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

COPD Symptoms and Treatment

Symptoms of COPD

COPD primarily manifests as progressive breathlessness on exertion, chronic cough, and sputum production, with symptoms worsening over time and during acute exacerbations. 1

The cardinal symptoms include:

• Dyspnea (breathlessness) - typically progressive and worse with physical activity, which can be assessed by the patient's ability to perform specific tasks like climbing stairs, shopping, or walking around the house 2
• Chronic cough - may be intermittent or present throughout the day 1
• Sputum production - chronic production of mucus, which becomes purulent during infectious exacerbations 2
• Wheezing and chest tightness - particularly during exacerbations 1

Treatment Approach

Smoking Cessation - The Most Critical Intervention

Smoking cessation is the single most important intervention for all COPD patients and must be strongly encouraged at every clinical encounter. 1

• Nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions significantly increases quit rates 2, 1
• Healthcare professionals should not smoke and should provide helpful strategies and encouragement at every visit 2

Bronchodilator Therapy - The Cornerstone of Treatment

For symptomatic COPD, long-acting bronchodilators are superior to short-acting agents and should be initiated early in the treatment algorithm. 2, 1

Mild COPD (Group A - Low Symptoms, Low Risk)

• Short-acting bronchodilators (β2-agonist or anticholinergic) as needed 2, 1
• If ineffective after trial, discontinue 2

Moderate COPD (Group B - High Symptoms, Low Risk)

• Start with a single long-acting bronchodilator - either LAMA (long-acting muscarinic antagonist) or LABA (long-acting β2-agonist) 2, 1
• LAMAs are preferred for exacerbation prevention 2, 1
• For persistent breathlessness on monotherapy, escalate to LABA/LAMA combination 2

Severe COPD (Group D - High Symptoms, High Risk)

• Initial therapy should be LABA/LAMA combination 2, 1
• This combination is superior to LABA/ICS for preventing exacerbations and has lower pneumonia risk 2
• Tiotropium 18 mcg once daily provides sustained bronchodilation (approximately 12% improvement in trough FEV1) and reduces exacerbations over 12 months 3, 4

Inhaled Corticosteroids (ICS)

ICS should NOT be first-line therapy but may be added for patients with persistent exacerbations despite optimal bronchodilator therapy. 2, 1

• Add ICS to LABA/LAMA if: FEV1 <50% predicted AND ≥2 exacerbations in previous year, OR blood eosinophil count ≥150-200 cells/µL, OR asthma-COPD overlap 1
• Critical caveat: ICS increases pneumonia risk, so use judiciously 2
• LABA/ICS may be first choice only for patients with asthma-COPD overlap or high eosinophil counts 2, 1

Inhaler Technique - A Common Pitfall

Proper inhaler technique must be demonstrated before prescribing and checked regularly, as 76% of patients make critical errors with metered-dose inhalers. 1

• Multiple device options exist: metered-dose inhalers with spacers, breath-actuated inhalers, and dry-powder inhalers 2
• During acute exacerbations, nebulizers may be easier for breathless patients 2
• Patients should rinse mouth after ICS use to prevent oral candidiasis 5

Management of Acute Exacerbations

When sputum becomes purulent, initiate empirical antibiotics for 7-14 days. 2, 1

• Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 2
• First-line antibiotics: amoxicillin, tetracycline derivatives, or amoxicillin/clavulanic acid 2
• Systemic corticosteroids (40 mg prednisone daily for 5 days) improve lung function and shorten recovery 1
• Increase bronchodilator therapy; consider nebulizers if inhaler technique inadequate 1

Additional Pharmacologic Therapies

For patients with continued exacerbations on LABA/LAMA/ICS:

• Roflumilast (PDE4 inhibitor) - consider if FEV1 <50% predicted with chronic bronchitis and hospitalization for exacerbation in previous year 2
• Macrolide antibiotics in former smokers - weigh against risk of resistant organisms 2

Important: Prophylactic antibiotics have no role in stable COPD. 2, 1

Non-Pharmacologic Interventions

Pulmonary rehabilitation programs significantly improve exercise tolerance and quality of life and should be offered to all patients with high symptom burden (Groups B, C, D). 2, 1

• Programs should include physiotherapy, muscle training, nutritional support, and education 1
• Exercise training combining aerobic and strength training provides optimal outcomes 2

Oxygen Therapy

Long-term oxygen therapy (LTOT) improves survival in hypoxemic patients with PaO2 ≤55 mmHg. 1

• Goal: maintain SpO2 ≥90% during rest, sleep, and exertion 1
• Oxygen concentrators are the preferred mode for home use 1

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients 2, 1
• Pneumococcal vaccination may be considered with revaccination every 5-10 years 1

Critical Medications to Avoid

Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients. 1