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

Treatment of Chronic Obstructive Pulmonary Disease (COPD)

Smoking cessation is the single most important intervention at all stages of COPD and must be strongly encouraged at every clinical encounter, as it prevents accelerated lung function decline even though it cannot restore already lost function. 1, 2

Non-Pharmacological Management (Essential First Steps)

Smoking Cessation:

• Active smoking cessation programs with nicotine replacement therapy (gum or transdermal patches) achieve higher sustained quit rates than counseling alone 1, 2
• This intervention should be addressed at every visit regardless of disease severity 3

Vaccinations:

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

Pulmonary Rehabilitation:

• Programs including physiotherapy, muscle training, nutritional support, and education improve exercise tolerance and quality of life 1
• Should be considered for patients with moderate to severe disease 3, 2

Nutritional Management:

• Both obesity and poor nutrition require treatment 3

Pharmacological Management (Staged by Disease Severity)

Mild COPD (FEV1 ≥60% predicted)

• Asymptomatic patients require no drug treatment 1, 2
• Symptomatic patients: Short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device 1, 2

Moderate COPD (FEV1 40-59% predicted)

• Regular long-acting bronchodilator monotherapy is recommended 1
• Long-acting muscarinic antagonists (LAMAs) are preferred over long-acting β2-agonists (LABAs) for exacerbation prevention 1
• Consider a corticosteroid trial (30 mg prednisolone daily for 2 weeks with spirometric assessment before and after) 3
• A positive response is defined as FEV1 increase of 200 ml AND 15% of baseline 3

Severe COPD (FEV1 <40% predicted)

• Combination LABA + LAMA therapy is first-line treatment 1
• Regular β2-agonist and anticholinergic combination therapy should be used 3, 2
• Consider corticosteroid trial to identify responders 3
• Assess for home nebulizer therapy using appropriate guidelines 3

Adding Inhaled Corticosteroids (ICS)

ICS should be added to LABA + LAMA only when:

• FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR 1
• Blood eosinophil count ≥150-200 cells/µL, OR 1
• Asthma-COPD overlap syndrome is present 1

LABA/ICS combinations may be first-choice initial therapy for patients with asthma-COPD overlap or high blood eosinophil counts 1

Inhaler Technique (Critical for Efficacy)

• Inhaler technique must be demonstrated before prescribing and regularly checked 1, 2
• 76% of COPD patients make important errors with metered-dose inhalers, while 10-40% make errors with dry powder inhalers 1
• Select an appropriate device to ensure efficient delivery 3

Advanced Disease Management

Long-Term Oxygen Therapy (LTOT)

• LTOT prolongs life in hypoxemic patients and should be prescribed for PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas 1, 2
• Goal is to maintain SpO2 ≥90% during rest, sleep, and exertion 1
• Oxygen concentrators are the easiest mode for home use 1
• Short bursts of oxygen may help intractable dyspnea in end-stage COPD 1

Arterial Blood Gas Assessment

• Estimation of arterial blood gas tensions is necessary in severe COPD to identify persistent hypoxemia with or without hypercapnia 3, 2

Surgical Options

• Surgery may be indicated for recurrent pneumothorax and isolated bullous disease 2
• Lung volume reduction surgery may be useful in selected patients 2

Management of Acute Exacerbations

Increase bronchodilator therapy and consider nebulizers if inhaler technique is inadequate 1

Antibiotics are indicated when ≥2 of the following are present:

• Increased breathlessness 1
• Increased sputum volume 1
• Purulent sputum 1
• Use 7-14 day course when sputum becomes purulent 1

Systemic corticosteroids:

• 30-40 mg prednisone daily for 5-7 days improves lung function and shortens recovery time 1

Critical Pitfalls to Avoid

Medications to Avoid:

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1, 2
• Theophyllines are of limited value in routine COPD management 3, 2
• There is no role for other anti-inflammatory drugs beyond ICS 3
• No evidence supports prophylactic antibiotics given continuously or intermittently 1, 2

Treatment Errors:

• Patients using LABA/ICS combinations should not use additional LABA for any reason 4
• More frequent administration or greater number of inhalations than prescribed is not recommended as higher doses of salmeterol increase adverse effects 4
• Subjective improvement alone is not a satisfactory endpoint for corticosteroid trials; objective spirometric improvement is required 3