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, regardless of disease severity. 1, 2, 3

Smoking Cessation (All Stages)

• Active smoking cessation programs with nicotine replacement therapy (gum or transdermal patches) combined with behavioral interventions achieve the highest sustained quit rates and prevent the accelerated decline in lung function characteristic of COPD. 1, 3

Pharmacological Management by Disease Severity

Mild COPD (Symptomatic)

• Initiate short-acting bronchodilators (β2-agonist or anticholinergic) as needed via appropriate inhaler device. 1, 2, 3
• Patients with mild COPD who are asymptomatic require no drug treatment. 2, 3

Moderate COPD

• Start regular long-acting bronchodilator monotherapy, with long-acting muscarinic antagonists (LAMAs) preferred over long-acting β2-agonists (LABAs) for superior exacerbation prevention. 1, 2, 3
• Perform a corticosteroid trial (30 mg prednisolone daily for 2 weeks with spirometric assessment before and after). 1
• A positive response is defined as FEV1 increase of 200 ml AND 15% of baseline; subjective improvement alone is insufficient. 1, 2
• If corticosteroid trial is positive, consider adding inhaled corticosteroids (ICS) to bronchodilator therapy. 1

Severe COPD

• Initiate combination LABA/LAMA therapy as first-line treatment, which provides superior bronchodilation and exacerbation prevention compared to monotherapy. 1, 3
• For patients with low exacerbation risk, LAMA monotherapy or ICS + LABA combination are acceptable alternatives. 1, 3
• Add ICS to LABA + LAMA (triple therapy) only if:
  • FEV1 <50% predicted AND ≥2 exacerbations in the previous year, OR 1, 3
  • Blood eosinophil count ≥150-200 cells/µL, OR 1, 3
  • Asthma-COPD overlap syndrome is present 1, 3

Very Severe/End-Stage COPD

• Prescribe long-term oxygen therapy (LTOT) for patients with PaO2 ≤55 mmHg (7.3 kPa) on arterial blood gas, maintaining SpO2 ≥90% during rest, sleep, and exertion; this improves survival in hypoxemic patients. 1, 3
• Consider referral for lung transplantation if BODE index >7, FEV1 <15-20% predicted, or three or more severe exacerbations in the preceding year. 3
• Short bursts of oxygen may help intractable dyspnea in end-stage disease. 1

Inhaler Technique and Device Selection

• Inhaler technique must be demonstrated before prescribing and checked regularly, as 76% of COPD patients make critical errors with metered-dose inhalers and 10-40% with dry powder inhalers. 1
• Select an appropriate inhaler device to ensure efficient delivery based on patient ability and preference. 1, 2

Non-Pharmacological Interventions

Pulmonary Rehabilitation

• Comprehensive pulmonary rehabilitation programs (including physiotherapy, muscle training, nutritional support, and education) improve exercise tolerance and quality of life in patients with moderate to severe COPD. 1, 2, 3

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 active treatment in COPD patients. 1

Management of Acute Exacerbations

• Increase bronchodilator therapy and consider nebulizers if inhaler technique is inadequate during exacerbations. 1, 3
• 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
• Non-invasive ventilation should be the first mode of ventilation for acute respiratory failure. 3
• Initiate or optimize maintenance therapy with long-acting bronchodilators before hospital discharge. 3

Critical Pitfalls to Avoid

• Beta-blocking agents (including eyedrop formulations) must be avoided in all COPD patients due to potential adverse effects. 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 and should not be used as first-line therapy. 1, 2, 3
• There is no role for other anti-inflammatory drugs beyond inhaled corticosteroids in COPD management. 1
• Patients using LABA/ICS or LABA/LAMA combinations should not use additional LABA for any reason. 4
• LABA/ICS combinations (such as fluticasone/salmeterol 250/50) are NOT indicated for relief of acute bronchospasm. 4