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

COPD Treatment

Smoking cessation is the single most important intervention for all COPD patients and must be addressed at every clinical encounter, as it is the only treatment proven to slow disease progression. 1, 2

Smoking Cessation (All Stages)

• Nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions significantly increases quit rates and should be offered to all smokers with COPD 1, 3
• Active smoking cessation programs with nicotine replacement achieve the highest sustained quit rates 2, 3

Pharmacological Treatment Algorithm

Mild COPD (Symptomatic)

• Start with short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device 1, 2
• Patients with mild COPD and no symptoms require no drug treatment 2, 3

Moderate COPD

• Initiate long-acting bronchodilator monotherapy as first-line treatment 1, 3
• Long-acting muscarinic antagonists (LAMAs) are preferred over LABAs for exacerbation prevention 1, 2
• Perform a corticosteroid trial (30 mg prednisolone daily for 2 weeks) with spirometric assessment before and after; a positive response is defined as FEV1 increase of 200 ml AND 15% of baseline 1, 3
• If persistent breathlessness occurs on monotherapy, escalate to dual bronchodilator therapy (LABA/LAMA) 3

Severe COPD

• Initiate LABA/LAMA combination therapy as first-line treatment for superior bronchodilation and exacerbation prevention 1, 3
• For patients with low exacerbation risk, LAMA monotherapy or ICS + LABA combination are acceptable alternatives 1, 3

When to Add Inhaled Corticosteroids (ICS)

• Add ICS to LABA + LAMA only if the patient meets ANY of these criteria: 1, 3
  • FEV1 <50% predicted AND ≥2 exacerbations in the previous year
  • Blood eosinophil count ≥150-200 cells/µL
  • Asthma-COPD overlap syndrome
• LABA/ICS combinations may be first-choice initial therapy specifically for patients with asthma-COPD overlap or high blood eosinophil counts 1

Inhaler Technique (Critical)

• Demonstrate proper inhaler technique before prescribing and check regularly at follow-up visits 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 inhaler device to ensure efficient delivery based on patient ability 1, 2

Acute Exacerbation Management

• Increase bronchodilator therapy and consider nebulizers if inhaler technique is inadequate 1
• Prescribe antibiotics (7-14 day course) when ≥2 of the following are present: increased breathlessness, increased sputum volume, purulent sputum 1, 3
• Administer systemic corticosteroids (30-40 mg prednisone daily for 5-7 days) to improve lung function and shorten recovery time 1, 3

Long-Term Oxygen Therapy (LTOT)

• Prescribe LTOT for patients with PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas 1, 3
• Goal is to maintain SpO2 ≥90% during rest, sleep, and exertion 1, 3
• LTOT improves survival in hypoxemic patients 1
• Oxygen concentrators are the easiest mode of treatment for home use 1
• In end-stage COPD, short bursts of oxygen may help intractable dyspnea 1

Pulmonary Rehabilitation

• Refer patients with moderate to severe COPD to comprehensive pulmonary rehabilitation programs 1, 2, 3
• Programs should include physiotherapy, muscle training, nutritional support, and education 1, 3
• These programs increase exercise tolerance and improve quality of life 1, 2

Vaccinations

• Annual influenza vaccination is mandatory for all COPD patients 1, 2, 3
• Pneumococcal vaccination should be administered, with revaccination every 5-10 years 1, 3

Nutritional Management

• Both obesity and poor nutrition require treatment in COPD patients 1
• Nutritional support should be integrated into rehabilitation programs 1, 3

Advanced Disease Considerations

• Consider referral for lung transplantation if BODE index >7, FEV1 <15-20% predicted, or three or more severe exacerbations in the preceding year 3
• Non-invasive ventilatory support should be considered for patients with severe nocturnal hypoxemia or respiratory muscle weakness 1
• Surgery may be indicated for recurrent lung collapses and isolated bullous disease 2
• Lung volume reduction surgery may be useful in selected patients 2

Critical Pitfalls to Avoid

• Never prescribe beta-blocking agents (including eyedrop formulations) in COPD patients 1, 2, 3
• There is no evidence supporting prophylactic antibiotics given continuously or intermittently 1, 2, 3
• Theophyllines are of limited value in routine COPD management 1, 2, 3
• Patients using LABA/ICS or LABA/LAMA 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 1