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

COPD Stage-Based Treatment Algorithm

Mild COPD (Symptomatic Patients)

For patients with mild COPD who are symptomatic, initiate short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device. 1

• Patients with mild COPD and no symptoms require no drug treatment 1
• When symptoms develop, a trial of short-acting bronchodilators should be prescribed 1
• Inhaler technique must be demonstrated before prescribing and regularly checked, as 76% of COPD patients make important errors with metered-dose inhalers 1

Moderate COPD

Regular use of long-acting bronchodilator monotherapy is the cornerstone of moderate COPD treatment, with long-acting muscarinic antagonists (LAMAs) preferred for exacerbation prevention. 1

• LAMAs such as tiotropium (once-daily) or aclidinium (twice-daily) provide sustained bronchodilation 2
• Alternative options include long-acting β2-agonists (LABAs) like indacaterol (once-daily) or formoterol/salmeterol (twice-daily) 2
• A corticosteroid trial (30 mg prednisolone daily for 2 weeks with spirometric assessment) should be performed, with a positive response defined as FEV1 increase of 200 ml AND 15% of baseline 1
• If the corticosteroid trial is positive, consider adding inhaled corticosteroids (ICS) to bronchodilator therapy 1

Severe COPD

Combination therapy with LABA/LAMA is first-line treatment for severe COPD, providing superior bronchodilation and exacerbation prevention compared to monotherapy. 1

• Approved LABA/LAMA combinations include indacaterol/glycopyrronium, umeclidinium/vilanterol, and olodaterol/tiotropium 2
• Regular β2-agonist and anticholinergic combination therapy should be used 1
• For patients with severe COPD and low exacerbation risk, LAMA monotherapy or ICS + LABA combination therapy are alternatives 1
• For patients with FEV1 <50% predicted and ≥2 exacerbations in the previous year, add ICS to LABA + LAMA combination therapy 1
• Consider adding ICS if blood eosinophil count ≥150-200 cells/µL or if asthma-COPD overlap syndrome is present 1

Very Severe/End-Stage COPD

Long-term oxygen therapy (LTOT) is indicated for patients with PaO2 ≤55 mmHg (7.3 kPa), with the goal of maintaining SpO2 ≥90% during rest, sleep, and exertion. 1

• LTOT improves survival in hypoxemic patients and is one of only two interventions (along with smoking cessation) proven to modify mortality 1
• Oxygen concentrators are the easiest mode of treatment for home use 1
• Short bursts of oxygen may help intractable dyspnea in end-stage disease 1
• Assess for home nebulizer therapy using appropriate guidelines 1
• Consider referral for lung transplantation if BODE index >7, FEV1 <15-20% predicted, or three or more severe exacerbations in the preceding year 3

Universal Interventions Across All Stages

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

• Nicotine replacement therapy (gum or transdermal patches) and behavioral interventions increase success rates 1
• Active smoking cessation programs with nicotine replacement achieve higher sustained quit rates 1

Pulmonary rehabilitation programs improve exercise tolerance and quality of life in patients with moderate to severe COPD. 1

• Programs should include physiotherapy, muscle training, nutritional support, and education 1
• Annual influenza vaccination is recommended for all COPD patients 1
• Pneumococcal vaccination may be considered, with revaccination every 5-10 years 1

Management of Acute Exacerbations

Exacerbations are classified as mild (treated with short-acting bronchodilators only), moderate (requiring antibiotics and/or oral corticosteroids), or severe (requiring hospitalization). 3

• Increase bronchodilator therapy and consider nebulizers if inhaler technique is inadequate 1
• Antibiotics are indicated when ≥2 of the following are present: increased breathlessness, increased sputum volume, purulent sputum 1
• Use a 7-14 day course when sputum becomes purulent 1
• Systemic corticosteroids (30-40 mg prednisone daily for 5-7 days) improve lung function and shorten recovery time 1
• Non-invasive ventilation (NIV) should be the first mode of ventilation for acute respiratory failure 3
• Maintenance therapy with long-acting bronchodilators should be initiated before hospital discharge 3

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1
• There is no evidence supporting prophylactic antibiotics given continuously or intermittently 1
• Theophyllines are of limited value in routine COPD management 1
• Never use LABA monotherapy without ICS in patients with asthma-COPD overlap 4, 5
• Do not use more than one LABA-containing medication simultaneously to avoid overdose risk 5