What is the recommended care plan for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

COPD Care Plan

A comprehensive COPD care plan should be built on a foundation of smoking cessation, staged pharmacologic bronchodilator therapy based on symptom burden and exacerbation risk, pulmonary rehabilitation for symptomatic patients, vaccinations, and long-term oxygen therapy when indicated—all aimed at reducing mortality, preventing exacerbations, and improving quality of life. 1, 2

Smoking Cessation (Highest Priority Intervention)

• Smoking cessation is the single most important intervention and must be addressed at every clinical visit regardless of disease severity, as it is one of only two interventions proven to modify survival in COPD (along with long-term oxygen therapy). 1, 2
• Nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions significantly increases quit rates and should be actively offered. 1
• Active smoking cessation programs with nicotine replacement achieve higher sustained quit rates than advice alone. 2

Pharmacologic Therapy: Staged Bronchodilator Approach

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

• Start with short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device. 1, 2
• Patients with mild disease and no symptoms require no regular drug treatment. 3
• Encourage continuation of all usual activities except the most strenuous jobs, as exercise is both safe and desirable. 3

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

• Initiate long-acting bronchodilator monotherapy as first-line treatment—either LAMA or LABA. 1, 2
• Long-acting muscarinic antagonists (LAMAs) are preferred over LABAs for exacerbation prevention. 1, 4
• Consider a corticosteroid trial (30 mg prednisolone daily for 2 weeks with spirometric assessment before and after) to identify steroid-responsive patients. 2
• A positive corticosteroid response is defined as FEV1 increase of 200 ml AND 15% of baseline. 2

Severe COPD (High Symptoms, High Risk - GOLD Group C/D)

• Initiate combination therapy with LABA + LAMA as first-line treatment for patients with severe disease and high exacerbation risk. 1, 2
• Most patients with severe disease will benefit from combination of β2-agonist and anticholinergic bronchodilators. 3
• Add inhaled corticosteroids (ICS) to LABA + LAMA only if: FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR blood eosinophil count ≥150-200 cells/µL, OR asthma-COPD overlap syndrome. 1
• Theophyllines can be tried but must be monitored closely for side effects and are of limited value in routine management. 3, 2
• High-dose treatment including nebulized drugs should only be prescribed after formal assessment. 3

Inhaler Technique (Critical for Treatment Success)

• Inhaler technique must be demonstrated to patients before prescribing and regularly re-checked, as 76% of COPD patients make important errors with metered-dose inhalers and 10-40% with dry powder inhalers. 1, 4
• Select an appropriate inhaler device to ensure efficient delivery based on patient ability. 2
• Always verify proper inhaler technique before escalating therapy or changing medications, as this is the most common cause of treatment failure. 4

Non-Pharmacologic Interventions

Pulmonary Rehabilitation

• Offer pulmonary rehabilitation to all patients with high symptom burden (GOLD groups B, C, and D), as it improves exercise tolerance, quality of life, and health status. 1, 2
• Programs should include physiotherapy, muscle training, nutritional support, and education. 1, 2
• Initiate rehabilitation within 3 weeks after hospital discharge, but not during hospitalization. 2
• Exercise training should combine constant load or interval training with strength training. 2

Exercise Prescription

• Encourage exercise within the limitations of airways obstruction for moderate and severe COPD. 3
• Breathlessness on exertion is distressing but not dangerous—patients can continue activities despite impairment. 3
• Patients with moderate COPD can often continue employment as long as it does not involve heavy manual work. 3

Nutritional Management

• Weight reduction in obese patients reduces energy requirements of exercise and improves ability to cope with disability. 3
• Malnutrition is common in severe COPD and may contribute to mortality—nutritional supplementation is recommended for malnourished patients. 3, 2
• Both obesity and poor nutrition require active treatment. 2

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients, with evidence showing 70% reduction in mortality in elderly patients. 3, 1, 2
• Pneumococcal vaccinations (PCV13 and PPSV23) are recommended for all patients older than 65 years. 2
• Pneumococcal vaccine may be considered with revaccination every 5-10 years, though COPD-specific studies are lacking. 3, 1

Long-Term Oxygen Therapy (LTOT)

• Prescribe LTOT for stable patients with PaO2 ≤55 mmHg (7.3 kPa) or SaO2 ≤88%, confirmed twice over 3 weeks. 1, 2
• LTOT is indicated for patients with evidence of pulmonary hypertension, peripheral edema, or polycythemia. 4
• LTOT improves survival in hypoxemic patients and is the only treatment besides smoking cessation proven to modify survival rates in severe COPD. 1, 2
• Oxygen concentrators are the easiest mode of treatment for home use. 1
• Goal is to maintain SpO2 ≥90% during rest, sleep, and exertion. 1, 2

Management of Acute Exacerbations

Bronchodilator Therapy

• Increase bronchodilator therapy with short-acting inhaled β2-agonists (salbutamol 2.5-5mg or terbutaline 5-10mg) with or without short-acting anticholinergics. 4
• Consider nebulizers if inhaler technique is inadequate during exacerbation. 1

Antibiotic Therapy

• Prescribe antibiotics (7-14 day course) when ≥2 of the following are present: increased breathlessness, increased sputum volume, or purulent sputum. 1, 2, 4
• Antibiotics are indicated when sputum becomes purulent or when mechanical ventilation is required. 1, 4

Systemic Corticosteroids

• Administer systemic corticosteroids (40mg prednisone daily for 5 days) to improve lung function, oxygenation, and shorten recovery time. 1, 4
• Alternative regimen: 30-40 mg prednisone daily for 5-7 days. 1

Self-Management Education

• Provide education including: smoking cessation strategies, basic COPD information, proper use of respiratory medications and inhalation devices, strategies to minimize dyspnea, and advice about when to seek help. 2
• Quality of life assessment is important and most easily measured by health profile questionnaire. 3

Advanced Therapies for Selected Patients

• Consider non-invasive ventilation (NIV) for patients with pronounced daytime hypercapnia and recent hospitalization. 2, 4
• Consider lung volume reduction (surgical or bronchoscopic) for selected patients with emphysema and significant hyperinflation refractory to medical care. 2

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) must be avoided in COPD patients. 1, 2, 4
• There is no role for other anti-inflammatory drugs beyond inhaled corticosteroids (sodium cromoglycate, nedocromil sodium, antihistamines, or mucolytics). 3, 2
• There is no evidence supporting prophylactic antibiotics given continuously or intermittently. 1
• Pulmonary vasodilators have no role in COPD with pulmonary hypertension. 3
• Overuse of ICS in COPD increases pneumonia risk—use selectively. 4

Follow-Up Care

• Regular follow-up should include: measurement of FEV1, reassessment of inhaler technique, review of patient's understanding of treatment regimen, evaluation of ability to cope with disease, and assessment for need of LTOT or home nebulizer in severe COPD. 2
• Breathlessness can be assessed by ability to perform specific tasks (climbing stairs, shopping, walking around house) and quantified using visual analogue or Borg scale. 3