• Treatment: Oxygen + oral steroids + nebulized salbutamol 5 mg repeated 4-6 hourly 2, 3
• If not improving: Add ipratropium 500 µg to beta-agonist and consider hospital admission 2

Overlap Exacerbation:

• Continue ICS/LABA throughout exacerbation 7
• Prednisolone 30-40 mg daily for 5-7 days maximum 7
• Antibiotics if 2-3 cardinal symptoms present (increased dyspnea, sputum volume, sputum purulence) 7
• Consider non-invasive ventilation if pH <7.35, PaCO2 >45 mmHg, respiratory rate >25/min despite initial therapy 7

Critical Implementation Points

Inhaler Technique:

Directly observe and correct inhaler technique before prescribing and before changing treatments—this is the most common cause of treatment failure. 3 Reassess technique at every visit.

Contraindications:

• Avoid beta-blockers in all COPD patients 3
• Do not use LABA monotherapy in asthma—always combine with ICS 5
• Do not combine with additional LABA-containing medications (overdose risk) 5

Monitoring:

• Asthma: Titrate ICS dose based on type-2 inflammation biomarkers (blood eosinophils, FeNO) rather than symptoms alone—this reduces exacerbations more effectively than symptom-based escalation 2
• COPD: Monitor for pneumonia with long-term ICS use 5, 4
• Both: Assess bone mineral density, monitor growth in pediatric patients, screen for glaucoma/cataracts with long-term ICS 5

Adjunctive Therapies:

• Pulmonary rehabilitation: Improves health status and dyspnea in COPD 3
• Vaccinations: Influenza annually for all patients; pneumococcal for COPD patients >65 years 3
• Long-term oxygen: For stable COPD patients with resting hypoxemia or evidence of cor pulmonale 3