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

Diagnosis and Treatment of COPD

Diagnosis

COPD must be confirmed with post-bronchodilator spirometry showing FEV1/FVC <0.70—this is mandatory and the only way to definitively diagnose the disease. 1, 2

When to Suspect COPD

Suspect COPD in any patient with:

• Smoking history (most critical risk factor) 1, 2
• Progressive dyspnea that worsens with exercise 1
• Chronic cough (intermittent or daily, with or without sputum) 1, 3
• Sputum production of any pattern 1
• Wheezing (audible or patient-reported) 1

Clinical Predictors That Rule In COPD

The strongest clinical predictors include:

• Smoking history >40 pack-years 4
• Age >45 years 4
• Peak flow <350 L/min + diminished breath sounds + smoking ≥30 pack-years (combination essentially confirms airflow obstruction) 4
• Maximal laryngeal height reduction 4

Required Diagnostic Workup

• Post-bronchodilator spirometry (gold standard, non-negotiable) 1, 2
• Complete medical history including asthma/allergies, family history, comorbidities, unexplained weight loss, occupational/environmental exposures 3, 1
• Physical examination with respiratory rate, weight, height, BMI 3, 1
• Chest radiograph for differential diagnosis 1

GOLD Severity Classification (Based on FEV1% Predicted)

• GOLD 1 (Mild): FEV1 ≥80% 1, 2
• GOLD 2 (Moderate): FEV1 50-79% 1, 2
• GOLD 3 (Severe): FEV1 30-49% 1, 2
• GOLD 4 (Very Severe): FEV1 <30% 1, 2

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Treatment Algorithm

Step 1: Smoking Cessation (HIGHEST PRIORITY)

Smoking cessation is the single most critical intervention that modifies disease progression and must be the first step in all smokers—it is the only intervention besides oxygen therapy proven to reduce mortality. 1, 2, 3

Pharmacotherapy for Smoking Cessation (Choose One or More):

• Nicotine replacement therapy (gum, patch, inhaler, nasal spray) 1, 3
• Varenicline (most effective for long-term abstinence) 1
• Bupropion SR 1, 3
• Nortriptyline (alternative option) 1

Brief Intervention Protocol (5 A's):

• Ask: Document tobacco use at every visit 3
• Advise: Strongly urge cessation in clear, personalized manner 3
• Assess: Determine willingness to quit 3
• Assist: Provide quit plan, counseling, pharmacotherapy, social support 3
• Arrange: Schedule follow-up contact 3

Step 2: Pharmacological Therapy for Stable COPD

All symptomatic patients merit a trial of inhaled bronchodilators—the inhaled route is always preferred. 3, 1

Initial Monotherapy (Start Here):

• Long-acting β2-agonists (LABAs): Formoterol, olodaterol 1, 5
• Long-acting anticholinergics (LAMAs): Tiotropium 1, 5

Key Point: Demonstrate proper inhaler technique before prescribing—60-80% of patients make errors with metered-dose inhalers. 1

Step Up to Combination Therapy When:

• Symptoms persist on monotherapy 3
• FEV1 <60% predicted with ongoing symptoms 2

Combination options:

• LABA + LAMA (better lung function and symptom relief than either alone) 3, 2
• LABA + Inhaled corticosteroid (ICS) for FEV1 <50% predicted 3

Triple Therapy (LABA + LAMA + ICS):

Reserved for patients with:

• FEV1 <50% predicted 3, 1
• Frequent exacerbations despite dual therapy 3
• Elevated blood eosinophils 6

Important: ICS reduces exacerbation frequency and slows health status deterioration in advanced disease (FEV1 <50%), but has minimal effect on FEV1 decline. 3

Step 3: Long-Term Oxygen Therapy (LTOT)

Prescribe LTOT for patients with PaO2 <7.3 kPa (55 mmHg)—this is the only treatment besides smoking cessation proven to improve survival. 3, 2

LTOT Criteria:

• PaO2 <55 mmHg (7.3 kPa) on arterial blood gas 3
• Goal: Maintain SpO2 ≥90% during rest, sleep, and exertion 3
• Recheck ABG in 30-90 days if oxygen prescribed during exacerbation 3

Critical Pitfall: Never withdraw oxygen based solely on improved PaO2 if initially prescribed in stable state—this may be detrimental. 3

Step 4: Pulmonary Rehabilitation

Offer pulmonary rehabilitation to all patients with dyspnea, reduced exercise tolerance, activity restriction, or impaired health status—strongly recommended for FEV1 <50% predicted. 3, 2

Benefits include:

• Reduced dyspnea 3
• Improved exercise capacity 3, 2
• Better health status 3
• Reduced hospitalizations 2

Note: These benefits occur despite minimal effect on pulmonary function tests—rehabilitation addresses secondary conditions like deconditioning, peripheral muscle dysfunction, anxiety. 3

Step 5: Nutritional Support

Screen all patients for malnutrition using BMI and weight change—weight loss and muscle wasting significantly increase mortality. 3, 2

Screening Criteria:

• Underweight: BMI <21 kg/m² (age >50 years) 3
• Significant weight loss: >10% in 6 months or >5% in 1 month 3

Nutritional therapy must be combined with exercise or anabolic stimuli to be effective. 3

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Management of Acute Exacerbations

Immediate Treatment:

1. Controlled oxygen therapy: Target SpO2 88-92% to avoid CO2 retention 7
2. Increase bronchodilator dose/frequency: Use combination β2-agonist + anticholinergic via nebulizer 3, 7
3. Systemic corticosteroids (0.4-0.6 mg/kg daily): Improves lung function and shortens recovery 7
4. Antibiotics: When sputum becomes purulent OR when 2 of 3 criteria present (increased dyspnea, increased sputum volume, purulent sputum) 3, 7

Critical Monitoring:

• Arterial blood gases: Ensure PaO2 >60 mmHg without PaCO2 elevation >1.3 kPa or pH <7.25 7
• Avoid sedatives/hypnotics: May worsen respiratory depression 7
• Reassess within 48 hours: Escalate care if no improvement 7

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Common Pitfalls to Avoid

• Never diagnose COPD without spirometry—clinical suspicion alone is insufficient 1, 2
• Never use LABA monotherapy in asthma—contraindicated and potentially fatal 5, 8
• Never give excessive oxygen—may precipitate hypercapnic respiratory failure 7
• Never ignore inhaler technique—verify before changing therapy 1
• Never prescribe ICS as monotherapy—always combine with bronchodilators 3