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

COPD Management

Stable COPD: Pharmacological Treatment Algorithm

Start all COPD patients with short-acting bronchodilators (β2-agonists or anticholinergics) as needed for symptom relief, then escalate based on FEV1 and exacerbation frequency. 1

Mild COPD (FEV1 ≥60% predicted)

• Use short-acting bronchodilators (albuterol or ipratropium) as needed for symptom relief 1
• No maintenance therapy required at this stage 1

Moderate to Severe COPD (FEV1 <60% predicted)

• Combine long-acting β2-agonists with long-acting anticholinergics to maximize bronchodilation 1
• For COPD specifically, use fluticasone/salmeterol 250/50 mcg twice daily (the only FDA-approved strength for COPD maintenance and exacerbation reduction) 2
• Add inhaled corticosteroids if FEV1 decline exceeds 50 mL/year or if frequent exacerbations occur (≥2 per year) 1

Monitoring Treatment Response

• Objective response is defined as FEV1 improvement ≥10% predicted and/or >200 mL 1
• Check inhaler technique, medication adherence, and symptom relief at every visit 1
• Monitor FEV1 and vital capacity to track disease progression 1
• Reinforce smoking cessation at every encounter 1

Exacerbation Management: Severity-Based Algorithm

Immediate Triage Decision

Send to hospital immediately if any of the following are present: loss of alertness, severe dyspnea, significant clinical deterioration, or uncertain severity 1, 3

Mild Exacerbations (Home Management)

• Increase bronchodilator dose/frequency (β2-agonists and/or anticholinergics) 1, 3
• Prescribe antibiotics if purulent sputum is present (indicating bacterial infection) 1, 3
• Consider short-course oral corticosteroids (prednisolone 0.4-0.6 mg/kg daily) if marked wheeze is present 1
• Encourage sputum clearance through coughing and adequate fluid intake 1

Severe Exacerbations (Hospital Management)

Initial Assessment:

• Perform pulse oximetry immediately and titrate oxygen to maintain SpO2 88-92% 3
• Obtain arterial blood gases if SpO2 <90% or respiratory acidosis suspected 3
• Obtain chest radiograph to exclude pneumonia, pneumothorax, or pulmonary edema (changes management in 7-21% of cases) 3
• Perform ECG if heart rate <60 or >110 bpm, or if cardiac symptoms present 3

Treatment Protocol:

• Administer systemic corticosteroids: prednisolone 30 mg/day orally for 7-14 days (oral preferred over IV) 1, 3
• Nebulize combined β2-agonist and anticholinergic bronchodilators 1, 3
• Provide controlled oxygen therapy via air-driven nebulizers with supplemental O2 by nasal cannulae to maintain SpO2 88-92% 1, 3
• Prescribe antibiotics (oral or IV) if infection is present 1, 3
• Initiate non-invasive ventilation (NIV) for patients with severe respiratory acidosis (pH <7.35) who fail initial therapy 1, 3

Critical Warning: High-flow oxygen can worsen hypercapnic respiratory failure and increase mortality in COPD patients 3

Post-Exacerbation Management

• Continue nebulized bronchodilators for 24-48 hours until clinical improvement 3
• Transition to usual inhaler therapy 24-48 hours before discharge 3
• Measure FEV1 before discharge to establish new baseline 3
• Check arterial blood gases on room air before discharge in patients who presented with respiratory failure 3
• Initiate pulmonary rehabilitation within 3 weeks after hospital discharge (not during hospitalization) 3

Non-Pharmacological Interventions

Surgical Options

• Bullectomy is indicated for patients with large unilateral or bilateral air cysts, demonstrated collapsed parenchyma on CT, and preserved transfer factor 1
• Lung transplantation benefits patients <65 years with FEV1 <25% predicted, PaO2 <7.5 kPa (56 mmHg), and PaCO2 >6.5 kPa (49 mmHg), with approximately 50% survival at 5 years 1

Pulmonary Rehabilitation

• Assess exercise capacity and respiratory muscle function to identify candidates for general body or respiratory muscle training 1
• Timing matters: initiate within 3 weeks post-discharge, not during hospitalization 3

Long-Term Oxygen Therapy

• Patients with PaCO2 ≥6.7 kPa (50 mmHg) or PaO2 ≤6.7 kPa (50 mmHg) require supplemental oxygen and should avoid air travel without it 1

Critical Safety Considerations

Corticosteroid Management

• For long-term oral corticosteroids, provide osteoporosis protection with calcium, vitamin D, hormone replacement, or bisphosphonates 1
• Add inhaled corticosteroids to minimize oral corticosteroid dose 1
• For high-dose inhaled corticosteroids (≥1,000 μg/day), use large-volume spacer or dry-powder delivery systems 1
• Instruct patients to rinse mouth with water after inhalation without swallowing to reduce oropharyngeal candidiasis risk 2

Common Pitfalls to Avoid

• Do not delay hospital evaluation when exacerbation severity is uncertain 1, 3
• Consider alternative diagnoses: pneumonia, pulmonary embolism, heart failure, pneumothorax 1, 3
• Avoid sedatives which can worsen respiratory depression 3
• Do not use IV corticosteroids without clear indication; oral is preferred 3
• Never use more than 1 inhalation twice daily of combination therapy; higher doses increase adverse effects without additional benefit 2
• Patients using long-acting β2-agonists should not use additional LABA for any reason 2